European Urology Today Vol. 34 No.1 – March/May 2022 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

Europe's Beating Cancer Plan includes PCa Europe's Beating Cancer Plan

An update from the EAU Policy Office

Communication from the commission to the European Parliament and the Council

EUREP21 held in Prague… in 2022 Popular Residents Education Programme returns

Vol. 34 No. 1 - March/May 2022

On display at EAU22 History Office acquires 17th-century Dutch matula

Let us give you a preview of EAU22! Plenary Sessions to offer a complete update on eight major urology topics The Scientific Congress Office (SCO) has prepared another exhaustive programme for the EAU’s Annual Congress in Amsterdam on 1-4 July. We spoke to the chairs of the eight plenary sessions as well as SCO Chair Prof. Albers about what you can expect from each of these major topics.

Dr. Alberto Breda (Barcelona, ES): Challenges in renal cancer The renal cancer landscape has evolved rapidly in recent years. Major advances have been made in medical therapies for metastatic disease and more recently, in adjuvant therapies for patients with high-risk localised disease. Our EAU Guidelines are rapidly evolving as Level 1 evidence becomes available. It is clear that promising options will change the game even more such as the growing evidence suggesting oncological efficacy of metastasis-directed therapies. Localised disease is also a hot topic, renal biopsy is rising from the ashes, and the implementation of new genetic strategies may offer a more personalised, patient-based strategy. From small renal masses to metastatic disease, kidney cancer has seen major advances. Plenary Session 1 has the potential to address all of these areas. The discussants will deliver key practical messages to urologists to update your evidencebased knowledge. We look forward to seeing you there!

Associated Plenary Session Plenary Session 1: Challenges in renal cancer Friday, 1 July (8.00-10.15)

Dr. Oscar Brouwer (Amsterdam, NL): Going viral in urology Although viruses may not always have played a leading role in urology, the COVID-19 pandemic may have changed this forever as it impacted everyday clinical practice in urology throughout the world, and many of our personal lives too. And who knows what lies ahead? Therefore, Plenary Session 2 will start off with lessons learned from the pandemic, and will extend to what is known about other identified viral infections relevant for urologists. Viral infections may impact fertility, endocrine function or potentially cause urological cancers, such as HPV-associated penile cancer.

Associated Plenary Session Plenary Session 2: Going viral in urology Friday, 1 July (8.00-10.15)

March/May 2022

Prof. Marc-Oliver Grimm A few years ago, this session format was (Jena, DE): pioneered by Mr. Tim O’Brien (GB) and supported Retroperitoneal Nightmares by Mr. Leigh. After Mr. Leigh has challenged many Plenary Session 3 will explore complications through the prism of the law courts. Leading medico-legal lawyer, Mr. Bertie Leigh (GB), is back and ready to cross-examine urologic experts concerning their decisions after surgery of retroperitoneal disease. The session will feature three scenarios: • The ruptured kidney tumour during minimallyinvasive surgery – was it the right approach given the potentially severe consequences? • The accidentally burned ureter – a matter of carelessness? • Complications of cytoreductive nephrectomy – outweighing risks vs. potential benefits, was it at all indicated?

Prof. Morgan Rouprêt (Paris, FR): Urothelial cancer in 2022 Bladder cancer is the tenth most common cancer in the world. In recent years, several new agents have been approved or are in development for the treatment of urothelial tumours. In this session, we will review the evolving therapeutic landscape of localised and advanced urothelial carcinoma (UC). The EAU Guidelines for bladder cancer are intended to help minimise morbidity and improve care for patients with this cancer. There is, however, an underuse of the guidelines. One reason is that non-indexed patients are treated by urologists in

Prof. Peter Albers (Dusseldorf, DE): PCa high-risk local treatment What is the optimal treatment for men with high-risk localised prostate cancer (PCa)? Are there changes in the current treatment paradigm? Experts aim to answer these questions through deliberations and careful examination of various contributing factors to provide potential solutions; whether combination treatments or treatment sequencing is the best multimodal approach; how magnetic resonance imaging (MRI) impacts the local strategy; and what is the prime management

Prof. Lars Dyrskjøt (Aarhus, DK): Liquid biomarkers in 2022 Liquid biomarkers have been documented to harbour diagnostic, prognostic and predictive value across multiple cancer types in retrospective and prospective studies. Liquid biomarkers now need to be tested in clinical intervention trials for guiding treatment decisions to document potential improved patient outcome and better quality of life. Plenary session 7 will give the audience an update on the current status of liquid biopsy analysis in bladder, prostate

experts, we can look forward to see Mr. O’Brien himself defending a cytoreductive nephrectomy with complications in our virtual court which is a particular highlight. The “nightmare” plenary session will, as always, remain very lively, entertaining, and informative in terms of decision-making, consent and surgical safety.

Associated Plenary Session Plenary Session 3: Nightmares in surgery of retroperitoneal disease Saturday, 2 July (8.15-10.30)

daily practice. We will describe how to improve personalised and targeted therapeutic strategies through the administration of highly selective and well-tolerated drugs in both neoadjuvant and adjuvant settings. In addition, we will focus on any technological advances in imaging and surgery that can improve risk stratification and outcomes for bladder cancer patients. This is especially true for bladder cancer, where patients are likely to undergo multiple surgeries over the natural history of the disease.

Associated Plenary Session Plenary Session 4: Perioperative treatment of urothelial cancer in 2022 Saturday, 2 July (8.15-10.30)

strategy for biochemical relapse after radical prostatectomy. Participants can also expect a thorough investigation if novel genomic classifications will fulfil a need. Experts in the field will also share vital insights on the advantages of upfront staging with prostate-specific membrane antigen (PSMA)-positron emission tomography (PET) scan, and if limited bone involvement detected by PSMA- PET is solely beneficial for palliative cases.

Associated Plenary Session Plenary Session 5: PCa high-risk local treatment Sunday, 3 July (8.00-10.15)

and kidney cancer in 2022. The session will cover results from both plasma- and urine-based analyses. Specific patient cases will be presented and discussed, and the audience will learn about novel intervention trials. Finally, the audience will have an idea what to expect in the near future regarding clinical use, and regarding novel tumour-agnostic approaches to liquid biopsy cancer detection.

Associated Plenary Session Plenary Session 7: Liquid biomarkers in 2022 and beyond: Ready for prime time? Monday, 4 July (8.00-10.15)

Prof. Jean-Nicolas Cornu (Rouen, FR): Management of LUTS/ BPO The field of management of lower urinary tract symptoms (LUTS) due do benign prostatic obstruction (BPO) is rapidly evolving. After failure of medications or in case of complications, interventional therapy is proposed, but there is no universal solution. This year’s dedicated plenary session will guide attendants in choosing the best option for surgical treatment, including new minimallyinvasive options. Worldwide recognised experts will summarise the principles and the results of each available technique (resection, vaporisation, enucleation, embolisation, waterjet, vapour thermal therapy, mechanical devices). These experts will then have a lively debate about clinical cases. Through this discussion, the keys for a tailored treatment will be exposed. Further challenges such as implementation of minimally-invasive options, medico-economic issues, long-term effects of the therapies, patient perspective, and definition of success will be debated. Finally, breaking news regarding future treatment innovations will be presented.

Associated Plenary Session Plenary Session 6: Personalised surgical management of LUTS/ BPO Sunday, 3 July (8.00–10.00)

Dr. Silvia Proietti (Milan, IT): Stones: The sky is the limit The impact of stone disease is significant worldwide, with its prevalence increasing at an impressive rate, including in the paediatric population. Similarly, the incidence of bilateral and multiple renal stones is on the rise; this implies that a non-negligible number of patients with bilateral urinary stones needs treatment of both renal units. Therefore, the ever-growing burden of stone disease requires highly effective and tailored approaches with an accurate postoperative follow-up and metaphylaxis. Moreover, the advancements in the endourological armamentarium, the downsizing of instruments together with the advent of single-use scopes, have made minimallyinvasive procedures increasingly attractive and widespread among the urological community. Along with that, the advances in laser technologies, with the advent of more powerful holmium systems together with the new thulium laser fibre, have provided urologists with different treatment options. Having said this, is the sky the limit for stone treatment? Where does the sky end for endourology? This plenary session will give you all the answers!

Associated Plenary Session Plenary Session 8: Stones: The sky is the limit Monday, 4 July (8.00-10.00)

European Urology Today

Update from the EAU Policy Office Advocacy Success Story: Prostate Cancer in the EU's Beating Cancer Plan Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

The report is from SAPEA, which is part of the European Commission’s Scientific Advice Mechanism.

s.collen@uroweb.org

The Scientific Opinion of the Group of Chief Scientific Advisors can be found at:

Since 2016 the EAU has been leading an advocacy campaign on early detection of Prostate Cancer, which has involved members of various scientific panels and committees in meetings and publications. Importantly, it has also involved national urological societies engaging with their national departments of health. One specific aim is that the European Commission should support EU governments with guidelines on risk stratified early detection of Prostate Cancer. This campaign was given a clear focus when the European Commission announced its Europe's Beating Cancer Plan, and as part of this, an update of the EU Recommendations on Cancer Screening. The update of the Recommendations included Prostate Cancer in the potential new cancers to benefit from EU-wide guidance, thanks to our joint advocacy. We are now closer to achieving this vision of EU-wide guidance as the EU’s scientific experts have also supported the EAU vision, and have called for the addition of “life-saving” prostate cancer early detection programmes. On 2 March, 2022 the Chief Scientific Advisors to the European Commission published a scientific opinion which is in favour of the development of EU-wide guidelines on risk stratified prostate specific antigen (PSA)-based prostate cancer screening, in combination with additional MRI scanning as a follow-up test.

European Urology Today Editor-in-Chief Prof. J.O.R. Sønksen, Herlev (DK) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) 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

The Chief Advisors followed the advise of a network of scientific experts. The experts issued a report concluding that there is a “strong scientific basis for introducing life-saving screening programmes in EU member states for both lung cancer and prostate cancer.”

European Parliament support early detection of Prostate Cancer Not only scientific advisors are calling for more efforts to beat prostate cancer, but thanks to our advocacy campaign, EU politicians are also calling for it. After a targeted campaign with Europa Uomo and researchers from the European Randomized Study of Screening for Prostate Cancer, we were able to secure changes to the European Parliament’s report on the EU’s Beating Cancer Plan. The Parliamentary report was voted on 16 February 2022, and included a call prostate cancer screening to be considered in the update of the Council recommendation in 2022. This recommendation is due to be published by the European Commission in the third quarter of 2022. Euro-MPs also called “for clear and tangible targets to be set for any new cancers that need to be tackled” which will help us in the implementation phase to ensure that any changes are time sensitive and measurable.

“The experts concluded that there is good scientific evidence for the benefit of risk stratified, organised, population-based PSAbased prostate cancer screening, particularly in combination with additional tests such as MRI scanning as a follow-up test.”

The EU takes steps to promote the use of Big Data and Real World Evidence in health At the EAU we have been at the forefront of a dynamic shift in use of evidence to include Real World Evidence (RWE) and Big Data to answer our urgent research questions where there is currently an unmet need. With our EU Innovative Medicines Initiative funded projects, PIONEER and now The experts highlighted that further research and ongoing monitoring are needed to identify the groups OPTIMA, we have been able to explore the that will most benefit from screening – particularly on possibilities offered by Big Data for prostate cancer, the ideal age range, and to ensure that an appropriate and we hope to extend that to other fields of urology in the future. balance of benefits and harms is maintained. The harms of ad hoc, opportunistic PSA testing for men were also noted in the report, and as something to be discouraged in order to reduce the risk of overdiagnosis and overtreatment, especially in older men. In response to the publication of the report, the Chair of the EAU Policy Office, Prof. Hendrik Van Poppel states: “We welcome the conclusions of the scientific experts, and we believe that if the European Commission and EU Member States act on this scientific advice, then it will help turn the tide on increasing mortality and ‘too late’ diagnosis of Prostate Cancer across the EU.”

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.

EAU Policy Office

European Urology Today

https://ec.europa.eu/info/sites/default/files/ research_and_innovation/groups/sam/ec_rtd_samcancer-screening-opinion.pdf (PDF)

It was found that there is good scientific evidence for the benefit of risk stratified, organised, populationbased PSA-based prostate cancer screening, particularly in combination with additional tests such as MRI scanning as a follow-up test. The use of active surveillance was noted as a helpful strategy for combating overtreatment.

Disclaimer

Together with the Group of Chief Scientific Advisors, they provide independent scientific advice to European Commissioners to support their decisionmaking. The full report can be downloaded at: www.sapea.info/topic/cancer-screening/

The European Union too is embracing these new tools for the benefit of health. The much anticipated legislation on the European Health Data Space (EHDS) is due to be published by the European Commission in April. The publication of this legislation will give much clarity on sharing of health data for medical use (primary purposes) while living abroad or travelling in other EU member states, and for research, policy making and regulatory purposes (secondary use). The European Medicines Agency (EMA), the EU’s joint regulator for medicines, has already initiated a pilot project of the EHDS, called DARWIN – Data Analysis and Real World Interrogation Network. In February it established the coordination centre of this network to develop and manage a network of real world data sources across the EU. In February too, Prof. James N’Dow from the EAU Executive Committee met with the EMA Big Data Taskforce to explain the work of the EAU on OPTIMA and PIONEER. Colleagues will also participate in upcoming workshops with stakeholders on issues such as Data Quality. The EAU also significantly contributed to the BioMed Alliance statement in December 2021 on the EHDS. The BioMed Alliance Task Force on Health Data Sharing proposed a set of recommendations for the governance, implementation and incentivisation of adoption of the EHDS. The statement particularly highlights the need to involve a broad range of

stakeholders and to align different legislative approaches with a clear and enabling EU legal framework. Read the full statement here. Biomed_ Alliance_EHDS_Statement.pdf (biomedeurope.org) The EAU is at the forefront of programmes and policies on use of health data to answer our unmet research needs to better the lives of our patients. The war in Ukraine and access to health care The war in Ukraine has caused much devastation in many cities across the country. War is devastating for health, and has led to many refugees leaving their homes and finding refuge in other European countries. The EAU has issued its own updated statement (https://uroweb.org/news/updated-statement-onthe-war-in-ukraine), and we have received many moving messages from Ukrainian colleagues, including a video message (https://youtu.be/ wM__3Im_DQo) from Prof. V. M. Lisovyi, the President of the Ukrainian Urological Association. One of our European network associations, the European Cancer Organisation, has established the ECO-ASCO Special Network on the Impact of the War in Ukraine on Cancer www.europeancancer.org and the EAU has joined this important network to represent the challenges and needs faced by the onco-urology healthcare professionals and patients. We have also connected this network to our national societies and patient organisations who are at the forefront of this response. On Wednesday, 23 March senior representatives of the WHO and EU Commission met with executive members of the associations involved, including Prof. Arnulf Stenzl who represented the urological community. The purpose of the meeting is to share the latest information from the WHO and EU, to exchange on the current challenges facing cancer centres, hospital networks and hospitals in the Ukraine and neighbouring countries, and the capacity to support Ukrainian cancer patient refugees in other countries. If you are working in a cancer centre that is delivering care to Ukrainian refugees, we would be happy to connect your centre to this network to facilitate good co-ordination between all of the relevant organisations and to help ensure that you are in the best place to receive any additional support your centre may need. The following website www.onco-help.org already contains many related resources and signposts to initiatives which are ongoing. If you have any web-based resources you think could be relevant, please do let s.collen@uroweb.org know.

Europe's Beating Cancer Plan Communication from the commission to the European Parliament and the Council

March/May 2022

Update from the Guidelines Office 2022 Guidelines update now available

T +31 (0)26 389 0680 guidelines@uroweb.org www.uroweb.org #eauguidelines

European Association of Urology

EAU PO Box 30016 6803 AA Arnhem The Netherlands

European Association of Urology

Guidelines 2022 edition

Guidelines

EAU Guidelines 2022

The EAU Guidelines are endorsed by

Now available online

75 national societies Endorsement by society

2022 edition

Over the course of the past year, we have continued to face a truly unprecedented healthcare crisis. The COVID-19 pandemic has not only persisted in testing the resources and capacity of health systems around the world but has also reaffirmed the need to place evidence-based healthcare at the heart of clinical decision making. Despite the challenges presented by the pandemic, the EAU Guidelines Office has continued to function, and we are honoured to announce the launch of the 2022 edition of the EAU Guidelines. With over 300 clinicians and patient representatives contributing to the production of this year’s guidelines, not only do we constantly build on our trusted reputation for independence, rigour, and high quality, but we also continue to ensure a balanced and representative view of the most up-to date information in urological care. For the 2022 edition of the EAU Guidelines, a number of Guidelines have expanded with the addition of new sections or completed comprehensive updates of particular sections, resulting in new and revised recommendations. Highlights from this year’s Guidelines include: Oncology Guidelines: • The Non-muscle-invasive Bladder Cancer Guidelines addressed the risk stratification introduced last year in more detail, which resulted in a number of revised recommendations. Updated information on urinary markers resulted in a revised recommendation for follow-up of NMIBC and the use of a urinary marker in a surveillance setting. The text was expanded with a number of new sections, most notably on chemoablation and neoadjuvant treatment. • In the Upper Urinary Tract Urothelial Carcinoma (UTUC) Guidelines, the prognostic section was considerably revised. Immunotherapy was introduced for high-risk non-metastatic disease management, which a complete revision of the metastatic disease section, resulting in a number of amended and new recommendations. • The Renal Cell Carcinoma (RCC) Guidelines introduce revised recommendations for diagnostic assessment and a new section on genetic assessment of RCC. In particular the sections on advanced/metastatic therapies have been extensively updated and restructured based on RCC histopathological entities, also addressing rare types and hereditary tumours, resulting in several new recommendations. • The Muscle-invasive and Metastatic Bladder Cancer Guidelines, include changes throughout the text, with a complete revision of their metastatic disease management section, including a revised flowchart for the management of metastatic urothelial cancer. • The EAU-EANM-ESTRO-ESUR-ISUP-SIOG Prostate Cancer Guidelines have been considerably revised, across all sections, but most notably; inclusion of a new section addressing clinically significant prostate cancer; the role of MRI in the diagnostic pathway/biopsy decision; the use of LDR and HDR brachytherapy in various stages of PCa management; the addition of ADT to radiotherapy for locally-advanced disease and the use of novel agents in the management CRPC. Non-Oncology Guidelines: • Updates to the Sexual and Reproductive Health Guideline, with a number of new recommendations added including the treatment of erectile dysfunction, premature ejaculation and penile curvature as well as the diagnostic work-up of male-infertility. • A new section addressing male urinary Guidelines Office

March/May 2022

•

incontinence has been included in the Nonneurogenic Male LUTS Guidelines. Significant revisions to the Guidelines on Urolithiasis, addressing radiation exposure and follow-up of urinary stones, all supported by four new algorithms which were produced based on two major systematic reviews. In the Infections Guidelines, the section on recurrent urinary tract infections was comprehensively updated and new treatment recommendations have been made. The Non-neurogenic Female LUTS Guidelines include new sections on laser treatment of overactive bladder and stress urinary incontinence. The updated Paediatric Urology Guidelines include new sections and recommendations on eosinophilic cystitis and nephrogenic adenoma, both included in the chapter on papillary tumours of the bladder.

The EAU guidelines are endorsed by 75 national urological societies and recognised as an important source for promoting the highest standard for urological care in Europe and beyond. The yearly publication of the EAU Guidelines would not be possible without the unwavering support of the EAU Executive Committee and Management team, our highly valued Guidelines Panels and young Guidelines Associates, the Guidelines Office staff members, our EAU membership and every user of the Guidelines globally. So, on behalf of the EAU Guidelines Office Board, thank you for your support and inspiration. We hope you enjoy using the 2022 update of the EAU Guidelines! The online version of the guidelines can be downloaded here (www.uroweb.org/guidelines). The full text and pocket versions of the 2022 European Association of Urology Guidelines will be available for collection as the EAU booth in Amsterdam for all Full EAU members.

Endorsement by Pan-African Urological Surgeons’ Association

The EAU Urology Cheat Sheets: A new tool to disseminate the EAU Guidelines Dr. Esther García Rojo, HM Hospitales and Roc Clinic, Madrid, Spain. esthergrojo@hotmail.com On behalf of the EAU Guidelines Office Dissemination Committee.

Consulting the #EAUguidelines has never been so easy! In August 2020, Urology Cheat Sheets was launched by a group of young urologists and residents from Spain as a project to disseminate scientific material covering specific urology-related topics in the form of “cheat sheets”. These were conceived as schematic display of information using algorithms, diagrams and summaries.

Update from the EAU Policy Office . . . . . . . . . 2

The European Association of Urology (EAU) Guidelines Office Dissemination Committee; whose ultimate goal is to raise awareness of the EAU guidelines and improve adherence to them; felt that the cheat sheet project had great potential to distribute the latest scientific evidence while providing the content in a visually eye-catching and simplistic way.

Recommended approach for biomarkers in testicular cancer. . . . . . . . . . . . . . . . . . . . . 8

Members of the Dissemination Committee create the sheets using the full text and diagrams of the original published guidelines. The text is then reviewed and finally approved by the Guidelines Panels, whereafter they are published on both the https:// urologycheatsheets.org* as well as the EAU website (www.uroweb.org). In October 2021, the first EAU Guidelines-specific Urology Cheat Sheets were published on Twitter. The sheets are now posted on a bimonthly basis on all official EAU social media channels as well as per guidelines topic on the new EAU website (www. uroweb.org/guidelines). All guidelines will be progressively covered, and regularly updated as new recommendations are released.

EAU Guidelines on Urological trauma Powered by the European Association of Urology

Overview and renal trauma

Overview

Definition and Epidemiology:

Trauma is a physical injury or a wound to living tissue caused by an extrinsic agent. Sixth leading cause of death worldwide, accounting for 10% of all mortalities. Half of all deaths due to trauma are in people aged 15-45 years being the leading cause of death in this age group. Death from injury is twice as common in males (motor vehicle accidents and interpersonal violence).

Classification of trauma:

According to the basic mechanism of the injury: penetrating or blunt injuries. Blast injury is a complex cause which includes blunt and penetrating trauma and burns. Penetrating trauma, is further classified according to the velocity of the projectile into: 1. High-velocity projectiles. Greater damage due to an expansive cavitation. 2. Medium-velocity projectiles. 3. Low-velocity items.

General management principles: 1.

2. 3. 4. 5. 6.

Initial evaluation: Imaging, laboratory analysis and specialist surgical input. Tetanus vaccine status should be assessed for penetrating injuries. Polytrauma managed in major trauma centres leads to improved survival. Damage control: rapid control of haemorrhage and wound contamination--> resuscitation -->definitive surgery in the stabilised patient. Established prophylaxis measures reduce thrombosis and are recommended. Antibiotics: 1 dose is recommended. Continuing antibiotics depends on injury grade, associated injuries and the need for intervention. Antibiotics should be avoided in lesser trauma. Urinary catheterisation: Prolonged catheterisation is required in bladder and urethral injury but not necessary in stable patients with low-grade renal injury. The shortest possible period of catheterisation is advised.

Renal trauma

Epidemiology, aetiology and pathophysiology:

5% of all trauma. Most common in young males. Overall population incidence of 4.9 per 100,000. The prevalence is higher in urban settings. Most injuries can be managed non-operatively with successful organ preservation. Penetrating injury: direct tissue disruption of the parenchyma, vascular pedicles, or collecting system. High-velocity bullets or fragments: potential for greatest destruction and associated with multiple organ injuries.

KIDNEY INJURY SCALE (based on AAST 2018 revision). AAST: American Association for the Surgery of Trauma

Evaluation and management:

Let us give you a preview of EAU22!. . . . . . . . 1

The sheets are currently receiving significant social media engagement, with an average of 30,000 impressions on Twitter alone. Posts promoting the EAU-Urology Cheat Sheets are among the ones with highest impact launched from the official EAU account (@uroweb) in 2021. The EAU Guidelines Office Dissemination Committee will continue to put all their efforts into the production of these sheets in order to bring the official guidelines, closer and closer to the whole urological community.

*The EAU only endorses the content related to the Guidelines that have been reviewed by the GO panel chairs.

Update from the Guidelines Office . . . . . . . . . 3 Introducing the EAU Equality, Diversity, Inclusion Taskforce. . . . . . . . . . . . . . . . . . . . . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7

Robotic vesico-vaginal fistula repair: Waste of money? . . . . . . . . . . . . . . . . . . . . . . 9 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . 10-13 ESUO: Metabolic endotoxemia and male infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 ESU section: ESU-ESOU Masterclass on NMIBC. . . . . . . . . 15 Topic highlights at the ESU-ESOU Masterclass on NMIBC . . . . . . . . . . . . . . . . . 15 EUREP21 report . . . . . . . . . . . . . . . . . . . . 16-17 Key BCa and PCa topics and updates . . . . . . 19 Key points and hot topics at ESOU22. . . . . . . 21 Urinary diversion for refractory female SUI. . 22 Patient Office section: EAU22 Patient Day in Amsterdam. . . . . . . . . 23 Introducing the EAU Patient Office Board. . . 23 Patient Information and EPAG in action . . . . 23 Drawing lessons from the EBU’s first virtual exam. . . . . . . . . . . . . . . . . . . . . . . . . 24 EUSP: Visiting Professorship in Switzerland truly fruitful experience. . . . . . . 24 Recruitment begins for the PRIME Study. . . . 25 The story of the pristine 17th-century Dutch matula EU-ACME: Credit Registry Report 2021 . . . . . 26 EAU RF PHOENIX: Recruitment started. . . . . 27 ESGURS: Setting up a mesh complications service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 ERN eUROGEN expands members . . . . . . . . 29 YUO/YAU section: Robotic kidney transplantation. . . . . . . . . . . 30 YAU: Experiencing mentorship. . . . . . . . . . . 31 BURST research collaborative gives updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ESRU organises NCO Board Meeting. . . . . . . 33 EAUN section: Neurogenic LUTS and CIC: Nurses’ point of view . . . . . . . . . . . . . . . . . . . . . . . . 35 “Spot-on” evidence-based urological nursing care. . . . . . . . . . . . . . . . . . . . . . . . . 35

European Urology Today

#EAU18

YUORDay22: Tailor-made for aspiring and young urologists After a two-year hiatus due to the COVID-19 pandemic, residents and young urologists can finally enjoy this year’s edition of YUORDay, which is a staple in the programme of the Annual EAU Congress dedicated to aspiring and promising urologists. Courtesy of the EAU Young Urologists Office (YUO) and the European Society of Residents in Urology (ESRU), the anticipated YUORDay22 will take place on Saturday, 2 July 2022 and led by renowned experts ESRU Chair Dr. Francesco Esperto (IT) and YUO Chair Dr. Michiel Sedelaar (NL). Battle for the championship One of the many highlights of YUORDay22 will be the EAU Guidelines Cup, a riveting competition that rose to popularity back in 2018 which puts a spotlight on who knows the EAU Guidelines the best. The top three participants, Dr. Anastasios Tsalavoutas (GR), Mr. Wojciech Malewski (PL), and Dr. Jose Antonio Lopez Plaza (ES) will show off their skills and battle it out on stage for the chance to be named champion at this year’s live EAU Guidelines Cup finale. Prizes await Aside from the prestige, awards, and bragging rights, the contenders of the EAU Guidelines Cup are entitled to three coveted prizes. The champion of the EAU Guidelines Cup will receive an Apple Watch, courtesy of the ESRU and the YUO.

The prize for the second place is the four-volume set of Campbell-Walsh Urology (12th edition). This series features new chapters, hot topics, vital updates with online access to 175 video clips. The third-prize winner of the EAU Guidelines Cup will have the privilege to choose from a selection of comprehensive masterclasses organised by the European School of Urology (ESU). The audience can anonymously compete via voting pads as well. The audience member with the highest score will receive admission to an ESU masterclass of his/her choice. Take a shot on Instagram and Twitter Anyone can take part in the unofficial EAU Guidelines Cup on the Uroweb Instagram (@Uroweb) and Twitter (@Uroweb) accounts to test their knowledge before EAU22. Ten rounds with a total of 20 questions will be posted, culminating in the start of EAU22. Stay tuned and join! Sessions to watch for Aside from the thrill and excitement from the EAU Guidelines Cup, YUORDay22 will also offer attendees interesting presentations on a myriad of topics. They can expect lively discussions on nightmare cases in ureteroscopy, transurethral resection of a bladder tumour (TURBT), and acute scrotum surgery which will be moderated Dr. Eliza Cristina Bujoreanu (RO), Dr. David Karsza (HU), and Dr. Noémie Luyts (BE). The dedicated session on hot topics for residents will highlight new evidences in prostate cancer, bladder cancer and upper urinary tract urothelial carcinoma (UTUC), as well as, centre on the developments in the treatment for stones, benign prostatic hyperplasia (BPH), and erectile dysfunction. Dr. Diego Carrión Monsalve (ES) and Dr. Sven Nikles (HR) will spearhead the session as moderators.

Contenders listening intently to the question

Excited finalist ready to give his answer comprise the mastering of TURBT and flexible ureteroscopy, as well as, coverage on incontinence surgery and new treatments for Peyronie's disease.

attendees with information on new opportunities for residents.

Moderators Dr. Angelika Mattigk (DE) and Dr. Karl Pang (GB) will oversee The “Research and academic” session which will focus on building collaborative prospective trials, coping with residency, women in surgical and academic urology.

Led by moderators Dr. Luca Afferi (CH) and Dr. Riccardo Campi (IT), the European Urology Scholarship Programme (EUSP) session will provide information on the current EUSP programmes, career benefits, and the Best Scholarship Award 2022. Before the EAU Guidelines Cup commences, Dr. Guglielmo Mantica (IT) and Dr. Taha Uçar (TR) will esteemed Chair of the European School of Urology lead the “Surgery tips and tricks” session, which will (ESU), Prof. Evangelos Liatsikos (GR), will provide

Winners and participants of the EAU Guidelines Cup at EAU19

ESU Courses: Prime updates and solid fundamentals This year, the European School of Urology (ESU) will offer prime urological updates, practical insights, best practices, and fundamentals through its highly-regarded course programme. For EAU22, the ESU organised 56 courses in 17 areas wherein 150 distinguished experts from 23 countries will lead the courses and mentor participants. Read on to know more about the newest additions to the course programme and how to enrol to ESU courses taking place during the congress. ESU Course 1 Theranostics in prostate cancer Chair & presenter: Prof. Boris Hadaschik (DE) Presenters: Prof. Wim Oyen (NL) and Prof. Philip Cornford (GB) The term “theranostics” is the combination of two words: therapeutic (thera) and diagnostic (nostic), which allows the combination of diagnosis, treatment, and continuous follow up of a disorder.

