European Urology Today Vol. 33 No.2 - March/May 2021 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

Vol. 33 No.2 - March/May 2021

Genital gender affirmation surgery

The e-informed patient

Digital uropathology in times of COVID-19

ESGURS update on penile reconstruction

Pros and cons of patient’s internet search

ESUP update on remote diagnosis, consultation and distant teaching

Mr. Wai Gin (Don) Lee

Dr. Markos Karavitakis

Prof. Rodolfo Montironi

Get ready for the EAU21 Virtual Congress! A preview of the hottest topics that will be discussed this summer As a preview of the EAU21 Scientific Programme, we spoke to seven experts who were involved in abstract selection and developing the plenary and thematic sessions. Get a glimpse of the EAU’s 36th Annual EAU Congress, the event of the year! Registration will remain open until 12 July, but the discounted early fee is only available until 1 June. See www.eau2021.org for all the available registration fees, the scientific programme and, of course, the latest congress-related news.

e Science at Europe’s largest Urology Congress

Join us!

Prof. Jean-Nicolas Cornu (Rouen, FR): Incontinence

2021.org

“Urinary incontinence is one of the most frequent urological conditions, especially in the elderly population. The impact of population ageing is already seen in urology wards where patients are older and older. During #EAU21 Virtual congress, a specific focus will be made on UI in the elderly, discussing overactive bladder treatments and surgical options. These options include bulking agents, slings, and artificial urinary sphincter. We will also specifically look at drugs: how and when to use them in daily practice.”

Prof. Evangelos Liatsikos (Patras, GR): Stones and endourology

Prof. Marc-Oliver Grimm (Jena, DE): Renal cell cancer

“Stones is always an

“Renal cell cancer (RCC) is

interesting and relevantScience part evolving rapidlylargest with regard to Urology Congress Cutting-edge at Europe’s

of urology, it represents a big part of the activities that urologists are doing in their practice. A lot of urologists combine the treatment of urological stones with another specialty. Around 40-50% of our practice is stones so it’s always an interesting topic to discuss.” “At EAU21 we will cover what is new in stone management. The track is designed to cover every part, from shockwave lithotripsy to percutaneous nephrolithotripsy (PCNL) and flexible ureteroscopy. We will discuss hot topics like metabolic evaluation, the medical treatment of urinary stones, and suggested dietary modifications. Stone analysis and the basic evaluation of stone patients are of use to us. We will also see a case discussion on a young boy, in order to address the paediatric side of stone treatment.” “Of course endourology is closely linked to developments in technology. So delegates can also expect us to cover everything to do with single-use ureteroscopes, and new developments in laser technology. These technologies evolve almost on a year-by-year basis. It’s important that people hear from the experts what is not just new but also what is objectively an improvement and useful in daily practice.”

“Finally, we will also look at surgical training and how this can be done in times of pandemic. Perhaps virtual training will play a larger role for our younger colleagues?”

Associated Plenary Session Plenary Session 7: Stones: Keeping with tradition or time for new concepts? Monday, 12 July (8:00-9:30)

molecular, diagnostic and treatment research and its implementation in clinical practice. The VHL mechanism in RCC is a good example and all its aspects will be discussed to set the scene of this session. This is a special lecture on behalf of the Society of Urologic Oncology (SUO). For the small renal mass, an update will be given on different approaches and will help you to make the right decision.”

Prof. Morgan Roupret (Paris, FR): Advanced bladder cancer “Scientific efforts of the last decade have yielded several novel diagnostic and therapeutic opportunities for patients suffering from localized muscle-invasive bladder cancer (MIBC) and metastatic disease. The management of patients with high-risk MIBC remains an unmet need. The EAU scientific committee office came up with a very challenging session for EAU21.” “To date, several definitions have been applied to determine which patients are considered at high-risk of recurrence after curative intent following radical cystectomy (RC). The current therapies that have arisen on the bladder cancer BC armamentarium have generated a myriad of options in terms of medical and surgical therapies, as well as optimal sequencing strategies. At EAU21 we will be looking at the increasing popularity of PET/CT for the staging of advanced bladder cancer, and what is the most appropriate preinterventional staging modality.”

“Experts in incontinence will also discuss pragmatic clinical situations in both sexes, e.g. an artificial sphincter dysfunction in an elderly male, and a case of stress urinary incontinence in an elderly female candidate for surgery. Key opinion leaders will also cover the growing legal and regulatory issues in the field of mesh implantation, and focus on the patient’s perspective.” “Beyond the plenary session, the rest of the EAU21 programme will also cover hot topics related to incontinence. This includes poster and thematic sessions on cutting-edge scientific reports, updated clinical trials results, and presentations on new instruments and devices.”

Associated Plenary Session Plenary Session 2: Optimal management of incontinence in the elderly patient Friday, 9 July (10:30-12:00)

“In larger tumours there has recently been a shift in surgery towards more nephron sparing. A pro and con discussion on this issue will help delegates finetune their clinical practice. In the mRCC setting prospective randomised trials tried to answer the role of nephrectomy in different eras of systemic therapy. The choice can be individualised and is also dependent on new treatment possibilities. Look forward to a mix of pre-recorded lectures by experts and interactive live discussion led by the session chairmen.”

Prof. Silke Gillessen (Bellinzona, CH): Advanced PCa “I think every urologist that deals with metastatic PCa will find something of interest at EAU21, particularly the plenary session. It’s a dynamic field and we’ve seen a lot of new developments in the last five years.”

metastatic disease after they have primary treatment. It seems that biologically these groups are different and have a different prognosis. Delegates can look forward to learning about which patients could benefit from which treatments.”

www.eau2021.org

“For instance, there are a lot of new treatment options for metastatic, hormone-sensitive PCa. We don’t yet know which option is best for which patient. We’re learning more and more that this is not one group of patients, but that there are differences between patients with, for example, high or low-volume disease, or patients who are de novo metastatic or patients who relapse with

“In the coming months we’re also expecting new data on the combination of different treatment options. We might have started about 40 years ago with hormonal treatment and androgen deprivation therapy alone. But adding chemotherapy or novel hormonal agents can be beneficial. For instance, the addition of radiotherapy for patients with low-volume disease can give an overall survival benefit. We will also soon know the effects of triple combinations, for instance ADT plus a novel hormonal agent, and also docetaxel. Or combining ADT, radiotherapy, abiraterone and docetaxel. Triple

Associated Plenary Session Plenary Session 4: Renal cancer: From localised to metastatic disease Saturday, 10 July (11:00-12:30)

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“The EAU Guidelines provide clear statements regarding the usage of perioperative systemic therapy in patients with MIBC. Then should we always perform a radical cystectomy after completer response? Our advanced bladder cancer plenary session will host a debate on the topic.” “Immunotherapy has recently brought a paradigm shift on treatment options for several cancers. In bladder cancer, several treatment options are currently available on metastatic disease. These outcomes provided the rationale to attempt utilization on an early phase of the disease. We will be exploring neo-adjuvant immunotherapy.” “And last but not least, molecular markers appears to be a the ‘new kids on the block.’ Many efforts have been recently made to classify urothelial carcinoma of the bladder from a molecular point of view, which has several implications for treatment choices and prognosis. This is a hot topic at EAU21 and we will see if molecular markers are suitable for being used currently in daily practice.”

Associated Plenary Session Plenary Session 3: Advanced bladder cancer in 2021: Going forward? Saturday, 10 July (11:00-12:30)

or quadruple combinations give us a lot of potential therapeutic options.” “Additional topics that we will discuss in the plenary, thematic and abstract sessions include the potential of personalised medicine, and differentiating between patients who will benefit versus those who won’t. Case presentations are a useful way to illustrate this. We will also look at new, more sensitive imaging options and imaging-guided treatment. Delegates can likely also expect analyses from ongoing trials in the ‘late breaking’ session.”

Associated Plenary Session: Plenary Session 5: Treatment for metastatic hormone-sensitive prostate cancer Sunday, 11 July (11:45-13:15) Continued on page 2

March/May 2021

European Urology Today

Continued from page 1

Prof. Alberto Breda (Barcelona, ES): Reconstructive surgery – WIP

“The importance of the topic also led to the creation of two dedicated thematic sessions. Thematic Session 18 will provide insights of robotic techniques for lymph node dissection during nephroureterectomy, radical nephrectomy with vena cava thrombectomy. Moreover, laparoscopic retroperitoneal partial nephrectomy will be discussed and compared to the robotic technique while the use of a novel robotic platform will be described for radical prostatectomy.”

“Technological improvement has been the engine that has pushed advances in urology over the last decades. The last frontier of the surgical development was the introduction of robot-assisted surgery, which redefined most of the best-known surgical techniques.” “The second, ‘Kidney transplantation in 2021’ (Thematic Session 19), will focus on robot-assisted “In 2021 we can state that the robot-assisted kidney transplantation, orthotopic kidney approach has become a routine, also for transplantation and management of special reconstruction surgery. The high dexterity and situations such as ureteral complications, enhanced vision offered by robot-assisted transplant in Jehovah’s witnesses and robotic procedures allows us to explore different prostatectomy in transplanted patients. techniques of neobladder after radical cystectomy and even to perform a safe and effective kidney “Finally, we will examine the future: the surgery of transplantation with a minimally invasive approach. 2030 is being covered in a variety of abstract This is why the Annual EAU congress will host, for sessions. The introduction of new technologies for the first time, a dedicated Plenary Session entitled robotic surgery is the next step of innovation. This “Reconstructive surgery: Did the robot take over?”. is leading to overcome challenges of outmost importance linked to this field. For example, the “The session will be divided in two main topics preoperative surgical planning is being discussed by world-renowned experts in the field: revolutionized by 3D reconstruction. The use of reconstructive surgery in benign disease and and in augmented reality and near-infrared fluorescence oncology. In the first case, uretero-pelvic junction and Indocyanine green (ICG) is currently reported surgery, iatrogenic ureteral injury repair, robotic in real-time assessment of tissue viability as well surgery in pediatric patients and kidney as structures identifications to avoid complication transplantation will be discussed. In the oncological and ischemia of the organ or of the anastomosis.” section, a focus on the various intracorporeal neobladder technique will be provided to end with Associated Plenary Session a panel discussion on their functional outcomes in Plenary Session 6: comparison with traditional techniques. The Reconstructive surgery: Did the robot take plenary session also features multiple debates with over? pre-recorded cases and live discussion.” Sunday, 11 July (11:45-13:15)

European Urology Today

For the latest updates on EAU21, please visit the website www.eau2021.org or follow us on Facebook, Twitter, LinkedIn and Instagram.

Dr. Jochen Walz (Marseille, FR): Early PCa detection “The screening and early detection of prostate cancer has of course been a hot topic in urology for many years (EORTC, Stockholm 3). At EAU21, we’re addressing the issue in a “nightmare session” with consultant solicitor Mr. Bertie Leigh.” “It’s very important to be aware of the advantages and disadvantages of early detection, and the risks associated with it. Unfortunately, in medicine nothing is ever a 100% vs. a 0% recommendation. You always have to balance advantages and disadvantages when considering treatment options or indeed screening for PCa. You have to balance the risk of overdiagnosis and overtreatment, with the risk of underdiagnosis and undertreatment.” “The plenary session on early detection will highlight details that urologists always have to keep in mind with early detection. In addition to the respective risks of over- and underdiagnosis, we have to be careful when we rely only on imaging, and then miss the disease because we overestimate capacity of the technology.” “The use of MRI for PCa detection is maturing and more widespread, but quality is still an issue. Not every MRI achieves the necessary quality to be helpful and reliable. There is a quality issue, so we have to work closely with radiologists on a European level.” “Beyond the plenary and thematic sessions, we received a lot of abstracts on topics that deal with new technology and surgery. Notably, a lot of abstracts looking at PCa recurrence and a post-treatment rise in PSA. Another hot topic is how to best use MRI as a triage test, and how much we can depend on this technology.”

Associated Plenary Session: Plenary Session 1: Nightmare session: PCa early detection Friday, 9 July (10:30-12:00)

Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Dr. D. Karsza, Budapest (HU) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Assoc. Prof. F. Sanguedolce, Barcelona (ES) Prof. S. Tekgül, Ankara (TR) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) J. Seesing, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680 F +31 (0)26 389 0674 EUT@uroweb.org Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

Patient Day Friday, 9 July 11:30 - 12:30 12:30 - 13:30 13:30 - 14:30 14:30 - 15:30 15:30 - 16:30 16:30 - 17:30 17:30 - 17:40 18:00 - 19:00

Prostate Cancer Bladder Cancer Kidney Cancer Life after Cancer Treatment Functional Urology Patient Poster session The Top-5 Best Patient Poster Awards Roundtable discussion, ‘The Road to Successful Intervention’

Visit eau2021.org for more information.