ESU Course 42 Practical tips for pelvic laparoscopic surgery: Cystectomy, radical prostatectomy adenomectomy and sacrocolpopexy Chair & presenter: Dr. Jose Maria Gaya Sopena (ES) Fellow presenter: Dr. Panagiotis Kallidonis (GR) This must-attend course will demonstrate patient positioning and trocar placement. Participants can expect beneficial insights, strategies, and techniques on laparoscopic adenomectomy, radical prostatectomy, radical cystectomy, and reconstructive surgery of the pelvic floor and sacrocolpopexy. Presenters who are experts in the field will also help identify complications and provide solutions. ESU Course 56 Prostate cancer challenges and controversies from guidelines to real-world Chair & presenter: Prof. Francisco Gómez Veiga (ES) Fellow presenters: Prof. Anders Bjartell (SE), Prof. Dr. Nicolas Mottet (FR), and Assoc. Prof. Rafael Sanchez-Salas (FR)

Based on nuclear medicine technologies, theranostics was introduced in the management of prostate cancer (PCa). The concept of theranostics has the potential to change PCa management and become an essential part of the urological armamentarium. The aim of this course is to provide an in depth overview of theranostics and to critically asses its performance, efficacy and limitations. During the course, participants will enrich their knowledge on various PSMA-PET tracers and radioligands; staging of primary disease and biochemical recurrence with PET imaging; radioligand treatment for metastatic PCa, and more. 14

European Urology Today

This ESU course will offer insights on how to minimise unnecessary biopsies through optimal use of prostate-specific antigen (PSA), new biomarkers, and magnetic resonance imaging (MRI). Participants will also learn how to stratify factors according to various approaches; how to select which at-risk patients to treat; and management after local progression. With eye-opening discussions on real cases and multiple-choice questions, this dynamic course will provide vital information on the diagnosis and treatment of advanced tumours, metastatic naïve, non-metastatic castration-resistant prostate cancer (nmCRPC), or metastatic castrate-resistant prostate cancer (mCRPC) including the latest advances for precision and personalised treatments. The course will examine new alternatives in detail, as well as, cost-effectiveness. The new ESU course will also comprise relevant topics such as:

ESU courses are led by esteemed key opinion leaders • Comparison between radiotherapy and surgery in treating locally-advanced PCa • Defining and treating oligometastatic PCa • Best treatment strategy in the naive metastatic setting • Identifying patients with CRPC, and more.

How to register You can enrol for the ESU courses when you register for EAU22. Please note that there are only limited seats available. Go to www.eau22.org/registration/ to sign up. You can also register for the courses onsite in Amsterdam but these are subject to availability. The registration fees* for the courses are as follows: ESU Course (2 hours) EAU members €50.00 Non-EAU members €65.00 Residents/ Nurse €32.50

ESU Course (3 hours) €65.00 €98.00 €32.50

ESU Hands-on Training Session €55.00 €55.00 €32.50

*Fees include 21% VAT

Immerse yourself in vital updates at our ESU courses March/May 2022

Join us in Amsterdam! EAU Guidelines at EAU22 The Guidelines Office (GO) is pleased to announce that it will once again facilitate multiple interactive activities during the Congress. These include: Two interactive workshop sessions on Guidelines Controversies Friday, 1 July, 10.30-12.00 and Sunday, 3 July, 11.45-13.15 These sessions will see pro and con presentations on areas within the EAU Guidelines which have highly conflicting evidence. Each set of presentations will be followed by a methodological comment/elaboration, and audience voting. Topics to be discussed are: • Follow-up after curative treatment of germ cell testicular cancer: should this be intense or cool? Should it be CT or non-CT based? • Does durability value more than morbidity in the management of BPO? • Should we give neoadjuvant chemotherapy to N2-N3 penile cancer patients? • Local relapse after external beam radiotherapy for prostate cancer. • A patient with a T2N0M0 bladder tumour cystectomy vs. trimodality treatment. • Is sexual and reproductive health still a matter of debate in the GU oncologic patient? Thematic and abstract sessions: • Friday, 1 July, 10.30-13.30 Prostate cancer early detection: What men need to know (Special Session) • Sunday, 3 July, 12.15-13.45 PIONEER real-world evidence, big data and prostate cancer

#EAU22

Road to EAU22

• Monday, 4 July, 10.30-12.00 Guidelines Session: Urolithiasis • Monday, 4 July, 10.30-12.00 Guidelines Session: Complications of prostate cancer treatment and their management • Monday, 4 July 12.15-13.45 Guidelines, evidence-based medicine and education Five European School of Urology courses: • Friday, 1 July, 11.00-14.00 Chronic pelvic pain in men and women

2022 1 May Early fee registration ends Deadline to submit late-breaking abstracts

• Saturday, 2 July, 11.00-14.00 Urinary tract and genital trauma

• Monday, 4 July, 8.30-11.30 Updates Renal, Bladder and Prostate Cancer Guidelines 2022: What has changed?

29June

EAU22 app is live

Online registration closes

who are registered

1-4 July

EAU22 Virtual Platform still online • Download your Certificate of Attendance as of 6 July • Visit the industry at the virtual exhibition until 11 July 2022, 17:45 hrs. • Review all scientific content on demand. After 11 July, all content will be available in the EAU22 resource centre for 3 years

guidelines@uroweb.org www.uroweb.org #eauguidelines

EAU22 congress live First class scientific programme, including • 2580 lectures, with 900 speakers • Live surgeries • Daily Meet-the-Experts sessions • 56 ESU courses and Hands-on Trainings • Patient Day on 4 July • Events: Opening Ceremony with live performances and awards; kick-off EAU’s 50th jubilee • 16 Industry sessions, 3 industry workshops, plus 1 EAUN (Nurses) industry session • Exhibition with 150 booths • Pick up your Guidelines and congress gift

European Association of Urology

Guidelines 2022 edition

Guidelines

EAU Members: collect your EAU Guidelines at EAU Booth D60

European Association of Urology

T +31 (0)26 389 0680

Access all abstracts via European Urology* * EAU Members and non-members

EAU Guidelines Cup live finale on YUORDay22 • Saturday, 2 July, 15.45-16.45 The competition aims to determine who among the EAU members knows the EAU Guidelines the best!

5-11 July

EAU PO Box 30016 6803 AA Arnhem The Netherlands

Late fee registration ends EAU22 Virtual Platform open • Check out the EAU22 scientific programme and create your personal programme • Review the abstract bodies and 5-minute abstract presentations • Visit & interact with leading industry

• Saturday, 2 July, 14.30-16.30 Updates and controversies: Incontinence, Bladder/Paediatric stones and Male LUTS Guidelines 2022: What has changed?

• Monday, 4 July, 12.00-15.00 Prostate cancer challenges and controversies from guidelines to real world

1 June

2022 edition

EAU Members can collect a free copy during the congress in Amsterdam (this does not apply to online only members). First come, first served; limited copies available.

www.eau22.org March/May 2022

European Urology Today

Introducing the EAU Equality, Diversity, Inclusion Taskforce Ambitious, long-term vision for an inclusive future for the urological community (See Fig. 3) Over 3,200 (17%) of the total membership database are female, most of them are under the age of 40 years. Although the recent years have shown an increase in female representation among EAU members, the speed is not the same as the increase seen in some of the European countries.

Dr. Silvia Proietti Member, EAU Equality, Diversity and Inclusion Taskforce San Raffaele Hospital Milan (IT)

“Over the last couple of years, the number of women in the medical and urological workforce has considerably increased and it is expected that this number will rise at a rapid pace.”

proiettisil@gmail.com A continuous hot topic for vivid discussions remains the disproportional representation of male physicians in various medical disciplines, in which urology is no exception. These debates on gender imbalance have triggered the EAU to critically review the level of inclusivity of its own organisation. This resulted in a strong ambition to actively act upon the underrepresentation of all minorities in terms of gender, country of origin, religion, age, social and ethnic backgrounds within its community. A special taskforce has been established to make this happen. In a series of articles, different aspects of the EDI strategy will be covered, starting with this first article focussing on gender imbalance.

When looking at various EAU activities, the increasing feminisation of urology is currently not reflected within its ranks. Up until 2021 women presented less than 20% of all posters, chaired less than 10% of the scientific sessions and made up around 12% of the faculty at the Annual EAU Congress was female. (See Fig. 2) While the situation is changing (this year the first female board member was appointed, as chair of the Guidelines Office), still some EAU Offices and Sections only consist of male members. In terms of future membership and development of the association this is certainly something that needs to be considered and transformed.

Why is EDI important? An environment that includes, respects, promotes and values individual differences along varying dimensions is of paramount importance in any organisation, but especially in a scientific organisation that is active across borders and is considered a networking hub for many different nationalities. Research has shown that inclusive organisations are more innovative and make better decisions in both clinical and scientific circumstances.

In the next 5-10 years these objectives should lead to the implementation of a diverse and inclusive structural urological framework with 5 concrete actions initially planned:

With the growing need for more urologists, the recruitment of medical students is essential in lowering the workload. Young physicians are more likely to be alienated from the organisation if they do not see themselves represented within an organisation. By expanding opportunities to teach, speak and lead to the wider urological community, the aim is not only to widen the urological talent pool, but also to foster belonging and to strive for continued unbiased excellence.

After an initial audit to assess the current situation on EDI in the urological community, the task force has commenced developing strategies and formulating potential solutions to identified issues. This resulted in the following aims & objectives of the EAU-EDI Task Force: 1. To provide similar opportunities and the same future career perspectives to our EAU members 2. To eliminate barriers in terms of gender (identity), ethnicity, country of origin, disability, and sexuality without reducing the quality of the clinical practice and educational output of the EAU 3. To create an inclusive environment dedicated to change within the EAU 4. To turn attention and resources toward structural and systemic interventions aimed to develop all and foster the development of minority members within the EAU

Gender balance in Europe Over the last couple of years, the number of women in the medical and urological workforce has considerably increased and it is expected that this number will rise at a rapid pace. Recent analysis of data from 9 European countries indicates that women currently make up 63% of all medical students, 48% of all urology residents and 24% of all urology consultants. (See Fig. 1) Analysis of diversity in EAU The EAU currently has over 19,000 members of whom the majority (14,000 members) practice in Europe.

Equality is the state of being equal, especially in status, rights, or opportunities. Diversity is the practice or quality of including or involving people from a range of different social and ethnic backgrounds and of different ages, gender and sexual orientation. Inclusion is the action or state of including or of being included within a group or structure.

•

5. A tailor-made monitoring framework will be developed for the EDI Task Force Strategy to monitor progress towards its objectives. In conclusion, the vision outlined in this article is ambitious and long-term, but it represents an important starting point to make the EAU urological community more diverse (and hence representative), equitable and inclusive which will ensure, undoubtedly, its bright future!

Dr. Saskia Morgenstern Consultant Urological Surgeon Agaplesion Markus Hospital Frankfurt, Germany

Ms. Tamsin Greenwell Chair, EAU EDI Taskforce Consultant Urological Surgeon, UCLH Honorary Assoc. Professor, UCL London, United Kingdom

Dr. Fardod O’Kelly Consultant Paediatric Urologist Beacon Hospital Dublin, Ireland

Dr. Ekhaterina Laukhtina Research Fellow, Dept. of Urology Comprehensive Cancer Center Medical University of Vienna, Austria

Dr. Idir Ouzaid Consultant Urological Surgeon, Groupe Hospitalier Bichat-Claude Bernard Paris, France

Dr. Laura Mertens Fellow Oncologic Urology Antoni van Leeuwenhoek, Netherlands Cancer Institute Amsterdam, The Netherlands

Dr. Silvia Proietti Consultant Urological Surgeon San Raffaele Hospital Milan, Italy

Dr. M. Carmen Mir Consultant Urological Surgeon IVO Foundation Valencia, Spain

Other sources on EDI 1. https://www.aamc.org/news-insights/press-releases/ majority-us-medical-students-are-women-new-datashow 2. Accreditation Council for Graduate Medical Education: Data Resource Book, Academic Year 2019–2020. Chicago: Accreditation Council for Graduate Medical Education 2020. Accessed May 9, 2021. Available at https://www.acgme.org/ About-Us/Publications-andResources/ 3. American Urological Association: Census Results. Available at https://www.auanet. org/research/ research-resources/aua- census/census-results. Accessed April 28, 2021. 4. Richter KP, Clark L, Wick JA, Cruvinel E, Durham D, Shaw P, Shih GH, Befort CA, Simari RD. Women Physicians

Gender female male undeﬁned

•

The EAU Equality, Diversity and Inclusion Taskforce

% Female 80

The term EDI stands for Equality, Diversity, and Inclusion.

1. A demographic and unconscious bias survey: to capture and analyse the current situation within the EAU and establish a benchmark upon which to measure the success of the strategies to enhance EDI 2. Establish a mentorship programme to provide career, academic and pastoral support for EAU members – initially this will be for younger members and via application in open competition. 3. Establish a diverse speaker panel to ensure equality in speaker and faculty opportunities and to attract young and diverse talented urologists. This will permit nomination (including selfnomination) of new talent. Application will be via a designated form and submission of a short recorded talk. 4. To establish a series of educational activities like webinars, podcasts around EDI and personal development to inspire and energise all urologists

EAU EDI Task Force The European Association of Urology (EAU), as a leader in the urological field, is convinced that by promoting Equality, Diversity, and Inclusion, urological care will be improved. With the establishment of the EDI Task Force with special focus on gender, EDI should be further encouraged and established within the EAU. The members of the Task Force were selected in open competition, based on their experience with leadership, teamwork, and diversity-related advocacy. The first team, focussing on gender imbalance, consists of 8 core members including female and male urologists at various levels of seniority in both academic and institutional service roles. The team is led by Associate Professor Tamsin Greenwell (UK). The other Task Force members are: Dr. Ekaterina Laukhtina (Austria), Dr. Laura Mertens (the Netherlands), Dr. Carmen Mir (Spain), Dr. Saskia Morgenstern (Germany), Dr. Fardod O’ Kelly (Ireland), Dr. Idir Ouzaid (France) and Dr. Silvia Proietti (Italy).

“The European Association of Urology (EAU), as a leader in the urological field, is convinced that by promoting Equality, Diversity, and Inclusion, urological care will be improved.”

What is EDI?

2015

2016

and Promotion in Academic Medicine.N Engl J Med. 2020; 383(22):2148-2157. Bailey EL.Br Women in medicine: increasing in number but not regard. J Gen Pract. 2020;70(695):296. Capella C, Schlegel L, Shenot P, Murphy A.Female Representation at High-profile Urology Conferences, 2014-2019: A Leadership Metric.Urology. 2021;150:72-76. T Adesoye , C Mangurian, EK Choo , C Girgis , H Sabry-Elnaggar , E Linos, Physician Moms Group Study Group. Perceived Discrimination Experienced by Physician Mothers and Desired Workplace Changes: A Cross-sectional Survey. JAMA Intern Med 2017; 177(7):1033-1036. Gomez LE, Bernet P.Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392.

2017

2018

2019

2021

2020

2,110

2,197

2,608

2,763

2,828

3,045

3,224

13,277

13,448

14,719

14,474

14,556

14,470

15,487

575

465

579

587

546

419

346

Fig. 3: EAU members by gender from 2015 until 2021

% Female 30

40 25

Medical Students Austria

France

Resident Germany

Ireland

Italy

Netherlands

Consultant Russia

Spain

2017

2018

2019 % Faculty

United Kingdom

2020 % Chairs

2020v

2021

% Poster PC

Figure 1: Female representation at Annual EAU Congresses from 2017-2021.

Figure 1: Gender Distribution in the Current Medical and Urological Workforce.

Fig. 1: Gender Distribution in the current medical and urological workforce

European Urology Today

Fig. 2: Female representation at Annual EAU Congresses from 2017-2021

March/May 2022

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

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

Oliver.Hakenberg@ med.uni-rostock.de

This 40-year-old man was an emergency referral for acute anuria, severe dyspnea and abdominal swelling. In addition, a large testicular tumour (10x20 cm) was seen. The history was vague as to the duration of the testicular swelling. Test results: • • • • •

Case study No. 71 A 28-year-old man has undergone several hypospadias repairs since childhood. Nevertheless, he is still complaining of dysuria and physical examination shows a meatal stenosis which only admits a guidewire (Fig. 1). His voiding urethrogram is also shown (Fig. 2). Discussion point • What surgical procedure is advisable?

Case study No. 72

Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunisia. E-mail: aminbouker@gmail.com Figure 1

α-fetoprotein was 13.149 IU/ml β-HCG 220 mU/ml LDH 650 U/l serum creatinine 119 µmol/l serum potassium 6.0 mmol/l

The patient was tested positive for COVID-19. The CT scan, performed without contrast media because of acute renal failure, is shown in fig. 1-3.

Figure 2

Evaluation of curvature and length of stenosis prior to planning surgery Comments by Prof. Tony Mundy London (GB)

You can tell a lot from a clinical photograph and from an x-ray image but there are some things that can’t be judged. Most notably, before any operation for hypospadias but particularly revision surgery, I would want to know whether he has a straight erection. He has an apparently straight penis in the photograph with no evidence of curvature in any direction but a formal evaluation before and after an injection of Caverject would be necessary before any surgery. There is obvious scarring and some swelling towards the right-hand side of the base of the penis and no clear distinct coronal sulcus at the base of the glans. Obviously I cannot comment on the appearance of the dorsum of the penis. The question here is not just about the state of the skin but also about the state of the dartos layer. Your “clinical comment” says that he has meatal stenosis but it doesn’t say how long that stenosis is and it is impossible to tell from the x-ray image. That is very important in planning revisional surgery. The imaging shows a bulbar penile urethra that is ballooned, presumably by the meatal stenosis, but there is no evidence of stenosis anywhere else although the proximal bulbar urethra is not clearly shown. It is however striking that the proximal

bulbar urethra is of considerably more narrow calibre than the more distal bulbar urethra and has not been “ballooned” in the same way. It may be that this is because it is normal urethra with a normal corpus spongiosum around it whereas more distally the urethra is “man-made” but I would be concerned about this disparity and would insist on a cystoscopy prior to any intervention as well as seeing the rest of the x-ray series. In theory, at least, it may well be that meatal stenosis is responsible for all of his symptoms of dysuria in which case it would be interesting, if it is indeed a very short stenosis, just to open up the meatus and see whether that resolves his symptoms. Knowing that that is the case would help decide whether to do any further surgery and, if so, how. Given that he is 28 he presumably would like to have a normal looking penis and be able to pass urine and ejaculate normally as well, but you never know unless you ask.

through the substance of the glans to the tip of the penis where the meatus is to be sited. The dissection in the substance of the glans will be to create a space in the glans which, with buccal mucosal grafting, can be closed up as a glanular urethra at a second-stage. This would require a little bit of manoeuvring of the skin in the region of the coronal sulcus to get a more normal appearance but it doesn’t look as though that would be too difficult. The full length of this ventral incision from the site of the present meatus to the tip of the “new meatus” could then be undermined on each side so that a 2 cm wide buccal mucosal graft can be harvested and then quilted onto the tunica, between the skin margins to form the basis of the new urethra.

If it is decided that the bulbar penile urethra needs to be reconstructed and that this is the time to do it then at the same stage a ventral stricturotomy and marsupialisation of the proximal penile and bulbar As always with revisional surgery the patient needs to urethra could be performed. Then, at the be counselled that this may be best done in stages, second-stage, the entire urethra could be closed particularly having had several operations, as this man up to give a more even urethral calibre. clearly has. I would expect to do a staged procedure, Alternatively, this could be done as part of the if he was my patient. second-stage. This would be about six months after the first stage. If the proximal bulbar urethra is normal then it may be best in the first instance to deal with the meatal If the proximal bulbar urethra has been shown to stenosis and the absent distal penile urethra. I would be normal then no further action would be make a dorsal incision at the meatus to open up the necessary. If, however, the proximal bulbar meatus, with or without ventral spatulation as well, urethra had been shown to be abnormal then it and extend that incision distally along the ventral may well be that a staged or single-stage buccal aspect of the shaft of the penis, through the glans to mucosal graft inlay urethroplasty may be necessary the tip of the penis. This incision would be through to restore that area to normal. Again, that would the skin and the dartos down on to the tunica of the be part of the staged urethroplasty of the rest of corpora cavernosa up to the tips of the corpora then the bulbar urethroplasty.

Fig. 1

Fig. 2

Fig. 3

Discussion point • What immediate and further management is necessary?

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

Case study No. 71 continued The required surgery was performed in two stages 6 months apart. First stage: A guidewire was inserted into the urethra. Ventral incision showed that the patient had undergone previous skin urethroplasty (Fig. 1). A stone was removed (Fig. 2). Hairy areas were excised and inner skin to skin anastomoses were done (Fig. 3). Excess skin was trimmed and the urethra was tubularised over a 24Ch Foley catheter and covered with dartos flaps (Fig. 4). Buccal mucosa graft (BMG) was harvested and quilted onto the distal aspect of the urethra (Fig. 5).

Second stage, 6 months later: Skin incision was made on the lateral edges of the BMG (Fig. 6) and due to localized skin contracture, the urethral plate was incised in the midline (Fig. 7) and a small BMG was added in an Asopa fashion. The distal urethra was tubularised and waterproofed with dartos fascia (Fig. 8) before skin closure.

March/May 2022

European Urology Today

Recommended approach for biomarkers in testicular cancer Early detection and monitoring of response to primary treatment is key Prof. Maria Pilar Laguna Pes Istanbul Medipol University Department of Urology Istanbul (TR)

Cancer Collaboration Group (IGCCCG) for metastatic disease, always in conjunction with the two TCspecific markers. These markers are used in the diagnosis, prognosis, detection of recurrence, and to monitor the response to systemic treatment.

Overall, elevation of one or two of these markers is seen in up to 60% of patients at diagnosis. The presence of the TC-specific markers increases with the plaguna@ clinical stage (CS) from 50.2% (44-56%) in CS I to medipol.edu.tr 93% in CS III (75.8-98.8%). An increase of both AFP and β-hCG is detected in up to 39% of patients with Testicular cancer (TC) is a relatively rare cancer non-seminomatous germ cell tumour (NSGCT), and compared to the incidence of other urological cancers around 90% of NSGCTs present with a rise in either in males. However, it is the most frequent solid AFP or β-hCG at diagnosis. Pure seminomas may also cancer in male adolescents and young adults with an, have modestly elevated β-hCG level at diagnosis in up as yet, unquantified social, professional, and family to 30% (9-32%) of patients. related impact. The good news is that around 70% of testis tumours are diagnosed at an early stage and Following orchidectomy, it takes several weeks for the that the overall mortality is low. Nevertheless, the serum markers to normalise according to their price to pay for cure may be high when considering half-life (≈ 3 weeks). As a rule, the persistence of the long life expectancy of these young patients. elevation or the increase in serum tumour marker Hence, early detection, monitoring of response to level after orchidectomy indicates the presence of primary treatment and recurrence, are of major metastatic disease, although a slight elevation above importance. upper normal limits may also be caused by other conditions. Conversely, although normalisation of This article aims to elucidate the current policy of the marker levels after orchidectomy is a favourable 2022 EAU TC Guidelines regarding the use of indicator, it does not exclude the possibility of biomarkers in the diagnostic work-up and monitoring metastatic disease. Overall sensitivity is around of TC, in the current context of so many emerging 50-60% and specificity, positive-predictive value molecular biomarkers. Key question is rather, (PPV) and negative-predictive value (NPV) are low in ‘Why do the 2022 Guidelines not recommend the use the primary diagnostic setting and lower in of micro RNAs (miR) in the diagnostic, treatment and seminoma than in non-seminoma TGCTs. follow-up pathways of TC patients and are the old recommendations still in place? Even though EAU22 “...the Guidelines focus on the includes a session on TC entitled “Is it prime time for biomarker-triggered follow-up?” minimum level of care to be Before embarking on a discussion about replacing a set of markers that have been used as a standard to guide diagnosis, management or follow-up of a rare disease for almost five decades, it may be helpful to refresh two concepts; ‘What are the key attributes of a quality Clinical Practice Guideline (CPG)’, and ‘Which criteria apply for a biomarker to be accepted as a new standard of care?’. CPGs aim to provide recommendations based on the best available evidence; providing a strength rating reflecting the certainty and evidence level of a given recommendation. They must be based on a critical, transparent, and reproducible methodology although guidelines can include expert opinion and consensus finding for areas with very diverse evidence or where no evidence exists. Given the variation in health care systems across Europe and world-wide, cost-effectiveness assessment is not addressed in EAU guidelines. Rather than providing an overview of all available tests, the Guidelines focus on the minimum level of care to be provided, solely based on the clinical effectiveness of various tests. Ultimate aim is to promote implementation and standardisation of care. Secondly, a universally applicable and accepted biomarker should ideally be non-invasive, i.e., be detectable in biological fluids such as urine or blood, and be easy to measure. Biomarkers must be capable of discriminating between healthy individuals (without disease) and those with the condition, be sensitive enough for the purpose of early diagnosis or detecting progression, with a long-serum half-life for the purpose of late diagnosis; be cost-effective with efficacy shown in prospective clinical trials, including sufficient patients numbers.

provided, solely based on the clinical effectiveness of various tests. Ultimate aim is to promote implementation and standardisation of care.“ In cases of metastatic TC, risk stratification is based on serum tumour marker levels immediately before initiation of systemic treatment. Before chemotherapy AFP and LDH levels may act as prognostic factors for OS in the non-seminoma intermediate-risk group. Although these tumour markers are routinely used for follow-up, only 25% of patients present with elevated AFP and β-hCG at relapse, and LDH may remain persistently elevated in 30% of patients despite cure. Most of the relapses are routinely diagnosed by imaging during follow-up. Both in primary diagnosis or during follow-up after orchiectomy, mildly elevated non-rising AFP (< 20 ng/ ml) or β-hCG (< 20 IU/L) may not indicate presence of TGCT. Other factors (e.g., pancreatic-, stomach-, liver- , kidney cancers or sarcomas), including hypogonadism, hypothyroidism, and marijuana use, can cause false-positive results. Further work-up is advised before initiating treatment for TC in these cases. Despite their limited accuracy and caveats, when measured in a standardised and timely manner and in conjunction with imaging, AFP, β-hCG and LDH still remain the cornerstone in the diagnosis, follow-up, and post-treatment monitoring of TC in the EAU Guidelines and other major national, international, or regional guidelines (e.g., NCCN, NHS, SWENOTECA, Princess Margaret Hospital, MD Anderson).

Characteristics of a biomarker Non-invasive Easy to measure Highly expressed in sample Discrimination Long-half life in biological samples Inexpensive Rapid results Cost-effectiveness Reproducibility

Conventional (AFP, β-hCG) Yes Yes No No Yes Yes Yes Unknown Yes

Table 1: Characteristics of classical biomarkers and miRNAs as biomarkers in testicular cancer regulate intra- and intercellular communication in autocrine, paracrine, and endocrine pathways. miRNAs play a role in the regulation of physiological and pathological processes and are necessary for various cell mechanism such as cycle regulation, migration and invasion, drug resistance and immune response. Their dysregulation has been described in the pathogenesis of many human cancer types. miRNAs may prevent cancer transformation or promote it, in case of abnormal expression. They are stable in the blood stream but their half-life in serum is variable, mostly short. Several clusters of miRs, including 371–373 and 302/367 but also others such as miR-367, miR-223-3, miR-449, miR-383, miR-514a-3p, miR-199a-3p and miR-214, have been proposed in several cancers as potential new biomarkers with a high specificity (> 99%). Of this group, miR-371a-3p locus, located at chromosome 19, represents the main miR cluster involved and expressed in TGCT tumorigenesis. This miR cluster is not unique to TC and regulates cell proliferation, drug resistance, migration, and invasion. However miR-371a-3p is the only miRNA extensively investigated as a TGCT biomarker in the diagnostic, staging, prognostic and follow-up setting and miR-371a-3p can discriminate between various testicular histotypes, including stromal and non-germ cell tumours. The expression of miR-371a-3p and miR-302/367 is significantly higher in all TCGT tissue than in healthy testis and higher levels of miR-371a-3p are found in the serum of TC patients than in controls. Specifically, TGCTs derived from germ cell neoplasia in situ (GCNIS) show higher miR-371a-3p levels than non-GCNIS tumours. The expression is only slightly increased in teratomas and absent in the prepubertal and post-pubertal types of yolk sac tumours. The higher discriminatory accuracy of miRNAs (particularly miR-371a-3p) compared to conventional TGCT markers has been confirmed in both retrospective but also prospective (multicentre) studies. Overall, depending on the clinical setting, a sensitivity and specificity of between 71% to 100% and 58% to 100%, respectively, has been reported, also depending on the clinical setting (diagnosis, early stage disease, chemotherapy response monitoring or presence of post-chemotherapy viable germ cell tumour). Areas under the curve (AUCs) were in general high although, depending on the clinical setting, could also be variable serum levels of miR-371a-3p correlate with clinical stage and tumour size and in CS I after orchiectomy, miR-371a-3p serum levels were shown to decrease by over 97% within 24 hours and over 99% in 72 hours.

At the moment, the best evidence for the M371 test (miR-371a-3p determination by quantitative polymerase chain reaction) is provided by a recent international prospective cohort study. Based on a cohort of 616 patients with either CS I or metastatic Last but not least, biomarkers should be able to play a Blood circulating miRNAs TC and 258 controls, miR levels were shown to be role in a screening setting and ultimately reduce When considering the above regarding the significantly associated with clinical stage, primary mortality. performance of the currently used biomarkers, it tumour size, and response to treatment. Sensitivity seems clear that new markers providing increased was shown as 90.1%, specificity 94.0%, PPV 97.2%. The current biomarkers accuracy, and minimising false-negative or falseand NPV 82.7% with an AUC of 0.966 for the primary Currently, the EAU TC Panel recommend serum biomarkers ∝-fetoprotein (AFP) and the beta subunit positive results are desirable. Basic- and translational diagnosis of TC; all of these parameters research is ongoing. Among other possible potential outperforming the classical markers. The test of human chorionic gonadotropin (β-hCG). AFP is a discriminated patients with localised GCT (CS I) from long glycoprotein of the group of the serum albumins, molecular biomarkers that meet the definition of a liquid biopsy, the most promising emerging those with systemic disease, with an AUC of 0.76, and produced mostly by the yolk sac, with a serum a diagnostic sensitivity and specificity of 83.4% and half-life of 5-7 days. β-hCG is a peptide hormone with candidates are blood circulating miRs. 60.1%, respectively. miR-371a-3p levels were higher a serum half-life of 18-36 hours and is expressed by Around 80% of the human genome is transcribed, in non-seminoma and increased with higher tumour the syncytiotrophoblast cells of some testicular germ however, only 1–3% is further translated into proteins. stage. Empirical data comparing the M371 test with cell tumours (TGCT), mainly by choriocarcinoma and Most of the human genome represents non-coding the classic TC markers showed that the new test is embryonal carcinoma but it is also elevated in some RNAs (ncRNAs), which play key regulatory functions. significantly more sensitive than the classic markers seminomas. A third marker, lactate dehydrogenase miRs are short-ncRNAs single stranded shape (β-hCG sensitivity 45%, AFP 28%, LDH 32%) even (LDH) is an unspecific marker of cell death with a molecules of approximately 19-22 nucleotides with a when combining all three markers (60%) in all half-life of around 24 hours. Although it has limited specific sequence. They are key molecules partially clinical settings. For each tumour stage there was a value in the primary diagnosis, LDH still plays a role decrease in serum miR-371a-3p after chemotherapy or in the risk-classification of the International Germ Cell complementary to one or more messenger RNA that 8

European Urology Today

miRNAs (miR-371a-3p) Yes Yes Cumbersome /technical variations Yes Yes No Unknown Not yet generalisable Unknown Unknown

orchidectomy, but the miRNA-371a-3p level decreased more rapidly in earlier stages. The data also confirmed the lack of expression of miR-371a-3p in teratoma or in case a somatic malignant component is present; further limitations of miR-371a-3p, either from this study or reported by others, include the low sensitivity (59%) in seminomas < 1 cm, the presence of false positives (up to 13% in CS I), and the lack of information regarding its role in a follow-up setting which needs to be clarified before imaging can either be replaced by this marker, or act as a reliable trigger for further imaging.