Cutting-edge Science at Europe’s largest Urology Congress 2

European Urology Today

March/May 2021

Recruitment for VENUS registry started Prospective registry for patients undergoing artificial urinary sphincter surgery Dr. Benoit Peyronnet University of Rennes Rennes (FR)

Prof. Frank Van Der Aa UZ Leuven Dept. of Urology Leuven (BE)

Joni Kats, MSc Clinical Project and Data Manager EAU RF Arnhem (NL)

peyronnetbenoit@ hotmail.fr

frank.vanderaa@ uz.kuleuven.ac.be

j.kats@uroweb.org

Co-authors: Dr. Raymond Schipper and Dr. Wim Witjes The VENUS registry is a prospective non-controlled cohort study evaluating the outcomes of artificial urinary sphincter (AUS) implantation surgery (Robot-assisted, Laparoscopic, Open or other) in female patients for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). The data collection is undertaken from multiple centres in Europe. The participation is by open invitation from the urologists of the EAU Section of Female & Functional Urology (ESFFU) of the European Association of Urology to all its members, along with other surgeons undertaking these procedures. The aim is to recruit a total of 150 patients in 2 years whereafter patients will be followed until the end of the registry which is 5 years after inclusion of the first patient. There will be no restriction on the number of patients enrolled as long as they are consecutive. The aim is to have a long-term collection of the dataset from as many centres as possible. Objectives The primary objective of the VENUS registry is to assess the safety and efficacy of AUS implantation surgeries (Robot-assisted, Laparoscopic, Open or other) for the treatment of female SUI due to ISD. The main outcome of the Registry will be the cure rate of AUS implantation surgeries. Cure is defined as urinary continence with no pads used or use of 1 light security pad, at each of the evaluation points. Cure rate will be calculated together with its 95% confidence intervals. Our secondary objectives are as follows: • To assess the urodynamic outcomes of AUS implantation surgeries (Robot-assisted, Laparoscopic, Open or other) in female patients with SUI due to ISD. • To assess the patient-reported outcomes and impact on quality of life of AUS implantation surgeries (Robot-assisted, Laparoscopic, Open or other) in female patients with SUI due to ISD. • To assess the impact on sexual function of AUS EAU Research Foundation

implantation surgeries (Robot-assisted, Laparoscopic, Open or other) in female patients with SUI due to ISD. Study update The registry is currently approved by the regulatory authorities in Spain, Germany, United Kingdom, Belgium and the most recent approval is received for 11 centres in France. For the Czech Republic the submission to the regulatory authorities is pending. Participating centres Czech Republic: Ass. Prof. R. Zachoval (Thomayer Hospital, Prague) EC submission pending France: Dr. B. Peyronnet (University of Rennes, Rennes), Prof. A. Descazeaud (CHU de Limoges, Limoges), Prof. G. Fournier (Hopital de la Cavale Blanche, Brest), Dr. X. Biardeau (CHU de Lille, Lille), Dr. A. Vidart (Hopital Foch, Suresnes), Prof. X. Game (CHU Rangueil, Toulouse) Dr. V. Cardot (Pole de Sante du Plateau, Meudon), Prof. P. Lecoanet (CHU Nancy, Vandoeuvre Les Nancy), Dr. O. Belas (Pole sante sud, Le Mans), Dr. G. Capon (University Hospital Bordeaux, Bordeaux), Dr. L. Wagner (University Hospital of Nimes, Nimes) Initiating Germany: Prof. KD Sievert (Klinikum Lippe, Detmold) Recruiting Dr. med. Justine Florence Katharina Hein (Klinikum Magdeburg, Magdeburg) EC submission Spain: Dr. López-Fando Lavalle (Hospital Ramón y Cajal, Madrid) Recruiting

United Kingdom: Dr. N. Thiruchelvam (CUH - Addenbrooke's Hospital, Cambridge) Recruiting Recruitment On 23 June 2020, the first patient was screened and so far a total of 2 patients are included in the registry, both at the site of Dr. López-Fando Lavalle (Hospital Ramón y Cajal, Madrid). The COVID pandemic makes it more difficult to start up recruitment. We hope to increase the inclusion rate in the coming months. Interested to join the VENUS Registry? Please fill in the feasibility questionnaire at https://www. surveymonkey.com/r/5YZPG8W or send an email to researchfoundation@uroweb.org.

Get ready for the EAU21 Virtual Congress!. . . . 1

Collaborator Boston Scientific Corporation

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

Study team Principal Investigator: Benoit Peyronnet Department of Urology University of Rennes, France Protocol Writing, - and Steering Committee: • Benoit Peyronnet, France • Frank Van Der Aa, Belgium • Wim Witjes, The Netherlands EAU Research Foundation: Wim Witjes, Scientific and Clinical Research Director Raymond Schipper, Clinical Project Manager Christien Caris, Clinical Project Manager Joni Kats, Clinical Project and Data Manager Joke Van Egmond, Clinical Data Manager

EAU RF: Recruitment for VENUS registry started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

EAU meets the EU’s health chief, Commissioner Kyriakides. . . . . . . . . . . . . . . . 8 Update from the EAU Guidelines Office. . . . . . 9 Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . 10-13 ESGURS: Penile reconstruction for genital gender affirmation surgery. . . . . . 14-15 New guidelines on Non-neurogenic Female LUTS. . . . . . . . . . . . . . . . . . . . . . . . . 15 A highly successful meeting amidst a pandemic . . . . . . . . . . . . . . . . . . . . . . . . . 16 ESU section: New ESU-ESUT-ERUS Virtual MC on Partial nephrectomy. . . . . . . . . . . . . . . . . . . 17 ESU-ESOU Virtual Masterclass on MIBC . . . . 18 Virtual masterclass elicits confidence in NMIBC treatment . . . . . . . . . . . . . . . . . . . 19 Your guide to ESU courses at EAU21. . . . . . . 20 ESUT: Natural 3D visual technologies for minimally invasive surgery. . . . . . . . . . . 21 The e-informed patient. . . . . . . . . . . . . . . . . 23 EUSP’s knowledge exchange during the pandemic & after. . . . . . . . . . . . . . . . . . . . . 24 ESUO: Progressive prostate cancer therapy in outpatient setting. . . . . . . . . . . . 25 ESFFU: Urodynamics for male lower urinary tract symptoms. . . . . . . . . . . . . . . . . 26 ESUP: Digital uropathology in times of COVID-19. . . . . . . . . . . . . . . . . . . . . . . . . . 27 YAU/YUO section: YAU Sexual and Reproductive Health Group. . YAU Trauma and Reconstructive Working Party. . . . . . . . . . . . . . . . . . . . . . . . Urology fellowship in Heilbronn during the pandemic. . . . . . . . . . . . . . . . . . . . . . . . Urology Cheat Sheets: A new way to study urology? . . . . . . . . . . . . . . . . . . . . . . .

28 28 29 29

ESOU21 zeroes in on most pressing onco-urology topics. . . . . . . . . . . . . . . . . . . 31 Philanthropic support in the developing world. . . . . . . . . . . . . . . . . . . . . 33 EAUN section: Spot-on evidence-based nursing care. . . . . 34 EAUN restructured after strategy change . . . 36 Obituary Adolphe Steg. . . . . . . . . . . . . . . . . 35

March/May 2021

European Urology Today

EAU21 Virtual Scientific Programme Thursday, 8 July 8:00 - 10:00

8:00 - 10:00

10:00 - 12:00

13:00 - 15:00

15:00 - 17:00

17:00 - 19:00

8:00 - 9:00

9:00 - 10:00

10:00 - 11:00 11:00 - 12:00

12:00 - 13:00 13:00 - 14:00

Urology beyond Europe Joint Session of the European Association of Urology (EAU) and the Urological Society of Australia and New Zealand (USANZ) Joint Session of the European Association of Urology (EAU) and the Federation of ASEAN Urological Associations (FAUA) Joint Session of the European Association of Urology (EAU) and Russian Society of Urology (RSU) Joint Session of the European Association of Urology (EAU) and the Japanese Urological Association (JUA) Joint Session of the European Association of Urology (EAU) and the Korean Urological Association (KUA) Joint Session of the European Association of Urology (EAU) and the Taiwan Urological Association (TUA) Joint Session of the European Association of Urology (EAU) and the Iranian Urological Association (IUA) Joint Session of the European Association of Urology (EAU) and the Pakistan Association of Urological Surgeons (PAUS) Joint Session of the European Association of Urology (EAU) and the Caucasus/Central Asian countries Joint Session of the European Association of Urology (EAU) and the Société Internationale d’Urologie (SIU) Joint Session of the European Association of Urology (EAU) and the Arab Association of Urology (AAU) Joint Session of the European Association of Urology (EAU) and the Urological Society of India (USI) Joint Session of the European Association of Urology (EAU) and the Maghreb Union Countries Joint Session of the European Association of Urology (EAU) and the Confederación Americana de Urología (CAU) Joint Session of the European Association of Urology (EAU) and the Canadian Urological Association (CUA) Joint Session of the European Association of Urology (EAU) and the Pan-African Urological Surgeons Association (PAUSA)

Poster Sessions Poster Session 01: Basic research and clinical developments in chronic pelvic pain, OAB and neurogenic bladder Poster Session 02: Step by step management LUTS/BPO: From drug treatment to minimally invasive therapies Poster Session 03: Ablative BPO surgery - The world of lasers Poster Session 04: Male and female stress urinary incontinence Evaluation and surgical solutions Poster Session 05: Urinary tract infections: Screening and diagnosis Poster Session 06: Urinary tract infections: Treatment and follow-up

EAU Section Meeting 10:30 - 19:00 Meeting of the EAU Section of UroTechnology (ESUT), in cooperation with the EAU Robotic Urology Section (ERUS) and the EAU Section of Urolithiasis (EULIS) 1 4

European EuropeanUrology UrologyToday Today

Friday, 9 July Plenary Sessions 10:30 - 12:00 Plenary Session 01: Nightmare session: PCa early detection 10:30 - 12:00 Plenary Session 02: Optimal management of incontinence in the elderly patient

Thematic Sessions 13:45 - 14:45 Thematic Session 01: Guideline Session I: Urethral strictures and female UI 13:45 - 14:45 Thematic Session 02: Semi-live I: Penile surgery 15:00 - 16:00 Thematic Session 03: Basic research in prostate cancer and potential clinical impact 15:00 - 16:00 Thematic Session 04: Seminal discoveries in male infertility: From diagnosis to treatment 15:00 - 16:00 Thematic Session 05: Urological trauma: What’s new, what’s controversial? 16:15 - 17:15 Thematic Session 06: Semi-Live II: Benign female surgery 16:15 - 17:15 Thematic Session 07: Treating Peyronie’s disease and erectile dysfunction: It’s not that hard!

Special Sessions 10:00 - 19:00 Patient information sessions 13:45 - 14:45 Special Session: Update on prostate cancer screening 2021 16:15 - 17:15 Special Session: Active Surveillance for intermediate risk prostate cancer: What urologist and patients should know Poster Sessions 10:00 - 11:00 Poster Session 07: Patient engagement 11:00 - 12:00 Poster Session 08: Urolithiasis: Research, new technology and stents 12:00 - 13:00 Poster Session 09: Urolithiasis: Epidemiology, imaging and conservative management 13:00 - 14:00 Poster Session 10: Urolithiasis: Endourology and ESWL 14:00 - 15:00 Poster Session 11: Guidelines 15:00 - 16:00 Poster Session 12: Renal transplantation: Expanding donors’ indications, optimising recipients’ outcomes 16:00 - 17:00 Poster Session 13: Urinary tract reconstruction, including pelvic organ prolapse and fistula repair 17:00 - 18:00 Poster Session 14: Striking features of urethral strictures 18:00 - 19:00 Poster Session 15: Cell biology, biomarkers and novel therapies in prostate cancer

Saturday, 10 July 11:00 - 12:30

11:00 - 12:30

Plenary Sessions Plenary Session 03: Advanced bladder cancer in 2021: Going forward? Plenary session 04: Renal cancer: From localised to metastatic disease

Thematic Sessions Thematic Session 08: Germline genetic testing and clinical consequences for patients and relatives in onco-urology 13:15 - 14:15 Thematic Session 09: Urinary biomarkers: Are we there yet? 15:15 - 16:15 Thematic Session 10: Immunotherapy in urothelial cancer 15:15 - 16:15 Thematic Session 11: Testis Cancer: Innovations by biomarkers and surgery 15:15 - 16:15 Thematic Session 12: Emerging threats by infectious diseases 16:30 - 17:30 Thematic Session 13: Telemedicine in urology 13:15 - 14:15

Special Sessions 15:15 - 17:15 EAU Specialty Sessions: YUORDay21: EAU Young Urologists Office (YUO) & European Society of Residents in Urology (ESRU) 16:30 - 18:00 Special Session: Controversies in Bladder Cancer 2021: Rapid-fire debates

Poster Sessions 10:00 - 11:00 Poster Session 16: Novel biomarkers, subtypes, and disease models in urothelial cancer 11:00 - 12:00 Poster Session 17: Male sexual dysfunction 12:00 - 13:00 Poster Session 18: Male infertility and hypogonadism 13:00 - 14:00 Poster Session 19: Liquid biopsies, biomarkers, and novel therapies in renal tumours 14:00 - 15:00 Poster Session 20: Nephron-sparing treatment in localised kidney cancer 15:00 - 16:00 Poster Session 21: Localised renal tumour diagnosis and prognosis in the digitalised era 16:00 - 17:00 Best abstracts Session: Best abstracts session 17:00 - 18:00 Poster Session 22: Renal tumours: Locally advanced and metastatic disease 18:15 - 19:15 Poster Session 23: Miscellaneous: Rare and complex urology and all about adrenals 18:15 - 19:15 Poster Session 24: Penile and testis cancer

Sunday, 11 July 11:45 - 13:15

11:45 - 13:15

Plenary Sessions Plenary session 05: Treatment for metastatic hormone-sensitive prostate cancer Plenary Session 06: Reconstructive surgery: Did the robot take over?

Thematic Sessions 15:00 - 16:00 Thematic Session 14: Guideline Session II: Prostate cancer - cN+ in newly diagnosed patients 15:00 - 16:00 Thematic Session 15: Complications/ solutions of robot-assisted urologic surgery: Quick answers 15:00 - 16:00 Thematic Session 16: How machine learning is transforming diagnostics 16:15 - 17:15 Thematic Session 17: Treatment sequencing in metastatic prostate cancer 16:15 - 17:15 Thematic Session 18: Semi-Live III: Laparoscopic and robotic surgery for malignant diseases

Poster Sessions 12:00 - 13:00 Poster Session 25: NMIBC: New insights for the diagnosis, management and follow-up 13:00 - 14:00 Poster Session 26: NMIBC: Treatment and prognosis 14:00 - 15:00 Poster Session 27: UTUC: Molecular characterisation and modern management 15:00 - 16:00 Poster Session 28: MIBC: Evolution of surgical management and morbidity 16:00 - 17:00 Poster Session 29: Metastatic prostate cancer 17:00 - 18:00 Poster Session 30: Clinical trials 18:00 - 19:00 Poster Session 31: Affordable urology, instruments and disposables and trauma

13:15 - 14:00

13:15 - 14:00 13:15 - 14:00

17:15 - 18:00 17:15 - 18:00 17:15 - 18:00

Video Sessions Video Session 13: Interesting techniques in urethral stricture management Video Session 14: Salvage robotic pelvic surgery Video Session 15: Pushing the boundaries in female reconstructive surgery Video Session 16: Robotic reconstructions Video Session 17: Augmented reality in robotic urological surgery Video Session 18: Interesting techniques for management of upper tract obstruction

Video Sessions Video Session 07: Improving outcomes following robotic cystectomy 12:30 - 13:15 Video Session 08: Award winning video session 12:30 - 13:15 Video Session 09: Challenging retroperitoneal surgery for testicular disease 17:45 - 18:30 Video Session 10: New perspectives in inguinal and pelvic lymph node dissection 17:45 - 18:30 Video Session 11: A tale of three kidneys: Complex and salvage robotic kidney surgery 17:45 - 18:30 Video Session 12: Robotic partial nephrectomy - get your clamp off! 12:30 - 13:15

Video Sessions 12:00 - 12:45 Video Session 01: Techniques to evolve radical prostatectomy 12:00 - 12:45 Video Session 02: Progress in sacrocolpopexy 12:00 - 12:45 Video Session 03: Innovative training and novel technologies 17:15 - 18:00 Video Session 04: Avoiding and managing complications 17:15 - 18:00 Video Session 05: Alternative approaches to bladder outlet obstruction 17:15 - 18:00 Video Session 06: Challenges in genital cancer surgery

March/May 2021

Cutting-edge Science at Europe’s largest Urology Congress

Monday, 12 July 8:00 - 9:30

Plenary Session Plenary Session 07: Stones: Keeping with tradition or time for new concepts?

Thematic Sessions 10:00 - 11:00 Thematic Session 19: Kidney transplantation in 2021 10:00 - 11:00 Thematic Session 20: Semi-Live IV: New standards in endourology 10:00 - 11:00 Thematic Session 21: Latest developments in paediatric urology

9:30 - 10:30 11:00 - 12:00 11.00 - 12.00 12:00 - 13:00

12:30 - 13:30 13:30 - 14:30

14:30 - 15:30 15:30 - 16:30 16:30 - 17:30 17:30 - 19:30

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13:30 - 14:30 13:30 - 14:30

14:30 - 15:30 14:30 - 15:30

15:30 - 16:30

16:30 - 17:30

Special Sessions Controversies on EAU Guidelines Session I Controversies on EAU Guidelines Session II History of urology at a glance Joint session of the EAU and the Advanced Prostate Cancer Consensus (APCCC) Meeting of the Young Academic Urologists (YAU) 7th ESO Prostate Cancer observatory: Innovations and care in the next 12 months PIONEER prostate cancer platform European Urology: Surgery-inMotion session ERN eUROGEN 2021: Update on rare and complex urology Best of EAU 2021 session

Poster Sessions Poster Session 32: Prostate cancer detection by MR, PET and Micro-US imaging Poster Session 33: Prostate cancer biopsy protocols and methods of targeting Poster Session 34: Education and training models in urology and E-health Poster Session 35: Prostate cancer screening, biopsy indication protocols and markers Poster Session 36: History and histories Poster Session 37: Active surveillance and focal therapy: Evolving concepts and long term outcome Poster Session 38: Paediatric urology Poster Session 39: Radical prostatectomy: Long-term outcome and how we can do better Poster Session 40: Transgender and adult and paediatric genital surgery Poster Session 41: Functional outcome of radical prostatectomy and how we can do better Poster Session 42: Detection of recurrence and salvage treatment options after primary treatment for prostate cancer Poster Session 43: How to manage high risk and advanced prostate cancer?

March/May 2021

Video Sessions 13:00 - 13:30 Video Session 19: Minimally invasive techniques in adrenal surgery 15:30 - 16:00 Video Session 20: Focal diagnosis and treatment 15:30 - 16:00 Video Session 21: Mini-PCNL for paediatric stones 15:30 - 16:15

For more details and the most up-to-date scientific programme, visit the EAU21 website: www.eau2021.org/programme

Video Session 22: Contemporary robotic kidney transplantation

EAU Section Meetings 11:00 - 12:00 Meeting of the EAU Section of Infections in Urology (ESIU): The threat of urogenital infections 12:00 - 13:00 Meeting of the EAU Section of Genitourinary Reconstructive Surgeons (ESGURS): Contemporary urogenital reconstruction and continence restoration: A practical guide 12:00 - 13:00 Meeting of the EAU Section of Outpatient and Office Urologists (ESUO): Andrological tips and tricks for outpatient and office urologists 13:30 - 14:30 Meeting of the EAU Section of Andrological Urology (ESAU): Unanswered questions in andrology 13:30 - 14:30 Meeting of the EAU Section of Urolithiasis (EULIS): Pathophysiology and management of urolithiasis: New perspectives and approaches in 2021 14:30 - 15:30 Meeting of the EAU Robotic Urology Section (ERUS): State of the art in robotic surgery: ERUS 2021 14:30 - 15:30 Meeting of the EAU Section of Transplantation Urology (ESTU): Surgical matters in kidney transplantation 16:00 - 17:30 Joint meeting of the EAU Section of Oncological Urology (ESOU) and the EAU Robotic Urology Section (ERUS) in conjunction with ESMO and ESTRO: Controversies in onco-urology 16:00 - 17:30 Joint meeting of the EAU Section of Urological Imaging (ESUI), the EAU Section of Uropathology (ESUP) and the EAU Section of Urological Research (ESUR): Ready for take-off: Molecular markers for clinical management of urological malignancies 16:15 - 17:15 Meeting of the EAU Section of Female and Functional Urology (ESFFU): Functional urology in 2021: What did we miss at EAU20 and what is essential?

European EuropeanUrology UrologyToday Today

EAU21: 65 abstract sessions featuring every single accepted abstract Exceptional high quality of abstracts results in each getting its chance in the spotlight Annual EAU Congresses aim to offer state-of-theart urological science. The abstracts selected for the 36th edition (EAU21) strongly reflect that mission. Due to the high quality of these abstracts, the Scientific Congress Office (SCO) decided to give every accepted abstract its chance in the spotlight during the five-day EAU21 Virtual Congress (8-12 July 2021). Over the course of 43 poster sessions, every lead researcher will give a one-minute presentation on their poster abstract, with the full five-minute presentation being available to delegates on demand on the EAU21 Congress Platform as of 1 July 2021. In addition to these 43 sessions, track leaders will pick and discuss five of the strongest abstracts within a certain topic during the “Best abstracts” poster session. Each accepted video abstract will be presented, too, in videos of eight minutes at the most spread over 22 video sessions. Each session will feature live discussions with abstract presenters and a Q&A box. This framework follows the 0.8% increase in the acceptance rate in comparison with EAU20 (30.5% versus 29.7%). In total, 4165 abstracts were submitted for EAU21 Virtual: 3902 poster abstracts and 263 video abstracts, of which 1204 and 65 were accepted respectively, giving a total of 1269 accepted abstracts. Topics Prostate cancer is the most popular topic in the pool of accepted abstracts. While this isn’t necessarily news as to the poster abstracts, prostate cancer climbed from the fourth to the top spot in the top four of the accepted video abstracts compared to last year.

Top four topics of accepted abstracts - poster: 1. Prostate cancer (290) 2. Urothelial cancer (150) 3. Benign lower urinary tract diseases (127) 4. Renal tumour (120) Top four topics of accepted abstracts – video: 1. Prostate cancer (13) 2. Uro-genital reconstruction (11) 3. Renal tumour (9) 4. Urothelial cancer (7) To be as complete as possible and to give each abstract submitter the chance to send their abstract under a topic that most closely fit their research, the SCO added three new topics to the abstract submission for EAU21 Virtual: affordable medicine/technologies, trials in progress, and patients. With the third, the EAU will be one of the first large scientific societies to actively enrol patients in its annual meeting. Global spread The abstracts track at EAU21 Virtual is going to be even more international than at EAU20, with abstracts from 54 countries being accepted (versus 52). Each continent will be represented. Continents with most accepted abstracts: 1. Europe 2. Asia 3. North America 4. Africa 5. Australia 6. South America On 8 June 2021, one month before the congress, all abstracts will be available in full text to EAU members in the EAU21 Resource Centre. All delegates will have access via the EAU21 Congress platform as of 1 July.

Schedule of ESU Courses at EAU21 Thursday, 8 July 2021

Sunday, 11 July 2021

ESU Courses 08:00 - 10:00 ESU Course 1 Surgical management of prolapse and urinary incontinence/female pelvic floor disorders 11:00 - 13:00 ESU Course 2 Practical aspects of cancer pathology for urologists. The 2021 WHO novelties 14:00 - 16:00 ESU Course 3 Andrology and infertility update 17:00 - 19:00 ESU Course 4 Ultrasound in urology

ESU Courses 08:00 - 10:00 ESU Course 15 Practical management of nonmuscle invasive bladder cancer (NMIBC) 10:30 - 12:30 ESU Course 16 Clinical and surgical management of upper tract tumours 13:00 - 15:00 ESU Course 17 Management and outcome in invasive and locally advanced bladder cancer 15:30 - 17:30 ESU Course 18 Percutaneous nephrolithotripsy (PCNL) 18:00 - 20:00 ESU Course 19 Recent advances in robotic urology of the prostate

Friday, 9 July 2021 ESU Courses 08:00 - 10:00 ESU Course 5 Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications 10:30 - 12:30 ESU Course 6 Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips and tricks and indications 13:00 - 15:00 ESU Course 7 Management of lower urinary tract dysfunction and BPO: From urodynamics to medical and surgical treatment 15:30 - 17:30 ESU Course 8 Metabolic workup and non-surgical management of urinary stone disease 18:00 - 20:00 ESU Course 9 Surgical anatomy for laparoscopic and robotic-assisted radical prostatectomy and cystectomy

Monday, 12 July 2021 ESU Courses 08:00 - 10:00 ESU Course 20 Robotic surgery and ablative treatment of renal tumours 11:00 - 13:00 ESU Course 21 Laparoscopy for beginners 14:15 - 16:15 ESU Course 22 Metastatic prostate cancer: Systemic treatments and options of local treatment in case of oligometastatic disease 17:30 - 19:30 ESU Course 23 Prosthetic surgery in urology

Saturday, 10 July 2021

Additional call for late breaking, game-changing developments The Scientific Congress Office is calling for the submission of game-changing, late breaking news for new trial results or other developments that could not be included in the regular scientific programme. These should be submitted in abstract form, but will be presented in a special session with expert discussants. At each Annual Congress, a special session is organised for new developments that occurred after the closing of the regular abstract submission deadline. This may include new results from trials that the congress delegates may be interested in, new breakthroughs in research or other developments that will have a large impact on daily practice. Submission for the late breaking, game-changing abstracts is open until June 1st. Send in yours via e-mail to Ms. Claudia van Ijzendoorn: c.vanijzendoorn@congressconsultants.com

ESU Courses 08:00 - 10:00 ESU Course 10 Advanced course on urethral stricture surgery 10:30 - 12:30 ESU Course 11 Prostate cancer imaging and biopsy 13:00 - 15:00 ESU Course 12 Prostate cancer screening and active surveillance: Where are we now? 15:30 - 17:30 ESU Course 13 Urinary tract and genital trauma 18:00 - 20:00 ESU Course 14 Robot-assisted laparoscopic radical cystectomy: Intracorporeal urinary diversions and nerve-sparing techniques. Surgical tricks and management of complications

How to register Participation in the ESU courses is subject to availability and only limited virtual seats are available! Don’t miss out and sign up for the courses now. Please go to https://eaucongress.uroweb.org/registration/ to register for EAU21 and enrol to the ESU courses of your choice. The registration fees* for the courses are as follows: EAU members € 23 Non-members € 35 Residents/nurses € 15 Fees Include 7.7% VAT.

Urology Today 6 European European Urology Today

March/May 2021

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

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

Oliver.Hakenberg@ med.uni-rostock.de

Case study No. 69

Case study No. 68 This 86-year-old man was referred with painless macroscopic haematuria. A CT scan, which had been performed without contrast media because of elevated serume creatinine, showed a ‘large tumorous lesion of the left lateral bladder wall’ (Figure 1, arrow sign). Cystoscopy showed that a mesh implanted for a laparoscopic left inguinal hernia repair several years previously had ingrown into the bladder and that around this foreign body papillary formations suggestive of a bladder malignancy were present. TUR-biopsy confirmed urothelial carcinoma grade 2 without

evidence of muscle-invasion but there was no detrusor tissue in the biopsies. Discussion point • Which management and treatment is advisable?