“In view of the excellent performance of miRs one can question why they are not yet included as TC biomarkers in the EAU Guidelines.“ The position of the EAU Guidelines In view of the excellent performance of miRs one can question why they are not yet included as TC biomarkers in the EAU Guidelines. When preparing the 2022 Guidelines, the TC panel once again carefully analysed and reconsidered the literature on miRNAs. The panel acknowledge that well-designed studies present excellent results for miR -371a-3p across the TC management pathway. These results show that miR-371a-3p outperforms the current markers and may present a turning point in the management of TC, impacting all possible clinical scenarios However, whilst the potential of these biomarkers is stressed, also shortcomings in the translational pathway and possible barriers for implementation were identified, which, on balance, preclude replacing the classical serum tumour markers by miRs in the 2022 EAU Guidelines. Usually, the process between biomarker discovery and meaningful clinical application is arduous and slow. The apparent lack of support of miRs in the TC Guidelines does not nullify the current scientific evidence but rather encourages well-designed studies with larger cohorts and appropriate follow-up for all possible clinical scenarios. Several of these projects are already ongoing on both sides of the Atlantic. From a clinical perspective, the biochemical properties of the miRNAs in general and of the miR-371a-3p cluster in particular makes them excellent biomarkers in TC. So far, the translational work has shown that they are able to provide reliable and accurate information outperforming the present TC serum markers. However, some outstanding queries need resolving before they can be incorporated into standard clinical practice, namely from sample collection to laboratory standardization, external diagnostic and prognostic validation, determine their value in a follow-up setting, cost-efficiency, either financial or in terms of measurable patient risk and lastly how to ensure the availability of the test at the point of care. Quality control is of paramount importance in order to avoid pitfalls that include sample collection, handling and storage, avoidance of haemolysis in the sample, extraction, and normalization. Although mainly RT-qPCR-based assays have been used, the best quantification method has yet to be determined. Overall, the technique is still time-consuming and requires sophisticated and expensive equipment which is not always available. So far results are available for miRNA 371a-3p alone, although other clusters with a longer serum half-life are already being explored. Either alone, or in combined clusters, panels may improve the prognostic ability or even expanding the diagnostic capabilities. March/May 2022

Regarding the quality of the published studies, there is nothing wrong with their design and methodology, but sample sizes are relatively small in most of them. The largest study (mentioned above) addresses a well-defined geographic area (Central Europe) known for the relatively high prevalence of TC and collates contributions from the groups pioneering in TC miRs. It is still unclear how the test will perform in other patient populations, when different sequencing techniques are used in other health care settings. Future validation studies will strengthen the diagnostic and predictive findings and address, or define, possible variations in outcomes. For all reasons mentioned above, and due to the lack of a well-designed cost-effectiveness analyses (only two simulations are available), at this moment in time it is still too early to recommend miR371a-3p in the EAU TC Guidelines. Two reviews, co-authored by the most prominent experts in the subject, conclude that “miR-371a-3p is a very suitable tumour marker for testicular germ cell

tumours, although further prospective studies should follow in order to identify advantages and limitations in the different clinical scenarios”. The EAU TC Panel concur with these limitations.

for CS I surveillance where tests for early diagnosis and a decrease of the imaging burden are urgently needed. References

A final consideration relates to the role of biomarker-triggered follow-up. In the current guidelines the minimal follow-up schedules present a combination of histopathology and clinical stage and include periodic physical examination, serum tumour markers determination and imaging, either by CT scan or MRI. The goal of a biomarkers will be to accurately predict the need for imaging and either replace or complement information on anatomical location and characteristics of the recurrence. Although still not ready for prime time, by introducing molecular profiling into clinical decision making miRs could have the greatest potential to become the future TC serum biomarker. In particular

Selleck MJ, Senthil M, Wall NR. Making meaningful clinical use of biomarkers. Biomark Insight, 2017; 12: 1-7. Regouc M, Belge G , Lorch A, Dieckmann KP, Pichler M. Non-Coding microRNAs as Novel Potential Tumor Markers in Testicular Cancer. Cancers, 2020; 12: 749. Leao R , Albersen M, Looijenga LHJ, et al. Circulating MicroRNAs, the Next-Generation Serum Biomarkers in 4 Testicular Germ Cell Tumours: A Systematic Review. Eur Urol, 2021; 80: 456-466. Dieckmann KP, Radtke A, Geczi L et al. Serum Levels of MicroRNA-371a-3p (M371 Test) as a New Biomarker of Testicular Germ Cell Tumors: Results of a Prospective Multicentric Study. J Clin Oncol, 2019; 37:1412-1423. Sauerbrei W, Taube SE, McShane LM, Cavenagh MM, Altman DG. Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK): An Abridged

Explanation and Elaboration. J Nat Cancer Ins, 2018; 110: 803- 811. Murray MJ, Huddart RA, Coleman N. The present and future of serum diagnostic tests for testicular germ cell tumors. Nat Rev Uro, 2016; 1: 715-725. Nappi L, Thi M, Lum A, et al. Developing a Highly Specific Biomarker for Germ Cell Malignancies: Plasma miR371 Expression Across the Germ Cell Malignancy Spectrum. J Clin Oncol, 2019; 37:3090-3098 MicroRNA-371a-3p as a blood-based biomarker in testis cancer Hamed Ahmadi a, Thomas L. Jang b, Siamak Daneshmand, Saum Ghodoussipour. Asian J Urol, 2021; 8: 400-406. Leão R, van Agthoven T, Figueiredo A et al. Serum miRNA predicts viable disease post-chemotherapy in testicular nonseminoma germ cell tumor patients. J Uro, 2018; 200: 126-135.

Robotic vesico-vaginal fistula repair: Waste of money? Summary of the counter-point view on the EAU22 debate on “The Utility of Robotic VVF Repair” Ms. Tamsin Greenwell Consultant Urological Surgeon University College London Hospital London (GB) Tamsin.greenwell2@ nhs.net Fig. 2: Vaginal view of post hysterectomy VVF

Up to 3.5 million women worldwide have a vesicovaginal fistula (VVF), the majority of which occur as a consequence of obstructed second stage of labour in low resource health care setting. [1,2,3] VVF are extremely rare (and all iatrogenic – as a consequence of surgery and / or radiotherapy) in well-resourced health care settings – with only 74 VVF recorded in England (population 55 million) in 2018-2019. [4] (Fig. 1 and 2) The aims of VVF management are anatomical closure of the VVF with restoration of urinary continence and volitional voiding. Spontaneous closure can occur in up to 12% of women following 3 - 6 weeks management with an indwelling catheter and anti-cholinergic medication after their precipitating injury. [5,6,7] Diathermy fulguration or fibrin glue have also been used with occasional successful closure of small fistula (< 5mm) [8,9] however there is no long-term data on either technique. The majority (> 90%) of VVF obstetric and iatrogenic require formal surgical repair. There continues to be debate about the best surgical approach (vaginal versus abdominal) for VVF repair. It is possible to close VVF vaginally in at least 70% of cases [10,11], with vaginal closure rates in excess of 85% reported in some series. [12] Anatomical closure rates are similar for both routes of repair however vaginal closure is less costly, with mean cost per repair of £3524.64 compared with £4751.83 per abdominal repair [13] mainly due to faster operative time and shorter length of stay. However recently there has

Fig. 1: Pessary VVF

March/May 2022

been an increasing number of reports (the majority of which (29/42 since 2005) are either single case reports (N = 21) or small case series of 5 or less (N = 8) about robotic abdominal repair of VVF enthusiastically touting this as the best way for future VVF repair! [14,15,16] Transvaginal VVF repair was first reported by Sims in 1838. [17] VVF should be repaired vaginally unless there is an absolute indication for abdominal repair (i.e., ureteric injury requiring reimplantation +/- small capacity bladder requiring clam cystoplasty). Relative indications are previous failed abdominal repair.

Fig. 3: Vaginal repair of VVF in process – inferior margin mobilised

Vaginal repair avoids a laparotomy (or in the case of robotic repair a transabdominal procedure) and its associated morbidities. It also avoids the need to bivalve the bladder which has associated longerterm functional morbidities. Vaginal repair is also associated with reduced post-operative pain, more rapid recovery, a shorter hospital stays and an earlier return to normal activities [13,18,19,20,21] compared with open abdominal repair. Local paravaginal interposition flaps (e.g., Martius fat pad) are immediately adjacent and readily available and it is relatively simple to perform simultaneous antiincontinence or prolapse surgery if indicated. There may also be a putative reduction in medicolegal litigation costs in high resource settings because of these advantages. The complications that have been reported with transvaginal repair include vaginal shortening and potential dyspareunia. [13, 18,19,20,21] There have been no published studies comparing vaginal repair with robotic repair – however the expectation would be that postoperative pain and inpatient stay would be similar. (Fig. 3 and 4) Transabdominal VVF repair may be transvesical using the O'Connor technique [22] (where the fistula is approached via a long anterior wall and bladder dome cystostomy) or extra-peritoneal, with dissection along the back wall of the bladder minimizing bladder trauma. [23] Robotic abdominal repair attempts to replicate these techniques. [24,25]

Both techniques utilise omental flap interposition. [26,27] Absolute indications for abdominal VVF repair are simultaneous ureteric involvement (obstruction or fistula) requiring concomitant ureteric reimplantation and or small capacity bladder requiring simultaneous augmentation cystoplasty. Relative indications for abdominal VVF repair are high fistula in a deep narrow or a floppy capacious vagina making surgical access impossible (the former can generally be overcome with an episiotomy and the latter with a vaginal retractor), previously irradiated tissues, complex fistulae (these can also be repaired vaginally in non-irradiated tissue with excellent outcomes using a modified approach) [28] and previous failed transvaginal approach. [23, 26] Complex fistulae are defined as those that are greater than 2cm in diameter, radiation induced (rare in low resource settings), involving the trigone or the urethrovesical junction. [29,30]

“Being in possession of a robot with insufficient vaginal surgical skills to close a VVF vaginally is NOT an indication for robotic abdominal repair - the patient and society would be better served by referral to an expert vaginal surgeon for closure.” Abdominal VVF repair permits simultaneous reimplantation of ureter(s) and/or clam cystoplasty if required. Omentum is also easily harvested without additional morbidity or incision in open abdominal repair, whereas in the case of robotic repair this will require redocking. The complications associated with the transabdominal open repair include the morbidity associated with a laparotomy, greater post-operative pain, longer recovery time and hospital stay and a marginally higher risk of failure, all of which (except the failure rate) are less with a robotic approach. [31,32] (Fig. 5 and 6) Although there are no randomized controlled trials to compare outcomes of vaginal and abdominal repair, series have consistently reported lower primary closure rates for abdominal repair. [12, 33] A recent systematic review of VVF repair cites a success rate for a vaginal closure of 91% versus 84% for abdominal repairs. [34] Robotic abdominal closure rates are difficult to calculate as the majority are single case reports – rates reported in series of > 5 are limited, with the largest series to date being 33. [15]

Fig. 4: Vaginal repair of VVF – appearance after Completion of vaginal closure

Fig. 5: Abdominal repair of VVF – bladder open and fistula indicated by forceps

Introduction of a new technique should only occur if it is better for society i.e. it is cheaper, yields better outcomes, or a reduced length of stay OR it is better for the patient i.e. yields better outcomes, a reduced length of stay or better cosmesis. A Da Vinci robot costs in excess of €2,000,000 to purchase, €110,000 annual maintenance contract fee and €1000s in disposable equipment costs per procedure (one recent US study suggested a mean of $1866 per procedure). [35,36] This compares poorly with the cost of a reusable vaginal Buckwalter type retractor of €6000 and the costs of the reusable scissors, forceps, needle holders and clips utilised for vaginal VVF repair. On a societal level the most clinically and cost-effective way to repair the overwhelming majority of VVF is vaginally.

Fig. 6: Abdominal repair of VVF – final appearance after abdominal closure of neobladder Vaginal fistula in patient with neobladder and Mitrofanoff

For those that have absolute indications for abdominal repair (<< 15% of all VVF) then robotic abdominal repair may be an alternative to open abdominal repair however the cost advantages of reduced length of stay and earlier mobilisation must be carefully weighed against the huge purchase, maintenance, and disposable equipment costs of the robot. Robotic surgery may also not be as cosmetic as enthusiasts maintain! Finally being in possession of a robot with insufficient vaginal surgical skills to close a VVF vaginally is NOT an indication for robotic abdominal repair - the patient and society would be better served by referral to an expert vaginal surgeon for closure!! The complete reference list of this article is available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Robotic vesico-vaginal fistula repair: Waste of money!” by Ms. Greenwell, March/May issue 2022. European Urology Today

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

resistant excluding extensively drug-resistant tuberculosis, third-generation cephalosporinresistant E coli, carbapenem-resistant A baumannii, fluoroquinolone-resistant E coli, carbapenem-resistant K pneumoniae and third-generation cephalosporin-resistant K pneumoniae.

fsangue@ hotmail.com

This study provides the first comprehensive assessment of the global burden of AMR, as well as an evaluation of the availability of data. AMR is a leading cause of death around the world, with the highest burden in low-resource settings.

Comprehensive study reveals global burden of bacterial antimicrobial resistance in 2019 Antimicrobial resistance (AMR) poses a major threat to human health around the world. The aim of the present study was to make comprehensive estimates of AMR burden to date. Investigators estimated deaths and disabilityadjusted life-years (DALYs) attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen–drug combinations in 204 countries and territories in 2019. They obtained data from systematic literature reviews, hospital systems, surveillance systems and other sources, covering 471 million individual records or isolates and 7,585 study-location-years. Predictive statistical modelling was used to produce estimates of AMR burden for all locations, including for locations with no data. The approach could be divided into five broad components: number of deaths where infection played a role, proportion of infectious deaths attributable to a given infectious syndrome, proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antibiotic of interest, and the excess risk of death or duration of an infection associated with this resistance. Using these components, the authors estimated disease burden based on two counterfactuals: deaths attributable to AMR (based on an alternative scenario in which all drug-resistant infections were replaced by drug-susceptible infections), and deaths associated with AMR (based on an alternative scenario in which all drug-resistant infections were replaced by no infection). They generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1,000 posterior draws, and models were cross-validated for out-of-sample predictive validity. Based on predictive statistical models, there were an estimated 4.95 million (3.62–6.57) deaths associated with bacterial AMR in 2019, including 1.27 million (95% UI 0.911–1.71) deaths attributable to bacterial AMR. At the regional level, the all-age death rate attributable to resistance was highest in western sub- Saharan Africa, at 27.3 deaths per 100,000 (20.9–35.3), and lowest in Australasia, at 6,5 deaths (4,3–9,4) per 100,000. Lower respiratory infections accounted for more than 1,5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome.

Based on predictive statistical models, there were an estimated 4.95 million (3.62–6.57) deaths associated with bacterial AMR in 2019… The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929,000 (660,000–1,270,000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths associated with AMR in 2019. One pathogen–drug combination, meticillinresistant S aureus, caused more than 100,000 deaths attributable to AMR in 2019, while six more each caused 50,000–100,000 deaths: multidrugKey articles

Understanding the burden of AMR and the leading pathogen–drug combinations contributing to it is crucial to making informed and location-specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics. There are serious data gaps in many low-income settings, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat. Source: Global burden of bacterial

antimicrobial resistance in 2019: a systematic analysis. Antimicrobial Resistance Collaborators.

Lancet 2022; 399: 629–55. Published Online January 20, 2022 https://doi. org/10.1016/ S0140-6736(21)02724-0

Clinical and microbiological efficacy of temocillin versus cefotaxime in adults with febrile urinary tract infection Use of third-generation cephalosporins, such as cefotaxime, is associated with an increased risk of selection for antimicrobial resistance, so alternative antibiotics need to be considered. The aim of the present study was to evaluate intestinal colonisation with third-generation cephalosporinresistant pathogens following use of temocillin, an alternative to cefotaxime that is potentially less prone to disturb the intestinal microbiota, in empirical treatment of febrile urinary tract infection (UTI).

RCT shows that temocillin gives less disturbance of the intestinal microbiota as compared with cefotaxime in the treatment of febrile UTI. Investigators performed a randomised, multicentre, superiority, open-label, phase 4 trial in patients who had been admitted to inpatient care in 12 Swedish hospitals with suspected or diagnosed febrile UTI (complicated or uncomplicated). To meet inclusion criteria, a patient was required to have at least one sign or symptom of pyelonephritis (i.e. flank pain, costovertebral angle tenderness and changes to urinary frequency or urgency or dysuria), a fever of 38°C or higher, and a positive urine dipstick (for nitrites, white blood cells or both). Participants were also required to have an indication for intravenous antibiotic treatment. Participants were randomly assigned (1:1) to receive either 2 g temocillin or 1-2 g cefotaxime, by local investigators opening consecutive sealed randomisation envelopes that were generated centrally in advance. Both drugs were administered intravenously every 8 h. The trial was open label for investigators and patients, but those doing the microbiological analyses were masked to the groups. Participants were treated with antibiotics for 7-10 days (or up to 14 days if they had bacteraemia), at least 3 days of which were on the study drug. At day 4 and later, participants who were showing improvement could be given an oral antibiotic (ciprofloxacin, ceftibuten,

cefixime or co-trimoxazole). Patients not showing improvement were regarded as having treatment failures. Rectal swabs were collected at three timepoints: at baseline (before the first dose), after the last dose of study drug, and 7-10 days after treatment stopped. The composite primary outcome was colonisation with Enterobacterales with reduced susceptibility to third-generation cephalosporins, or colonisation with toxin-producing Clostridioides difficile, or both, to evaluate disturbance of the intestinal microbiota. Between 20 May 2016 and 31 July 2019, 207 patients were screened for eligibility, of whom 55 patients were excluded. 152 participants were randomly assigned to groups: 77 (51%) patients received temocillin, 75 (49%) patients received cefotaxime. The composite primary endpoint was met by 18 (26%) of 68 participants receiving temocillin versus 30 (48%) of 62 patients receiving cefotaxime (risk difference -22% [95% CI -42% to -3%]), showing superiority of temocillin versus cefotaxime (i.e. less disturbance of the intestinal microbiota). 43 adverse events were reported in 40 (52%) of 77 patients in the temocillin group, versus 46 adverse events in 34 (45%) of 75 patients in the cefotaxime group. Most events were of mild to moderate severity. 21 (27%) patients in the temocillin and 17 (23%) patients in the cefotaxime group had an adverse event that was considered to be associated with the study drug. Temocillin was found to be less selective than cefotaxime for Enterobacterales with reduced susceptibility to third-generation cephalosporins, and it could therefore be a favourable alternative in the empirical treatment of febrile UTI. Use of this antibiotic could reduce hospital transmission and health-care-associated infections by these pathogens.

Source: The clinical and microbiological efficacy of temocillin versus cefotaxime in adults with febrile urinary tract infection, and its effects on the intestinal microbiota: a randomised multicentre clinical trial in Sweden. Charlotta Edlund, Anders Ternhag , Gunilla Skoog Ståhlgren, Petra Edquist , Åse Östholm Balkhed, Simon Athlin, Emeli Månsson, Maria Tempé, Jakob Bergström, Christian G Giske, Håkan Hanberger, Temocillin Study Group. Lancet Infect Dis. 2022 Mar;22(3):390-400. doi: 10.1016/S1473-3099(21)00407-2. Epub 2021 Oct 28. PMID: 34756180 DOI: 10.1016/S1473-3099(21)004072.

Impact of different urinary tract infection phenotypes within 1st year posttransplant on renal allograft outcomes In this register study from Switzerland, the clinical impact of urinary tract infections (UTI) during the first year after renal transplantation on renal function and graft survival was examined. The population included 2,368 transplantations with a total of 2,363 UTI events during the first year. Patients were categorised into four groups based on the UTI events within the first year after transplantation: (i) no colonisation or UTI [n = 1,404; 59%], (ii) colonisation only [n = 353; 15%], (iii) occasional UTI with 1-2 episodes [n = 456; 19%] and (iv) recurrent UTI with ≥ 3 episodes [n = 155; 7%].

Register study illustrates importance of prevention of urinary tract infections for longterm graft function and survival One-year mortality and graft loss rate were not different among the four groups, but patients with recurrent UTI had a 7-10ml/min lower eGFR at one

year (44 ml/min vs 54, 53 and 51ml/min; p < 0.001). There was no difference in long-term patient survival (p = 0.33). However, patients with recurrent UTI demonstrated a 10% lower long-term death-censored allograft survival (p < 0.001) which was confirmed as a strong and independent risk factor for reduced deathcensored allograft survival in a multivariable analysis (HR 4.41, 95% CI 2.53-7.68, p < 0.001). The authors concluded that colonisation and occasional UTI have no impact on pertinent outcomes, whereas recurrent UTIs do decrease renal function and allograft survival. Thus, better strategies to prevent and treat recurrent UTI are needed.

Source: Impact of different urinary tract infection phenotypes within the first year post-transplant on renal allograft outcomes. Jakob E Brune, Michael Dickenmann, Caroline Wehmeier, Daniel Sidler, Laura Walti, Dela Golshayan, Oriol Manuel, Karine Hadaya, Dionysios Neofytos, Aurelia Schnyder, Katia Boggian, Thomas Müller, Thomas Schachtner, Nina Khanna, Stefan Schaub, Swiss Transplant Cohort Study. Am J Transplant, 2022 Mar 14. doi: 10.1111/ajt.17026. Online ahead of print.

Pretransplant endotrophin predicts delayed graft function after kidney transplantation Delayed graft function after kidney transplantation is common and increases morbidity and health care costs. There is evidence that endotrophin, a specific fragment of pro-collagen type VI, promotes the inflammatory response in kidney diseases. In this study, the hypothesis that pretransplant endotrophin in kidney transplant recipients may be associated with the risk of delayed graft function was investigated.

High pre-transplant plasma levels of endotrophin are associated with delayed graft function Pretransplant plasma endotrophin was assessed using an enzyme-linked immunosorbent assay in three independent cohorts with 806 kidney transplant recipients. The primary outcome was delayed graft function, i.e. the necessity of at least one dialysis session within one week posttransplant. In the discovery cohort median pretransplant plasma endotrophin was higher in 32 recipients (12%) who showed delayed graft function when compared to 225 recipients without delayed graft function (58.4 ng/mL [IQR 33.4-69.0]; n = 32; vs. 39.5 ng/mL [IQR 30.6-54.5]; n = 225; p < 0.008). Multivariable logistic regression fully adjusted for confounders showed that pretransplant plasma endotrophin as a continuous variable was independently associated with delayed graft function in both validation cohorts, odds ratio 2.09 [95% CI 1.30-3.36] and 2.06 [95% CI 1.43-2.97]. Thus, pre-transplant plasma endotrophin, a potentially modifiable factor, was independently associated with an increased risk of delayed graft function and might be an avenue for therapeutic interventions.

Source: Pretransplant endotrophin predicts delayed graft function after kidney transplantation. Martin Tepel, Firas F Alkaff, Daan Kremer, Stephan J L Bakker, Olivier Thaunat, Subagini Nagarajah, Qais Saleh, Stefan P Berger, Jacob van den Born, Nicoline V Krogstrup, Marie B Nielsen, Rikke Nørregaard, Bente Jespersen, Nadja Sparding, Federica Genovese, Morten A Karsdal, Daniel G K Rasmussen. Sci Rep, 2022 Mar 8;12(1):4079. doi: 10.1038/ s41598-022-07645-y.

EAU EU-ACME Office

European Urology Today

March/May 2022

Prof. Serdar Tekgül Section Editor Ankara (TR)

inclusion criteria) and who are starting long-term ADT with or without concomitant radiotherapy to the primary.

serdartekgul@ gmail.com

It should also be noted that this is the first study to show that an intensification of systemic treatment provides a meaningful benefit in terms of MFS and overall survival, whereas such a conclusion remained debatable with previous trials such as the GETUG-12. The impact of such intensification therapy with new hormone agents in the peri-operative setting remains open to debate. Important trials such as the PROTEUS trial are still recruiting.

New standard of care in very high risk prostate cancer In this analysis, presented during the last ESMO meeting, the STAMPEDE trial focused on the population with N+M0 (locally advanced cancers and M0 on conventional imaging), or with high-risk N0M0 (i.e. localised cancers defined as very high risk when ≥ 2 criteria were present among which T3-4, PSA ≥ 40 ng/mL and Gleason score ≥ 8), in a de novo situation (therefore accessible to local radiotherapy) or in a situation of recurrence after local treatment. This population of relapsed patients was marginal in the inclusions (3%), and local radiotherapy was planned in 85% of cases (99% for N0 patients versus 71% for N+ patients). The current standard of treatment recommended in this trial was based on an ADT of at least 3 years, often associated with radiotherapy. The randomisation was done on the addition of abiraterone (ABI) +/- enzalutamide (ENZA) to the standard of care. Indeed, to increase the power of the experimental arm, the authors pooled the cohort of patients who received ADT + ABI (period 2012-2013) with the cohort of patients treated with ADT + ABI + ENZA (period 2014-2015), using the method of meta-analysis, and without major risk on the results. These per-protocol modifications were described in a specific amendment in 2019, making it possible to rigorously analyse metastasis-free survival (MFS) as the primary endpoint in this hybrid population, based on conventional imaging.

MFS was significantly improved in the ADT + ABI +/- ENZA arm (180 events) versus ADT alone (306 events, HR = 0.53, IC95: 0.44-0.64, p < 0.0001), with reduction in the risk of metastasis of 47%. In this phase 3 trial, the characteristics of the 1,974 patients were comparable in the 2 arms: median age 68 years, median PSA 34 ng/mL, N1 39%. The median follow-up was 72 months (85 months for the ADT + ABI cohort and 60 months for the ADT + ABI + ENZA cohort), and the vast majority of patients had received the planned 2 years of combined treatment. MFS was significantly improved in the ADT + ABI +/- ENZA arm (180 events) versus ADT alone (306 events, HR = 0.53, IC95: 0.44-0.64, p < 0.0001), with reduction in the risk of metastasis of 47%. This survival benefit was observed in all interest subgroups. The MFS at 6 years was 82% in the experimental arm vs. 69% in the control arm. The addition of ENZA to the ABI did not improve the results (HR 1.02) but caused additional toxicity (37% vs. 58% of adverse effects of grade ≥ 3, in terms of hypertension, liver toxicity, fatigue and erectile dysfunction). Overall survival data were also reported as a secondary endpoint and showed a net benefit in favour of the addition of ABI (HR = 0.60, IC95: 0.48-0.73, p < 0.0001), confirmed in all the subgroups of interest (improvement in overall survival from 77% to 86% at 6 years in the experimental group). Treatment with ADT + ABI +/- ENZA also significantly improved the other endpoints (versus ADT alone), such as specific survival and progression-free survival. Although the authors did not provide information on what happened after these 2 years in terms of tolerability or sequence of further treatments, this trial undoubtedly demonstrated that ABI administered for 2 years should be the new standard of care for patients with very high-risk M0 or N+ PCa (as defined by the STAMPEDE Key articles

March/May 2022

Source: Abiraterone acetate and prednisolone with or without enzalutamide for high-risk non-metastatic prostate cancer: a meta-analysis of primary results from two randomised controlled phase 3 trials of the STAMPEDE platform protocol. Gerhard Attard et al. STAMPEDE Investigators. Lancet. 2022 Jan 29;399(10323):447-460. doi: 10.1016/S0140-6736(21)02437-5. Epub 2021 Dec 23. PMID: 34953525

Prospective assessment of focal HIFU outcomes In the study by Reddy et al. the authors aimed at reporting on oncological outcomes and adverse events following focal high-intensity focused ultrasound (HIFU) for non-metastatic prostate cancer. They analysed data from 1,379 patients with at least 6 months of follow-up from a prospective multi-institutional registry; 24% of the patients had more than 5 years of follow-up. At 7 years, the authors report a failure-free survival of 69%, a metastasis-free survival of 100% and an overall survival of 100%. Failure-free survival was defined as evidence of cancer requiring whole-gland salvage treatment or third focal therapy treatment, systemic treatment, development of prostate cancer metastases, or prostate cancer-specific death; thus, it did not encompass a second HIFU. In the overall population, approximately one-fifth of men needed a second session of focal HIFU over the study period; the re-treatment-free survival at 7 years was 43%.

The authors conclude that HIFU has good cancer control in the medium term amongst intermediate and high-risk prostate cancer patients. It has to be acknowledged that the median follow-up for participants was 32 months and many patients might not have had time to develop recurrence. The authors conclude that HIFU has good cancer control in the medium term amongst intermediate and high-risk prostate cancer patients. While these findings are of interest for the scientific community, the equivalence or noninferiority of focal treatment to surgery needs to be demonstrated. On this matter, trials such as IP4-CHRONOS and PART are ongoing. The authors acknowledge the fact that they counsel patients regarding the potential need for a second HIFU after primary treatment. In fact, the retreatment-free survival was relatively low, with 43% of patients free of second treatment at 7 years. While a second treatment was not counted in the definition of failure-free survival by the authors, we believe this deserves attention. In fact, in case of recurrence after a second treatment, which is not unlikely given a 69% overall failure-free rate with 32 months of median follow-up, surgery and nerve-sparing procedures might become difficult. Thus, even in case of an uneventful procedure, the risk of impaired continence recovery is concrete. I would like to congratulate the authors with their efforts. In absence of a direct comparison with radical surgery from a randomised controlled trial,

HIFU for intermediate and high-risk patients should be regarded as experimental and patients should be extensively counselled about reintervention and the possibility of worse recovery compared with primary surgery. Open questions remain on the optimum definition of successful HIFU, the best surveillance strategy and the optimum second treatment, be it a second HIFU or not.

Source: Cancer control outcomes following focal therapy using high-intensity focused ultrasound in 1379 men with nonmetastatic prostate cancer: A multi-institute 15-year experience. Reddy D, Peters M, Shah TT, et al. Eur Urol. 2022 Feb 2:S0302-2838

Is Retzius-sparing safe in high-risk prostate cancer surgery? In the study by Dell’Oglio et al., the authors aimed at assessing in a single-institution series the oncological and functional outcomes after Retzius-sparing (RS) robotic radical prostatectomy (RARP) in the high-risk prostate cancer setting. Indeed, although RS-RARP has been previously demonstrated to be a valid surgical option, its safety in high-risk settings remains debatable given a potential higher risk of positive margins. The majority of published series focused on low and intermediate risk cases. Overall, 340 high-risk prostate cancer patients were retrospectively included, operated on by multiple surgeons, between 2011 and 2020 at a single high-volume centre. Only 42% of patients underwent preoperative MRI. Oncological outcomes were assessed by the rate of positive margins, biochemical recurrence, and need for salvage/adjuvant treatments. Intraoperative and 90-day complications were evaluated by the EAU Intraoperative Adverse Incident and by the Dindo-Clavien classifications. Continence (0-1 safety pad) and sexual function recovery were assessed at each follow-up visit.

Only 4% of patients experienced intraoperative complications. The 90-day complication rate was 14% with a 7.5%rate of Clavien-Dindo grade 3 complications. Only 4% of patients experienced intraoperative complications. The 90-day complication rate was 14% with a 7.5%-rate of Clavien-Dindo grade 3 complications. Pathological data revealed a pT3-4 stage in 55%, positive margins in 29%, and a node disease in 17%. Median follow-up was 4 years. Additional treatment was used as adjuvant therapy in 28% and as salvage therapy in 26% of cases. At 4 years of follow-up, the biochemical recurrence-free rate was 63.6%. At a multivariable analysis, prostate volume, grade group at biopsy, nerve-sparing procedure and full bladder neck preservation were independent predictors of positive surgical margins. Biochemical recurrence was independently predicted by grade group (p = 0.04) and margin status (p < 0.001). Those factors were also predictors of additional treatment, in addition to pT and pN stages. The 14 intraoperative complications included three iliac vessel injury and 2 ureter injury during lymph node dissection, one double J positioning for bladder neck injury, one complete dissection of the obturator nerve. The 1 and 2-year urinary continence and erectile function recovery were 84% and 85%, and 43% and 50%, respectively. The present study suggests that RS-RARP may be considered as a valid surgical option, even for the treatment of high-risk prostate cancer. The main limitations were the retrospective design, the single-centre design with outcomes derived from a high-volume and well-recognised expert institution, and the lack of validated

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com questionnaires used for functional outcomes assessment. Moreover, longer follow-up allowing to consider stronger clinical endpoints is awaited. Multicentre validation and a clear definition of high-risk cases which should be excluded from RS-RARP (anterior tumours with extracapsular extension) are also needed.

Source: Retzius-sparing robot-assisted radical prostatectomy in high-risk prostate cancer patients: Results from a large single-institution series. Dell'Oglio P, Tappero S, Longoni et al. Eur Urol Open Sci. 2022 Mar 4;38:69-78.

Antimicrobial prophylaxis in TURP: Randomised trial results The authors sought to determine whether omitting antimicrobial prophylaxis is safe in patients undergoing transurethral resection of the prostate without preoperative pyuria and a preoperative catheter. They conducted a multicentre, randomised, controlled trial in five hospitals. Patients with pyuria (> 100 white blood cells/ml) and a preoperative indwelling catheter were excluded. Postoperative fever was defined as a body temperature ≥ 38.3 ˚C. A noninferiority design was used with a 6% noninferiority margin and null hypothesis (H0) that the infection risk is at least 6% higher in the experimental (E) than in the control (C) group; H0 : C (antimicrobial prophylaxis group) - E (no antimicrobial prophylaxis group) ≥ Δ (6% noninferiority margin). A multivariable, logistic regression was performed regarding post-transurethral resection of the prostate fever and antimicrobial prophylaxis with co-variates: (clot) retention and operating time.

This data demonstrates the safety of omitting antimicrobial prophylaxis in patients undergoing transurethral resection of the prostate … 474 of the patients included for multivariable analysis and 211/474 (44.5%) received antimicrobial prophylaxis vs. 263/474 (55.5%) patients without antimicrobial prophylaxis. Antibiotics were fluoroquinolones in 140/211 (66.4%), cephazolin in 58/211 (27.5%) and amikacin in 13/211 (6.2%) patients. Fever occurred in 9/211 (4.4%) patients with antimicrobial prophylaxis vs. 13/263 (4.9%) without antimicrobial prophylaxis (p = 0.8, risk difference 0.006 [95% CI -0.003-0.06, relative risk 1.16]). We were able to exclude a meaningful increase in harm associated with omitting antimicrobial prophylaxis (p = 0.4; adjusted risk difference 0.016 [95% CI -0.020.05]). This data demonstrates the safety of omitting antimicrobial prophylaxis in patients undergoing transurethral resection of the prostate without preoperative pyuria and a preoperative indwelling catheter.

Source: Antimicrobial Prophylaxis in Transurethral Resection of the Prostate: Results of a Randomized Trial. Baten E, Van Der Aa F, Goethuys H, Slabbaert K, Arijs I, van Renterghem K. J Urol. 2021;205(6):1748-1754.

EAU EU-ACME Office

European Urology Today

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

The impact of smoking on sexual function The authors aimed to evaluate the hypothesis that there is an improvement in sexual function following smoking cessation (as smoking is a well-established risk factor for sexual dysfunction). They analysed the association between cigarette smoking and smoking cessation with sexual function among participants of the REduction by DUtasteride of prostate Cancer Events (REDUCE) study. The investigators analysed baseline data of 6,754 men aged 50-75 years divided into: lifelong non-smokers, former smokers and current smokers. They examined total testosterone (TT, normal range ≥ 10 nmol/L) and sexual function variables: self-reported sexual activity, low libido, and erectile dysfunction (ED). Differences between current vs. non-smokers and former vs. current smokers were analysed using the chi-square test, linear and logistic regressions.

… cigarette smoking was associated with worse sexual health compared to nonsmokers… A total of 3,069 (45.4%) men were non-smokers, 2,673 (39.6%) former smokers and 1,012 (15%) current smokers. Current smokers were significantly younger than former and nonsmokers (mean age 61.6, 63.2, and 62.7 years, respectively), leaner (mean body mass index 27.0, 27.7, and 27.2 kg/m2 , respectively) and had less hypertension (32.4%, 41.6%, and 36.8%, respectively; all p < 0.01). In uni and multivariable analysis, current smokers had higher mean TT than non-smokers (485.4 vs. 451.2 nmol/L, p < 0.001), higher prevalence of low libido (25.6% vs. 21.0%, p = 0.002) and ED (31.6% vs. 26.0%, p < 0.001) with comparable sexual activity (81.7% vs. 82.8%, P = 0.420). In multivariable analysis, former smokers had statistically significantly less prevalence of low libido (odds ratio [OR] 0.8, p = 0.013) and ED (OR 0.8, p = 0.006) compared to current smokers. In conclusion, cigarette smoking was associated with worse sexual health compared to nonsmokers, while former smokers had better erectile function and libido than current smokers. Smoking cessation may improve male sexual health and counselling on smoking cessation may be considered at the time of sexual health evaluation.

Source: The impact of smoking on sexual function. Mima M, Huang JB, Andriole GL, Freedland SJ, Ohlander SJ, Moreira DM. BJU Int. 2022 Feb 15. doi: 10.1111/bju.15711. Online ahead of print.

Aquablation therapy compared to TURP in men with LUTS due to BPH The aim of this study was to determine if Aquablation therapy can maintain long-term effectiveness in treating men with moderate to severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with a baseline prostate volume between 30 and 80 mL at 5 years, compared to TURP. In a double-blinded, multicentre, prospective, randomised, controlled trial, 181 patients with Key articles

moderate to severe LUTS secondary to BPH underwent TURP or Aquablation. The primary efficacy end point was reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety end point was the occurrence of Clavien-Dindo persistent grade 1 or grade 2 or higher operative complications at 3 months. Assessments included IPSS, Male Sexual Health Questionnaire (MSHQ), International Index of Erectile Function (IIEF) and uroflow (Qmax). The patients were followed for 5 years.

The authors conclude that the improvement in net health outcomes from Aquablation therapy outweigh those offered by a TURP… The primary safety end point was successfully achieved at 3 months where the Aquablation group showed a lower event rate than TURP (26% vs. 42%, p = 0.0149 for superiority). Procedure-related ejaculatory dysfunction was lower for Aquablation (7% vs. 25%, p = 0.0004). The primary efficacy end point was successfully achieved at 6 months, where the mean IPSS decreased from baseline by 16.9 points for Aquablation and 15.1 points for TURP. The mean difference in change score at 6 months was 1.8 points larger for Aquablation (p < 0.0001 for non-inferiority, p = 0.1346 for superiority). At 5 years, IPSS scores improved by 15.1 points in the Aquablation group and 13.2 points in TURP (p = 0.2764). However, for men with larger prostates (≥ 50 mL), IPSS reduction was 3.5 points greater across all follow-up visits in the Aquablation group compared to the TURP group (p = 0.0123). Improvement in peak urinary flow rate was 125% and 89% compared to baseline for Aquablation and TURP, respectively. The risk of patients needing a secondary BPH therapy, defined as needing BPH medication or surgical intervention up to 5 years due to recurrent LUTS, was 51% less in the Aquablation arm compared to the TURP arm. The authors conclude that the improvement in net health outcomes from Aquablation therapy outweigh those offered by a TURP when considering the efficacy benefit along with the lower risk of needing a secondary BPH therapy and avoiding retrograde ejaculation. Following Aquablation therapy, symptom reduction and uroflow improvement at 5 years have shown to be durable and consistent across all years of follow-up compared to TURP. Larger prostates (≥ 50 mL) demonstrated a larger safety and efficacy benefit for Aquablation over TURP.

Source: Five-year outcomes for Aquablation therapy compared to TURP: Results from a double-blind, randomized trial in men with LUTS due to BPH. Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Aho T, Kramolowsky E, Thomas A, Kaufman Jr RP, Badlani G, Plante M, Desai M, Doumanian L, Te AE, Roehrborn CG.

This latter issue has been addressed by a recent study undertaken in a few Turkish centres by comparing, in a randomised controlled trial, the effects of the insertion of UAS of 9.5/11 Fr vs. a 12/14 Fr, in patients selected for retrograde intrarenal surgery (RIRS) for the treatment of urinary stones. Sample size constituted of 160 patients per arm, although no details were provided on how this figure was calculated. All procedures began with a semi-rigid ureteroscopes in order to inspect the ureter and dilate it at the same time, prior to the insertion of the assigned UAS. In all cases, a Flex-X2 digital scope from Storz was used (7.5 Fr in the tip); a 30-W Holmium-YAG laser was set for dusting the targeted stones, in order to reduce the need for fragments’ extraction. At the end of the procedure, the ureters were assessed by retrieving the UAS under endoscopic control; the Traxer ureteric injury scale was used to report the ureteric injury. Follow-up time-points with imaging were set at 1-month follow up to evaluate the stone-free rate (fragments < 3 mm), and at 1 year post-op for the assessment of eventual ureteric stricture.

… this study supports the use of smaller UAS to reduce risk of ureteric injury, by keeping at the same time similar outcomes obtained with larger UAS… The authors reported an overall statistically different higher rate of ureteric injury in the group of 12/14 Fr UAS (23.7 vs. 39.3%, p < 0.001), which was consistent with a higher rate of high-grade injury (5 vs. 11.9%, p = 0.013). No statistically significant differences were reported in terms of stone-free rate, operation time and complication rates (90.6 vs. 95.6%, p = 0.077; 53.7 vs. 52.8 mins, p = 0.552; (6.7 vs. 3.37%, p = 0.449). At the 1-year follow-up check, only one patient in group-1 developed a ureteric stricture, while in group-2 four patients experienced this late complication; nevertheless, this difference was not statistically significant, due to the few events reported. Overall, this study supports the use of smaller UAS to reduce risk of ureteric injury, by keeping at the same time similar outcomes obtained with larger UAS.

Source: The Impact of Ureteral Access Sheath Size on Perioperative Parameters and Postoperative Ureteral Stricture in Retrograde Intrarenal Surgery. Can Aykanat, Melih Balci, Cagdas Senel, Ali Yasin Ozercan, Seref Coser, Yilmaz Aslan, Ozer Guzel, Ahmet Asfuroglu, Erdem Karabulut, Altug Tuncel. J Endourol. 2022 Mar 1. doi: 10.1089/end.2021.0751. Online ahead of print.

Can J Urol. 2022 Feb;29(1):10960-10968.

Bigger ureteral access sheaths correlate with higher risk of ureteric injury The ureteral access sheath (UAS) is a fundamental tool in flexible ureteroscopy in the context of the treatment of urinary stones, as it facilitates multiple passages through the upper urinary tract, reduces the endo-cavitarian pressure, improves visibility, and may potentially even increase the stone-free rates. Different calibres and lengths are available, in order to accommodate varied sizes of ureteroscopes, and to allow access to longer/ shorter urinary tracts (e.g. male/female), respectively. On the other hand, the insertion of a UAS may cause ureteric injury, especially in tight ureters. Furthermore, it has been postulated that the larger the UAS that is inserted, the higher the risk of ureteric stricture, due to prolonged ischaemia as a result of vessels compression.

Pre-ureteroscopy stenting, risk of post-operative infection: what matters? It is widely known that stenting prior to ureteroscopy for the treatment of upper urinary tract stones may increase the risk of post-operative infection. Depending on the circumstances in which the stent is placed, e.g. during a pyelonephritis secondary to an obstructive ureteric stone, all the tubes are colonised by bacteria producing a biofilm which depends on dwelling time: the longer a stent is left in place, the higher the chance for it to be colonialised. This situation leads to a higher risk of postoperative infection, due to its manipulation during the endoscopic manoeuvres. Nevertheless, the magnitude of this risk and the chance for the event to happen are not fully investigated. Three European tertiary centres have conducted a retrospective study to address these issues: they identified an overall cohort of 467 patients who were pre-stented, and match-paired them with a control arm of non-pre-stented patients.

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de

For the purpose of the match-pair, 152 patients were removed and the statistical analysis was then conducted. The events in observation consisted of postoperative febrile UTIs defined as fever > 380 ; the variables collected consisted of gender, stone size/ site/number, operative time, pre-operative culture, dwelling time of pre-intervention stent (monthly cut-off, up to 6 months prior surgery). Matched variables included age and gender.

…It is also the first in stating a potential cut-off for the dwelling time (2-4 months) significantly correlated to the infection. In terms of demographics, it is worthwhile to notice that more than a quarter (26%) of the adjusted pre-stented cohort had a pre-operative positive urine culture with respect to 10% observed in the control arm. No statistics on this difference of rates were reported by the authors, but it is likely that it has some kind of impact on the end points. By comparing the matched populations the pre-stented patients had a 2.67 higher risk in experiencing a febrile UTI (RR: 2.67, p = 0.03). When looking at the time needed for a presurgical stent to correlate with the febrile UTI, the authors found that the risk became substantial at 4 months of dwelling. Furthermore, when only the adjusted pre-stented cohort is considered, the months of stent dwelling correlated with the event lowered to just two (RR 3.94, p = 0.02). Regardless of its limitations, the study confirms the data in literature regarding the higher risk of post-operative UTIs and sepsis in pre-stented patients. It is also the first in stating a potential cut-off for the dwelling time (2-4 months) significantly correlated to the infection. This latter outcome may have some implications in the management of the waiting lists, in particular to consider changing the stent at 3 months if surgery cannot be undertaken beforehand. Nevertheless, it is unknown whether this rule should apply to other types of longer-standing ureteric stents (heparinised, silicone, etc.).

Source: Post-Ureteroscopy Infections Are Linked to Pre-Operative Stent Dwell Time over Two Months: Outcomes of Three European Endourology Centres. Robert M. Geraghty, Amelia Pietropaolo, Luca Villa, John Fitzpatrick, Matthew Shaw, Rajan Veeratterapillay, Alistair Rogers, Eugenio Ventimiglia, and Bhaskar K. Somani. J Clin Med. 2022 Jan; 11(2): 310.

Do we need antibiotic prophylaxis after hypospadias surgery? Use of prophylactic antibiotics after hypospadias repair is a widespread practice. The rationale of perioperative and postoperative antibiotics was to reduce the risk of urinary tract infection (UTI) in the early postoperative period following the placement of a catheter., Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Some studies also reported that antibiotics were effective in reducing urethroplasty complications (the risk of meatal stenosis and fistula). Little evidence is currently available regarding the

EAU EU-ACME Office

European Urology Today

March/May 2022

effectiveness of preoperative antibiotics in both stented and stent-less repair. Although the potential benefit of antimicrobial prophylaxis is unclear and still controversial, most paediatric urologists administer preoperative and postoperative antibiotics independently of a stent placement. The authors report the results of a randomised, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-todistal hypospadias. Boys were eligible for this multicentre trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5–10 days. Participants were randomised in a doubleblind fashion to receive oral trimethoprimsulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI) and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis.

In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis. In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject.

Source: Randomized trial of prophylactic antibiotics vs. placebo after midshaft-todistal hypospadias repair: the PROPHY Study. Faasse MA, Farhat WA, Rosoklija I, Shannon R, Odeh RI, Yoshiba GM, Zu'bi F, Balmert LC, Liu DB, Alyami FA, Beaumont JL, Erickson DL, Gong EM, Johnson EK, Judd S, Kaplan WE, Kaushal G, Koyle MA, Lindgren BW, Maizels M, Marcus CR, McCarter KL, Meyer T, Qureshi T, Saunders M, Thompson T, Yerkes EB, Cheng EY.

recovery of patients. There is an increasing accumulation of data showing that lower urinary tract dysfunction (LUTD) in childhood might affect lower urinary tract function and psychological well-being later in adulthood. Authors have looked at long-term functional outcome, psychological outcome and quality of life (QoL) of adolescents and young adults treated for childhood LUTD compared to healthy age-matched controls. They also evaluated the association with past treatment outcomes. A single-centre cross-sectional study of former patients treated in childhood (currently 16-26 years old) was conducted. Participants completed a survey composed of validated questionnaires: the Overactive Bladder Questionnaire, the Hospital Anxiety and Depression Scale, the Paediatric Quality of Life Inventory and the Short Form 36 Health Survey.

… adolescents and young adults treated for childhood LUTD are more prone to present with urinary tract symptoms later in life, especially if treatment duration was extensive… 52 former patients (out of 133) agreed to participate and 69 control subjects were included (mean age 21 2.9 years). Urinary tract symptoms were more common in former patients than controls. Storage symptoms more frequently reported were (urge) urinary incontinence, stress urinary incontinence (SUI) and nocturia. Voiding symptoms more frequently reported were intermittency and feeling of incomplete emptying. There were no differences in urinary tract symptoms or urinary incontinence subdivided by childhood treatment outcome. Results of the overactive bladder questionnaire revealed higher urinary symptom bother scores and lower disease-specific QoL in former patients compared to controls. General QoL and psychosocial well-being were not significantly different between the two groups. A childhood treatment duration extending 2,5 years was an independent prognostic factor for subsequent urinary tract symptoms later in life. Psychological comorbidity was more often present in former patients (35%) versus controls (10%), p < 0.01. Although general QoL and psychosocial well-being later in life is much less affected, adolescents and young adults treated for childhood LUTD are more prone to present with urinary tract symptoms later in life, especially if treatment duration was extensive. It has been shown that more urinary tract symptoms, lower disease-specific QoL scores and equal general QoL scores and mental health scores occurred in former patients versus healthy age-matched controls. A longer treatment duration at childhood was predictive for subsequent urinary tract symptoms later in life.

Source: Long-term functional and psychosocial outcome in adolescents and young adults treated for lower urinary tract dysfunction in childhood. De Wall LL, Kouwenberg MM, Cobussen-Boekhorst JGL, Feitz WF, Tak YR.

A group of researchers have explored the utility of the contrast-enhanced ultrasound (CEUS) during a fully ultrasound-guided PCNL in flank position, in patients not presenting hydronephrosis. The lack of a substantial dilation of the collecting system is known to cause higher rates of punctures needed to target the desired calyx, which in turns may expose the patients to a higher rate of bleeding.

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

tebj@medisin.uio.no A randomised controlled trial was designed in order to compare the CEUS-guided PCNL versus the conventional US-guided PCNL, with patients positioned in their lateral flank. Patients in the former group had the contrast injected in the renal pelvis endoscopically through a 6-F ureteral catheter. The visibility of the contrast was 5-7 minutes in the contrast-enhanced US mode, and puncture was obtained under guidance of both B and contrast modes. A sample size of 60 patients per arm was calculated in order to confirm the hypothesis that the CEUS-guided PCNL was superior to the conventional US-guided PCNL, in terms of a 40% higher success rate of gaining access to the kidney through the calyceal fornix.

..success rate of calyceal fornix access was obtained in 86.1 vs 47.2% (p =0.002) of the cases…” The primary end point was the success rate of calyceal access through the fornix, while secondary end points included success rates in gaining access at first needle shot, renal puncture time, and stone-free rate (SFR) defined as residual fragments (if any) < 4 mm at 4-week CT-scan follow-up. No difference in demographic distribution was observed; partial or complete staghorn renal stones involved more than 50% of patients in both arms (58,4 vs. 58,4%). At pre-surgery CT-scan, no hydronephrosis was observed in the majority of patients (58.3%). Nevertheless, the remainder of the patients presented mild hydronephrosis, so that a substantial proportion of patients presented some sort of urinary tract dilation. Unfortunately, definition regarding how

the grades of dilation were reported was not provided. Overall, the primary end point was reached, as success of calyceal fornix access was obtained in 86.1 vs. 47.2% (p = 0.002) of the cases, as by antegrade pyelography realised in day-3 post-op. CEUS-guided PCNL also allowed for a higher rate of 1-attempt successful puncture (91.7 vs. 77.8%), which also included cases with access obtained outside the calyceal fornix. Nevertheless, this difference was not statistically significant. Also SFR was higher in the intervention arm, although again the difference was not statistically significant (80.6 vs. 60.6%, p = 0.07). On the other hand, renal puncture time and drop of haemoglobin were statistically lower in the CEUS group (36 vs. 61 seconds, p = 0.001; 2.5 vs. 14.5 g/L, p = 0.01). Finally, a learning curve should be considered when approaching this interesting technique.

Source: Feasibility of contrast-enhanced ultrasound and flank position during percutaneous nephrolithotomy in patients with no apparent hydronephrosis: a randomized controlled trial. Zeng-Qin Liu, Jing Xie, Chu-Biao Zhao, Yan-Feng Liu, Zai-Shang Li, Ji-Nan Guo, Hong-Tao Jiang, Ke-Feng Xiao. World J Urol. 2022 Jan 21. doi: 10.1007/s00345-02203933-4. Online ahead of print.

BALTIC22

2022 7th Baltic Meeting in conjunction with the EAU

27-28 May 2022, Vilnius, Lithuania www.baltic22.org

J Pediatr Urol. 2021 Dec;17(6):759.e1-759.

J Pediatr Urol. 2022 Jan 25:S1477-5131(22)00011-0. doi: 10.1016/j.jpurol.2022.01.008. Epub ahead of print. PMID: 35144885.

PCNL: contrast-enhanced ultrasound is efficient Long-term outcome of children treated for lower urinary tract dysfunction Lower urinary tract dysfunction in children may be the cause of incontinence, urinary tract infection, vesicoureteral reflux and constipation with varying impact on the well-being of children. Behaviour modification and changing voiding habits along with pharmacologic treatment, pelvic floor muscle retraining, biofeedback therapy will usually provide rapid

Percutaneous nephrolithotomy (PCNL) is a complex procedure for the treatment of renal stones, depending on the successful puncture of the targeted calyx. Several new techniques have been proposed and investigated to assist the practitioners in order to obtain renal access in the most precise and safe way. Among the latest techniques, the microbubble contrast for ultrasound has been proposed as a potentially effective tool to minimise (or rule out) the use of X-ray exposure, and to easily identify the targeted calyx in real-time. An application has been made to the EACCME® for CME accreditation of this event

Key articles

March/May 2022

European Urology Today

Metabolic endotoxemia and male infertility Prebiotics and probiotics: new options in the treatment of idiopathic male infertility? Probiotics significant augmentation in testosterone level and A recent study by Dardmeh et al. [7] demonstrated sperm quality of infertile men after using a that probiotics could be an alternative solution in combination of prebiotic/probiotic therapy. Data eliminating obesity drawbacks on semen quality. The showed a direct impact of prebiotic/probiotic therapy study was performed on male mice to investigate the on the function of the pituitary gland in terms of effect of probiotics (Lactobacillus rhamnosus) on enhancing FSH and LH serum levels. sperm kinematic parameters, testicular weight, lipid profiles and reproductive hormones such as follicle Since many studies show that prebiotics and High fat or high calories stimulating hormone (FSH), luteinizing hormone (LH) probiotics are the key regulators of microbiota Animal experiments and human observational alekoxelaia@ and testosterone. Probiotics have a positive effect on improvement, they may have an influential studies have shown that consumption of diets gmail.com male fertility by either a direct or indirect influence. therapeutic impact on the above-mentioned containing either high fat or a high number of The direct effect improves spermatogenesis and disturbances (metabolic endotoxemia) and in this way calories leads to significant changes in gut bacterial maturation process whereas the indirect effect works may open a new avenue in the treatment of idiopathic Infertility is a global health problem which affects populations. It also increases the circulating levels out by eliminating the adverse effects of obesity and male infertility. 10–15% of couples in the reproductive age. There is of plasma endotoxin, implying a breakdown in gut elevating the total antioxidant capacity. In another growing evidence to support the theory that mucosal wall integrity and the passage of study, Amandine Everard et al. [8] demonstrated that References lifestyle factors affect male fertility through Gram-negative bacteria membrane potent immune 1. Nehal N Mehta et al. Experimental endotoxemia induces prebiotic (oligofructose) treatment restored alterations in endocrine profiles, spermatogenesis stimulant into the systemic circulation. Interestingly, adipose inflammation and insulin resistance in humans. Akkermansia muciniphila abundance and improved and sperm function. Thus, the identification of the magnitude of this ‘metabolic endotoxemia’ is Diabetes 2010 Jan 59 (1): 172 -81. gut barrier/gut permeability and metabolic factors contributing to infertility may be critical to reported to be more pronounced in mice placed on 2. Gomez-Elias et al. Association between high-fat diet parameters. A. muciniphila improved metabolic offer simpler and/or more effective therapeutic a high fat diet than on an isocaloric high feeding and male fertility in high reproductive disorders in diet-induced obese mice, normalised options than those currently available. The carbohydrate diet. This suggests that dietary fat is performance mice. Scientific Reports | (2019) 9:18546 | diet-induced metabolic endotoxemia, adiposity, and increasing worldwide prevalence of metabolic more efficient in transporting bacterial endotoxin https://doi.org/10.1038/s41598-019-54799-3 the adipose tissue marker CD11c. Similarly, A. syndrome (MetS), especially in younger from the gut lumen into the circulation, mediated 3. Ning Ding et al. Impairment of spermatogenesis and muciniphila treatment reduced body weight and populations, is a risk factor for fertility disorders. by transfer of endotoxin across the intestinal wall in sperm motility by the high-fat diet – induced dysbiosis of improved body composition (fat mass/lean mass However, it remains unclear whether there is a lipid laden chylomicrons. gut microbes. Gut 2020;69:1608–1619. doi:10.1136/ ratio) without changes in food intake. This study direct correlation between MetS and male gutjnl-2019-319127 clearly demonstrated the lack of a direct relationship infertility. Obesity and a diet high in fat or calories, Intestinal permeability 4. Tremellen et al. Gut endotoxin leading to a decline in between the abundance of Gram-negative bacteria which is typically consumed by obese individuals, Furthermore, there are reports that a high fat diet Gonadal function (GELDING) – a novel theory for the within the gut and metabolic endotoxemia (i.e. have been reported to cause a breakdown in the unfavourably alters the gut microbial composition, development of late onset hypogonadism in obese men. caused by serum LPS) because gut colonisation by A. normal gut mucosal barrier function, leading to the leading to an increase in intestinal permeability due Basic Clin Androl 2016 26:7 muciniphila decreased metabolic endotoxemia passage of gut bacteria membrane remnants into to disordered tight junction proteins (zonulin, 5. Linn B. Hakonsen et al. Does weight loss improve semen arising on an HF diet. An explanation for this the systemic circulation, initiating a chronic state of occludin) and a reduction in the colonic mucous quality and reproductive hormones? results from a counterintuitive result may be that A. muciniphila systemic inflammation. Inflammation, particularly barrier. In his study, Kelton Tremellen postulated for cohort of severely obese men. Reproductive health 2011; regulates gut barrier function at various levels. So, in adipose tissue, has been implicated in diet and the first time that in the gut transmucosal passage of 8:24 obesity-related insulin resistance in experimental bacterial lipopolysaccharide (LPS) from the lumen into according to previous data, gut microbiota contribute 6. Karma L. Pearce et al. Obesity related metabolic to gut barrier alterations during obesity and are the models. [1] the circulation is a key inflammatory trigger endotoxemia is associated with oxidative stress and underlying male hypogonadism. [4] High-fat diet has reason of metabolic endotoxemia. impaired sperm DNA integrity. Basic Clin Andrology 2019 High-fat diet a prominent role in increasing oxidative stress and May 13;29:6. Anti-oxidant probiotic strains Gómez-Elías et al [2] induced a metabolic syndrome- lowering antioxidant effect. A recent study was carried out by Valcarce et al. [9] to 7. Dardmeh F. Lactobacillus rhamnosus PB01 (DSM 14870) like condition in experimental models. supplementation affects markers of sperm kinematic evaluate the effect of two selected anti-oxidant (C57BL/6xBALB/c) F1 male mice were fed a high-fat “The increasing worldwide parameters in a diet-induced obesity mice model. 2017, probiotic strains (Lactobacillus rhamnosus CECT8361 diet (HFD, 30% fat) for 19 weeks, while controls PLoS One 12(10):1–17 and Bifidobacterium longum CECT7347) on sperm received a normal-fat diet (NFD, 6% fat). HFD-fed prevalence of metabolic syndrome 8. Amandine Everard. Cross-talk between Akkermansia criteria of asthenozoospermic men. Four parameters animals exhibited increased body weight, (MetS), especially in younger muciniphila and intestinal epithelium controls were evaluated: sperm motility, sperm viability, DNA hypercholesterolemia, hyperglycaemia and glucose diet-induced obesity. Proc Natl Acad Sci 2013 May 28; 110 fragmentation, and level of ROS. Viability was not intolerance. HFD-fed males exhibited a higher populations, is a risk factor for (22). affected while the other three tested parameters amount of gonadal fat, proposed to increase testicular fertility disorders.” 9. Valcarce. Probiotic administration improves sperm demonstrated a significant improvement after and epididymal temperature, thus affecting sperm quality in asthenozoospermic human donors. Benificial probiotic treatment. These findings support the production, maturation and storage. However, Diet composition and obesity Microbes 2017 8:2 importance of using probiotics to improve fertility of HFD-fed mice exhibited a decrease in epididymal There is mounting evidence that obesity has negative human males. 10. Maretti C, Cavallini G The association of probiotic with a weight, consistent with the lower epididymal sperm repercussions for reproductive physiology in males. prebiotic (Flortec, Bracco) to improve the quality/quantity count. Also, sperm analysis showed significant A large part of this evidence has accumulated from of spermatozoa in infertile patients with idiopathic Placebo-controlled study differences between HFD and NFD-fed mice in cauda oligoasthenoteratospermia: a pilot study. Andrology 2017 Finally the first placebo-controlled study was epididymal sperm count, sperm viability, morphology animal studies employing diets high in fat and sugar (‘high fat’ or ‘western’ diets). While excessive fats and conducted by Maretti and Cavallini10 and reported a 5:439–444 and progressive motility. carbohydrates are supposed to be major determinants of diet-induced obesity, a growing body of research Impairment of sperm motility suggests that the relationships between diet Ning Ding et al. [3] investigate if HFD-induced gut composition and obesity are more complex than microbiota dysbiosis can functionally influence spermatogenesis and sperm motility. Faecal microbes originally thought, involving interactions between derived from the HFD-fed or NFD-fed male mice were dietary macronutrients. Elevation of reactive oxygen transplanted to the mice maintained on NFD. The gut species (ROS) may have a detrimental effect on sperm quality and hence fertilisation potential. This is microbes, sperm count and motility were analysed. undoubtedly an important finding, given the clear Transplantation of the HFD gut microbes into the negative impact of obesity on male reproduction and NFD-maintained (HFD-FMT) mice resulted in a the strong relationship between diet and obesity risk. significant decrease in spermatogenesis and sperm Send your application to become member of one of the eleven motility, whereas similar transplantation with the YAU Groups now! Healthy reproduction diet microbes from the NFD-fed mice failed to do so. However, there is no clear definition of what a Transplantation with HFD microbes also led to ‘healthy diet’ for reproduction is. For most men, intestinal infiltration of T-cells and macrophages as Submission deadlines: 1 March - 1 July - 1 November switching to a ‘healthy diet’ means reducing the well as a significant increase of pro-inflammatory intake of food containing saturated fat and added cytokines in the epididymis, suggesting that Please check our website for details regarding the eligibility criteria epididymal inflammation has likely contributed to the salt and sugars and eating a wider variety of and application procedure: www.uroweb.org/education/youngunprocessed food (as recommended by nutritional impairment of sperm motility. RNA-sequencing dietary guidelines). There is a clear need to further revealed significant reduction in the expression of urologists-office-yuo/yau or contact the office via yau@uroweb.org those genes involved in gamete meiosis and testicular explore how diet impacts male reproductive function in order to develop evidence-based mitochondrial functions in the HFD-FMT mice. Ning preconception nutritional guidance for men. In their Ding et al. revealed an intimate linkage between cohort study, Linn B. Hakonsen et al. observed that HFD-induced microbiota dysbiosis and defects in the altered androgen profile tends to improve spermatogenesis with elevated endotoxin, following weight loss and that weight loss may dysregulation of testicular gene expression and potentially lead to improvement in semen quality. localised epididymal inflammation as potential [5] In a pilot study of 37 infertile men, Karma L. causes. [3] Pearce et al. confirmed a significant positive correlation between body mass index (BMI), Metabolic endotoxemia European Urological Scholarship Programme (EUSP) increased intestinal permeability (serum zonulin), Obesity and a high fat/high calorie diet are both metabolic endotoxemia (LBP), sperm DNA oxidative reported to result in changes in gut bacteria and Don't forget to submit your online applications for Short Visit, intestinal wall permeability, leading to the passage of damage (seminal 8 OHdG) and increasing levels of Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor bacterial endotoxin (lipopolysaccharide-LPS) from the sperm DNA fragmentation. Metabolic endotoxemia was positively correlated with increasing levels of gut lumen into the circulation (metabolic Programme before 1 May. sperm DNA oxidative damage. This relationship endotoxemia), where it initiates systemic remained significant, even after adjustment for inflammation. Endotoxin is known to reduce For more information and application, please contact relevant confounders such as age, BMI and days of testosterone production by the testis, both by direct abstinence. These observations suggest that inhibition of Leydig cell steroidogenic pathways and the EUSP Office – eusp@uroweb.org or check our website metabolic endotoxemia and its associated oxidative www.uroweb.org/education/scholarship/ stress may be a key driver of sperm DNA damage in EAU Section for Urologists in Office (ESUO) obese men. [6] Dr. Alekzander Khelaia ESUO, Board Member National Centre of Urology European University Tbilisi (GE)

European Urology Today

indirectly by reducing pituitary LH drive, thereby also leading to a decline in sperm production. Gramnegative bacteria, which comprise 70% of the total bacterial load in the human gut, contain a potent immune stimulant in their cell wall, referred to as lipopolysaccharide (LPS) or endotoxin.