Case provided by Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail: oliver.hakenberg@med.uni-rostock.de Figure 1

A 35-year-old man suffered a straddle injury to the urethra without pelvic fracture. A few weeks later, he complained of dysuria and a urethrogram showed a stricture which was treated by direct vision internal urethrotomy (DVIU). Already three weeks later, a recurrence occurred. During the following two years, the patient underwent eight endoscopic procedures, either dilatation or DVIU. Eventually, a urethroplasty was performed. One year later, the patient is still complaining of dysuria and was referred to our centre without any detailed reports of the previous procedures. A new urethrogram was done (Fig. 1).

Partial cystectomy en bloc with entire mesh, extraperitoneally Comments by Prof. Arnulf Stenzl Tübingen (DE)

The assumption in this case is that a papillary tumour formed around a foreign body infiltrating the bladder wall. Although we don’t know whether G2 meant Low grade or high grade it may very well have been high grade due to the CT (without contrast material though) and due to the fact that the tumour may have derived from chronic inflammation originating from a foreign body. Any further imaging including MRI (with or without VI-RADS) will not really be helpful. What are the options? In an otherwise healthy and fit man – despite his age - one would go for

another deep transurethral resection into the perivesical space, maybe even an en bloc resection might be feasible. Depending on the results in a fit patient consider radical cystectomy with maybe a ureterocutaneous diversion. In this gentleman, however, with chronic renal insufficiency and maybe other comorbidities you should consider an excision of the tumour bearing bladder wall including a safety margin and the entire mesh. I don’t favour a partial cystectomy but under these circumstances it might be an advisable option. The fact that the tumour may have originated from the mesh and the insertion of this mesh will have altered lymphatic drainage in this area makes any excision of this tumour more dangerous for spillage. Therefore, the partial cystectomy done en bloc with the entire mesh should be done extraperitoneally in

order to avoid any possible spillage into the extravesical space and peritoneum. I would strongly discourage any minimally-invasive surgery, because of the danger of spillage through a regular transperitoneal access and otherwise the limited possibility of doing a minimally invasive partial cystectomy en bloc with the tumour bearing foreign body extraperitoneally. Any chance for a non-surgical bladder preserving strategy? Radiation either as mono or part of a multimodality therapy in this case may not be a good option because of more expected side effects with a foreign body and concomitant inflammation. He is presumably unfit for any cisplatin based chemotherapy, and we don’t know his PDL-1 status.

Fig. 1

Discussion point • Which treatment is advisable?

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

Case study No. 68 continued Since the primary histology was somewhat inconclusive, and due to the fact that the surgical mesh was incorporated into the bladder wall and the tumour, we performed partial cystectomy. The final pathology report confirmed a solid urothelial carcinoma growing through the entire bladder wall (pT3b G3), with negative surgical margins. Two lymph nodes had been removed which were negative. Since this man is 86 years old and took some time to recover from surgery no further treatment was deemed appropriate.

Base best treatment option on tumour grade, aetiology and comorbidities Comments by Prof. Morgan Rouprêt Paris (FR)

Which management and treatment is advisable ? There is no doubt in my mind that we are dealing with a difficult case of primary bladder cancer in an elderly patient. The tumour appears to be “large” on the CT. We have to be extremely careful as CT artifacts are common with foreign body in the bladder wall. Some data are missing here to make a decision. Do we have a pre-operative positive cytology? Do we have images of the upper urinary tract? Are we facing a pTaG2 tumour or a pT1G2 tumour. This is not the same, as several G2 tumours (> 60%) can be translated in high grade tumours in the most recent WHO classification. High grade includes some G2 and all G3 tumours. Consequently, we are facing a difficult situation from real life because the presence of detrusor is a surrogate of the quality of the TUR. I am a bit concerned about the term “biopsy” which seems to suggest that the endoscopic procedure was not complete and exhaustive. To be very straight forward:

March/May 2021

• I would ask the pathologist to provide the Grade of the tumour according to the WHO 2004 classification (low versus high) • I would advocate a second-look with a so-called good ‘old fashioned’ TURB as there are too many uncertainties around the T stage and the Grade of the tumour We know from clinical experience that the foreign body could have launched and triggered the carcinogenic pathway within the bladder wall. I am also concerned about the existence of histological variants within the tumour when the carcinogenic pathway has (possibly) been initiated by a foreign body. We know from the EAU guidelines that we have to base the decision on bladder-sparing treatment or radical cystectomy in elderly/frail patients with invasive bladder cancer on tumour stage and comorbidity. Management First option: Please be aware that we could also face a bladder tumour case (Ta Low Grade) on top of a foreign body which has induced a “so-called” chronic abscess imitating cancer of the bladder wall. And in that case, the problem could be solved by simple surveillance after a deep TURBT. In our department, we have had this experience in a limited number of women who had persisting disabling symptoms after conservative management of TVT mesh through the bladder wall. Urologists must be aware that a complete resection of the MESH can help resolve the symptoms and could

be advocated here. Thus complete TURBT and complete removal of the mesh (external approach) could also be an option to discuss. Second option: One can hypothesize that this man is facing a situation of high-risk urothelial carcinoma of the bladder with a kidney obstruction. Theoretically, a radical cystectomy and a ileal conduit should be proposed contingent upon the fact that the pathological assessment can confirm we are at least facing T1 high grade tumour. We cannot rely only on the size of the tumour nor on its “aspect” on CT. I would be reluctant to deliver intravesical instillation of BCG or Mitomycin in that particular situation (bladder extravasation risk). Facing a high risk bladder cancer, and regardless of his age, I would not hesitate to propose a radical cystectomy, after a careful evaluation (anaesthesiology and geriatric oncology). However, a cystectomy decision in a 86-year-old gentleman is a tough and last-resort decision which should not be made based on the existence of “a large tumour” only, but much more on what has been seen by the urologist during the TUR. Only more details from the pathologist, a discussion within a tumour board and an accurate evaluation of the patient’s comorbidities, will help us to make the best decision in such a difficult situation. References European Association of Urology Guidelines on Muscleinvasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines.

Witjes JA, Bruins HM, Cathomas R, Compérat EM, Cowan NC, Gakis G, Hernández V, Linares Espinós E, Lorch A, Neuzillet Y, Rouanne M, Thalmann GN, Veskimäe E, Ribal MJ, van der Heijden AG.Eur Urol. 2021 Jan;79(1):82-104.

European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update. Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Sylvester R, Zigeuner R, Capoun O, Cohen D, Escrig JLD, Hernández V, Peyronnet B, Seisen T, Soukup V.Eur Urol. 2019 Nov;76(5):639-657. Laparoscopic surgical complete sling resection for tension-free vaginal tape-related complications refractory to first-line conservative management: a single-centre experience. Rouprêt M, Misraï V, Vaessen C, Cour F, Haertig A, Chartier-Kastler E.Eur Urol. 2010 Aug;58(2):270-4.

European Urology Today

EAU meets the EU’s health chief, Commissioner Kyriakides …and more news from the European Union Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

s.collen@uroweb.org On 24 March 2021, Prof. Christopher Chapple (GB), Prof. Hein Van Poppel (BE) and Prof. James N’Dow (GB) from the EAU Executive team and Mrs. Sarah Collen (BE), EAU Policy Manager, met with EU Commissioner for Health, Stella Kyriakides. The focus of the meeting was to introduce the work of the EAU and our members and to discuss two particular EU initiatives which are of keen interest to us: Europe’s Beating Cancer Plan and the European Health Data Space. Prof. Chapple led the discussion by introducing the EAU and our many initiatives. He also touched upon ERN eUROGEN, the European Reference Network for rare and complex urorectogenital diseases and conditions, and the invaluable network of clinical expertise it has established across Europe.

“The Commissioner confirmed that the EAU will be one of the key stakeholders as the review of the 2003 EU Council Recommendations on Cancer Screening gets underway.” Europe’s Beating Cancer Plan was published by the European Commission on World Cancer Day, 4 February 2021. The plan is wide-ranging: it covers all phases of cancer, from prevention and early diagnosis to treatment and care and survivorship. The EAU has been encouraging the European Commission to address risk-stratified early detection of prostate cancer through guidelines and qualityassurance work at EU level. In order to do this, the 2003 EU Council Recommendations on Cancer Screening will need to be revised to add new cancers as they currently only address breast, colorectal and cervical cancer. This is exactly what Europe’s Beating Cancer Plan has promised to do: the European Commission will review these recommendations this year and look to add prostate, lung, and gastric cancer to the list of cancers addressed. During the meeting with the Commissioner, Prof. Van Poppel was able to say that what prostate cancer needs is a risk-stratified and targeted approach, and this starts with well-informed men. This was well received by the Commissioner, who confirmed that the EAU will be one of the key stakeholders as the review gets underway. We also discussed important initiatives under Europe’s Beating Cancer Plan such as the Comprehensive Cancer Centres. We were able to feed in our experience with the Prostate Cancer Centres of Excellence, Prostate Cancer Units and the work conducted with the European Cancer Organisation on essential quality requirements for prostate cancer

care. This led nicely into a discussion on a new initiative under the Cancer Plan called the InterSpecialty Training Programme, where we think we could add our expertise through our multidisciplinary training and guidelines. Prof. N’Dow was then able to introduce the EAU-led Prostate PIONEER project on harnessing the power of big data for better prostate cancer outcomes, which has been driven by the EAU Guidelines Office as it strives for better and more personalised guidelines for prostate cancer patients. This project will be important for Europe’s Beating Cancer Plan and the European Health Data Space. We discussed how valuable we find the project of digitalisation and enhanced secure and ethical sharing of health data. We will work with the European Commission to ensure this will be a successful endeavour, which means better use of data for better patient outcomes. Further news from the European Union As the headlines have been quite dominated by COVID-19 vaccine rollout (or delays), you may have missed some of the other developments happening at EU level. This month has seen the approval of a major EU funding programme, EU4Health, which will have 5.1 billion Euros available for funding health projects across the EU over the next 7 years. Priorities for this programme will be: • Crisis preparedness and management of crossborder health threats. This will include funding for surveillance, preparedness and response, antimicrobial resistance, medicines shortages and security of supply. • Health promotion and disease prevention. A major chunk of this funding is likely to go to implementing Europe’s Beating Cancer Plan and additionally to prevention of other noncommunicable diseases and related risk factors, mental health, transfers of best practices, and health information. The programme is obliged to spend at least 20% on prevention programmes. • Strengthening health systems and improving their resilience and resource efficiency. Funding will be available for innovative health care models, resilience testing methodology, planning, and forecasting health workforce. • Digital transformation of healthcare and health systems. The European Health Data Space and projects on health data sharing will benefit from this funding. • Strengthening the implementation of the health legislation. Besides regulations applying to the clinical practice, this also includes regulations on in-vitro diagnostics, tobacco control and the pharmaceutical legislation. The first work programme in 2021 will have €316 million available and we are likely to see calls for proposals for projects being launched in summer 2021. There will be increasing amounts available throughout the years, rising to over €900 million available in 2027. EAU’s leading role in implementation of EU Medical Device Regulation On 26 May 2021, the EU’s Regulation on Medical Devices will be applied across the European Union. This Regulation was agreed upon in 2017 and the implementation was delayed by one year as the

anticipated date last year was during the early days of the COVID-19 crisis. The implementation of the corresponding In-Vitro Diagnostic Regulation has also been pushed back by a year and will be implemented on 26 May 2022. An important new feature of both pieces of legislation is the creation of expert panels to support the scientific assessment and advices. The EAU team meets with Stella Kyriakides, the European Commissioner for Health and Food Safety These expert panels will provide opinions on assessments from EU notified bodies of clinical evaluations of certain high-risk medical devices. We are very excited to announce that Prof. Jens Rassweiler (DE) has been appointed as the vice-chair of the expert panel on urology and nephrology. This is a great recognition of Prof. Rassweiler’s expertise and is a significant appointment as it means that Prof. Rassweiler will have a leading oversight role to play as the new high-risk medical devices in urology come onto the market. The advice of the expert panels will play an important role in ensuring the coherent approach of notified bodies across the EU and in ensuring that patient safety is Figure 1: Distribution of patients between countries, with the paramount. It will be very number of full members displayed. The total mean patient difficult for notified bodies to ignore a negative assessment of numbers requiring long-term care between 2013 and 2019 are a device by the expert panel. We shown. From: W.F.J. Feitz, L. Oomen, E. Leijte, D E. Shilhan, congratulate Prof. Rassweiler on M. Battye, Members of ERN eUROGEN. Rare and Complex Urology: Clinical Overview of ERN eUROGEN. European his appointment, and we look Urology, 2021, ISSN 0302-2838. https://doi.org/10.1016/j. forward to supporting him in eururo.2021.02.043. Prof. Jens Rassweiler his role as we move forward. ERN eUROGEN update ERN eUROGEN is very proud to announce that their first peer-reviewed article “Rare and Complex Urology: Clinical Overview of ERN eUROGEN” has been accepted and published in European Urology. This important paper provides an overview and identifies challenges in data collection from the network’s patient population treated by their Healthcare Provider (HCP) members. ERN eUROGEN analysed the patient population between 2013 and 2019, and the data show that ERN eUROGEN’s HCPs and expert multidisciplinary teams are treating an increasing number of patients and performing an increasing number of complex surgical procedures. However, despite a well-structured continuous monitoring system, challenges persist regarding definitions of diagnostic codes, extraction of patient numbers and procedures, and validation of these data; therefore, improvements are needed in patient registration. The network is expanding in 2021 (with an expected 30 new full HCP members and new disease areas), which will also facilitate the provision of equal care for all patients suffering from rare urorectogenital diseases and complex conditions in Europe. ERN eUROGEN will continue to follow this up with a view to further publications. Future actions will include re-evaluation of network members and current practices to maintain expertise levels, continuation of patient registry development, and research aimed at providing new insights and optimal care studies on rare diseases. Knowledge sharing is also expanding with more frequent webinars, development of clinical guidelines, and the start of the ERN Mobility Programme facilitating expertise exchange between HCPs. The network is very grateful to all who contributed to and helped with the landmark publication in European Urology, and they encourage readers to share it widely with their networks. The Open Access paper can be viewed on Elsevier’s ScienceDirect platform here: http://tiny.cc/eUROGENpaper European Parliament’s Special Committee on Beating Cancer tackles PCa early detection In a public hearing on early detection and screening of cancer on 18 March 2021, Members of the European Parliament (MEPs) heard from Prof. Van Poppel, the EAU Adjunct Secretary General, on the issue of early detection of prostate cancer.