March/May 2022

Report

ESU-ESOU Masterclass on NMIBC Impressions, vital TURB updates and more Dr. Charlotte Soenens ZorgSaam Zeeuws Vlaanderen Terneuzen (NL)

commenced with Course Director Prof. Marek Babjuk asking for a moment of reflection and shared some thoughtful words. With Ukraine still in our minds, we proceeded to get started with the NMIBC masterclass.

alone in the outpatient clinic. During the break, we processed this newly-acquired information, chatted with the exhibitors, and enjoyed coffee and some Czech pastries.

charlottesoenens@ hotmail.com

The first topic covered diagnostic strategy which had one golden rule: do a complete transurethral resection of the bladder (TURB). The en-bloc resection of the tumour seemed the way to go as it optimises the specimen for better staging by a pathologist. The percentages found in the slides showed how often we understage our patients. We kept this in mind: muscle is key!

As surgeons, we all face difficult operations. In the next presentation “How to manage difficult situations during TURB?”, the experts taught us how to handle such situations. After this interesting discussion, the obturator nerve block had no more secrets and now we know how to handle a large bladder perforation.

Dr. Eva Van Bos UZ Leuven Leuven (BE)

The options to enhance visualisation of the tumour were presented. Prof. Dr. Fredrik Liedberg gave an overview of the patients who are most at-risk and might benefit from an early cystectomy. In contrast to this, Prof. Joan Palou taught us that patients with a low risk of recurrence might benefit from fulguration

evavanbos@ gmail.com

The first day ended with impressive case presentations by the participants which even incited discussions among the faculty. We were very lucky that we had good weather and that our hotel was situated next to the Moldau river. So we went for an evening walk along the river and afterwards, we processed everything over some local food and drinks. Day 2 highlights The second day commenced with TURB videos of difficult tumour locations. Thanks to Prof. Bernard Malavaud, polyps in a diverticulum no longer gave us tachycardia.

We can hardly remember the last time we physically attended an international urological event. Since the implementation of travel restrictions due to COVID-19, we were stuck behind our computers. Thankfully, this time we have had the opportunity to attend onsite. As information on non-muscle-invasive bladder cancer (NMIBC) continues to expand, and it is a disease we encounter daily, we decided to apply to the ESU-ESOU Masterclass on NMIBC. The masterclass took place in the beautiful city of Prague from 24 to 25 February 2022. Day 1 recap On the first day, we woke up to learning about the dreadful news about Ukraine. The masterclass

The next discussion was about risk stratification in NMIBC reinforced in some cases. We can now easily calculate the progression and

Meet the faculty members of the NMIBC Masterclass

To be able to attend in person is a wonderful change of pace

recurrence rate using the EAU NMIBC risk calculator. What followed was an extensive overview about different intravesical treatment methods and possible complications, presented by Prof. Alfred Witjes and Dr. Alberto Breda. This was good to know especially when there is shortage of Bacillus Calmette-Guérin (BCG). Prof. Morgan Rouprêt highlighted the definitions of BCG failure and unresponsive disease. There was a clear consensus on the importance of risk stratification and consideration of (early) cystectomy. Mr. Hugh Mostafid roused us with some future predictions such as would there be a holy grail marker? After a refreshing lunch break, the masterclass concluded with real-life case presentations and the experts’ opinions on these cases. We would like to thank the EAU and ESU for organising this masterclass and for giving us the opportunity to learn with close interactions with the experts in the field.

Report

Topic highlights at the ESU-ESOU Masterclass on NMIBC Fresh experiences and newly-gained NMIBC knowledge Dr. Maximilien Goris-Gbenou Hopital Privé Beauregard Marseille (FR)

mcgoris@gmail.com Bladder cancer is the 10th most common cancer globally. [1] The average five-year survival rate is approximately 77%, which declines with greater degree of spread, from 95.8% for in situ disease to less than 6% with distant metastases. [2] The management of non-muscle-invasive Bladder Cancer (NMIBC) is very challenging and requires continuous upgrading of knowledge and skills.

the masterclass ESU-ESOU Masterclass on NMIBC, which took place in Prague from 24 to 25 February 2022. This excellent masterclass allowed me to review the EAU Guidelines on NMIBC and experience knowledge exchange with experts.

I am convinced that the en-bloc resection will be the standard of transurethral resection of bladder tumour (TURBT) for a certain type of NMIBC, although in my opinion the technique for extracting large specimens needs to be improved and better standardised.

Topics highlights I learned a lot from the different topics that were presented during the masterclass. There were so many interesting topics that I found educational and beneficial such as epidemiology; pathology and molecular classification of bladder cancer; work-up in patients with gross haematuria; endoscopic surgery in NMIBC; lasers in NMIBC surgery, standard transurethral resection of the bladder (TURB) with photodynamic diagnosis (PDD); en-bloc resections; office fulguration using laser; how to manage difficult situations during TURB; and many more.

Similarly, I value the very interesting clinical cases presented by the participants. I also had the opportunity to present my first clinical case. Discussions concerning clinical cases were riveting and knowledge-enriching.

During the last day, the faculty members and participants have discussed many other fascinating Why I applied topics: TURB in difficult locations and situations (e.g. When restrictions were enforced due to the COVID-19 tumour in the diverticulum, ureteric ostium pandemic, physical meetings were almost noninvolvement, bladder neck involvement, anterior existent and many of them were cancelled. bladder wall, and dome of the bladder); risk Fortunately, I was able continue to share and stratification and risk-adjusted management; practical exchange knowledge with the urology community steps of each intravesical treatment method; bladder through virtual meetings, as well as, being a reviewer instillation; management of patients with Bacillus of Urologic Oncology: Seminars and Original Calmette-Guérin (BCG) failure with current and Investigations, Urology®, World Journal of Urology, perspective treatment options; and the future NMIBC International Journal of Urology, Urologia treatments. Internationalis and Minerva Urologica e Nefrologica. Despite my experience in onco-urology, I appreciated Despite these experiences, it was important to update many of the topics discussed during the masterclass my knowledge on the management of NMIBC, meet which have been very useful for my practice. Through European urologists in a smaller convivial format, and the masterclass, my knowledge on the following was benefit from the expertise of the European School of updated: current options of endoscopic tumour Urology (ESU) and ESOU and EAU Section of visualisation; strategies and techniques of TURB Oncological Urology (ESOU) faculty. I have achieved including different en-bloc techniques; management my goals. of difficult situations during TURB; and patients with BCG failure including different options as radical I had the pleasure of being selected to participate at cystectomy for NMIBC. March/May 2022

What I enjoyed the most about the masterclass The topics presented at the masterclass were relevant and interesting. The intimate format and the engaging informal atmosphere was an optimal learning environment. I have had lively discussions with young urologists from all over Europe, as well as, with faculty members such as Prof. Joan Palou and Prof. Bernard Malavaux. Events such as this masterclass make it possible to ensure continuous training. These serve as a framework for the development of research collaborations, research, and projects on NMIBC to improve patient treatment and follow-up.

The intimate setup of the masterclass was conducive to learning

References: 1. Saginala K, Barsouk A, Aluru JS, Rawla P, Padala SA, Barsouk A. Epidemiology of bladder cancer. Med Sci. 2020;8(1):15 2. National Cancer Institute. Cancer of the urinary bladder - Cancer stat facts. SEER; 2020. Available from: https://seer.cancer.gov/ statfacts/html/urinb.html. Accessed September 28, 2020

Join a ESU masterclass One of participants, Dr. Mohammed Alfawzan (SA), also shared his impressions of the masterclass: "It was a great opportunity to join this prestigious masterclass which was led by an outstanding panel, and to meet eminent professors and colleagues from different countries. I would also like to express my appreciation to the organisers. I look forward to attending other masterclasses as well."

Interested in joining an ESU masterclass as well? Please visit www.esumasterclasses.org or scan the QR code for more information.

European Urology Today

EUREP21 19th European Urology Residents Education Programme 4-9 February 2022, Prague, Czech Republic

EUREP21: “I would do it again in a heartbeat!” Expectations, experiences, and team spirit Dr. Andreas Christodoulides Urologist and andrologist Nicosia General Hospital, Aglandjia (CY) andreaschristo doulides1986@ gmail.com Words cannot describe the feeling of contentment and fulfilment after attending this unprecedented programme. EUREP21 was spearheaded by urology’s outstanding key opinion leaders from all over the world who were the programme lecturers and tutors. The experience was like no other. EUREP21 was an exceptional place of knowledge, debates and discussions blended with team spirit and a dose of humour. Where do I begin with this report? Everything was well organised from the get go. The EUREP21 website was consistent and updated. I always received prompt responses to my emails concerning the programme. Guidance was offered as to arriving and departing from Prague which I appreciate as I have never been

to this glorious city. The venue choice, the Clarion Congress Hotel, and the lecture hall offered plenty of luxurious space, amenities and incredible staff. The lectures have met and exceeded my expectations. A thorough revision of urology and andrology was given by renowned urologists in the field. Everything ran smoothly and no technical difficulties arose. I was sad to see that some of our professors were not able to attend the congress due to COVID-19. Nonetheless, the participants got the chance to meet and greet them virtually and we were lucky enough to gain vital insights from them. I really enjoyed the interactive discussions and especially the playful yet professional atmosphere. EUREP21 was an exceptional place of knowledge, debates and discussions

Every resident had a chance to participate by asking questions, answering inquiries, and contributing to ongoing discussions. Even though we all came from different countries, the organisers and lecturers made sure that language was not a barrier and no question remained unanswered. EUREP21 had a respectful and educational atmosphere all in all. I really enjoyed meeting and connecting with colleagues from all over the world. I have met and enjoyed the company of truly amazing people. I hope to see them again soon in future congresses.

To top things off, we were given the opportunities to participate in the Hands on Training (HOT) courses on laparoscopy, endourology and ureteroscopy, as well as, take the E-BLUS and ESTs1 exams. Thank you EUREP21 once again for everything you have managed to offer us in just 6 days! It goes without saying that evening dinner gatherings and outings were much appreciated. Indeed, we did have a lot of fun despite our heavy learning

schedule. Needless to say, Prague was simply outstanding in all aspects. I am honoured to have been given the opportunity to participate at EUREP21. I would do it again in a heartbeat! This was a once-in-a-lifetime opportunity and I highly recommend it to residents to seize the opportunity and attend! Thanks again!

A full urological experience Perspectives of a tutor Dr. Juan Gómez Rivas Chairman, Young Academic Urologists (YAU) E-BLUS tutor Hospital Clínico San Carlos Madrid (ES) juangomezr@ gmail.com After being part of EUREP for years, I can say that the spirit of this programme has been maintained throughout its 19 editions. EUREP manages to form the optimal environment where young urologists

from all over the world convene for an intensive urological learning experience.

in laparoscopy and endourology. This is also evident in the increasing number of residents who have taken practical accreditation exams. Moreover, the European School of Urology (ESU) contributes to this progress by creating novel practical learning modules. In laparoscopy, the ESU has produced training modules intended for those who possess intermediate skills, such as vascular damage repair and pyeloplasty in addition to the basic skills.

EUREP21 provided participants with the support and resources in both theoretical and practical levels. For five days, the best experts in the field delivered the fundamental aspects of urology. Participants enhanced their technical skills during the optional hands-on training courses, and took standardised exams of the European School of Urology (ESU): the EST-s1 (Endoscopic Stone Treatment step-1) and E -BLUS (European training in Basic Laparoscopic Urological Skills). Throughout my years as a technical skills tutor, I notice a growing interest of the residents to improve

A moment of tutoring during the hands-on training courses

Without a doubt, this EUREP edition has made it possible to overcome the consequences of the pandemic and return to face-to-face learning. In addition, 2022 will be a very special year since we will have a second edition this year: EUREP22. I look forward to see participants this September!

EUREP21 delivers key aspects of urology A participant’s standpoint Currently, I am in my first year after finishing my urology residency programme in Madrid, Spain. Attending the 19th European Urology Residents Training Programme (EUREP21) has been a pleasant experience. Adhering to rules and regulations with regard to the COVID-19 pandemic, the commitment of the European School of Urology (ESU) to resume face-to-face activity in a safe environment has been a complete success. Activities outside the meeting area were cancelled and the programme has been planned in a more compact way, grouped by thematic areas for each day: • • • • •

Day 1: Functional urology Day 2: Urological cancer Day 3: Prostate cancer and male voiding LUTs Day 4: Paediatric urology, trauma and infection Day 5: Andrology, stones and upper tract endourology European Urology Today

Dr. Pablo Abad López Hospital Clínico San Carlos Madrid (ES)

pablo.abad@salud. madrid.org

Despite these changes, the objective of EUREP21 to review the key aspects of urology has been maintained, in part for the preparation for the exams of the European Board of Urology (EBU), and also to update and standardise urological clinical practice. The programme brought together residents and young urologists, not only from all

corners of Europe, but also from many parts of the world. In addition, EUREP21 provided us participants with the excellent opportunity to take both hands-on training and skills exams (E-BLUS and EST-s1) to certify our training at the end of the residency period.

In conclusion, joining EUREP21 has been an excellent chance for urologists who finished our training programme in 2021, as well as, for those who will finish it this year. I can only recommend those who will do so in a future to not to miss out on the possibility to enrol in this programmes. I wish EUREP further success and many more editions in the future!

Taking part at EUREP21: A once-in-a-lifetime experience Dr. Fares Kosseifi Groupe Hospitalier Public Sud de l'Oise (GHPSO) Creil (FR)

fareskosseifi@live.com

After three years of COVID-19 restrictions, the 19th EUREP21, which was held in Prague, was here to announce the return of the long missed live physical meetings. Organisation Once you arrive on site at the Clarion Congress Hotel, you cannot help but notice the results of the hard work and dedication of the whole EUREP team, particularly by Mrs. Wendy Dennissen and Mrs. Claudia Herrmann. The programme went smooth as planned and our safety remained their top priority and COVID-19 rules and regulations were implemented.

Renowned experts and wide spectrum topics The five-day journey was a mixture of high level evidence-based topics covering a wide spectrum of urology; from uro-oncology, andrology, endourology, stones, traumatology, male lower urinary tract symptoms (LUTS), infections, to paediatric urology. These topics were presented and discussed by renowned leading experts and mentors based on the latest EAU Guidelines and with a touch of their personal experience. The extensive coverage on all aspects of urology in five daily modules was offered in an interesting way, mixing theoretical courses with critical analysis, case discussions, multiple-choice questions (MCQs) and coffee breaks, of course. Coffee breaks Even coffee breaks were productive! These created opportunities for international knowledge exchange and meetings with our fellow urology residents. Alongside the social and recreational aspect of the coffee breaks, the 3D laparoscopy contest was an added thrill. This year, I managed to break the all-time record challenging future residents to come and break my record!

Hands-on training sessions Furthermore, to break the routine and allow more interactions and practical improvement, the hands-on trainings (HoTs) dry lab courses on laparoscopy, ureteroscopy and endoscopic resection were organised. Highly-qualified and patient tutors were there to guide us and provide us with a lot of tips and tricks. Each resident had the chance to participate in up to two HoTs. I personally did the laparoscopic and ureteroscopic trainings, allowing me to pass the E-BLUS (European training in basic laparoscopic urological skills) and the EST-s1 (Endoscopic Stone Treatment step 1) exams. Best group name for EUREP21 For the best group name for EUREP21, I suggested “UrOMICRON”, which stands for “Urologists On a Mission, Crossing Restrictions and Offering Non-stop updates”. It won the winning name for this year! I dedicate this win to my French colleagues as there were not a lot of them this year. I encourage and urge them to participate in the future editions of EUREP. A professional booster Once you leave Prague, you cannot help but feel the boost EUREP21 gave you to proceed with your

Fresh perspectives to residents Elevating competencies and aiding career advancement Dr. Nino Karazanashvili Pineo Medical Ecosystem Tbilisi (GE)

socialise with peers and lecturers, and gain new friends. The courses start in the morning and last almost the whole day, but the friendly, engaging atmosphere with the right amount of coffee breaks helped us stay fit and motivated.

ninikarazanashvili@ gmail.com

In the modern world, every field of urology is expanding at a very high pace so obtaining accurate and up-to-date information is vital in gaining excellent expertise. We all had a chance to meet and

communicate with leading experts in urology in a friendly environment, and I am sure that this experience will help us, participants, in the future. The hands-on training (HOT) sessions are a beloved part of EUREP, which includes training sessions on different procedures in urology under the guidance of an experienced tutor. When residents have sufficiently gained skills during the training, they had the opportunity to take exams, such as E-BLUS for laparoscopy or ESTs1 for ureteroscopy.

For many of us, EUREP21 was the first in-person event after a long pause due to the COVID-19 pandemic. Residents were very enthusiastic about attending the real-time courses in the beautiful city of Prague. EUREP surely represents one of the leading educational events for young urologists. The programme covers most of urology in several days and experts in the field run intensive and highlyinteractive courses based on the EAU Guidelines.

The Fellow of the European Board of Urology (FEBU) exam is another important highlight of EUREP21, which aims to evaluate the standards set by the EBU examination committee. A lot of residents might not have enough information regarding it, and during the event, they could address their questions to specialists who will gladly answer them. I am sure that the exam will increase the chances of a successful urological career.

The final-year residents benefit from the programme. By participating in this event, one can increase one’s knowledge of current practices in urology, be a part of healthy competition, assess one's understanding of the EAU Guidelines,

I am a national communication officer from Georgia for the European Society of Residents in Urology (ESRU). The association connects residents from Europe, motivates them, and engages them in many educational, scientific, and social activities. The ESRU

ESU Chair Prof. Liatsikos imparts encouraging words to participants

All smiles for "UrOMICRON", pictured with ESU's Claudia and Wendy

professional life, bond with your colleagues all around the globe, interact with your mentors and tutors, and start your career with more knowledge and energy. If you have the chance to join EUREP, seize the opportunity! I would like to take this opportunity to thank the Saint Joseph Hospital in Paris and the Groupe Hospitalier Public Sud de l'Oise (GHPSO) in Creil for their support and guidance, which enabled me to participate at EUREP21.

board meeting takes place several times a year, and one of them is usually during a EUREP edition. Aside from all the above-mentioned possibilities we had during EUREP21, the programme offers so much more than that. You meet new people around the same age with a similar background as you and you start bonding with them. Making friends has never been so easy, enjoyable, and so much fun. Apart from amazing events organised by EUREP, you get to know a new and beautiful city, with gorgeous views and plenty of fun places, including restaurants and bars. Discovering a new city, culture, and food with newly gained friends can be an awesome experience. EUREP is expanding, and so are the opportunities it offers. If you want to be involved in modern European medicine, being a part of this big event is the best possible chance. It is not overrated, and it is a must-do experience at the end of your residency year. This is not only my point of view but each of us who experienced EUREP. I want to express my gratitude to the European School of Urology, its chairman Prof. Evangelos Liatsikos, the organisers, all of the mentors and tutors, my colleagues from ESRU, and my newly gained friends. I would like to briefly address the current circumstances in Ukraine. During EUREP21, everyone was so happy to see each other, shared positive emotions, and gained new friends regardless of nationalities. I extend my support to Ukraine during these difficult times. Let’s choose peace.

EUREP21: Building bridges across the world Learn from the experts, enhance your skills and boost your network Dr. Skander Zouari Tunis El Manar University Faculty of Medicine of Tunis, Charles Nicolle hospital Tunis (TN) zouari.skander@ gmail.com

The 19th European Urology Residents Education Programme (EUREP21) took place between 4 and 9 of February 2022 in Prague. This edition was quite special as it was originally planned to commence last year but was postponed due to the COVID-19 pandemic. Thanks to the collaborative efforts between the European Association of Urology (EAU) and the European School of Urology (ESU), the event for final-year residents could finally take place. March/May 2022

EUREP21 covered the main topics in urology in five different modules in five days. It may sound crazy but the EAU and ESU made it happen. In this huge plenary room, around 260 residents from all over the world following the lectures of each faculty member conscientiously. I was the only resident from Tunisia, and I did not know anyone before coming here.

and the interaction between the audience and the faculty were a major point of the courses.

Hands-on training courses Hands-on training courses was an important side of the event. It covered the practical aspect of EUREP21. The participants learned tips and tricks on minimallyinvasive surgery from dedicated tutors. I, myself, participated in the laparoscopy and ureteroscopy I heard about EUREP when I participated in my first EAU event, the ESU-ESOU Masterclass on Nonworkshops. Dr. Murat Arslan and Dr. Otaš Durutovic Muscle-Invasive Bladder Cancer, back in the same city taught me every aspect of these procedures and corrected my mistakes to help me improve my two years ago. At that time, someone told me “Once you’re in the final year of your residency, you certainly performance. I am grateful for their expert advice. should not miss this once-in-a-lifetime opportunity”. So I applied and I could not be more excited when I Expand your network and make new friends was selected to participate. One of the aspects of EAU events that I miss the most is socialising. Sharing thoughts and ideas about the The schedule was tight and we had to strictly stick to content of the lectures with the other participants was the programme. Each lecture was a sort of a review of exhilarating. We could also talk about our the EAU Guidelines, which is based on the current experiences, our perspectives, and career aspirations. available evidence. There were also clinical cases and We also had an enjoyable time during the congress at times, intense discussions and questions that dinner and exploring the city after the courses. I met a lot of nice people, gained new friends, shared some enriched the programme. The quality of the content

Expert Dr. Arslan guides me during the hands-on training

quality time together, and made new good memories. Global EAU and ESU I feel fortunate to have had the chance to participate at EUREP21. It was a blast! I am thankful to the EAU and the ESU for encouraging young urologists from all over the world to attend and uniting them through their calling in urology. I am also grateful to the faculty members, board members, and organisers whose efforts made this valuable programme run smoothly especially in these challenging times. There is nothing more amazing than learning from the experts while being with your peers. I highly recommend it to each resident in urology. You will love it! European Urology Today

ESU Event Calendar

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MAY 2022 12

EAU Podcasts are your source for up-to-date information across the full urological spectrum. Get actionable insights from thought leaders in the field, explore advancements in urology and tackle hot-button issues. From Guidelines updates to practical tips in daily practice, we aim to cover it all!

ESU course on Lasers in endourology during the national congress of the Urological section of the Serbian Medical Association

Vrnjacka Banja (RS)

19-20

Virtual ESU-ESUI Masterclass on Prostate biopsy

26-28

EAU URO Tech: A joint meeting of ESUT-EULIS

Istanbul (TR)

ESU course on Neurogenic lower urinary tract dysfunctions: Where are we in 2022? during the national congress of the Romanian Association of Urology

Bucharest (RO)

ESU course during the 7th Baltic Meeting in conjunction with the EAU

Vilnius (LT)

Listen on your preferred podcast platform: JUNE 2022 9

Listen whenever, wherever!

ESU course on Tips and tricks in challenging surgeries during the national congress of the Spanish Urological Association

Burgos (ES)

Virtual ESU course on Andrology during the national congress of the Iraqi Urology Association

Baghdad (IQ)

17-18

ESU-ESUT Masterclass on Urolithiasis

Patras (GR)

28-30

Art in Flexible, Step 1

Berlin (DE)

JULY 2022 1-4

37th Annual EAU Congress

Amsterdam (NL)

11-15

ESU – Weill Cornell Masterclass in General urology

Salzburg (AT)

SEPTEMBER 2022 2-7

ESU-ESUT Masterclass on Lasers in urology

2022 17-18 November 2022, Barcelona, Spain www.esulasers.org

20th European Urology Residents Education Programme (EUREP)

Prague (CZ)

14-15

ESU-ESFFU Masterclass on Functional urology

Nijmegen (NL)

22-24

OMI-MEX Urology Seminar, Santa Fe (MX)

29-30

ESU-ESUT Masterclass on Laparoscopy

Bassano del Grappa (IT)

OCTOBER 2022 5-7

ESU-ERUS courses during the 19th Meeting of the EAU Robotic Urology Section (ERUS)

Barcelona (ES)

ESU course on Benign prostatic obstruction: How is new technology influencing standard of care surgical treatment? during the national congress of the Hellenic Urological Association

Athens (GR)

13-15

ESU ESTs2 workshop – Endoscopic stone treatment step 2

Prague (CZ)

19-20

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

Madrid (ES)

22-23

EAU Update on Prostate cancer (PCa22)

Hamburg (DE)

26-30

CAU & 9th Confederación Americana de Urologia Residents Education Programme (CAUREP)

Cancun (MX)

NOVEMBER 2022 10-13

ESU courses during the 14th European Multidisciplinary Congress in Urological Cancers (EMUC)

Budapest (HU)

17-18

ESU-ESUT Masterclass on Lasers in urology

Barcelona (ES)

23-27

4th South East Asian Urology Residents Education Programme (SEA-UREP) in collaboration with the European School of Urology

Manilla (PH)

ESU-ESUT Masterclass on Focal therapy for localised prostate cancer

Paris (FR)

24-25

DECEMBER 2022 6-8

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

European Urology Today

Art in Flexible, Step 2

Berlin (DE)

www.uroweb.org/education

March/May 2022

Report

Key BCa and PCa topics and updates ESU course at the 30th Turkish Urology Society Annual Meeting Dr. Bülent Akduman Dept. of Urology Zonguldak Bülent Ecevit University School of Medicine Zonguldak (TR) akdumanb@ yahoo.com

Prof. Hale Basak Çaglar Anadolu Medicine Center Johns Hopkins International Kocaeli (TR)

The virtual course “Update in bladder and prostate cancer” courtesy of the European School of Urology (ESU) took place during the 30th Turkish Urology Society Annual Meeting last year. Prof. Dr. Fredrik Liedberg (SE) moderated and presented at the ESU course wherein a total of 363 enthusiastic colleagues, who were mostly urologists, attended. Topics covered The course comprised of presentations on topics such as the EAU Guidelines recommendations on metastatic prostate cancer (mPCa) and nonmuscle-invasive bladder cancer (NMIBC), biopsy in prostate cancer (PCa), tips and tricks in radical prostatectomy, bladder cancer (BCa) treatment (e.g. transurethral resection of the bladder

[TURB], repeat transurethral resection [reTUR] and en-bloc resection), and the role of immunotherapy in BCa. At the end of the scientific lectures, a PCa case was discussed by a multidisciplinary team which consisted of urologists and a radiation oncologist which included us together with Dr. Roderick Van Den Bergh (NL), Dr. Prasanna Sooriakumaran (GB), and Dr. Levent Özdal (TR). Afterwards, Prof. Burak Turna presented a BCa case. The panellists also comprised a multidisciplinary team which consisted of Prof. Maximilian Burger (DE), Prof. Liedberg, Prof. Murat Bozlu (TR), Prof. Bülent Karabulut (TR), and Prof. Hale Bacak Çaglar (TR) to represent a multidisciplinary team.

“There were intense discussions about the use of a prostatic MRI before prostate biopsy for all patients. The panellists were not on the same page about the routine use of MRI for all patients.”

How the hybrid format was carried out

ESU courses always deliver vital knowledge

Patient case deliberations Dr. Akduman presented a case about a 65-year-old male patient with severe lower urinary tract symptoms (LUTS) and a high PSA level. There were intense discussions about the use of a prostatic magnetic resonance imaging (MRI) before prostate biopsy for all patients. The panellists were not on the same page about the routine use of MRI for all patients. Dr. Van Den Bergh stated that there is no standard for MRI for patients who are planned to be treated with radical radiotherapy, but not with surgery.

The need for a staging with molecular imaging such as prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) scan was discussed among the panellists. Majority decided to recommend a radical radiotherapy and androgen deprivation therapy (ADT) for the patient after demonstration of a nodal metastases. However, since the patient had more than three metastatic focuses, it was decided that he is not considered as a patient with oligometastatic disease. In conclusion, a systemic therapy consisting of docetaxel and ADT was recommended.

As a counterpoint, the radiation oncologist from the panel, Prof. Çaglar, stated that the use of MRI for radiotherapy planning is increasing. She also mentioned a recent publication of dose escalation of the intraprostatic dominant lesion detected by MRI with simultaneous integrated boost technique, as mentioned in the FLAMES randomised trial, wherein the outcomes were increased without excess amount of radiationinduced toxicity. The discussions on the case proceeded after the PCa diagnosis was obtained with high-risk features.

The course programme comprised case discussions

Masterclasses in Urology Broaden your knowledge and enhance your skills Let leading experts guide you with: • In-depth lectures • Live and semi-live surgeries • Case presentations • Practical hands-on training

ESU - Weill Cornell Masterclass in General urology

ESU-ESFFU Masterclass on Functional urology

Access lectures Review the lectures of this ESU course via UROsource, the EAU learning library for urologists which contains about 70,000 items of scientific content. Visit https://urosource. uroweb.org/?session_id=11779#show or scan the QR code with your smartphone.

ESU-ESUT Masterclass on Laparoscopy

2022 2022 2022 11-15 July 2022, Salzburg, Austria

14-15 September 2022 Nijmegen, The Netherlands

www.esu-masterclasses.org

www.esusalzburg.org

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

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

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

www.esu-masterclasses.org

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

ESU-ESUT-ESUI Masterclass on Focal therapy for localised prostate cancer

2022 2022 24-25 November 2022, Paris, France

19-20 October 2022, Madrid, Spain www.esuerectile.org

29-30 September 2022 Bassano Del Grappa, Italy

www.esu-masterclasses.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

www.esu-masterclasses.org

March/May 2022

European Urology Today

EAU Education Online course series

Advanced Prostate Cancer The full Advanced Prostate Cancer series is available for participation

The new Advanced Prosate Cancer series is comprised of 5 courses which offer clinicians a complete view on clinical aspects, diagnosis and treatments of prostate cancer. Courses in the Advanced Prostate Cancer series: Course 1:

Basis of Androgen Deprivation Therapy (ADT)

1 CME c

redit

Course 2: Non-Metastatic Hormone-Sensitive Prostate Cancer

2 CME c

redits

Course 3: Metastatic Hormone-Sensitive Prostate Cancer

2 CME c

redits

Course 4: Non-Metastatic Castration-Resistant Prostate Cancer

1 CME c

Course 5: Metastatic Castration-Resistant Prostate Cancer

3 CME c

Prof. Nicolas Mottet Main Coordinator CHU St Etienne, Department of Urology, Saint-Étienne (France) In line with EAU Guidelines. This course series is supported by an independent educational grant from Janssen, the Pharmaceutical Companies of Johnson & Johnson.

redit

redits

Free access with MyEAU account

Each course is individually accredited by EACCME

www.uroweb.org/education-events/education 20

European Urology Today

March/May 2022

Key points and hot topics at ESOU22

ESOU 22

21-23 January 2022 Madrid, Spain

A well-rounded programme and a transformation in 2023 By Erika De Groot Contemporary updates and multidisciplinary insights on genitourinary cancers, the 19th Meeting of the EAU Section of Oncological Urology (ESOU22) delivered these and more when it commenced in Madrid, Spain from 21 to 23 January 2022. Chair Prof. Morgan Rouprêt (FR) spearheaded the hybrid ESOU22 meeting where 1,000 enthusiastic participants convened, a third of whom followed the sessions online. This report provides some of the key points of hot topics addressed during at the meeting, as well as, exciting news to look forward to in 2023. Some key messages In the state-of-the-art lecture “Molecular advances in risk stratification of localised prostate cancer”, Dr. Daniel Spratt (US) stated, “At present, nearly all treatment decisions in prostate cancer are based on prognosis until we have true predictive biomarkers.” He added that the current standard of care risk-stratification tools such as standard National Comprehensive Cancer Network and D'Amico risk classifications have an “unacceptable performance” as these inherently over- and underestimate the cancer risk and disease aggressiveness for patients and thus, affect their treatment. Dr. Spratt also stated that gene expression tests have proven to be superior in prognostication, and that he foresees that artificial intelligence with digital pathology and radiomics with magnetic resonance imaging (MRI)-based machine learning may provide more cost-effective solutions. Dr. Mary-Ellen Taplin (US) presented “Neoadjuvant treatments before radical prostatectomy for high-risk prostate cancer: Developments and challenges” wherein some of her lecture’s key points included that biomarkers suggest favourable response in SPOP-mutated tumours and poor response in p53-mutated and ERG+/PTEN-loss tumours. She added that ongoing correlative

ESOU Chair Prof. Rouprêt announces new onco-urological event

Majority of participants attended the hybrid meeting onsite

analyses are being performed to investigate response and resistance such as single-cell sequencing analysis which may be promising.

other clinical parameters such as clinical exam, serum PSA, serial prostate biopsies, urinary markers, and genomic tests.”

Access and (re)view all presentations via the ESOU22 Resource Centre https://resource-centre.uroweb.org/ resource-centre/ESOU22.

During the debate on monitoring patients on active surveillance (AS), Prof. Caroline Moore (GB) offered her insights on the adequacy of MRI, and Dr. Juan Gómez Rivas (ES) offered his as a counterpoint: prostate biopsy is mandatory.

In “New tools for the conservative management of UTUC”, Dr. Guido Giusti (IT) advised that in case of a high-grade disease, nephroureterectomy is still the first treatment option, and that kidney-sparing surgery (KKS) should always be offered for lowgrade disease and imperative cases. He emphasised that identifying the grade is of uttermost importance, and a strict follow-up is mandatory.

Well-rounded programme This year, the hands-on training (HOT) course "Prostate MRI reading for urologists"; the STEPS (Session To Evaluate ProgresS) programme; the Educational Session organised through the collaboration of the ESOU, European School of Urology (ESU), and EAU Robotic Urology Section (ERUS); and the joint session of the ESOU and European Urology Oncology journal complemented the lectures of the meeting.

According to Prof. Moore, the EAU Guidelines recommend MRI for all men on AS. She stated that the DETECTIVE consortium affirmed that confirmatory biopsy can be omitted, and that the ASIST study underscored high-quality MRI and accurate reporting are essential. “When an MRI-led approach is used, the majority of men can omit scheduled biopsy and adherence to AS is increased,” said Prof. Moore. Dr. Gómez Rivas concluded that further data in monitoring disease progressions is needed with regard to the use of MRI instead of prostate biopsy, and that the role of MRI on AS is not yet standardised. He said, “We need protocol optimisation. Additionally, we should use MRI with

In her lecture “Future directions of systemic treatment for mRCC: What can we expect in the next 5 years?”, Dr. Laurence Albiges (FR) stated that she expects that the integration of adjuvant therapy into clinical practice will be important, and that there are going to be new combinations tested over the next several years, including a potential role for triplet therapy. New agents are under evaluation (including hypoxia inducible factor [HIF]-2alpha inhibition) and at present, there are insufficient biomarker-driven trials. Dr. Albiges added that new algorithms focusing on PD-1 resistance strategies are needed.

Great news for 2023 Although ESOU22 was the last edition of the meeting, a new European onco-urological event awaits in the summer of 2023. "I am pleased to announce that UROonco23 will take place next year! This massive European event will be a fusion of previous specialised meetings, a culmination of onco-urology expertise and developments. Expect a new formula, larger scope, and broader audience!", stated Prof. Rouprêt. More details will follow in the coming months. Stay tuned!

Preliminary ESU programme in Amsterdam ESU Courses Adrenals • Adrenals for urologists Andrology • Office management of male sexual dysfunction • The infertile couple – Urological aspects

Neurogenic and non-neurogenic voiding dysfunction • Chronic pelvic pain in men and women • Practical neuro-urology • Lower urinary tract dysfunction and urodynamics Paediatric urology • Practical approach to paediatric urology

Female urology • Advanced vaginal reconstruction • Prolapse management and female pelvic floor problems

Penile and testicular cancer • Male genital diseases • Testicular cancer

General urology • How to proceed with hematuria • Ultrasound in urologyUpdate renal, bladder and prostate cancer guidelines 2022, what has changed? • Updates and controversies: Incontinence, bladder / paediatric stones and male LUTS guidelines 2022: What has changed? • Improving your communication and presentation skills • How to write the introduction and methods • How to write results and discussion • Practical aspects of cancer pathology for urologists. The 2022 WHO novelties

Prostate cancer • Robot-assisted laparoscopic prostatectomy • Retropubic radical prostatectomy: Tips, tricks and pitfalls • Focal therapy in prostate cancer • Prostate cancer imaging: When and how to use it • Prostate cancer screening and active surveillance – Where are we now? • Prostate biopsy: Tips and tricks • Metastatic prostate cancer • Oligometastatic prostate cancer • Prostate cancer update: 2021-2022 • Surgery or radiotherapy for localised and locally advanced prostate cancer • Prostate cancer challenges and controversies from guidelines to real-world • Theranostics in prostate cancer

Infections • Dealing with the challenge of infection in urology Kidney transplantation • Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications Male LUTS • Management of BPO: From medical to surgical treatment, including setbacks and operative solutions

#EAU22

March/May 2022

Renal tumours • Advanced course on laparoscopic renal surgery • Treatment of small renal masses • Robot renal surgery Trauma • Urinary tract and genital trauma

www.eau22.org

Urethral strictures • Advanced course on urethral stricture surgery Urolithiasis • Percutaneous nephrolithotripsy (PCNL) • Update on stone disease • Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips, tricks and indications • Metabolic workup and non-surgical management of urinary stone disease • Advanced endourology in the non-standard patients with urolithiasis Urological surgery • Laparoscopy for beginners • Advanced course on upper tract laparoscopy: Kidney, ureteropelvic junction (UPJ), ureter and stones • Peno-scrotology and basic lower urinary tract endoscopy – Questions you are scared to ask • Prosthetic surgery in urology • Lymphadenectomy in urological malignancies • Practical tips for pelvic laparoscopic surgery: Cystectomy, radical prostatectomy adenomectomy and sacrocolpopexy Urothelial tumours • Practical management of non-muscle invasive bladder cancer (NMIBC) • How we manage upper tract tumours • Robot-assisted laparoscopic radical cystectomy • Management and outcome in invasive and locally advanced bladder cancer • Nerve-sparing cystectomy and orthotopic bladder substitution. Surgical tricks and management of complications • Perioperative immunotherapy and multidisciplinary management of localized genitourinary cancers

European Urology Today

Urinary diversion for refractory female SUI An overview of indications and considerations In the particular case of previous pelvic radiotherapy, bladder outlet procedures are at higher risk of failure, regardless of the type of procedure (synthetic slings, colposuspension, artificial urinary sphincter). [4] There is also a higher rate of complications, in particular device exposure. [4] Patients should be informed and made aware of these complications before undergoing continence surgeries, especially when prosthetic devices are implanted.

Dr. Marie-Aimée Perrouin Verbe Dept. of Urology Nantes Hôtel-Dieu Hospital Nantes (FR) marieaimeeperrouin@ me.com In some complex cases of female refractory stress urinary incontinence (SUI), or after failure of surgical curative options, urinary diversion (UD) may be considered. However, the optimum timing and the type of UD (continent UD or non-continent UD) may be challenging due to the scarcity of data in the literature. Moreover, performing these surgeries may also prove challenging as the patients have frequently undergone previous SUI procedures or pelvic radiation therapy.

Moreover, with pelvic radiotherapy sometimes leading to detrusor overactivity and poor bladder compliance, bladder outlet procedures may also be at risk of de novo or increased storage symptoms as well as high-pressure bladder. [4] In these cases, urodynamic studies are mandatory to assess bladder dysfunction, and if necessary, a concomitant augmentation cystoplasty can be performed alongside bladder outlet surgery. The UD (continent or non-continent) is an alternative option to discuss in these cases; the non-continent diversion is proposed to patient who are not able to self-catheterise. [4]

achieved with a concomitant bladder neck closure or obstructive surgery (autologous fascial sling, bladder neck aponeurotic sling), a continent UD can be proposed, in patients willing and/or able to selfcatheterise. [6] However, in cases of devastated bladder neck/ urethra, there is a substantial risk of persistent urethral incontinence with continent UD. This risk is enhanced in case of prior radiation therapy, as there is a higher risk of poor wound healing, placing patients at elevated risk of failure after continent urinary diversion. [4] Finally, as previously mentioned, radiation therapy may also lead to poor bladder compliance, with a risk of high bladder pressure and urethral incontinence. In these situations, a non-continent UD may be proposed as first option (see Fig. 1).

4) Conclusion/implication for practice There is limited published data in the literature evaluating the treatment of refractory stress urinary incontinence in females whilst considering factors such as multiple pelvic surgeries, radiotherapy and other pelvic pathologies leading to intrinsic sphincter deficiency. UD has been described without consensus as an option of last resort, when previous curative options have failed, and is probably the best option in case of devastated bladder neck/urethra. There is no data to help us choose the type of UD according to the situation. However, when the chances of achieving urethral continence are limited, or after radiotherapy, non-continent UD seems to be the best option to consider to limit complications and achieve quality of life. The optimum timing for re-intervention is even more controversial. Patient’s counselling is mandatory to best guide them in their choice of treatment and type of UD.

Regarding the technical aspect of performing a non-continent diversion such as ileal conduit, preserving the bladder appears to be a poor strategy, 1) When should urinary diversion be considered as because of the high risk of pyocysts. In a paper References an option? 1. Harding C, Lapitan MC, Arlandis Guzman S, Bo K, In a systematic review recently published by published in 2002 by Chartier-Kastler, 33 patients with Costantini E, Groen J, et al. EAU Guidelines on There is no clear recommendation regarding when and Dobberfuhl, on the management of female SUI after neurogenic bladders who underwent non-continent how to perform UD for the management of complex or pelvic radiotherapy, the author advocates that UD is the UD, the rate of non-concomitant cystectomies was 63%, Management of Non-Neurogenic Female Lower Urinary refractory SUI in female patients. This is in contrast from standard care for female patients suffering from Tract Symptoms (LUTS) 2021 [Available from: https:// and a high rate of pyocysts was observed (21%). [7] refractory idiopathic overactive bladder syndrome, uroweb.org/wp-content/uploads/EAU-Guidelines-on-Nonrefractory SUI after failed bladder outlet procedures This rate can reach 50% in the literature, and the where UD is clearly recommended. [1] Neurogenic-Female-LUTS-2021.pdf. with devastated bladder neck/urethra. An example of International Consultation in Incontinence recommends 2. Nadeau G, Herschorn S. Management of recurrent stress this is a procedure after a long-term indwelling urethral to systematically remove the bladder during the The EAU has recently released new guidelines on incontinence following a sling. Curr Urol Rep. catheter. [4] Whatever the mechanism in these cases of procedure. [8] non-neurogenic female LUTS. They state that patients 2014;15(8):427. devastated bladder neck/urethra, UD (continent or with intractable UI related to multiple pelvic surgeries, 3. Tricard T, Al Hashimi I, Schroeder A, Munier P, Saussine C. non-continent) may be proposed as a first line option. 3) Long-term outcomes and complications after radiotherapy and other pelvic pathologies which Real-life outcomes after artificial urinary sphincter The author also suggests not to prescribe long-term urinary diversion for female SUI ultimately lead to intrinsic sphincter deficiency or explantation in women suffering from severe stress indwelling catheter, to avoid any severe complications A few studies have been published reporting outcomes fistulae may be offered reconstructive options such as incontinence. World J Urol. 2021;39(10):3891-6. such as iatrogenic hypospadias, intrinsic sphincter of UD in females with refractory SUI. non-continent UD (for example ileal conduit) or 4. Dobberfuhl AD. Evaluation and treatment of female stress deficiency, bladder neck injury or urethro-cutaneous neobladder (orthotopic or heterotopic) with continent urinary incontinence after pelvic radiotherapy. Neurourol fistulae, in both non-neurogenic and neurogenic Cox and Worth reported their outcomes after a catheterisable conduit. [1] Urodyn. 2019;38 Suppl 4:S59-S69. female patients. [4,5] In patients not willing to undergo minimum of 1-year follow-up in 18 female patients who 5. Gambachidze D, Lefevre C, Chartier-Kastler E, Perrouin a UD or who have contra-indications to this surgery, a underwent non-continent UD (ileal conduit) for It was reported that UD may be an option in case of Verbe MA, Kerdraon J, Egon G, et al. Management of suprapubic catheter may be offered in carefully selected refractory SUI. [8] 8 required revisions of their stomas failure of surgical curative options for female SUI. urethrocutaneous fistulae complicating sacral and perineal patients with a certain degree of persistent urethral and 13 developed complications related to persistent pressure ulcer in neurourological patients: A national continence. [4] discharge from the bladder. A further 8 patients In a paper by Nadeau et al. reviewing recurrent stress multicenter study from the French-speaking Neuro-urology required a secondary cystectomy. incontinence following sling implantation, the authors Study Group and the Neuro-urology committee of the In the particular case of vesico-vaginal fistulae after consider UD as the most invasive intervention for SUI. French Association of Urology. Neurourol Urodyn. radiation therapy, the EAU guidelines on nonIn the paper published by Tricard et al., patients who They claim it should be used as the last resort in this 2019;38(6):1713-20. neurogenic female LUTS report that modified surgical underwent UD after AUS explantation were described indication. [2] They highlight the importance of techniques are often required as standard techniques as satisfied and reported an improvement in quality of 6. Basavaraj DR, Harrison SC. The Mitrofanoff procedure in counselling patients on the significant risk of the management of intractable incontinence: a critical may be at higher risk of failure or poorer results. [1] life at last follow-up. [3] complications and the need for life-long monitoring. appraisal. Curr Opin Urol. 2006;16(4):244-7. Temporary or permanent UD may be proposed in these 7. Chartier-Kastler EJ, Mozer P, Denys P, Bitker MO, Haertig A, particular cases. [1] However, the type of diversion In his review of UD in women after radiotherapy, A recently published French study from Tricard et al. Richard F. Neurogenic bladder management and (continent or non-continent) is not specified. excluding fistulae, Dobberfuhl states that in the case reported the outcomes of 111 patients who underwent cutaneous non-continent ileal conduit. Spinal Cord. of a devastated outlet, UD remains a standard an artificial urinary sphincter (AUS) for SUI. [3] Over a 2002;40(9):443-8. 2) When indicated, how to choose between continent treatment option, provided that the quality of life period of 26 years, 29 patients required 35 8. Abrams P, Andersson KE, Apostolidis A, Birder L, Bliss D, and non-continent urinary diversion? benefits are carefully weighed against a reported explantations. Among them, 4 patients were managed Brubaker L, et al. 6th International Consultation on As reported in the EAU guidelines, there is insufficient 65-83% postoperative complication rate. [4] In the with urinary diversions (three cystectomies and one Incontinence. Recommendations of the International evidence in the literature to comment on which same review, the rate of patients improved after UD neck bladder closure with continent UD). 13 AUS were Scientific Committee: Evaluation and treatment of urinary procedure offers the best outcomes, in particular for was 66%. However, these results are difficult to incontinence, pelvic organ prolapse and faecal reimplanted in 11 patients, with 6 patients (46%) finally quality of life. [1] extrapolate specifically in patients with refractory SUI, requiring UD (continent with bladder neck closure, or incontinence. Neurourol Urodyn. 2018;37(7):2271-2. as they included female patients who had undergone 9. Cox R, Worth PH. Ileal loop diversion in women with non-continent UD) because of urethral perforation or In case of non-devastated bladder neck/urethra, when UD after radiotherapy in various conditions, including incurable stress incontinence. Br J Urol. 1987;59(5):420-2. device infection. urethral continence wants to be achieved, or can be bladder or cervical cancer. [4]

Refractory female SUI/ Failure of cura4ve op4ons

Non devastated urethra/ Bladder neck

Devastated urethra/ bladder neck

Prior radiotherapy

Yes

Urinary diversion may be an op3on, the non-con3nent diversion being proposed in pa3ent who are not able to self-catheterise

Non con4nent urinary diversion

Con4nent urinary diversion s4ll feasible

to be discussed as ﬁrst op3on as prior radiotherapy may lead to poorer results on urethral con3nence and poor bladder compliance in case of con3nent diversion

if the pa3ent is able/willing to self catheterise but must be aware of poorer results on urethral con3nence++ risk of poor bladder compliance: concomitant augmenta3on cystoplasty ?

Non con4nent urinary diversion to be discussed as ﬁrst op3on as devastated urethra may lead to recurrent urethral incon3nence also to be discussed as ﬁrst op3on in case of prior radiotherapy

Con4nent urinary diversion with bladder neck closure pa3ent must be informed of the risk of recurrent urethral incon3nence

Fig. 1: Treatment options for refractory female SUI

European Urology Today

March/May 2022

EAU22 Patient Day in Amsterdam The first-ever in-person EAU Patient Day on Monday, 4 July 2022 Prof. Eamonn T. Rogers Chair, EAU Patient Office Galway (IE)

emacruairi@me.com Following the success of the Patient Day held last July at the EAU21 Virtual Congress, the first-ever in-person Patient Day will be held on Monday, 4 July, at the EAU22 Congress in Amsterdam, The Netherlands. The EAU22 Patient Day will bring further awareness to the patient’s perspective. In line with our mission “to raise the level of urological care in Europe”, we have put together a programme full of interesting sessions on various topics, with the support of our EAU Patient Advocacy Group (EPAG). There will be three sessions dedicated to specific urological cancers on Patient Day. •

Led by the World Bladder Cancer Patient Coalition (WBCPC), the Bladder cancer session aims to

•

explore ways to create and maintain meaningful patient-physician relationships and support networks. The Kidney cancer session, led by the International Kidney Cancer Coalition (IKCC), intends to discuss how communication between health care practitioners (HCPs) and cancer patients can be improved through shared decision-making. Europa Uomo will lead the Prostate Cancer session with the primary goal of improving the

quality of life of prostate cancer patients through awareness and empowerment. There is also a session on Functional Urology, led by the World Federation for Incontinence and Pelvic Problems (WFIPP), where sustainable continence care, living with incontinence, and reaching out to patients who lack digital and literacy skills, will be discussed.

aware of their concerns, and being enlightened of their goals and daily experiences. This brings us back to our mission “to raise the level of urological care in Europe”, and you can actively take part in it. Mark the new date in your calendar and we hope to see you in Amsterdam on Monday, 4 July 2022! •

For more information visit: www.eau22.org/patient

Finally, there will be two roundtable discussions. •

EAU Patient Advocates Lounge We would love to welcome you at the Patient Advocates Lounge, a space especially created for patient advocates, to relax in between sessions and connect with peers. Enjoy a cup of coffee or tea and do not forget to check out the electronically accessible Patient Posters at the e-kiosk.

•

We look forward to connecting with you in our Lounge!

The Roundtable: Incontinence is a collaboration with WFIPP and revolves around promoting awareness on incontinence, it’s management, and future innovations. The Roundtable: Fatigue in Prostate Cancer Patients will provide a venue for HCPs, patient advocates, and most especially patients and their caregivers, to discuss and understand fatigue in prostate cancer patients, and how this can be better managed.

As we would like to make this day as inclusive and wide-ranging as possible, we invite urologists and HCPs to join Patient Day and take advantage of this opportunity to hear out patients and what they have to share. What better way to improve health service delivery than by hearing their perspective, being

The Patient Advocates Lounge is located adjacent to the EAU Booth on the Exhibition Floor, Booth D64.

Presentation Skills Workshop for patient advocates The EAU Patient Office offers patient advocates the opportunity to attend the Presentation Skills Workshop. • Enhance your presentation skills • Learn to captivate and inspire your audience with your personal style of presentation Where: Patient Advocates Lounge When: once a day from 1 - 4 July To register, send an email to info@patientinformation.org

Introducing the EAU Patient Office Board Pushing for meaningful patient involvement in urological care The EAU Patient Office was established in 2021. With its Chair having a seat at the table of the EAU Board, patients are given a representative with a voice in the decision-making process. Now, with the establishment of the EAU Patient Office Board, it solidifies its commitment of raising the level of urological care in Europe by inviting the general public, the patients, and their families to contribute to this mission. The Board is composed of 10 board members, headed by the chair.

Prof. James N’Dow is the EAU Adjunct Secretary General for Education. He is the former Chair of the EAU Guidelines Office and the Director of the Academic Urology Unit of the University of Aberdeen. Dr. Jens Rassweiler is a Professor and Head of the Urology at Klinikum Heilbronn, the academic hospital of Heidelberg University in Germany. He is also the Chair of the EAU Section Office.

The EAU Patient Office Board is headed by its Chair, Prof. Eamonn T. Rogers (Galway, IE). Prof. Rogers is a urologist at the University College Hospital, Galway, Ireland. He is also adjunct Professor of Urology at the University of Illinois Medical School in Chicago, USA, and a former President of the Irish Society of Urology.

Dr. Michael Van Balken, a self-proclaimed ‘uroholic’, is an EAU Patient Information Working Group member and a board member of the Dutch Society of Urology (NVU). He is based in Arnhem (NL) and has special interest in low health literacy.

The Board will support the Patient Office and is responsible for overseeing the various activities relating to Patient Information content and projects undertaken by the EPAG.

Mrs. Mary Lynne Van Poelgeest-Pomfret is a long-standing international patient advocate promoting rights of patients at both international and international levels. She is the President of the World Federation of Incontinence and Pelvic Problems (WFIPP) and a member of the EAU Patient Advocacy Group (EPAG).

Dr. Markos Karavitakis is a urologist from Athens, Greece, with a special interest in laparoscopic surgery. He is the treasurer of the Hellenic Urological Association and also an EAU Patient Information Working Group member.

Prof. Hein Van Poppel is an Oncologic Urologist at the University Hospital in Leuven, Belgium. Formerly adjunct Secretary General Education, he has pushed for the EAU Patient Information initiative and the establishment of the EAU Patient Office. He is currently chair of the EAU Policy Office of the EAU.

Prof. Evangelos Liatsikos is the Chair of the European School of Urology. He is a Professor of Urology and the Director of Urology Department at the University Hospital in Patras, Greece.

Dr. Lydia Makaroff has a PhD in immunology, a Master’s degree in Public Health, and has over 10 years of international experience in non-communicable disease policy research. She is the President of the World Bladder Cancer Patient Coalition (WBCPC) and CEO of Fight Bladder Cancer UK.

Prof. Dr. Maria Ribal is the Chair of the EAU Guidelines Office and Head of the Uro-Oncology Unit of Hospital Clinic in Barcelona, Spain.

Patient Information and EPAG in action Collaborating for the World Cancer Congress 2022 For the first time since its establishment in 2019, the EAU Patient Advocacy Group (EPAG) member organisations: the Association of European Cancer Leagues (ECL), the International Kidney Cancer Coalition (IKCC), and the World Bladder Cancer Patient Coalition (WBCPC), together with the EAU Patient Information (PI) initiative, have joined forces to submit a session proposal to the World Cancer Congress (WCC) 2022, which will be held in Geneva Switzerland, from 18 to 20 October 2022. The presenters have been selected and announced and the session proposal has been chosen to be featured on WCC’s online platform. It involves a pre-recorded session that will be made available to all Congress registered participants from 18 October until 31 December 2022.

2020: Mapping the kidney cancer patient experience worldwide. The survey included 2,012 respondents in 41 countries, including the United States, South Korea, Canada, France, India, the United Kingdom, Japan, Spain, Australia, Germany, Brazil, Italy, The Netherlands, and Sweden.

The WCC programme has been built across six themes that provide the framework through which the global cancer community will deliver a variety of innovative and interactive sessions covering the full spectrum of cancer control. The session submitted by the EPAG and the EAU revolves around the theme ‘People living with cancer’.

Finally, Mr. Alex Filicevas of WBCPC will talk about the Start-up guide for bladder cancer patient groups. This guide promotes the establishment of bladder cancer patient groups in different countries and provides pre-made resources and share best-practice examples for getting started. It also informs, supports, and creates unity among bladder cancer patient groups to grow the global community of bladder cancer patient groups.

This is followed by a presentation from PI Working Group Member Ms. Louisa Fleure. The presentation, titled Androgen deprivation therapy educational programme for European prostate cancer patients, will talk about how the programme helps prostate cancer patients improve their quality of life as well as maintain strong intimate relationships while on Androgen Deprivation Therapy.

The session, titled Empowering genitourinary cancer patients to become their own best advocates, is composed of three presentations. It will be organised by Ms. Esther Robijn of EAU and chaired by ECL Director Dr. Wendy Yared.

Everyone is invited to be part of this global initiative in addressing the largely unmet needs of patients.

The first presentation will be from Dr. Rachel Giles and Mr. Michael Herbst of the IKCC Netherlands and South Africa, respectively. They will share the results and implications of their study called Global patient survey

The Roundtable: Incontinence is supported by an unrestricted grant from Medtronic The Roundtable: Fatigue in Prostate Cancer Patients is supported by an unrestricted grant from Bayer HealthCare Pharmaceuticals Inc.

March/May 2022

For more information, please visit: www.worldcancercongress.org/

EAU Patient Day is supported by an unrestricted grant from Pfizer Oncology The Presentation Skills Workshop is supported by an unrestricted gran from Pfizer Oncology

European Urology Today

Drawing lessons from the EBU’s first virtual exam An interview with Prof. Serdar Tekgül, Chairman of the Examination Committee By Loek Keizer

new territory and extremely challenging. We decided to take some risks.”

In November 2021, the European Board of Urology held its first Virtual Oral Exam, an online alternative to the in-person oral exams held in previous years. With the exams completed, graded and analysed, the Chairman of the EBU’s Examination Committee Prof. Serdar Tekgül (Ankara, TR) can draw some conclusions and explain how the exam will proceed in 2022. Paediatric Urology and examination Prof. Tekgül is currently chairman of the Urology Department at Hacettepe University in Ankara, Turkey, where he also started his urological career in the early 1990s. Prof. Tekgül specialised in paediatric urology and served in several EAU positions over the years, including Guidelines panels, and as faculty member at several EAU events. He is currently also the President-Elect of the European Society for Paediatric Urology.

Prof. Serdar Tekgül, Chair EBU Examination Committee

Tekgül: “I mainly help provide questions for the paediatric parts of the exam, but I also bring together the contributions from all of our experienced board members and finalise the exams each year. It’s a big responsibility!”

The first virtual oral EBU exam It is the oral part of the EBU exam that required the biggest adjustment to the pandemic conditions of the past two years. “For obvious reasons we had to postpone the exam twice, so we had a backlog of “My role in the EBU started about ten years ago,” said hundreds of candidates who were waiting to become Prof. Tekgül. “First as one of the board members, and a Fellow of the EBU (FEBU). We looked around for then I had a position in the examination committee inspiration and explored the possibility of an online where I served for about five years. I was elected exam. Some universities had done this with success, Chairman of the examination board four years ago.” but always limited to their own students. Doing it internationally like we would have to was completely “I have a lot of experience with exam committees, having chaired the exam committee when the first Turkish urological exams were started in the early 2000’s. I was also one of the founders the European Society of Paediatric Urology’s board exam before moving to the EBU.”

“There is a disadvantage when you don’t interact, it’s not really like an exam. This was of course our concern, but creating interactivity with so many online candidates is not really possible. We did our best to avoid any technical issues: we provided a mock exam to prepare people for the format of the exam, and we had candidates check their connectivity beforehand. Despite these precautions there were of course some problems, which are inevitable when dealing with connectivity. In roughly 10% of the cases, we did not have usable video files. There are many reasons: technical, logistical, insufficient familiarity with the set-up and so on.” In the end, this round of exams yielded 440 clear and evaluable candidates. Two online reviewers independently scored the candidates. If there was a 20% discrepancy between the two (as was the case 65 times), a third reviewer also checked. The final scoring of 440 people took about six weeks, a bit longer than the anticipated three weeks. At the end of the day, there was a 84% pass rate. Unexpected conclusions “Starting out, our concern was that not doing the exam live would not be a good imitation of an oral exam. But in the end we came to the conclusion that this is in fact more objective,” said Prof. Tekgül.