Prof. Hein Van Poppel gives his speech in the virtual European Parliament during the public hearing on early detection and screening of cancer

European Urology Today

The hearing was designed to take stock of screening programmes currently supported by the European

Union (breast, cervix, and colorectal cancer) and to address the three additional cancers that are to be considered by the European Commission this year in a review of the 2003 EU Council Recommendations on Cancer Screening (prostate, lung, and gastric cancer). Prof. Van Poppel reminded the participants that prostate cancer is the most common male cancer and a condition that is on the rise with ageing populations across Europe. It is also a killer of too many men, and in Germany it has overtaken colorectal cancer to become the second-highest cancer killer in men behind lung cancer. It is a condition that can cause much suffering for men and their families. In the past, 1 out of 2 men who were diagnosed with prostate cancer died. Using prostate-specific antigen (PSA) testing allowed for a lot more cancers to be diagnosed. Prostate cancer mortality had fallen more in comparison with any other cancer, but at the cost of overdiagnosis and overtreatment, which led for PSA testing to be discouraged. As a result of this, while prostate cancer mortality had declined for a long time, it is now on the increase again due to reduced testing. Prof. Van Poppel said that science has moved on since 2003, and doctors now have a way of reducing the risk of overdiagnosis and overtreatment. Risk calculators are used to avoid doing too many biopsies, along with MRI. On Europe’s Beating Cancer Plan, he stressed that information to men on prostate cancer and early detection saves lives, especially for a cancer such as prostate which could be easily detected and cured in its early stages. Nobody should die from prostate cancer anymore, he underlined. Europe’s Beating Cancer Plan has a unique opportunity to add prostate cancer to the list of cancers that benefit from EU guidelines and quality assessment work. Véronique Trillet-Lenoir, rapporteur for the file in the European Parliament, summarised the event in her concluding remarks, and she agreed with Prof. Van Poppel’s analysis that screening programmes for other types of cancer such as prostate should be included in the EU recommendations. We look forward to the Parliament’s final report including this important issue. The recording and presentations from the hearing can be found at https://www.europarl.europa.eu/ committees/en/hearing-why-screening-and-earlydetectio/product-details/20210309CHE08442. March/May 2021

Update from the EAU Guidelines Office PIONEER Prostate Cancer Study-a-thon Over the course of five days, from 8 to 12 March, PIONEER (the European Network of Excellence for Big Data in Prostate Cancer) joined forces with EHDEN (the European Health Data and Evidence Network) and OHDSI (the Observational Health Data Sciences and Informatics community) to host a virtual prostate cancer (PCa) study-a-thon to inform shared healthcare decision-making for prostate cancer patients managed by watchful waiting (WW): a conservative management option for prostate cancer patients with a life expectancy of less than 10 years at time of diagnosis. The patient’s disease is ‘watched’ for development of local or systemic progression until they required palliative treatment with the intention being to maintain quality of life.

“It is hoped this continued collaboration will culminate in the submission of two high-impact scientific papers.” A study-a-thon brings together a concentration of researchers, epidemiologists, statisticians, clinicians, and patients to research a specific clinical question in, for instance, five days, truncating what would normally take months or even years. For the PIONEER Prostate Cancer Study-a-thon, more than 240 participants including data scientists, clinicians, epidemiologists, patients, and statisticians from 20 different countries came together. Twenty databases from across six countries with prostate cancer patient data participated. Two high-impact scientific papers will soon be submitted for peer-review. The first assesses the impact of comorbidities and life expectancy on the long-term outcomes of patients managed with WW. The second involves the development of prediction models for the time to symptomatic progression, palliative treatment initiation, or death within a specific timeframe for WW patients. The aim of this study-a-thon was to assess selection criteria and long-term outcomes of prostate cancer patients on watchful waiting by using an international network of real-world data spanning the years watchful waiting has been a recognised prostate cancer management approach. Building on past experience Building on the experience of the OHDSI COVID-19 study-a-thon (https://www.ohdsi.org/covid-19updates/) in 2020 and prior EHDEN study-a-thons, the

PIONEER study-a-thon began on 8 March; however, preparation for the event began months beforehand with the: • Completion of a literature review of 14,996 articles. The aim of the review was to inform the study regarding the varying definitions of watchful waiting, the reported outcomes across the studies reviewed as well as the characteristics of the patients included in these studies. This information supported the development of the study protocol and informed the discussion on defining the patient cohorts. • Drafting of the study protocol which guided the Data Sources team and helped them to identify and invite data holders both internally and externally to partake in the study, ultimately making the analytics possible. • Patient outreach initiative. The study-a-thon management team felt very strongly that the patient voice needed to be represented within the workstreams. To achieve this, a number of patient representatives were invited to share their personal stories of prostate cancer diagnosis and treatment with the participants as well as to participate in the Patient Characterisation and Phenotyping workstreams. • Development of a Microsoft Teams environment that acted as the virtual hub for the study-a-thon. Over the course of the five days, there were 10 global overarching sessions and 15 team meetings within the four active workstreams, with all participants generating over 870 engagements including posts, replies, reactions and mentions across the platform. How we achieved our aims The study-a-thon participants were divided across four workstreams/sub-teams.

“One of the highlights of the studya-thon was the inclusion of patient representatives.” Clinical characterisation who described the demographic and clinical characteristics of patients with prostate cancer under conservative management and the estimated clinical outcomes of these patients, including those who initiated treatment. Cohort diagnostics and clinical characterisation results from several databases are available, covering 340,000 unique patients. Explore the clinical characterisation results with the Shiny App (https://data.ohdsi.org/ PioneerWatchfulWaiting/)

Gary Hooker – Patient representative “I was very nervous before I joined on the first day and didn't know what to expect, but everybody was very welcoming and listened to the views from the patient’s perspective, not many organisations do that. Not only did I feel listened to, but some of my views and suggestions were taken up by the clinical characterisations team. Thank you for the wonderful opportunity, I really enjoyed the experience and wouldn't hesitate to join another study-a-thon in the future.” Peter Prinsen - Clinical Data Scientist (Netherlands Cancer Registry (NCR) / Netherlands Comprehensive Cancer Organisation (IKNL) “Last year, we started converting the NCR to the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). So far it was mainly an exercise in understanding our own data and writing the ‘Extract, Transform, and Load’ (ETL), so this study-a-thon was a great opportunity for us to test the work we have done, and we learned a lot this week! It brought our understanding of the OMOP CDM, the quality of our ETL, and our experiences with running scripts to a new level. We are excited to continue this work, join the PIONEER community, and hopefully join many more study-a-thons in the future!”

The Prediction team developed a prediction model, in the context of WW, that predicts an outcome (symptomatic progression, death, death without symptoms) at a specific moment in time (6, 12, 24 months) based on a combination of patient characteristics.

weekly team meetings, will culminate in the submission of two high-impact scientific papers (both already drafted) and an exciting presentation of the PIONEER study-a-thon team to the OHDSI community in May. For updates on the PIONEER study-a-thon or PIONEER in general, follow us on Twitter @ProstatePIONEER or LinkedIn. To sum up this first exciting stage of the PIONEER Prostate Cancer Study-a-thon some of the insights of various participants: from data holders to clinicians and patients are given below. Funding PIONEER is funded through the IMI2 Joint Undertaking and is listed under grant agreement No. 777492. IMI2 receives support from the European Union’s Horizon 2020 research and innovation programme and the European Federation of Pharmaceutical Industries and Associations (EFPIA).

Last, but perhaps the most integral team Data Sources and Study Execution who identified and recruited appropriate databases to the study developed the code to run analyses for clinical characterisation and to compile results in an easy-to-install R package (https://github.com/ ohdsi-studies/PioneerWatchfulWaiting), and debugged and adapted the code as required to match the requirements of the different data providers and to reflect changes in the research question. One of the highlights of the study-a-thon was the inclusion of patient representatives. Over the course of the five days, four prostate cancer patients shared their personal stories of their diagnosis, treatment, and ongoing follow-up where applicable. The patients also made valuable contributes to the clinical characterisation and phenotyping teams by bringing their unique perspective to the discussions. Overall, participants found that including patients in the study helped them gain additional perspectives on their work and impacted greatly with regards to framing how the study-a-thon outcomes should be used and disseminated to different stakeholder groups. Looking to the future Over the course of the next month, the study-a-thon team will continue to run analyses across more databases, adding to the results of the clinical characterisation study whilst the prediction team will work towards external validation of their prediction model. It is hoped this continued collaboration, with

The European Health Data & Evidence Network (EHDEN) has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 806968. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA.

“This innovative initiative by PIONEER was a unique opportunity to work together with a wide range of multidisciplinary experts to carry out an intense, data-driven research project.” OHDSI is a multi-stakeholder, interdisciplinary collaborative to bring out the value of health data through large-scale analytics. All solutions are open-source. OHDSI has established an international network of researchers and observational health databases with a central coordinating centre housed at Columbia University.

The 2021 EAU Guidelines are here! EAU PO Box 30016 6803 AA Arnhem The Netherlands

Guidelines Publications As the 36th Annual EAU Congress (EAU21) will be a virtual meeting from 8 to 12 July 2021, the full text and pocket versions of the 2021 European Association of Urology (EAU) Guidelines were launched on the EAU website on 1 April. The PDFs of the documents and other accompanying materials are available for members to download. In addition, the EAU Pocket Guidelines App has been launched as well, and it can be downloaded in the Google Play Store for Android devices or the Apple App Store for iOS. As standard, full members will receive a copy of the pocket guidelines in the mail. T +31 (0)26 389 0680

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

European Association of Urology

Guidelines 2021 edition

Guidelines

Luc Belmans – Data holder Medaman “This innovative initiative by PIONEER was actually a great experience. It was well planned and excellently organised on many levels. It was a unique opportunity to meet and work together with high-level clinical professionals and a wide range of multidisciplinary experts to carry out an intense, data-driven, and strictly focussed research project, with the ultimate aim to advance the knowledge of better treatment options for patients affected by prostate cancer across the world.”

Phenotyping who defined the study phenotypes/ cohorts clearly, unambiguously, and accurately to generate meaningful evidence considering differences/nuances between the databases. To date, 64 phenotypes have been defined via the ATLAS tool.

European Association of Urology

Giorgio Gandaglia – Urologist “Being involved in the PIONEER study-a-thon represents a unique opportunity to meet key opinion leaders and extremely talented people with different experiences with the goal to improve prostate cancer treatment. Everyone is giving a contribution based on his/her specific knowledge and this is just great. The opportunity to interact with stakeholders and patients allowed us to understand the value of what we are doing and the potential impact of the results of our study.”

Figure 1: Study-a-thon overview

2021 edition

Guidelines Office

March/May 2021

European Urology Today

Key articles from international medical journals Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

No SARS-CoV-2 in semen specimens, abnormal sex hormone secretion In the past several months, the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2)-associated infection (coronavirus disease 2019 [COVID-19]) developed rapidly and has turned into a global pandemic. Although SARS-CoV-2 mainly attacks respiratory systems, manifestations of multiple organs have been observed. A great concern was raised about whether COVID-19 may affect male reproductive functions. In this study, investigators collected semen specimens from 12 male COVID-19 patients for virus detection and semen characteristics analysis. No SARS-CoV-2 was found in semen specimens. Eight out of 12 patients had normal semen quality. They also compared the sex-related hormone levels between 119 reproductive-aged men with SARS-CoV-2 infection and 273 age-matched control men. Higher serum luteinizing hormone (LH) and a lower ratio of testosterone (T) to LH were observed in the COVID-19 group. Multiple regression analysis indicated that serum T: LH ratio was negatively associated with white blood cell counts and C-reactive protein levels in COVID-19 patients.

Higher serum luteinizing hormone (LH) and a lower ratio of testosterone (T) to LH were observed in the COVID-19 group.

“urinary tract infection”, and “D-mannose”. Only clinical studies, systematic reviews, and metaanalyses reporting efficacy or safety data on D-mannose versus placebo or other competitors were selected. Evidence was limited to human data. The selected studies were organised in two categories based on the presence or absence of a competitor to D-mannose.

Outcome measures were allograft failure from any cause including death and allograft failure censored for patient death defined by the requirement for long-term dialysis or repeat transplant.