The EBU offers three different exams every year, and Prof. Tekgül is closely involved in, and ultimately responsible for, drawing them up. There is an in-service assessment, which is an online multiple choice question exam. It is a learning tool which provides validation comments on the questions; the analysis shows participants a comparison to their peers. Then there are two parts of the EBU exam: written and oral. The written exam was typically taken at set times in secured test centres in Europe but is also offered online since last year. European Board of Urology (EBU)

The format would not be an interactive conversation between candidate and examiner considering the high number of candidates. Questions were prepared (in ten different languages) and the candidate had set times to respond orally. The candidate’s feedback was recorded by the computer. Case data and visuals like X-ray or CT scans were shown on screen. (Fig. 1)

Fig. 1: Scrollable CT scan

“Every examiner has a different attitude or body language when asking questions, there can be (mis-) leading of candidates and there is always subjectivity in these interactions. But in the setup we used, there was no person, just the screen and the camera. We feel in the end that it was more objective. Questions were standardised, asked in a standard way. The pass rate was a little lower than the 95% pass rate of previous years and, we feel, more accurate.”

“I think it was a good outcome. It has in fact led us to decide that we are going to use the same system in the upcoming exam held in Warsaw. The same software and set-up, but with presence of a reviewer in the room. Not to ask the questions but to oversee the process. We will have forty different rooms, simultaneously. The results will still be reviewed online. We want the candidates to be on-site because it will eliminate all connection problems.” 280 people already registered for the June exams, as have around 50 reviewers. The Examination Board has been collecting feedback from participants and faculty alike. “The people who passed were very happy. The people who had technical issues were less pleased. Some knew it was their own fault, others were less understanding. The majority gave good, constructive feedback. We understand, we empathise, and we will allow a compensation for this year’s exam. This was the first-ever attempt at this. We will have problems to be corrected, and are on the right track to a better exam. I hope these candidates understand we had to take some risks and we tried our hardest to avoid technical issues.” “There are already a lot of possible solutions to solve the technical problems encountered, like using a dedicated app to record the candidate's responses and then sending the verified files to the EBU, rather than relying on a potentially unstable live connection. Having recorded answers also opens the door to using AI systems to help in the grading.” As it stands, there are plenty of valued EBU colleagues to help with the reviewing and Prof. Tekgül is grateful for their help. “I would like to thank all of the reviewers and all of my colleagues who were very supportive and helpful in setting up this new exam.” “One project we are working on, is to make this system applicable globally for the International Certification oral exam, open to non-European candidates.” The next FEBU Oral Exam will take place in Warsaw on 27 June, 2022. Find out more about the EBU and its exams on www.ebu.com

Visiting Professorship in Switzerland truly fruitful experience Prof. Gianluca Giannarini admires observed robot-assisted monoblock and igloo techniques Prof. Gianluca Giannarini Urology Unit Santa Maria della Misericordia University Hospital Udine (IT) gianluca.giannarini@ hotmail.it Last December I had the honour to be invited as Visiting Professor at the Department of Urology, Luzerner Kantonspital, Lucerne (CH). This initiative was carried out under the auspices and support of the European Urology Scholarship Programme of the European Association of Urology. Highly reputed referral centre The Department of Urology in the Luzerner Kantonspital is a highly reputed referral centre in Switzerland and is particularly devoted to oncourology and robotic surgery as well as complex stone surgery. It can count on a strong multidisciplinary tumour board and is the only certified cancer centre in central Switzerland. Since 2010, it has been the Swiss centre with the highest yearly volume of robotic cases. The department is chaired by Prof. Agostino Mattei, who trained in Berne (CH) under the guidance of Prof. Studer and in Bordeaux (FR) under the mentorship of Dr. Gaston, and was appointed Professor of Urology at the University of Geneva (CH). The medical team is composed of nine senior staff members, ten residents European Urological Scholarship Programme Office

European Urology Today

and one to two rotating research fellows, some of them from abroad. During the past 10 years, several young surgeons were trained in robotic surgery under the direct supervision of Prof. Mattei. Sincere friendship I am particularly bound to Swiss urology and urologists since I have spent my 2-year clinical fellowship and several shorter research periods at the Department of Urology of the University of Berne in my early career. I have known Prof. Mattei for many years, since my very first brief stay as a resident in Berne where he was a junior staff member. A sincere friendship has grown over the years, and I am proud to acknowledge him as one of my Swiss mentors. Thus, when I received the invitation to be a Visiting Professor in his department, I was especially pleased. My visit to Lucerne had a very tight schedule of one week. I was soon involved in all routine clinical activities in the department, and I was exposed to daily interaction with both medical and nurse staff, greatly facilitated by my fluency in German.

Relaxing dinner at local café after a full day in the operating theatre

Monoblock technique I participated in the daily in-patient and out-patient case discussion, and I actively discussed the cases presented at the weekly multidisciplinary tumour board with the attending medical and radiation oncologists, radiologists, pathologists and nuclear medicine physicians.

Igloo I also admired the ‘igloo technique’ for robotassisted radical prostatectomy, encompassing maximum nerve sparing in selected patients for early recovery of urinary continence and sexual function. I found the training sessions, during which Prof. Mattei taught nerve-sparing radical prostatectomy to junior fellows, of particular interest. All steps of the surgical procedure are standardised, and meticulous attention is given to detail. The teaching atmosphere was very friendly.

I attended two whole-day sessions in the operating theatre, where I could observe cases of robotassisted surgery for prostate and kidney cancer. In particular, I appreciated the ‘monoblock technique’ for a standardised, simplified extended (or super-extended) pelvic lymph node dissection at the time of radical prostatectomy with the aim of

avoiding the spread of fatty and lymphatic tissue within the abdominal cavity.

Lively debate I also contributed to the educational activities of the department by giving lectures on controversial issues

in prostate and bladder cancer, which led to a lively debate among the medical staff. Furthermore, I had the opportunity to propose ideas for future collaborative research projects. Finally, the social part of the stay could not be missing (photo). Fruitful experience In conclusion, the Visiting Professorship is a unique programme that allows us to visit renowned institutions across Europe and exchange experiences among urological teams with diverse backgrounds. My visit to Lucerne has been a truly fruitful experience, and I once again thank Prof. Mattei for his kind invitation, and the European Urology Scholarship Programme for granting this initiative. March/May 2022

Recruitment begins for the PRIME Study Prostate Imaging using MRI +/- contrast Enhancement Dr. Veeru Kasivisvanathan University College London and UCLH PRIME Chief Investigator

Mr. Vinson Wai-Shun Chan University College London and University of Leeds PRIME Research Assistant

primestudy@ ucl.ac.uk Twitter: @veerukasi

Twitter: @VinsonChan

Ms. Aqua Asif University College London and University of Leicester PRIME Research Assistant

Mr. Arjun Nathan University College London and UCLH PRIME Academic Clinical Fellow

Country

Site

Principal Investigator

United Kingdom

University College London Hospital

Veeru Kasivisvanathan, Caroline Moore

Royal Free Hospital

Paras Singh

Addenbrooke’s Hospital

Tristan Barrett, Christof Kastner

Whittington Hospital

Maneesh Ghei

Denmark

Herlev Gentofte University Hospital

Lars Boesen

Finland

Helsinki University Hospital

Antti Rannikko

Germany

University Hospital Essen

Claudia Kesch, Boris Hadaschik

Martini-Klinik am UKE

Lars Budaeus

Heinrich Heine University Düsseldorf

Jan Philipp Radtke, Lars Schimmöller

University Hospital Frankfurt

Felix Chun, Felix Preisser

University Hospital Reina Sofía

Enrique Gómez Gómez, Daniel José López Ruiz

University Hospital La Moraleja

Miguel Angel Rodríguez Cabello, Carolina Aulló Gonzanlez

Mayo Clinic, Rochester

Lance A Mynderse

NYU Langone

Samir S. Taneja

Weill-Cornell Medical Center

Daniel Jason Aaron Margolis, Jim C Hu

Icahn School of Medicine, Mount Sinai

Ash Tewari

Sorbonne Université

Raphaele Renard Penna

Centre Hospitalier Universitaire de Bordeaux

Gregoire Robert

Spain United States of America

France

Twitter: @ArjunSNathan

Twitter: @AquaOishee Background Multiparametric MRI (mpMRI) is internationally recommended for men who present with suspicion of prostate cancer. This change in guidelines recommendation has created a new demand on resources.

full mpMRI. All MRI scans are reported using Likert and PI-RADS v2.1 scores.

Patients with non-suspicious MRI (scores 1 or 2) on bpMRI and mpMRI and low risk of PCa will be recommended to undergo PSA surveillance. Patients with suspicious MRI (scores 3,4 or 5) on either bpMRI We believe that every man who needs an MRI should or mpMRI will undergo MRI-targeted biopsy. have access to one. Suspicious areas will be labelled with their location and whether they were suspicious on either bpMRI or Would removing the dynamic contrast enhanced (DCE) mpMRI. Targeted biopsy cores will be stored images from mpMRI help in delivering our goal? separately from areas that were uniquely suspicious The DCE sequence can be time and labour consuming on DCE so that conclusions can be made on whether due to the use of intravenous contrast. Recent data the pathology was from suspicious areas on the has suggested that the DCE sequence may not be bpMRI or mpMRI or both. Systematic biopsies will necessary and the biparametric (T2W and DWI) also be taken. The simplified study schema is shown sequences may detect as much clinically significant below in Figure 1. prostate cancer (csPCa). Primary outcome: The proportion of men with Replacing the mpMRI scan with a bpMRI scan can clinically significant cancer detected (Gleason score ≥ increase the number of MRI scans performed in any 3+4) / Gleason Grade Group 2 or greater). given day, reduce costs from the need for medical staff to be present and reduce the need for use of Key secondary outcomes: contrast medium. This would make meeting the high 1) Agreement between bpMRI and mpMRI in score demand of MRI scans now required in prostate cancer of suspicion; diagnosis more feasible. 2) Proportion of men with clinically insignificant cancer detected (Gleason grade 3+3 / Gleason Limitations of some of the previous studies in this grade group 1) and; area: 3) Agreement between bpMRI and mpMRI on • Small sample size, single institution retrospective treatment decision eligibility studies • No true blinding of the radiologists reporting the Study recruitment and current status We are delighted to announce that the PRIME study bi-parametric MRI to the DCE sequence has attracted over 60 sites from 22 countries expressing • Using an MRI scoring system that already assumes that DCE has no role in differentiating interest to take part. Sites thereafter undergo quality control of their MRI facilities to assess their eligibility, between who needs a biopsy and who doesn’t using the Prostate Imaging Quality (PI-QUAL) scoring • No MRI-targeted biopsies system (1). The PI-QUAL scoring system was developed from the PRECISION study (2), and gives a score of 1-5 Aim for an MRI scan relating to its image quality. A score of The PRIME study, therefore, aims to assess whether 1 means no mpMRI sequences are of diagnostic quality, bi-parametric MRI (T2W & DWI) is non-inferior to a score of 3 means mpMRI quality was of sufficient multi-parametric MRI (T2W, DWI and DCE) in the diagnostic quality and a score of 5 means each diagnosis of clinically significant prostate cancer. sequence is independently of optimal diagnostic quality (1). Sites are helped to improve their MRI Sample size quality so that they can take part in the study. The full 500 patients site recruitment process is shown in Figure 2. Intended length of recruitment Current Status 24 months MRI quality control has occurred for 40 centres, with now 32 of them achieving an optimal PI-QUAL score Patient eligibility criteria of 5. Currently, there are 26 sites in the set-up stage. Key inclusion criteria: 1. Men at least 18 years of age referred with clinical The coordinating site, University College London suspicion of prostate cancer 2. Serum PSA ≤ 20ng/ml 3. Able to provide written informed consent

Centre Hospitalier Universitaire de Lille

Arnauld Villers, Philippe Puech

The Netherlands

Radboud University Medical Center

Maarten de Rooij, Bas Israël

Belgium

Ghent University Hospital

Pieter De Visschere

Italy

University Hospital of Udine

Rossano Girometti

University of Rome Tor Vergata

Roberto Miano

San Giovanni Battista Hospital

Marco Gatti, Giancarlo Marra

San Raffaele Hospital

Alberto Briganti

Sapienza University of Rome

Valeria Panebianco

Singapore

Tan Tock Seng Hospital

Jeffrey J Leow

Brazil

Hospital Sírio-Libanês

Publio Cesar Cavalcante Viana, Adriano Basso Dias

Argentina

Centre de Urologia CDU

Marcelo Borghi, Hernando Rios Pita

Canada

Princess Margaret Cancer Centre

Sangeet Ghai

Australia

Alfred Health, Monash University

Jeremy Grummet, Richard O'Sullivan

Peter MacCallum Centre Centre

Declan Murphy

Table 1: Sites undergoing contracting process and their principal investigators

Hospital (UCLH), is the first site to have completed the site initiation visit. Our team looks forward to opening more sites internationally throughout 2022. We anticipate recruitment to close by Q1 2024. Implications of study If bpMRI is non-inferior to mpMRI, then bpMRI will become the new standard of care for prostate cancer detection in men with suspected prostate cancer. This will allow a greater capacity to deliver MRI scans so that every man who needs a scan will be able to get one. If however, the DCE sequence in mpMRI identifies a large proportion of significant cancer and significantly influences staging and treatment eligibility decisions, then mpMRI will be recommended to stay the standard of care. Funding The PRIME Study (NCT04571840) is funded by Prostate Cancer UK, The John Black Charitable Foundation, the European Association of Urology Research Foundation, and the Dieckmann Foundation.

Chief Radiologists: Dr. Clare Allen, Dr. Francesco Giganti Chief Pathologists: Dr. Alex Freeman, Dr. Aiman Haider Health Economists: Prof. Laura Lorelle, Dr. Caroline Clarke, Miss Jessica Weng EAU Research Foundation: Dr. Wim Witjes, Ms. Christien Caris, Prof. Anders Bjartell, Ms. Joke Van Egmond Trial Network: PRECISION & START Consortium Study website https://www.ucl.ac.uk/surgery/research/departmenttargeted-intervention/urology/prime-trial-information References 1. Giganti F, Allen C, Emberton M, Moore CM, Kasivisvanathan V. Prostate Imaging Quality (PI-QUAL): A New Quality Control Scoring System for Multiparametric Magnetic Resonance Imaging of the Prostate from the PRECISION trial. Eur Urol Oncol. 2020;3(5):615-9. 2. Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. New England Journal of Medicine. 2018;378(19):1767-77.

The Trial Management Group includes: Chief Investigator: Dr. Veeru Kasivisvanathan University College London NCITA Trials group: Prof. Caroline Moore, Dr. Pramit Khetrapal, Dr. Chris Brew-Graves, Dr. Nicola Muirhead, Ms. Réka Novota, Mr. Phil Ryan, Prof. Shonit Punwani, Prof. Mark Emberton, Mr. Alexander Ng, Ms. Aqua Asif, Mr. Vinson Wai-Shun Chan, Mr. Arjun Nathan, Ms. Marimo Rossiter Statistics by University of Birmingham Test Evaluation Research Group, Dr. Yemisi Takwoingi, Prof. Jon Deeks, Dr. Ridhi Agarwal.

Key exclusion criteria: 1. Prior prostate biopsy or prostate MRI 2. Contraindication to MRI or prostate biopsy Study design PRIME (NCT04571840) is a prospective, international, within-patient, multicentre, level 1–evidence clinical trial evaluating whether bpMRI is noninferior to mpMRI in the detection of csPCa. Men with clinical suspicion of PCa undergo mpMRI as per standard of care. The DCE sequence is then blinded from the radiologists to report the bpMRI. The DCE sequence will then be unblinded to the radiologist to report the EAU Research Foundation

March/May 2022

Fig. 1: Simplified study scheme

Fig. 2: Flow chart of the site approval process

European Urology Today

The story of the pristine 17th-century Dutch matula Preserving the past of urology: A new addition to the EAU’s historical collection By Loek Keizer The EAU, through its History Office, has recently acquired a unique artifact from the history of urology: an original 17th century matula. This matula, or uroscopy flask, was first acquired by former EAU History Office member Dr. Erik Felderhof in 2002, who recognised its importance to urology. Dr. Felderhof is also a founding member of the Dutch Urological Society’s Historical Association. The matula was originally discovered during the controversial construction of the first metro lines in Amsterdam in the early 1970s. It was buried in the Nieuwmarkt area, very close to the old city’s centre. The Nieuwmarkt (“New Market”) square itself is home of the Waag, or weighing house. This characteristic building has its own importance in medical history. The Waag The building now known as the Waag was originally built in 1488 as a city gate, as part of the old Amsterdam city wall. It was converted to a weighing house when the original walls were torn down in the 16th century. Several guilds also met in the Waag building, including the surgeons’ guild. It was in the attic of this building that the Dutch master Rembrandt van Rijn was commissioned to paint the surgeons at work, resulting in 1632’s The Anatomy Lesson of Dr. Nicolaes Tulp.

“This Matula likely dates from the early 17th century and it is a miracle to see that it still exists in such a good condition with very nice colouring by oxidation of several metals in the glass.”

The Waag on the Nieuwmarkt square, the area where the matula was discovered in the 1970s (Nikolay Antonov/Shutterstock.com)

Close-up of the 400 year-old matula, showing its discolourations and distinctive shape

The Matula This Matula likely dates from the early 17th century and it is a miracle to see that it still exists in such a good condition with very nice colouring by oxidation of several metals in the glass. Matulas were used at the time to inspect a patient’s urine (uroscopy) and many diseases were attributed to the qualities of the urine, like colour or clarity. The dimensions are approximately 15cm tall and 12cm at its widest point.

restored etching of a uroscopist after a painting by Gerrit Dou. This etching is also part of the EAU Historical collection, acquired as part of the De Vries collection.

This recently acquired matula complements another matula that was purchased by the EAU a couple of

years ago. The latter matula is probably a bit younger in age as the glass is much thinner. Indeed over time the glass blowing techniques evolved and made it possible to make even thinner glass that was more transparent. Obviously that process made this type more fragile and unfortunately this matula now in the EAU collection has been preserved only partially. Both matulas are on display as part of the permanent exposition of the EAU Historical collection at the EAU Headquarters in Arnhem (The Netherlands). They are accompanied by a recently

Dr. Felderhof is “proud that the matula has its final destination in the safe hands and the collection of the EAU’s History Office.” Professor Philip Van Kerrebroeck, chairman of the EAU History Office, in turn, is grateful that Dr. Felderhof was willing to part with this exceptional piece of history, so characteristic of the earliest days of urology.

The Nieuwmarkt area of Amsterdam is further steeped in history when it served as a rallying point for the Jewish population of Amsterdam and its surrounding area before being sent to their deaths in the Holocaust. The Nieuwmarkt was at the centre of further controversy when many blocks of authentic houses were demolished to make way for the Amsterdam Metro in the 1970s. Mass protest and riots prevented the expansion of the underground system in this part of town. It was during these works that the matula (and many other items from Amsterdam’s Golden Age) was excavated.

EAU History office

The matula as part of the uroscopy exhibit at the EAU Central Office

The matula is placed in the exhibition by its donator, Dr. Felderhof under the watchful eye of History Office Chairman Prof. Van Kerrebroeck and its newest member, Dr. Pieter Dik.

Credit Registry Report 2021 Check your registered credits an generate and print CRR online! More than 18,000 medical professionals from Europe and beyond have already joined the EU-ACME/CNE programme including almost 5,000 EAU Junior Members and more than 2,000 urological nurses. However, only 31% have collected CME/CNE/CPD credit points last year. Withing the EU-ACME programme, members are recommended to obtaining a minimum of 200 credits in five years in compliance with the EBU CME/CPD system. The EU-ACME/CNE programme provides access to the online CME/CNECPD portfolio (MyCME/CNE), allowing its members to check and register activities at any time. Many members have already used our online system and registered activities attended in 2022. How to check your online account? Log in to MyCME/CNE - your online CME/CNE/CPD portfolio, through www.eu-acme.org, go to Credit Registry Report and check if all activities are properly listed under your name.

How to add activities to your online CME/CNE/CPD portfolio – MyCME/CNE? If you miss any CME/CNECPD activity you may register it directly online in MyCME/CNE by going to Request registration of CME/CNE/CPD activity. You will find manuals in the Knowledge Base on our website. During the application process you will be prompted to upload a documental proof: - Whenever you attend a live educational event, e.g. conference, congress, meeting – you should receive a certificate of attendance. If the meeting is accredited it should be clearly stated on the certificate by which institution with the total of granted credit. Please indicate on a certificate how many hours you actually spent in the educational activity. - If you wish to have credits added to your account for a scientific publication/ presentation, etc., please send a documental proof e.g. a certificate, an article, a copy of a programme, with clearly visible title and authors of the presentation/scientific publication. (point 8 of the manual)

After validation of your application and checking the documental proof, we will update your account. How to request a new password? If your forgot your password please click on the link “Forgot password” on log in screen to reset it. Electronic Credit Registry Report The yearly Credit Registry Reports for the EU-ACME members is generated electronically only. This way you will be able to access and print your CRR at any time. If you wish to receive a hard copy of the yearly CRR, please log in to your online account and check the box for the option: “I wish to receive a hard copy of my yearly CRR.” Make sure your personal data and e-mail address are correct to enable the EU-ACME Office to send you the Credit Registry Report information on time and to the correct email address!

EU-ACME MCQ winners 2021 From January 1 to December 31, 2021, EU-ACME members answered multiple questions published in European Urology. Three participants who answered most questions correctly were awarded a free registration for the 37th Annual EAU Congress in Amsterdam to be held from 1-4 July this year. The 2021 winners are: • R.B. Drobot, Rafal, Poland (CME-141503) • R.M. Marques Bernardino, Portugal (CME-143935) • M.D. Deger, Turkey (CME-143755) The EU-ACME committee congratulates the winners for their successful participation in our online CME programme!

Have you moved? Changed name? New employer? Update your details online at www.eu-acme.org!

EU-ACME Office

European Urology Today

March/May 2022

EAU RF PHOENIX: Recruitment started Prospective registry for patients undergoing penile prosthesis implantation Mrs. Christien Caris EAU Research Foundation Arnhem (NL)

c.caris@uroweb.org

Dr. Wim Witjes EAU Research Foundation Arnhem (NL)

w.witjes@ uroweb.org This registry is officially entitled ‘Prospective Registry for patients Undergoing Penile Prosthesis Implantation for Male Erectile Dysfunction’. Our intention is to prospectively collect data from 1,000 patients with a penile prosthesis implant (PPI), as used in daily urological practice, regardless of the type of implant. All surgeons who implant penile prostheses are welcome to participate. This will enable us to report on patient and partner satisfaction, as well as assess the mechanical reliability of the different PPIs on the market. Goal The study goal is to demonstrate whether this therapeutic option is a good treatment in patients with erectile dysfunction (ED) who do not respond to other treatments (refractory ED). Furthermore, we hope to identify clinical and surgical factors that correlate with patient outcome, surgical complications and mechanical reliability of the devices used in daily urological practice. With the results, treatment recommendations and guidelines can be further improved resulting in better care for this group of ED patients. Questionnaire translation process In the registry, treatment satisfaction, sexual function and quality of life will be assessed by means of specific patient questionnaires. After identification of all necessary questionnaires, we found not all questionnaires were available in the required languages and a translation process was started. For some questionnaires single forward translation was used while for others, such as the Quality of Life and Sexuality with Penile Prosthesis questionnaire (QoLSPP) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire, a recognised professional methodology was used, in line with the international ISPOR guidelines (the professional society for health economics and outcomes research), including forward and backward translation, as well as cognitive debriefing. Cognitive debriefing Cognitive debriefing is testing the translated questionnaires on a small group of relevant patients (e.g. patients who are treated with an implant or patients with ED) in order to test alternative wording and to check understandability, interpretation and cultural relevance of the translation. This testing was done by means of patient and partner interviews by urologists interested in participating in the registry. The value of each question in the QoLSPP questionnaire will be validated with the registry outcome measures at a later stage. Status update The interviewing process is taking longer than expected, because of COVID-19 among other things, and is ongoing in Germany, France, Sweden and the Netherlands. In Belgium (Dutch language), Italy, Spain, Portugal and United Kingdom, the interviews have been completed and questionnaires have been finalised. They have been implemented in the database. These countries, except for the UK where we await ethical committee approval, have started recruitment. Despite the challenges we faced surgical lockdowns and restrictions in surgical capacity due to COVID-19 - recruitment is progressing EAU Research Foundation

March/May 2022

Institution

Jessa Hospital UZ Leuven AZ Maria Middelares University hospital of Liège Erasme Hospital University Clinics of Brussels ULB Clinique Saint Jean AZ Sint‐Jan Innsbruck Medical University Montpellier University Hospital CHU Lyon Sud Hôpital d'Instruction des Armées Sainte Anne Martha‐Maria Hospital Nuremberg University Hospital Schleswig Holstein, Campus Kiel Universitätsklinikum Hamburg‐Eppendorf (UKE) Vivantes Klinikum Am Urban University Hospital Essen (AöR) University Clinic of Cologne IRCCS San Raffaele Hospital Bologna University Hospital, Policlinico S.Orsola Hesperia Hospital University of Foggia University of Naples "Federico II" Centro Hospitalar Universitário São João Centro Hospitalar Universitário Lisboa Norte (CHULN) Hospital Trofa Saúde Sava Perovic Foundation Fundació Puigvert Hospital Clínic de Barcelona Hospital Universitario 12 Octubre Hospital Universitario HM Montepríncipe Hospital Universitario Puerta de Hierro Majadahonda Hospital Universitario La Zarzuela Hospital General Universitario Gregorio Marañon Hospital Germans Trias i Pujol Hospital Universitario La Paz Lyx Institute of Urology Lund University, Skane Hospital, Erasmus MC University Medical Center Radboudumc Antonius Hospital Maxima Medical Centre Zaans Medisch Centrum UCL University Hospitals of Leicester NHS Trust Nottingham City Hospital

City

Hasselt Leuven Gent Liege Brussels Brussels Brugge Innsbruck Montpellier Pierre Benite (LYON) Toulon Nuremberg Kiel Hamburg Berlin Essen Cologne Milano Bologna Modena Foggia Napoli Porto Lisboa Trofa Belgrade Barcelona Barcelona Madrid Boadilla del Monte Majadahonda Madrid Madrid Barcelona Madrid Madrid Malmö Rotterdam Nijmegen Nieuwegein Veldhoven Zaandam London Leicester Nottingham

Country

Belgium Belgium Belgium Belgium Belgium Belgium Belgium Austria France France France Germany Germany Germany Germany Germany Germany Italy Italy Italy Italy Italy Portugal Portugal Portugal Serbia Spain Spain Spain Spain Spain Spain Spain Spain Spain Spain Sweden The Netherlands The Netherlands The Netherlands The Netherlands The Netherlands United Kingdom United Kingdom United Kingdom

Status

Recruiting Recruiting Initiated Pending EC approval Pending EC approval Pending EC approval Pending EC approval Pending EC approval Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Recruiting Pending EC approval Pending EC approval Pending EC approval Pending EC approval EC approval. Start of recruitment after investigator change Pending EC approval Pending EC approval Interested EC approval. Contract signature process ongoing Recruiting Recruiting Recruiting Recruiting Recruiting Pending EC approval Recruiting Recruiting Recruiting Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending validation translated questionnaires Pending EC approval Pending EC approval Pending EC approval

# of patients 40 0

3 1 1 0 3 2 2 0

reasonably well. A status overview (cut-off date 31 March 2022) is given in the table above. Patient account Since the questionnaires are an important part of this registry (the patient satisfaction score, measured by means of the EDITS questionnaire, is the main outcome parameter), it is of the utmost importance that questionnaires are completed by the participating patients (and partners). To make it easier for the patient to complete the outcome measures (PROMS), the Marvin data entry system enables creating a patient account so the patient can complete the questionnaires online at his convenience. We recommend using the possibility to create a patient account for as many patients as possible. Clinical data pre, per and post-surgical implantation are being collected and entered into the database by urologists and their representatives. Welcome to join All European centres who offer PPI to their patients with erectile dysfunction are welcome to join. High as well as low-volume centres can participate in order to get a good representation of daily clinical urological practice. In this registry we will collect pre-defined parameters related to this type of surgery. All registered devices that are used as implant in daily urological practice can and should be included. No extra visits are required to collect the data, patients are seen on a regular basis according to standard clinical practice. Patient inclusion should be consecutive. Quite some centres have already shown interest in setting up such a registry. They will start participating by contributing their patient data after receipt of the patient’s consent. ADDITIONAL CENTRES ARE WELCOME Should you be interested in participating in this registry, please contact the EAU RF by sending an email to C.Caris@uroweb.org. Principal investigators: Dr. Koen Van Renterghem, Hasselt (BE) Dr. Federico Deho, Milano (IT) Funders: Boston Scientific Corporation Coloplast Corporation

Become an EAU member today!

Apply online today and be part of the largest urological community. uroweb.org/membership

Formal sponsor: EAU Research Foundation European Urology Today

Setting up a mesh complications service Recognising the individual needs of each woman London Complex Mesh Team UCLH London (GB)

uclh.enquiries. uclh_lcmc@nhs.net Clinical Lead: S. Elneil, Deputy Clinical Lead: T. Greenwell, Urologists: J. Ockrim, H. Gresty, Colorectal Surgeon: A. Obichere, Imaging: P. Aughwane, Service Manager: H. Rowbottom, H. Light, Senior Clinical Fellow: S. Palmieri, Post CCT Fellow: A. Khan and Advanced Nurse Practitioner: E. Kuria. Synthetic pelvic mesh was used for the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) for decades and became increasingly popular from the 1990s when surgical kits with precut mesh and applicators were developed and launched. The true number of women with pelvic mesh in situ or with mesh complications worldwide is unknown (IMMDS, 2020). In England, Hospital Episode Statistics (HES) data have given an indication of the scale of mesh insertions and removals in the National Health Service (NHS) (Gurol-Urganci I, 2018) (Keltie K, 2017). One study analysed the complication rates in 92,246 women who had a midurethral tape (retropubic- TVT or trans-obturator- TOT) inserted between April 2007 and March 2015. The proportion of patients who experienced any complication during their procedure or up to 5 years postoperatively was 9.8% and 5.9% of women required re-admission for treatment within 5 years. (Keltie K, 2017). There has been growing international appreciation, debate, and scrutiny over complications relating to pelvic mesh such as bleeding, infection, organ perforation including extrusion into the urinary and colonic tracts, vaginal exposure, mobility problems, sexual dysfunction, and pain (Petri E, 2012). There are several notable class action lawsuits in various countries (Dyer, 2020) (Reuters, 2021). A number of reports have been issued including the FDA safety alerts in 2008 and 2011, the Medicine and Healthcare products Regulatory Agency (MHRA) review in 2014, the Scottish Mesh Review in 2017 and most recently the IMMDS review led by Baroness Cumberledge in 2020. The latter highlighted the need for specialised services to help women with mesh complications.

Fig. 2: Mesh centres in England

Fig. 4: Sagittal T2 MRI showing a normally positioned retropubic TVT mesh

England. The London Complex Mesh Centre (LCMC) launched in July 2021. A further two are due to start in 2022, with further units being set up in Scotland, Wales, and Northern Ireland.

characteristics may suggest an aetiology of patients’ symptoms and MRI also allows for the identification of other pathology which may contribute to the presenting issues.

Patient and public involvement Multi-disciplinary pathways of care were developed over a number of years with the input of multiple patient focus groups – all of whom had a predominance of mesh-injured women. Their input was key to developing a surgical service alongside the input of pain and psychology support to form an integral part of the pathway. Patient working groups have regular meetings with MDT teams to ensure that processes, pathways, and communications are regularly updated and stay in step with what patients want and need, and advocacy panels communicate with national patient support groups. Regular communication and meetings between the mesh centres ensures that the delivery of care is standardised and will be monitored nationally with annual meetings, audit, and publication enshrined within this process.

In our opinion, imaging informs decision-making in MDT meetings and allows the surgical team to better plan any intervention they perform. At present, there is some limited evidence regarding the efficacy of US and little to no published data regarding MRI (Duckett J, 2020). The mesh centres are collecting data, and analysis will validate the utility of imaging for management. These analyses will be shared so other centres can also benefit from experience.

References

MDT teams include urologists, urogynaecologists, colorectal surgeons (where appropriate), radiologists, chronic pain medicine, psychology, anaesthesia, physiotherapy, and clinical nurse specialists. The surgeons within mesh services have specialist interests and training in complex female urogenital reconstruction. External referrers are invited to join MDTs once a month to present their cases and mesh centres work closely with other, NHS trusts to accept patient referrals.

Fig. 5: Intra-operative view of groin dissection to remove TVTO

Informed consent and patient information Much of the controversy over mesh insertion and Ultrasound provides a detailed view of the portions of complications has centred on governance issues and whether women gave fully informed consent. It is vital the tape which run between the urethra and vagina. It is excellent for assessing the position of this portion that mesh centres provide women with information on the risks and benefits of the full range of options of the tape and for identifying complications such as urethral or bladder extrusion. Because mesh sits deep for their symptoms. This is tailored to the individual within the pelvis, transvaginal or transrectal probes woman in line with GMC guidance and according to are required to get the best possible quality images of the ‘Montgomery’ principle. This includes information leaflets that have been produced in partnership with the mesh. the British Society for Urogynaecology (BSUG), the British Society of Urological Surgeons (BAUS), the Patient Information Forum alongside NHS England. Patient decision aids can also guide women through their choice of management (BSUG, 2021).

Fig. 1: Intra-operative view of vaginal exposure of TVTO

Specialist commissioning Concerns regarding the safety of pelvic mesh inserted for incontinence and prolapse has led to a high vigilance pause in insertions in the UK. NHS England has commissioned specialist mesh centres to meet the complex needs of women with mesh complications. Fig. 3: Transverse view of urethra on transrectal ultrasound showing urethral extrusion of mesh Upon this advice, NHS England set up seven geographically distributed complex mesh centres in EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)

European Urology Today

MRI gives an overview of the pelvis, enabling assessment of the portions of the mesh further away from the urethra. Altered tissue enhancement

Summary The evolution of the currently recognised problems with polypropylene mesh and the lessons that have been learnt and continue to be learnt from these have offered a real opportunity to develop an integrated service that brings together surgical, medical, and psychological expertise to support and benefit patients who have previously been let down by the lack of a dedicated infrastructure. Together, clinicians, patients, and advocates have the ability to facilitate pathways that will offer the highest quality of care, evolve the understanding of the best and tailored management pathways, and communicate this information to national and international clinical audiences. We hope that the success of this model of care will disseminate to all surgical practices for the benefit of all patients. Disclosures Intra-operative images and radiology images used with permission of patients for publication.

MDT working Mesh centres offer women a holistic care pathway involving an MDT of specialists with weekly meetings.

Imaging Magnetic resonance imaging (MRI) and ultrasound (US) play a key role in the identification of mesh and characterisation of the type of mesh implant, position, and relationship with pelvic structures.

Education and training The surgical management of mesh removal has not been credentialled yet by any professional body, and thus multiple techniques have been developed over the years. Urologists tended to favour endoscopic laser of mesh fibres whereas urogynaecologists tended to ‘oversew’ exposed mesh or ‘trim fibres’. Both approaches have never been fully evaluated. Over time, mesh removal surgery has evolved to include vaginal removal of mesh, paralabial/groin dissections to remove obturator mesh arms, retropubic dissections, female urethroplasty, fistula repair, bladder and/or ureteric reconstruction, and bowel resection. There is a skills gap in more complex mesh removal surgery (IMMDS, 2020). The UK mesh centres are working to build skills and support formal credentialling of expertise. Cadaveric workshops, mentoring and proctoring across surgical specialities will improve training in this field. Annual mesh congress meetings will encourage group learning and collaboration across centres.

Patient outcome data, research and audit It is recognised that there is no high quality data comparing outcomes of different techniques of mesh removal surgery (IMMDS, 2020) (Giarenis I, 2020). Evidence to guide practice has relied on cohort studies (Carter P, 2020) (Toia B, 2021 ) (Forzini T, 2015). Patient reported outcome measure (PROM) questionnaires are utilised to document progression in symptoms from baseline and after treatment. Mesh centres in the UK are working with patient groups and NHS England to agree a standardised PROM so that data can be pooled across mesh centres for the future. Regular audit of outcomes and complications forms part of this governance structure. NHS Digital are supporting the establishment of a central mesh complications and outcomes registry but, at present, this data is captured in individual centres. Safety reporting to the MHRA is undertaken.

‘First Do No Harm’. The report of the independent medicines and medical devices safety review. July 2020. https:// www.immdsreview.org.uk/downloads/IMMDSReview Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, Tincello DG, van der Meulen J. Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence. JAMA. 2018 Oct 23;320(16):1659-1669. doi: 10.1001/jama.2018.14997. PMID: 30357298; PMCID: PMC6233805. Keltie K, Elneil S, Monga A, Patrick H, Powell J, Campbell B, Sims AJ. Complications following vaginal mesh procedures for stress urinary incontinence: an 8 year study of 92,246 women. Sci Rep. 2017 Sep 20;7(1):12015. doi: 10.1038/s41598-017-11821-w. PMID: 28931856; PMCID: PMC5607307. Petri E, Ashok K. Complications of synthetic slings used in female stress urinary incontinence and applicability of the new IUGA-ICS classification. Eur J Obstet Gynecol Reprod Biol. 2012;165(2):347-351. Dyer C. Johnson and Johnson pays hundreds of women in Scotland harmed by mesh implants. BMJ. 2020 Jun 2;369:m2201. doi: 10.1136/bmj.m2201. PMID: 32487670. Reuters news report “J &J fails in final bid to appear Astralian pelvic mesh class action ruling. 2021 https:// www.reuters.com/business/healthcarepharmaceuticals/ jj-fails-final-bid-appeal-australianpelvic-mesh-classaction-ruling-2021-11-05/ Reuters news report “Boston Scientific in $189 million settlement with U.S. states over surgical mesh devices. 2021 https://www.reuters.com/article/us-bostonscientific-settlement-idUSKBN2BF29D FDA Public Health Notification: Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence Issued: October 20, 2008 www.amiform. com/web/documents-risques-op-coeliovagi/fdanotification-about-vaginal-mesh FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse Date Issued: July 13, 2011

The complete reference list of this article is available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Setting up a mesh complications service” March/ May issue 2022.

March/May 2022

ERN eUROGEN expands members Renewed funding and other exciting updates planned for 2022 Ms. Jen Tidman ERN eUROGEN Business Support Manager Nijmegen (NL)

Funding The previous EC grants for the ERNs’ coordination and operational activities ended on 28 February 2022. These grants were subject to the EC financial rules for grants where coordinating institutions needed to co-fund grants by 40%, with the EC funding 60% of the total eligible costs.

jen.tidman@ radboudumc.nl

As part of the EU4Health programme (2021-2027), the EC announced an increase in the funding to the ERNs to €26 million (which may increase by a maximum of 20%) to be divided between the 24 ERNs. After intense and ultimately successful lobbying by the ERN Coordinators Group, the EC changed the financial rules for the ERNs (and only the ERNs) to 100% funding by the EC, making grant reporting more efficient.

The European Commission (EC) established the European Reference Networks (ERNs) focusing on 24 specific medical domains in 2017, connecting EU healthcare providers (HCPs) and their experts (in collaboration with patient advocates) to improve the healthcare management of patients suffering from rare New direct grants, beginning on 1 March 2022, will or low-prevalence complex diseases and conditions. ensure the ERNs’ continuity until 2023, when multiannual grants (including grants for the IT and The ERNs facilitate knowledge sharing and transfer, data-related activities currently supported by the quality of care and care coordination, training and Connecting Europe Facility) will also simplify funding education, and stimulation of research, thereby and reduce grant management requirements. establishing new ways to reduce adverse outcomes for patients and subsequently diminishing the cumulative ERN eUROGEN is finalising the agreements for an cost for society. approved €200,000 9-month bridging grant to bring it into the same timelines as the other 23 ERNs and has The ERNs also provide highly specialised advice using submitted an 18-month proposal for €1.1 million, a secure web-based tool known as the Clinical Patient which will be evaluated between March and June 2022, Management System (CPMS). Expert MDTs can with results announced by the EC in July. Therefore, we diagnose, suggest treatment or surgery, and provide hope to have some good news to toast at the Annual post-operative and transitional support across national EAU Congress where we will have a Special Session borders within and between ERNs. and exhibition stand! ERN eUROGEN is the European Reference Network for Rare Urogenital Diseases and Complex Conditions and was established in collaboration with the EAU, which remains a network Supporting Partner. The EC considers diseases rare when they affect <1:2000 (<0,05%), but in some highly complex urogenital conditions, the rate is significantly lower, e.g., urethral diverticula in 1: 250,000 (0,0004%). New members On 1 January 2022, after the 2019 call to join the existing ERNs, 29 new members joined ERN eUROGEN, nearly doubling the network’s size! It now includes 57 HCPs from 20 EU member states, their urogenital specialists, urology and surgical departments, and MDTs (all listed on the ERN eUROGEN website). We created a welcome package for the new members comprising a welcome videoconference, network overview, and updated governance statutes (which will also be agreed upon by all existing members). We will prioritise onboarding and integrating the new members, training them to use CPMS, and ensuring they can actively participate in all current and future ERN-related activities.

2022 activities & objectives ERN eUROGEN will use the funding for its activities and objectives relating to coordination, dissemination, collaboration, development of clinical practice guidelines and clinical decision support tools, evaluation, CPMS, the ERN eUROGEN patient registry, and training and education. Internal criteria The network sets the internal criteria that a HCP must meet to join and remain a network member. In 2022, at the request of our European Patient Advocacy Group (ePAG) and with their full involvement, we will review and update these criteria. We will also be applying to cover three new expertise areas (urological aspects of paediatric renal transplants, male infertility, and paediatric oncological urology). In terms of dissemination, we regularly update our website, issue a regular e-newsletter, and have a presence on social media so please subscribe and follow us for the latest updates. We encourage our members to present network-related results and information at scientific meetings and submit work relating to the network to peer-reviewed journals

Workstream Meeting with new members, February 2022

(e.g., the papers we have published on our clinical results in European Urology and EJSO). Supporting Partners Besides the EAU, we also have as Supporting Partners ESPU, ESSIC, EUPSA, and ARM-Net, and we collaborate with all to maximise work and avoid duplication. We are currently working with the EAU Guidelines Office paediatric panel over our guidelines, the EAU Research Foundation over our registry, and hope to collaborate with the new EAU Patient Office.

This presentation is owned by the ERN and may contain information that is confidential, proprietary or otherwise legally protected.

ERN eUROGEN Welcome Videoconference For New Members Joining 2022 Presented by the ERN eUROGEN Coordination Team & ePAG Representative

21 February 2022

Your ERN logo here

Co-funded by the EU

ERN eUROGEN participates in all the EC's cross-ERN working groups, collaborates with other ERNs relating to multi-systemic rare diseases and complex conditions that require input from more than one ERN, and has begun a global collaboration programme so far including Australia, New Zealand, and developing countries. ERN evaluation process ERN eUROGEN has a lead role in the ERN evaluation process with involvement in the EC monitoring working group, producing a dashboard for monthly data reporting, and extensive input to the EC’s Assessment, Monitoring, Evaluation and Quality Improvement System for the ERNs (AMEQUIS). The first complete evaluation of the ERNs and their HCPs will occur later this year (results in 2023) then every five years. CPMS panel discussions We hold regular CPMS panel discussions, have published a paper on our use of CPMS (available on our website), have piloted cross-ERN CPMS panel discussions requiring expertise from more than one ERN, and provided extensive input relating to the development of a new, easier to use CPMS. ERN eUROGEN registry The ERN eUROGEN registry went live in January 2022. We are collecting standardised, long-term data from our HCPs on patients living with rare urogenital diseases or complex conditions, tracking long-term outcomes into adulthood, and evaluating the efficacy of treatments, resulting in improvements in care and facilitating much-needed research. The latest EC funding call allowed pilot schemes to reimburse HCPs for their experts giving CPMS March/May 2022

advice and registry data entry. If our proposal is accepted, ERN eUROGEN will be launching pilots for both schemes and evaluating them to see if additional investment leads to increased use of these EC-provided tools.

“The ERNs also provide highly specialised advice using a secure web-based tool known as the Clinical Patient Management System (CPMS).” ERN eUROGEN Exchange Programme ERN eUROGEN also trains and educates urologists, surgeons, and related healthcare professionals. The ERN Exchange Programme is due to restart (after COVID-19 related suspension), and we are arranging visits for individuals to HCPs to spread knowledge and stimulate collaboration. The EC is developing an ERN Academy to which ERN eUROGEN will contribute recordings of highly specialised surgeries. Our already successful educational webinar programme will continue with now weekly webinars. We will also produce an Elsevier-published book on rare and complex urology with chapters from our experts and ePAG advocates. The future We will keep the EAU and its members posted on developments, but we hope you agree that the future looks bright for ERN eUROGEN. If you have any questions, are interested in referring a case to us, or would like to get involved, please look at our website to learn more: www.eurogen-ern.eu or email eurogen@uroweb.org European Urology Today

Young Urologists/Residents Corner Robotic kidney transplantation Update from the ERUS-RAKT Working Group Dr. Riccardo Campi Member, YAU Kidney Transplantation working group University of Florence Carregi Hospital Florence (IT) riccardo.campi@ gmail.com

Dr. Angelo Territo Chairman, YAU Kidney Transplantation working group Dept. of Urology Fundació Puigvert Barcelona (ES) territoangelo86@ gmail.com

Fig. 1: Overview of the currently most active urological centres performing robot-assisted kidney transplantation (RAKT)

Platform for prospective data collection The scientific collaboration between the centres In recent years, robot-assisted kidney transplantation included in the ERUS-RAKT group was enabled by the (RAKT) has emerged as a feasible and safe alternative early development of a project-specific web-based to the traditional open approach, offering the benefits platform for prospective granular data collection from of minimally-invasive surgery to both surgeons and patients undergoing RAKT at each participating recipients. [1,2] institution. Such a platform, developed and managed by a team of researchers at the University of Florence, After its inception and development [3-5], RAKT was allowed all group members to share data on RAKT progressively adopted in the living donor setting in using a standardised data collection process and selected referral transplant centres worldwide. [6] established clinical end points. Thanks to this In 2016, the European Association of Urology (EAU) collaborative initiative, the ERUS-RAKT working group Robotic Urology Section (ERUS) RAKT working has published several key papers in peer-reviewed group, led by Dr. Alberto Breda, was founded, which journals over the last years, exploring the feasibility developed into an international collaboration aimed and safety of RAKT in a variety of clinical scenarios. at standardising the technique of RAKT. The aim was to assess the perioperative and functional Recent reports by the ERUS-RAKT working group outcomes of RAKT using standardised metrics as After the first report detailing the early European well as to expand the indications for minimally experience with RAKT from living donors and invasive kidney transplantation in Europe and proving the technical feasibility, safety and beyond. favourable perioperative and short-term functioning of RAKT in experienced hands [2] (with Active centres lower rates of symptomatic lymphoceles and To date, the most active centres in the ERUS-RAKT wound infections as compared to previous consortium are located in Spain (Dept. of Urology of experiences [7]), Territo et al. reported an update the Fundaciò Puigvert, Hospital Clinic and Bellvitge regarding the mid-term outcomes of patients who University Hospital in Barcelona), Italy (Dept. of underwent RAKT with a minimum of 1-year Urological Robotic Surgery and Renal Transplantation follow-up. [8] In this work, optimum functional of Careggi University Hospital in Florence), Belgium outcomes and a low rate of mid-term postoperative (Dept. of Urology of Ghent University Hospital), adverse events (such as incisional hernia, ureteral Germany (Dept. of Urology of University Saarland in stenosis, and vascular complications) were Homburg/Saar) and France (Dept. of Urology and reported. The latest update published by the group Renal Transplantation of the University Hospital of in 2021 (the largest European multicentre study on Rangueil in Toulouse) (see Fig. 1). RAKT) confirmed that RAKT can achieve good surgical and functional results that are competitive Fruitful collaboration and teamwork with those of the gold standard’ open kidney The fruitful collaboration between such European transplantation in centres with a wide experience in transplant centres led by urological teams is the open kidney transplantation and robotic urologic result of strong determination and resilience of a surgery. [6] group of pioneers aiming to advance the field of kidney transplantation by leveraging the benefits of Notably, considering the lack of evidence on the minimally-invasive surgery. In this regard, the learning curve of RAKT, another study by Gallioli et contributions of Dr. Alberto Breda (Barcelona), Prof. al. evaluated the number of procedures needed to Karel Decaestecker (Ghent), Prof. Antonio Alcaraz achieve proficiency in RAKT from living donors and Dr. Mireia Musquera (Barcelona), Prof. Francesc based on a a-priori developed Trifecta. [9] The Vigués Julià (Barcelona), Prof. Sergio Serni and Dr. authors found that a minimum of 35 cases are Graziano Vignolini (Florence), Prof. Michael Stoeckle necessary to reach reproducibility in terms of (Homburg), Prof. Paolo Fornara (Halle), Prof. Volkan rewarming time, complications and functional Tugcu (Istanbul (TR)) and Dr. Nicolas Doumerc results. (Toulouse), among others, to both the clinical and scientific achievements of the ERUS-RAKT working Outcomes of RAKT in challenging cases and group during the last five years, were invaluable. new frontiers The ERUS-RAKT working group also analysed the Update on RAKT at EAU22 outcomes of RAKT from living donors in selected Despite being relatively ‘young,’ the ERUS-RAKT and more challenging clinical scenarios. In this working group has achieved several goals and has regard, Siena et al. reported no significant provided a robust foundation for significant further differences in terms of median vascular research in this field. anastomosis and rewarming times between RAKT using grafts with multiple vessels and those with In the lecture entitled Robotic kidney transplantation: standard single-vessel anatomy [10], confirming Update for the ERUS-RAKT Working Group, to be the feasibility and safety of RAKT in these cases presented at the 37th Annual EAU Congress in after proper ex-vivo vascular reconstruction on Amsterdam (NL) during Thematic session 12: Difficult the bench table. Similarly, Prudhomme et al. cases in renal transplantation (Speaker: Dr. R. Campi), explored the outcomes of RAKT among obese vs. the mosaic of evidence built by the ERUS-RAKT group non-obese recipients. They found that RAKT is over the last years will be analysed comprehensively. safe in this challenging patient cohort if Urologists and transplant surgeons will be given key performed by experienced surgeons, and it can insights to understand the contemporary role of achieve good graft function in the short-mid-term robotics in the field of kidney transplantation. follow-up. [11] On behalf of the ERUS-RAKT working group

European Urology Today

Lastly, the group has confirmed the feasibility and safety of postoperative percutaneous diagnostic or therapeutic procedures (such as graft biopsy, placement of a nephrostomy tube or drainage of postoperative fluid collections) after RAKT [12] and has highlighted the potential added value of the robotic platform regarding the assessment of graft and ureteral reperfusion thanks to intraoperative fluorescence vascular imaging with indocyanine green. [13,14] In a seminal report, Vigues et al. reported for the first time the technical feasibility of robot-assisted orthotopic kidney transplantation, focusing on technical nuances and early postoperative outcomes. [15] RAKT from deceased donors In more recent years, the ERUS-RAKT working group has further moved the field forward by assessing the impact of robotics in frontier areas of kidney transplantation with either single centre or multicentre studies. In particular, the group at Careggi University Hospital in Florence has pioneered a technique and a specific logistical framework to perform RAKT from deceased donors. [16,17] While being more challenging from a logistical standpoint, these reports highlight the feasibility and safety of RAKT in the broader and more complex setting of deceased donors, provided proper recipient selection, surgical team experience and excellent organisation of the kidney transplantation pathway are present. Further studies are needed to compare the outcomes of RAKT vs. open kidney transplantation, aiming to assess the benefits and limits of robotic surgery for kidney transplantation from deceased donors. Novel cold ischemia device for RAKT To overcome the limitations of the traditional strategy to achieve regional hypothermia during RAKT, Dr. Breda, Dr. Territo and colleagues at Fundación Puigvert in Barcelona successfully developed a novel cold ischemia device according to the IDEAL recommendations [18] allowing the maintenance of a constant low graft temperature during the rewarming time. [19] While waiting for prospective multicentre studies validating the benefits of this device in larger cohorts of recipients, the study by Territo et al. provides a foundation for optimisation of surgeons’ learning curve and, most importantly, functional outcomes after RAKT from both living and deceased donors. Intracorporeal versus extracorporeal RAKT After previous preliminary reports showed the technical feasibility of robot-assisted kidney autotransplantation (RAKAT) in experienced hands [20], Breda et al. recently compared the outcomes of intracorporeal versus extracorporeal RAKAT, showing similar postoperative functional outcomes and highlighting the promising role of this procedure for well-selected patients. [21] Another major step toward the definition of the benefits of robotic surgery for kidney transplantation from living donors is represented by exploratory studies suggesting the non-inferiority of RAKT vs. open kidney transplantation regarding intraoperative, perioperative and functional outcomes [22] as well as postoperative systemic inflammatory responses. [23]

Future projects Based on the robust evidence on RAKT discussed above, the ERUS-RAKT working group is designing prospective multicentre projects aiming to increase the quantity and quality of evidence supporting the benefits of robotics in this inspiring field. These projects will provide evidence on the best indications and cost effectiveness of RAKT and will hopefully achieve the following goals in the near future: a) integration of augmented-reality technologies into pre and intra-operative planning of RAKT using grafts from both living and deceased donors; b) comparison of postoperative, functional and patient-reported outcomes after robotic vs. open kidney transplantation by means of prospective high-quality (ideally randomised) trials; c) definition of standardised modular training programmes for RAKT, taking advantage of step-by-step learning modules and specific simulators (as previously achieved for other urological procedures [24,25]) in order to increase the number of urologists offering minimally invasive kidney transplantation at a higher number of transplant centres in Europe. To reach this goal, the ORSI Academy in Belgium is now offering structured courses on RAKT (https:// invivox.com/sales-rep/orsi-academy); d) improvement of RAKT programmes from deceased donors (which require a complex logistical framework as compared to the living donor setting). In conclusion, while several key goals have already been achieved by the ERUS-RAKT working group during the last years, further research is needed to expand the indications for RAKT in Europe and beyond. Harnessing the power of scientific collaboration between referral urological centres performing RAKT will be key to improve the quality of the evidence as well as patient outcomes and quality of life. References 1.

Wagenaar S, Nederhoed JH, Hoksbergen AWJ, et al. Minimally Invasive, Laparoscopic, and Robotic-assisted Techniques Versus Open Techniques for Kidney Transplant Recipients: A Systematic Review. Eur Urol. 2017 Aug;72(2):205-217. doi: 10.1016/j.eururo.2017.02.020. 2. Breda A, Territo A. Can the robotic approach replace open surgery in kidney transplantation? World J Urol. 2021 Sep;39(9):3699-3700. doi: 10.1007/s00345-020-03312-x. 3. Giulianotti P, Gorodner V, Sbrana F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patient. Am J Transplant. 2010 Jun;10(6):1478-82. doi: 10.1111/j.1600-6143.2010.03116.x. 4. Decaestecker K, Territo A, Campi R, et al. Robot-Assisted Kidney Transplantation. In: Medical Robotics - New Achievements. Edited by Serdar Küçük and Abdullah Erdem Canda. IntechOpen, DOI: 10.5772/intechopen.90276. Available from: https://www.intechopen.com/ chapters/70819

The complete reference list of this article is available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Robotic kidney transplantation as safe alternative” March/May issue 2022. March/May 2022

Young Urologists/Residents Corner Experiencing mentorship The valuable and complex process of giving and receiving explained Dr. Cristina Bujoreanu Dept. of Urology Prof. Dr. I. Chiricuta Institute of Oncology Cluj-Napoca (RO) bujoreanucristina@ yahoo.com

Assoc. Prof. Bogdan Petrut Dept. of Urology Prof. Dr. I. Chiricuta Institute of Oncology Cluj-Napoca (RO) bogdan.petrut@ gmail.com Mentorship offers a catalyst experience for growth and is a valuable tool in surgical training, as it requires the development of a complex set of skills. A main part of mentorship unfolds in the operating room by teaching and learning operatory steps without endangering the patient and influencing operatory results. However, mentorship is more than coaching and developing technical skills, it should also bring guidance in navigating the lifestyle of a surgeon. Mentorship in surgery is about creating a highly qualified professional experience by exploring the potential of medicine, within the ethics and values of a white coat. Consolidation of ethics Mentorship is a transformative process, both professional and personal, that can have a high impact on us and may last a lifetime. It entails more than educational and coaching aspects, as it is not only focused on academic transfer of skills and knowledge with performance goals. The core of mentorship is a consolidation of ethics and values such as honesty, consistency and transparency [1] while mentors model, inspire and motivate with the joy of creating professional and personal growth for unexperienced mentees. There are many mentorship styles divided mainly in 2 groups: traditional and transformational. There is not one perfect style as each of them (and their subtypes) suits different personalities and resource availability. Giving and receiving Many organisations and institutions successfully built programmes for mentor-mentee structures [2], but an authentic mentor-mentee relationship is rarely assigned; it is more likely found, bringing mutual satisfaction in giving and receiving. [3] And, even more important, no matter how many years pass, it always remains a work in progress. Because people and career paths change, the relationship is constantly transformed and needs to be nurtured. Depending on one’s needs and stage in life, different mentorship relationships may develop simultaneously by seeking expert guidance and developing networks of mentor-mentee. Multidisciplinary approach Moreover, the treatment of our patients may require a multidisciplinary approach that only works successfully in a well-integrated team, with the value of mentorship being seen across all hierarchic levels of the hospital. The benefits of mentorship are undeniable for both parties involved. Studies show that for mentees it improves career satisfaction, stress management, academic productivity, work-family balance and lowers burn-out risks. For mentors, it increases research productivity, career advancement opportunities and personal satisfaction. [4]. Mentorship in surgery Among surgical specialties, urology is associated with a high level of burn-out that could lead to personal sequelae, career regret and leaving academic medicine. [5] Studies reported 38.8% of practising urologists and 68% of urology trainees present burn-out symptoms and structured mentorship programmes lower this figure (p = 0.019). [4,6] Urology is a highly technical surgical field with steep learning curves and requires cognitive training during March/May 2022

mentorship. The cognitive load between mentoring and performing the actual surgical steps does not differ significantly, but the stress experienced by the mentor differs, depending on assisting low or high quality performances, and is related to situation awareness and risk prediction of the operatory performance. [7,8] How the mentor perceives the surgical act of the mentee reflects on the level of trust given to the trainee when he/she exerts different surgical skills. Trust Trust was objectively analysed with EEG features during robot assisted surgeries. The 5 more predictive features making the difference between Trustworthy (the mentor was satisfied with the performance of the trainee) and Concerning performances (mentor not satisfied) were: stress, mental workload, frustration, surprise and modularity. [9] Mentorship in minimally invasive treatment such as laparoscopy and robotic approaches requires highly developed surgeons in high volume centres which are rare, especially for oncologic pathologies. A commitment to mentorship and availability is required for a long period, to cover the steep learning curve and reach the independent practice level of the mentee, without endangering surgical outcomes. [10] A study regarding long-term (32 months) proctorship in robotic surgery training showed a reduced learning curve with a score of 4.2 in 5-point Likert scale among participants. [11] Surgical coaching also brings increased selfassessment ability and involvement in ongoing improvement with self-directed learning.

moments and avoid what could sabotage success. where each note is best suited on a score to play a [19,20] Even more, mentorship could be defined as beautiful song. [21] the development of emerging leaders by established leaders, as the skill of leadership can The complete reference list of this article is available Mentorship in context be defined as harnessing and growing emerging from the EUT Editorial Office. Please send an e-mail Nevertheless, culture and perceptions play key roles talent. Moreover, in the noise of diverse to: EUT@uroweb.org with reference to the article in relationship dynamic and coaching in surgery. A opportunities and possibilities, mentorship is the “Experiencing mentorship” by Dr. Bujoreanu, March/ study identified 3 main concerns at the centre of May issue 2022. surgical coaching: the value of technical improvement, art of making music, as a leader understands concerns about image and authority and loss of regulatory self-control. [12] Related to gender-specific role models, women are underrepresented in academia, leadership positions [13] and surgical specialties, especially urology. [14]. Even in the publishing world, there is a minority of publications EAU 2022 Industry Satellite Symposium with women as first author. [15] The gender dynamic of a mentorship relationship can bring behavioural challenges as men may tend to prefer hierarchical interactions based on challenges and independence and women may tend to incline towards encouragement and equalizing behaviour. On the other hand, a mixed gender mentorship may bring diverse insights and working styles that could stretch Sunday 3 July, 2022 • 17:45 – 19:15 (CEST) the potential of growing and learning. [16]

Advancing patient care in the evolving prostate cancer treatment landscape

Gender in mentorship The role of gender in mentorship is a controversial topic. [17] A study showed that women experience difficulties in finding a mentor, regardless of gender. When mentored, they are significantly more involved in research and publishing activities while the gender of the mentor does not have a significant influence. The study also suggested that a same gender role-model could offer better mentorship in balancing personal and professional lives. [18] It is crucial for mentees to define their own needs and search to fulfil them with not only one, but more expert mentors, but in reality… not all mentees in search of guidance find a matching mentor that easily. Regardless of gender, mentors are extremely valuable resources for guidance in career development and exploring publishing and teaching potential. Successful mentorship A successful mentorship relationship brings connection via compatible personalities. The mentor must see potential in the mentee and the mentee must find qualities in the mentor that he or she is aspiring to, all in the context of trust, boundaries, confidentiality and a set of objectives and expectations. Studies on successful mentorship revealed the following key characteristics: reciprocity, mutual respect, clear expectations, personal connection and shared values, the self-motivation of the mentee being the heart of the mentoring process. The mentor lights the way, but it is the mentee paving it [1] with pro-active contribution, work ethic, honest communication/ feedback and respect for the guidance.

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Agenda

Overall survival and delaying progression to mCRPC: Are these endpoints gold standards for prostate cancer treatment? 17:45

Welcome and introduction

Bertrand Tombal