Of 385 patients, 191 were assigned to steroid withdrawal (mean [SD] age, 46.5 [12.1] years), and 194 patients to continued corticosteroids (mean [SD] age, 46.3 [12.6] years). The median (interquartile range) Most of the studies also showed D-mannose can play follow-up time was 15.8 (12.0-16.3) years. Based on a role in the prevention of rUTI or urodynamicsintent-to-treat analysis, the adjusted hazard ratio of associated UTI and can overlap antibiotic treatment in allograft failure from any cause including death was 0.83 (95% CI, 0.62-1.10; p < 0.2) and for allograft some cases. failure censored for patient death it was 0.78 (95% CI, After exclusion of non-pertinent studies/articles, 13 0.52-1.19; p < 0.26) and did not differ between the two studies were analysed. In detail, six were randomised groups. In a per-protocol-analysis among 223 patients controlled trials (RCTs), one was a randomised who continued the trial-assigned treatment (n = 114 vs cross-over trial, five were prospective cohort studies, n = 109) for at least 5 years, the results were the and one a retrospective analysis. Seven studies same. Also, the outcomes in both groups did not compared D-mannose to placebo or other drugs/ differ from similarly treated contemporary registry dietary supplements. Six studies evaluated the patients who met trial eligibility criteria and were efficacy of D-mannose comparing follow-up data with treated with the same regimens. The authors the baseline. concluded that long-term corticosteroid medication may not be necessary in low to medium immune risk D-mannose is well tolerated, with few reported renal transplantation. adverse events (diarrhoea was reported in about Source: Early corticosteroid cessation vs 8% of patients receiving 2 g of D-mannose for at long-term corticosteroid therapy in kidney least 6 months). Most of the studies also showed transplant recipients: long-term outcomes of a D-mannose can play a role in the prevention of randomized clinical trial. Woodle ES, Gill JS, rUTI or urodynamics-associated UTI and can Clark S, Stewart D, Alloway R, First R. overlap antibiotic treatment in some cases. The JAMA Surg. 2021 Feb 3:e206929. doi: 10.1001/ possibility to combine D-mannose with polyphenols jamasurg.2020.6929. Epub ahead of print. PMID: or Lactobacillus seems another important option 33533901; PMCID: PMC7859872. for UTI prophylaxis. However, the quality of the collected studies was very low, generating, consequently, a weak grade of recommendations as suggested by international guidelines. Data on Interventions for preventing D-mannose dose, frequency, and duration of thrombosis in solid organ treatment are still lacking. The authors conclude that D-mannose alone or in combination with several dietary supplements or Lactobacillus has a potential role in the non antimicrobial prophylaxis of recurrent UTI in women. Despite its frequent prescription in real-life practice, authors believe that further well-designed studies are urgently needed to definitively support the role of D-mannose in the management of recurrent UTIs in women.

Source: Role of D-Mannose in the Prevention of Recurrent Uncomplicated Cystitis: State of the Art and Future Perspectives. Cosimo De Nunzio, Riccardo Bartoletti, Andrea Tubaro, Alchiede Simonato and Vincenzo Ficarra.

transplant recipients Graft thrombosis is one of the leading causes of kidney graft failure. Currently there are no standardised protocols for thromboprophylaxis. Many transplant units use unfractionated heparin (UFH) and fractionated heparins (low molecular weight heparin; LMWH). Antiplatelet agents such as aspirin might have a role in preventing graft thrombosis. However, any pharmacological thromboprophylaxis comes with the risk of major blood loss following transplantation. This systematic review looked at benefits and harms of thromboprophylaxis in patients undergoing solid organ transplantation.

Prof. Serdar Tekgül Section Editor Ankara (TR)

serdartekgul@ gmail.com

control, any heparin (including LMWH) may make little or no difference to the number of major bleeding events (3 studies, 180 participants: RR 2.70, 95% CI 0.89 to 8.19; I² = 0%; low certainty evidence). The effect of heparin on other outcomes (including death, patient and graft survival, transfusion requirements) remains unclear (very low certainty evidence). Three studies (n = 144) investigated antiplatelet interventions in kidney transplantation: aspirin versus dipyridamole, and Lipo-PGE1 plus low-dose heparin to ’control’ in patients who had a diagnosis of acute rejection. None of these reported on early graft thromboses. The effect of aspirin, dipyridamole and Lipo PGE1 plus low-dose heparin on any outcomes is unclear (very low certainty evidence). The authors concluded that UFH may increase the risk of major bleeding in kidney transplant recipients, however, this is based on low certainty evidence, and that currently there is no good evidence to guide antithrombotic prophylaxis in renal transplantation.

Source: Interventions for preventing thrombosis in solid organ transplant recipients. Surianarayanan V, Hoather TJ, Tingle SJ, Thompson ER, Hanley J, Wilson CH. Cochrane Database Syst Rev. 2021 Mar 15;3:CD011557. doi: 10.1002/14651858.CD011557.pub2. PMID: 33720396.

The quest for an intermediate surrogate for overall survival in localised prostate cancer

Overall survival is considered the gold standard endpoint for cancer trials. However, the natural history of localised prostate cancer poses challenges in clinical trials design. Follow-up needs to be long This is the first report about semen assessment and before achieving a significant number of events. Thus, sex hormone evaluation in reproductive-aged male Antibiotics 2021, 10(4), 373; https://doi.org/10.3390/ The authors searched the Cochrane Kidney and there is a growing interest in validating intermediate COVID-19 patients. Although further studies are antibiotics10040373 Transplant Register of Studies up to November 2020. endpoints which could be correlated with overall needed to clarify the reasons and underlying Studies in the Register are identified through searches survival. Previously, the international Intermediate mechanisms, the present study presents an abnormal of CENTRAL, MEDLINE, and EMBASE, conference Clinical Endpoints in Cancer of the Prostate (ICECaP) sex hormone secretion among COVID-19 patients, proceedings, the International Clinical Trials Register working group established metastasis-free survival as Early corticosteroid cessation (ICTRP) Search Portal and ClinicalTrials.gov. suggesting that attention should be paid to a surrogate endpoint for overall survival for men with vs. long-term corticosteroid reproductive function evaluation in the follow-up. localised prostate cancer. However, patients included Only randomised controlled trials (RCTs) and in this analysis have been treated by radiotherapy in therapy after kidney Source: Evaluation of sex-related hormones and quasi-RCTs designed to examine interventions to 90% of cases. The diffusion of this model in a surgery transplant semen characteristics in reproductive-aged prevent thrombosis in solid organ transplant setting may be questioned. No surgical trials were male COVID-19 patients. Ma L, Xie W, Li D, Shi L, recipients were included for all donor types without included in the event-free survival analysis. Ye G, Mao Y, Xiong Y, Sun H, Zheng F, Chen Z, Long-term corticosteroid treatment after renal any age limit for recipients. Nine studies (712 Qin J, Lyu J, Zhang Y, Zhang M. transplantation has well known side-effects. However, participants) were identified. Seven studies (544 In the present article, the authors performed a second Journal of medical virology, 2021-01, Vol.93 (1), cessation of corticosteroids is associated with a higher participants) included kidney transplant recipients. two-stage meta-analytical approach to p.456-462. DOI: 10.1002/jmv.26259 PMID: 32621617 risk of short-term rejection. The long-term outcomes Selection bias was high or unclear in eight of the nine comprehensively assess intermediate clinical of patients who withdraw from corticosteroids remain studies; five studies were at high risk of bias for endpoints across the most common treatments in uncertain. The aim of this prospective, randomised, performance and/or detection bias; while attrition localised prostate cancer (radical radiotherapy, radical double-blind and placebo-controlled trial was to prostatectomy, and hormone therapy). Published and reporting biases were in general low or unclear. Recurrent UTI in women: compare long-term renal transplant outcomes of randomised trials investigating a therapeutic option D-mannose may play a role patients randomised to early steroid withdrawal or for localised or biochemically recurrent prostate …currently there is no good continued steroid treatment. cancer and reporting overall survival and at least one Urinary tract infections (UTI) are highly frequent in intermediate clinical endpoint were included. evidence to guide antithrombotic women, with a significant impact on healthcare clinical endpoints were: time to …authors concluded that long-term prophylaxis in renal transplantation. Intermediate resources. Although antibiotics still represent the biochemical failure, time to local failure, time to standard treatment to manage recurrent UTI (rUTI), distant metastases, time to biochemical failure plus corticosteroid medication may not D-mannose, an inert monosaccharide that is Three studies (n = 180 participants) primarily clinical failure, biochemical failure-free survival, be necessary in low to medium metabolised and excreted in urine and acts by investigated heparin in kidney transplantation. Only progression-free survival, and metastasis-free inhibiting bacterial adhesion to the urothelium, survival. Preplanned subgroups across treatment immune risk renal transplantation. two studies reported on graft vessel thrombosis in represents a promising non-antibiotic prevention kidney transplantation (n = 144). These small studies types were assessed. Postoperative radiotherapy was strategy. The aim of this narrative review was to were at high risk of bias in several domains and included in the surgical subgroup. Another analysis critically analyse clinical studies reporting data The trial was conducted in 28 US transplant centres reported only two graft thromboses between them. It evaluated only patients with high-risk disease and concerning the efficacy and safety of D-mannose in therefore remains unclear whether heparin decreases those with duration of follow-up > 9 years. Overall, between November 1999 and December 2002 with the management of rUTIs. linkage to a mandatory national registry with the risk of early graft thrombosis or non-graft after screening, 75 randomised trials were included validated outcome ascertainment. 386 low to thrombosis (very low certainty). UFH may make little (53,631 patients). A non-systematic literature search, using the PubMed, moderate immune risk adult recipients of a living or no difference versus placebo to the rate of major EMBASE, Scopus, Web of science, Cochrane Central or deceased donor kidney transplant without bleeding events in kidney transplantation (3 studies, Intermediate clinical endpoints evaluating Register of Controlled Trials and Cochrane Central delayed graft function or short-term rejection in the n = 155; RR 2.92, 95% CI 0.89 to 9.56; I² = 0%; low biochemical failure showed poor correlation with Database of Systematic Reviews databases, was certainty evidence). Sensitivity analysis using a first week were included. Patients were overall survival. Correlation with local failure was also performed for relevant articles published between randomised to receive tacrolimus and fixed-effect model suggested that UFH may increase poor. Correlation of progression-free survival was January 2010 and January 2021. The following Medical mycophenolate mofetil with or without the risk of haemorrhagic events compared to placebo moderate (R² 0.46). Metastasis-free survival showed Subjects Heading were used: “female/woman”, corticosteroids 7 days after transplant. (RR 3.33, 95% CI 1.04 to 10.67, p = 0.04). Compared to the strongest correlation (R² 0.78). Key articles

EAU EU-ACME Office

European Urology Today

March/May 2021

Prof. Oliver Hakenberg Section Editor Rostock (DE)

CRPC progressing on abiraterone. Patients were randomly assigned to receive testosterone cypionate (dose of 400 mg intramuscularly once every 28 days) or enzalutamide until progression or severe toxicity. Patients were concurrently maintained on continuous testosterone suppression.

The primary end point was clinical or radiographic PFS. 195 men were randomly assigned to receive either BAT or enzalutamide. Median follow-up time among patients was 31.9 months. The median PFS was 5.6 months in the BAT arm versus 5.7 months in the enzalutamide arm (HR, 1.13; 95% CI, 0.82 to Findings from radiotherapy trials were similar with 1.57). OS was not different between arms (32.9 vs. good correlation between progression-free survival 29.0 months). Survival outcomes in men with short and overall survival. Nineteen trials used radical prior response to abiraterone (< 6 months) favoured prostatectomy as primary treatment. Six (32%) trials BAT (HR, 0.55). Overall, 39.3% of patients initially on BAT crossed over to receive enzalutamide, whereas included postoperative radiotherapy. Biochemical failure-free survival was poorly correlated with overall 47.6% of patients crossed from enzalutamide to BAT. survival. Progression-free survival and biochemical Crossover to enzalutamide following BAT was failure showed moderate correlation. Distant associated with greater benefits for all secondary metastases and metastasis-free survival showed end points including median OS (37.1 versus 30.2). strong correlation with overall survival. Patients who received the treatment sequence of BAT followed by enzalutamide had significantly longer PFS2 compared with the opposite sequence These results raise concerns about (28.2 vs. 19.6 months; HR, 0.44; 95% CI, 0.22 to the conclusions drawn in all studies 0.88). AR-V7 status was not predictive of clinical outcomes irrespective of the treatment received. The evaluating biochemical-based incidence of adverse effects was comparable in the endpoints, even in trials with long- two groups, except for fatigue (48.5% of grade1-2 on enzalutamide versus 31.5% on BAT). Oliver.Hakenberg@ med.uni-rostock.de

term follow-up…

To compare, the surrogate threshold effect for biochemical failure overall was 0.31 for all subgroups examined compared with 0.80 for metastasis-free survival overall. This effect was even superior (0.90) in studies assessing hormone therapy with or without radiotherapy.

The TRANSFORMER trial is interesting, as it compares two diametrically opposite treatment options at 2nd line mCRPC stage.

This aggregate meta-analysis confirms the strong correlation between metastasis-free survival and overall survival, validating the use of this surrogate as potential across all eligible trials in localised prostate cancer, including trials dealing with surgery and hormone therapy. Thus, metastasis-free survival remains a valid surrogate endpoint after surgery, a result that was not shown in previous ICECaP studies.

The TRANSFORMER trial is interesting, as it compares two diametrically opposite treatment options at 2nd line mCRPC stage. In the present trial, BAT was not superior to enzalutamide but outcomes showed similar efficacy in terms of PFS, OS, PSA progression. Interestingly, BAT could improve quality of life by limiting treatment effects on fatigue and sexual function, in this specific context of patients progressing after abiraterone. Further evaluation is However, no other endpoint appeared as a good warranted to assess the benefit from the sequence surrogate for overall survival. The correlation between BAT followed by enzalutamide in mCRPC patients biochemical/local failure and overall survival was previously treated by abiraterone. They run a high risk insufficient to use it as surrogate endpoint for overall of crossed resistance to a second-line new-generation survival. hormone therapy as a single therapy. These results raise concerns about the conclusions drawn in all studies evaluating biochemical-based endpoints, even in trials with long-term follow-up and those that included high-risk disease. Such conclusions may be particularly relevant in doseescalation trials powered to reduce local failure, which is clearly not correlated with overall survival. Future development should focus on the assessment of novel endpoints, such as new generation imaging or biomarkers, to identify potential additional surrogate endpoints.

Source: TRANSFORMER: A randomized phase II study comparing bipolar androgen therapy versus enzalutamide in asymptomatic men with castration-resistant metastatic prostate cancer. Denmeade SR, Wang H, Agarwal N, et al.

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

Radical cystectomy remains a complex procedure with a high risk of postoperative complications and function impairment. Minimally invasive surgery including robotics aims at reducing surgical harms and facilitating patient recovery. However, the available randomised controlled trials failed to prove any significant difference between open (ORC) and robot-assisted (RARC) radical cystectomy. Only minor and major complications rates at 30 and 90 days from surgery were evaluated and all these were limited by an extracorporeal approach for urinary diversion. The impact of radical cystectomy on health-related quality of life (HRQoL) remains largely unexplored.

Lancet Oncol 2021;22:402-410.

Bipolar androgen therapy potentially improves quality of life Although highly effective, therapeutic resistance to androgen deprivation therapy inevitably occurs. Second-generation hormone therapies have become standard therapy and provide overall survival benefits by inhibiting AR. But resistance increases with the number of treatment lines at castrationresistant stage. Preclinical studies have suggested that AR upregulation might induce cellular vulnerability allowing prostate cancer cells to be killed by exposure to supraphysiologic testosterone. This could lead to a downregulation of AR levels and potential resensitisation to androgen-ablative therapies. In this phase 2 study, the authors hypothesised that such a bipolar androgen therapy (BAT) would have superior efficacy in CRPC as a result of chronic exposure to low androgen and adaptively sensitise these cells to anti-androgens. The TRANSFORMER (multicentre, open-label, randomised) trial compared the effects of BAT versus enzalutamide in asymptomatic men with Key articles

March/May 2021

J Clin Oncol. 2021 Feb 22:JCO2002759.

Quality of life after open vs. robotic radical cystectomy

In the present article, the authors reported the intermediate year of a randomised trial comparing ORC and RARC with intracorporeal urinary diversion. The primary endpoint was an interim analysis of 1-yr HRQoL outcomes. HRQoL was assessed from patient-reported questionnaires (EORTC QLQ-C30 generic and bladder cancer–specific). The first 58 consecutive patients were included in this interim analysis (30 RARC, 28 ORC). Clinical characteristics were comparable since both groups were homogeneous. The mostly used urinary diversion was the orthotopic Padua ileal bladder for both approaches (75%). A totally intracorporeal approach with no need for open conversion was performed in the robotic group. The intraoperative transfusion rate was significantly lower for the robotic approach (RARC 0% vs. ORC 14%; p = 0.048) with a trend towards significance for the overall transfusion rate (p

= 0.055). Operative time was longer in the robotic group (303 vs. 204 min; p < 0.001). Hospital stay was comparable between the groups (RARC 10 d vs. ORC 15 d; p = 0.464). Complication and readmission rates were similar. Seven patients experienced disease recurrence and received salvage chemotherapy. Survival analysis demonstrated comparable outcomes for the two groups at 1 year in terms of overall survival (RARC 86% vs. ORC 93%), and disease-free survival (RARC 82% vs. ORC 86%). Baseline HRQoL assessment was comparable between the groups. Overall, both cohorts reported significant worsening of physical functioning, body image, and sexual functioning at 1 year. Patients undergoing ORC reported a greater 1-yr impairment of role functioning, fatigue, dyspnoea, insomnia, constipation, diarrhoea, financial difficulties, and abdominal bloating and flatulence. Conversely, patients receiving RARC reported 1-yr significant impairment of urinary symptoms and problems. These results highlighted the important impact of radical cystectomy on body image and physical and sexual functioning, irrespective of the surgical approach. No statistically significant difference favoured RARC or suggested a faster return to normal activities of daily life with robotic surgery. However, patients experienced higher impairment in terms of symptoms such as fatigue, insomnia, and gastrointestinal symptoms after ORC and a more invasive approach.

… patients experienced higher impairment in terms of symptoms such as fatigue, insomnia, and gastrointestinal symptoms after ORC and a more invasive approach. Longer follow-up and larger cohort are awaited to obtain higher evidence and to comment on potential impact of robotic surgery, in terms of immediate postoperative outcomes (hospital stay, transfusion) and of mid-term functional and quality of life outcomes.

Source: Comparison of patient-reported health-related quality of life between open radical cystectomy and robot-assisted radical cystectomy with intracorporeal urinary diversion: Interim analysis of a randomised controlled trial. Mastroianni R, Tuderti G, Anceschi U, et al. Eur Urol Focus 2021 :00059-6.

Comparison prostatic artery embolisation and TURP in single-centre trial Prostatic artery embolisation (PAE) for the treatment of lower urinary tract symptoms secondary to benign prostatic obstruction (LUTS/BPO) still remains under investigation. The investigators compared the efficacy and safety of PAE and transurethral resection of the prostate (TURP) in the treatment of LUTS/BPO at 2 years of follow-up. A randomised, open-label trial was conducted. There were 103 participants aged ≥ 40 with refractory LUTS/ BPO. International Prostate Symptoms Score (IPSS) and other questionnaires, functional measures, prostate volume, and adverse events were evaluated. Changes from baseline to 2 years were tested for differences between the two interventions with standard two-sided tests.

… inferior improvements in LUTS/ BPO and a relevant re-treatment rate were found 2 years after PAE compared with TURP. The mean reduction in IPSS after 2 years was 9.21 points after PAE and 12.09 points after TURP (difference of 2.88 [95% confidence interval 0.04-5.72]; p = 0.047). Superiority of TURP was also found for most other patient-reported outcomes except for erectile function. PAE was less effective than TURP regarding the improvement of maximum urinary flow rate (3.9 vs. 10.23 ml/s, difference of -6.33 [-10.12 to -2.54]; p < 0.001), reduction of postvoid residual urine (62.1 vs. 204.0 ml; 141.91

Mr. Philip Cornford Section editor Liverpool (GB)

philip.cornford@ rlbuht.nhs.uk

[43.31-240.51]; p = 0.005), and reduction of prostate volume (10.66 vs. 30.20 ml; 19.54 [7.70-31.38]; p = 0.005). Adverse events were less frequent after PAE than after TURP (total occurrence n = 43 vs. 78, p = 0.005), but the distribution among severity classes was similar. Ten patients (21%) who initially underwent PAE required TURP within 2 years due to unsatisfying clinical outcomes, which prevented further assessment of their outcomes and, therefore, represents a limitation of the study. The authors conclude that inferior improvements in LUTS/BPO and a relevant re-treatment rate were found 2 years after PAE compared with TURP. PAE is associated with fewer complications than TURP. The disadvantages of PAE regarding functional outcomes should be considered for patient selection and counselling.

Source: Prostatic artery embolisation versus transurethral resection of the prostate for benign prostatic hyperplasia: 2-yr outcomes of a randomised, open-label, single-centre trial. Dominik Abt, Gautier Müllhaupt, Lukas Hechelhammer, Stefan Markart, Sabine Güsewell, Hans-Peter Schmid, Livio Mordasini, Daniel S Engeler. Eur Urol 2021 Feb 18;S0302-2838(21)00092-0. doi: 10.1016/j.eururo.2021.02.008. Online ahead of print.

Cardiac failure associated with BPH medical therapy Increased risk of cardiac failure with α-blockers in hypertension studies and 5-alpha reductase inhibitors in prostate studies have raised safety concerns for long-term management of benign prostatic hyperplasia. The objective of this study was to determine if these medications are associated with an increased risk of cardiac failure in routine care. This population-based study used administrative databases including all men over 66 with a diagnosis of benign prostatic hyperplasia between 2005 and 2015. Men were categorised based on 5-alpha reductase inhibitor exposure and/or α-blocker exposure with a primary outcome of new cardiac failure utilising competing risk models.

Cardiac failure risk was highest for α-blockers alone (HR 1.22; 95% CI 1.18-1.26)… The data set included 175,201 men with a benign prostatic hyperplasia diagnosis with 8,339, 55,383, and 41,491 exposed to 5-alpha reductase inhibitor, α-blocker and combination therapy, respectively. Men treated with 5-alpha reductase inhibitor and α-blocker, alone or in combination, had a statistically increased risk of being diagnosed with cardiac failure compared to no medication use. Cardiac failure risk was highest for α-blockers alone (HR 1.22; 95% CI 1.18-1.26), intermediate for combination α-blockers/5alpha reductase inhibitors (HR 1.16; 95% CI 1.12-1.21) and lowest for 5-alpha reductase inhibitors alone (HR 1.09; 95% CI 1.02-1.17). Nonselective α-blockers showed a higher risk of cardiac failure than selective α-blockers (HR 1.08; 95% CI 1.00-1.17). In routine care, men with a benign prostatic hyperplasia diagnosis and exposed to both 5-alpha reductase inhibitor and α-blocker therapy had an increased association with cardiac failure, with the highest risk for men exposed to nonselective α-blockers.

Source: Cardiac failure associated with medical therapy of benign prostatic hyperplasia: A population based study. Avril Lusty, D Robert Siemens, Mina Tohidi, Marlo Whitehead, Joan Tranmer, J Curtis Nickel. J Urol2021 Feb 22;101097JU0000000000001561. doi: 10.1097/JU.0000000000001561. Online ahead of print.

EAU EU-ACME Office

European Urology Today

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

tebj@medisin.uio.no

Nephrectomy associated with increased mortality after renal trauma The majority of high-grade renal trauma can be managed conservatively. However, nephrectomy is still common for acute management. The investigators hypothesised that when controlling for multiple injury severity measures, nephrectomy would be associated with increased mortality. They identified high-grade renal trauma patients from the US National Trauma Data Bank® from 2007-2016. Exclusion criteria were age <18 years, severe head injury and death within 4 hours of admission. Conditional logistic regression analysis was performed to determine if nephrectomy was independently associated with mortality, controlling for age, gender, race/ethnicity, mechanism of injury, shock, blood transfusion, Glasgow Coma Scale, Revised Trauma Score and Injury Severity Score.

The association between nephrectomy and death did not differ by mechanism of injury. The authors identified 42,898 patients with high-grade renal trauma (grade III-V), of whom 3,204 (7.5%) underwent nephrectomy. Unadjusted mortality was 16.6% in nephrectomy vs. 5.7% in non-nephrectomy patients. In multivariable logistic regression, nephrectomy was associated with 82% increased odds of death (OR 1.82, 95% CI 1.63-2.03, p < 0.001). Other significant associations with death included age, non-white race, penetrating mechanism, hypotension, blood transfusion, lower Glasgow Coma Scale, lower Revised Trauma Score and higher Injury Severity Score. The association between nephrectomy and death did not differ by mechanism of injury.

The main limitation of such algorithms is the way in which variables are selected to build up a model, as it mostly relies on surgeons’ subjective perception and experience. Artificial Intelligence (AI) is an evolving technology that may overcome such a limitation: with a process called “machine learning”, data are variably selected or deselected according to how a model is predicting the outcome. When the machine is fed with new data, the predicting models may change adapting to possible new findings. AI is the last frontier in medicine. Over the last years, it has been applied in different fields of health care, especially in cancer care. Its use in the context of benign diseases has been more limited but there is mounting evidence in this area as well. An Indian group has recently published a pivotal study to determine the accuracy of models built up by means of AI to predict the stone-free rate after PCNL. 100 patients were recruited as harbouring partial or complete staghorn renal calculi according to CT findings. Different classes of variables were included in the machine learning process, involving patients’ past medical history, kidney stones characteristics, renal anatomy, stone’s composition and biochemical findings. The output was defined as SFR yes/no at post-op imaging, although no details were provided in terms of SFR definition and time point at which SFR were assessed. Moreover, the study was retrospectively designed. The authors tested different AI methods to select variables and build up predicting models. They found that the Linear Discriminant Analysis was the best approach to select the features of interest, and that the Random Forest was the best performing classifier with 81% of accuracy.

This was the first attempt to introduce AI in the prediction of the SFR after PCNL, which may open the way to multiple future applications, including the ability to predict different outcomes.

In the US National Trauma Data Bank, nephrectomy is independently associated with increased risk of mortality after adjusting for patient demographics, injury characteristics and multiple measures of overall injury severity. Nephrectomy may impact overall survival and must be avoided when possible.

Regardless of the limitations of the study, it was the first attempt to introduce AI in the prediction of SFR after PCNL. The main points of interest are the versatility of such technology, including the ability to predict different outcomes (and not just the SFR) as well as to continuously refine the models according to Source: Nephrectomy is associated with increased the machine learning process. One of the main issues is the need to share the ’big-data dataset, which faces mortality after renal trauma: An analysis of the National Trauma Data Bank from 2007-2016. Ross restrictions from the General Data Protection Regulation E Anderson, Sorena Keihani, Rupam Das, Heidi A currently in force.

Hanson, Marta L McCrum, James M Hotaling, Jeremy B Myers. J Urol 2021 Mar;205(3):841-847. doi: 10.1097/ JU.0000000000001366. Epub 2020 Oct 6.

Next frontier in stone disease: Predicting outcomes through Artificial Intelligence

Source: Application of Artificial Intelligence-based classifiers to predict the outcome measures and stone-free status following percutaneous nephrolithotomy for staghorn calculi: Crossvalidation of data and estimation of accuracy. Bm Zeeshan Hameed, Milap Shah, Nithesh Naik, Harneet Singh Khanuja, Rahul Paul, Bhaskar K Somani.

These are among the main reasons why there still is a paucity of PROMs in many fields of medicine, including urology. Stone disease is one of the most frequently occurring urological diseases and certainly is a condition where PROMs are urgently needed. The Ureteric Stent Symptoms Questionnaire was the first tool of this type dealing with one of the most common interventions in stone disease: the insertion of a ureteric stent. After its introduction in 2003, the urological community noticed for the first time how a simple stent insertion could actually significantly affect a patient’s quality of life. The first PROM introduced to properly assess stone disease conditions was the Wisconsin Quality of Life (WISQoL), which has mainly been used in the research field.

The USIQoL measure was developed based on multiple phases in the framework of a complex and upto-date psychometric methodology, innovative in the field of urology A further PROM in stone disease has been recently published by a British group: the Urinary Stones and Intervention Quality of Life (USIQoL) group. Its measure was developed following multiple phases in the framework of a complex and up-to-date psychometric methodology, innovative in the field of urology. Among the most relevant features, it is worth mentioning that the very first phase involved patients and their families in order to collect items that could be of interest from merely a patient’s point of view. An initial draft with 60 items was developed in three phases, before it was tested with 212 patients (phase 4) which led to the removal of unstable items. The final questionnaire was then tested with 369 patients and validated (phase 5), with very good psychometric indicators. The tool consists of 15 items grouped in 3 scales, involving pain with physical health (six items), psychosocial health (seven items) and work performance (two items). An overall score on a 0-100 (logit) scale is then obtained, with higher scores indicating greater bother from the symptoms. The USIQoL can be tested on patients either with the disease or after an intervention. However, it needs external and linguistic validations before widespread use.

Source: Urinary Stones and Intervention Quality of Life (USIQOL): Development and validation of a new core universal patient-reported outcome measure for urinary calculi. Hrishikesh B Joshi, Hans Johnson, Amelia Pietropaolo, Aditya Raja, Adrian D Joyce, Bhaskar Somani, Joe Philip, Chandra Shekhar Biyani, Tim Pickles. Eur Urol Focus. 2021 Jan 8;S2405-4569(20)30313-8. doi: 10.1016/j.euf.2020.12.011. Online ahead of print.

TISU trial: Which treatment option is better for ureteric stones

Four sets of cohorts were considered: the intention-totreat (ITT) and the per-protocol (PP) populations, both with and without the patients who ended up passing the stones spontaneously in the meantime. The ITT including all patients (ITT-1) was considered the primary population of reference. The secondary endpoints involved health-related quality of life measurements, including pain scale, QoL questionnaires and use of analgesic. Between July 2013 and June 2017 a total of 613 patients were randomised; crossover was asymmetrical, with more patients from the SWL group changing group of intervention (12% vs 4%); 86 patients of the SWL arm received 2 sessions of the intervention (40% of those who eventually undertook SWL); patients who passed their stones before intervention were similarly distributed (17% vs. 12%).

The primary outcome showed a difference of 11.7% of patients needing further treatment after 6 months between SWL (22.1%) and URS (10.3%), No differences were found in terms of stone size, location and main demographics. The primary outcome showed a difference of 11.7% of patients needing further treatment after 6 months between SWL (22.1%) and URS (10.3%), with the upper bound of the 95%CI being 17.8% (5.6-17.8%), which was below the margin of 20% to establish noninferiority. Nevertheless, this non-inferiority margin was not found in the remaining 3 sets of populations. Complication rates, such as Clavien-Dindo grade ≥ 3, were similarly low in both arms (3.6 vs. 2.7%). With respect to the secondary outcomes, more patients in the SWL arm took analgesics than those in the URS arm, but this was the only difference found by the investigators. Overall, these data confirm that SWL may be considered a non-inferior treatment when an active treatment is deemed necessary in the case of a ureteric stone. Similarly, URS confirms better stone clearance with a lower rate of re-intervention needed. The trial did not provide a cost-effectiveness analysis.

Source: Shockwave lithotripsy versus ureteroscopic treatment as therapeutic interventions for stones of the ureter (TISU): A multicentre randomised controlled non-inferiority trial. Ranan Dasgupta, Sarah Cameron, Lorna Aucott, Graeme MacLennan, Ruth E Thomas, James N'Dow, John Norrie, Ken Anson, Francis X Keeley Jr, Sara J MacLennan, Kath Starr, Sam McClinton. Eur Urol 2021; S0302-2838(21)00171-8. https://doi: 10.1016/j.eururo.2021.02.044. Online ahead of print.

Assisted reproductive technologies increase risk of congenital urogenital malformations

Assisted reproductive technologies (ART) have become the mainstay of therapy for infertility. ART mainly include intrauterine insemination, in vitro fertilization The need to appropriately counsel a patient suitable for (IVF), embryo transfer, artificial insemination, in vitro a percutaneous nephrolithotomy (PCNL) is a very maturation, intracytoplasmic sperm injection (ICSI), USIQoL: A New, effective tool important aspect of a patient’s treatment. It may have cryopreservation of egg, sperm, and embryo and for evaluation of quality of life an impact on the way the surgery is approached pre-transplant genetic testing. Due to its invasive nature psychologically, on patient expectations, and on how and the multiple endocrine manipulations required, the in urinary stone patients any potential complication or sequela may affect his/ Nevertheless, the debate whether one option is to be use of ART has raised concerns about an increased risk her quality of life. preferred is still ongoing among practitioners, with SWL of congenital malformations. Measurements of health-related quality of life (HRQoL) supporters highlighting its minimal invasiveness versus Over the last years, a number of algorithms have been are becoming an essential part of the outcomes others who value the greater effectiveness of URS. The authors report the results of a systematic review assessment of intervention in medicine, especially if screening 33 papers and a total of 1316 cases of ART reported in literature to support clinicians and patients and help the decision-making process in case different they are developed from the patients’ perspective with To address this issue, the Therapeutic Interventions for offspring with urogenital tract malformations and indications overlap. All these tools have been built upon the aid of the so-called patient-reported outcome symptomatic Stones – TISU - trial has been undertaken 24,516 cases of naturally conceived offspring with the basis of predefined variables, traditionally measure (PROM). with the participation of 25 centres in the UK. Its results urogenital tract malformations. Six studies were have been published recently. conducted in Asia, 18 studies in Europe, 7 studies in recognised as playing a role in the outcomes of interest, with the stone-free rate being the first and foremost one. Usually, PROMs are available in the form of North America, and 2 studies in Oceania. questionnaires which at first glance may appear The design of the study was a non-inferiority trial to On the other hand, none of them (Guy’s stone score, obvious and simple. However, the methodology which test SWL (max. 2 sessions) as a non-inferior treatment A total of 21 studies investigated the correlation CROES nomogram, S.T.O.N.E. nephrolithometry, S-ReSC is behind these tools is quite complex. It may require option compared to URS in terms of no further between ART and the risk of hypospadias. The score) has been widely adopted in clinical practice, as lengthy and challenging steps for development and treatment needed after 6 months from randomisation, meta-analysis showed that ART were correlated with an increased risk of hypospadias in male infants. Male their characteristics have been variably criticised and refinement, that have been standardised by the COSMIN with a margin of 20% of success rate with respect to ART offspring were 1.87 times more likely to have robust validations are still lacking, so they are mostly (Consensus-based Standards for the Selection of Health URS on the upper bound of the estimated 95% used for investigational purposes. Measurement Instruments) checklist. Confidence Interval (95%CI). hypospadias than naturally conceived male offspring. Key articles

J Endourol, 2021 Mar 10. doi: 10.1089/end.2020.1136. Online ahead of print.

Furthermore, their worldwide diffusion is limited by validation studies in different languages and cultural environments.

The active treatment of renal and ureteric stones offers multiple options according to stone size and site. Shock Wave Lithotripsy (SWL) and ureteroscopy (URS) are both considered first options for the treatment of ureteric stone < 10 mm in diameter (either distal or proximal), while URS is the preferred option for larger ureteric stones.

EAU EU-ACME Office

European Urology Today

March/May 2021

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de A total of 9 studies investigated the correlation between ART and the risk of postnatal cryptorchidism in infants. The meta-analysis showed that ART were correlated with an increased risk of congenital cryptorchidism in infants. The ART offspring were 1.83 times more likely to have cryptorchidism than the naturally conceived offspring. The meta-analysis showed that compared with ICSI, IVF showed no significant correlation with the risks of hypospadias and cryptorchidism.

Parents undergoing ART are at risk for the generation of CUTM overall, hypospadias, and cryptorchidism in their offspring. In offspring conceived by ART, multiple pregnancies may result in a higher risk of CUTM than singleton pregnancies. The effects of the IVF and ICSI techniques on urogenital tract malformations in offspring were not significantly different. Future studies on the relationship between ART and congenital malformations should include a sub-fertile group as control. There is a need for more studies to explore the relationships between the causes of infertility and congenital malformations.

Source: Assisted reproductive technologies and the risk of congenital urogenital tract malformations: A systematic review and metaanalysis. ZhiCheng Zhang, Xing Liu, Chun Wei, Jin Luo, Yan Shi, Tao Lin, DaWei He, GuangHui Wei. Journal of Pediatric Urology, Volume 17, Issue 1, 2021, Pages 9-20.

The value of Doppler US to evaluate the clinical significance of echogenic focuses on ultrasonography in children There are some controversies in diagnosis of small size renal stones in children. The initial diagnostic modality to be used to detect kidney stones in children is ultrasonography (US). Computed tomography is the gold standard but there are concerns about radiation exposure. Especially in the asymptomatic patient or in patients with vague symptoms, clinical significance of US findings is highly questionable and the need for further imaging is hard to define. Nephrolithiasis is detected on ultrasound by the presence of an echogenic focus, posterior acoustic shadowing and/or twinkle artefact (TA). Ultrasonographic (US) colour Doppler twinkling (or twinkle) artefact is a phenomenon that may aid in the detection of nephrolithiasis and this has been investigated mainly in adults. This artefact is likely due to a form of intrinsic noise known as phase jitter within the Doppler circuitry of the US machine.

commonly associated with nephrolithiasis, it is relatively insensitive in routine clinical practice and has a high false-positive rate when 5-mm unenhanced CT images are used as the reference standard.

TA in children has lower sensitivity, specificity and positive predictive value, but similar negative predictive value for diagnosing nephrolithiasis. 599 ultrasound reports were reviewed and 293 met inclusion criteria. 69 had diffuse twinkle without echogenic focus and 224 showed TA with single echogenic focus. 135 patients had confirmatory information available. Nephrolithiasis was diagnosed using TA and confirmed on confirmatory studies for 49 ultrasounds. The majority of confirmed stones were in the kidney (n = 40; 82%) and mean size of confirmed stones on ultrasound was 5 mm (range 1.5-10). Sensitivity, specificity, positive predictive value and negative predictive value of TA for detecting nephrolithiasis were 83%, 78%, 74% and 86% respectively. Compared to the adult literature, TA in children has lower sensitivity, specificity and positive predictive value, but similar negative predictive value for diagnosing nephrolithiasis. The presence of TA should be weighed in the setting of other clinical and radiographic evidence of nephrolithiasis.

Source: Does twinkle artifact truly represent a kidney stone on renal ultrasound? Kathleen Puttmann, Daniel Dajusta, Alexandra W. Rehfuss. In Press, Journal of Pediatric Urology Available online 30 March 2021 https://doi.org/10.1016/j.jpurol.2021.03.026

More radiotherapy: Is there a cost? Multiple studies have suggested an oncological benefit for dose-escalation of external-beam radiotherapy (EBRT) in the management of localised prostate cancer. However, escalation beyond certain thresholds is not feasible given the narrow therapeutic ratio from added toxicity. The addition of low dose-rate (LDR) brachytherapy boost to ERBT (ERBT-LDR) can maximise the biologically equivalent dose. In observational studies, it has been suggested to improve diseasespecific and overall survival for men with intermittent risk and high-risk disease. However, there is a dearth of randomised studies using modern ERBT doses and validated patient reported outcomes (PROs) to adequately assess this combination. This paper presents PROs from men undergoing EBRT alone and ERBT-LDR for localised prostate cancer enrolled in the Comparative Effectiveness Analysis of Surgery and Radiation (CESAR) study.

This study should inform patients considering ERBT-LDR that it comes with a cost in terms of worse urinary irritative and bowel function. Participants completed the 26-item Expanded Prostate Cancer Index Composite (EPIC), the 36-item Medical Outcomes Study Short-Form Health Survey (SF-36) and a 5-item treatment regret scale at baseline, 6-months, 1 year, 3 years and 5 years. The minimum clinically important difference in scores on EPIC is from 5 to 7 for urinary irritation and from 4 to 6 for bowel function.

695 men met inclusion criteria and received either EBRT (n = 583) or EBRT-LDR (n = 112). Patients in the TA has been shown to be highly predictive of EBRT-LDR group were younger (median age, 66 years nephrolithiasis in adults with renal colic and ureteral [interquartile range [IQR], 60-71 years] vs 69 years [IQR, stones. The authors investigate if TA is reliable for 64-74 years]; p < .001), were less likely to receive pelvic diagnosing nephrolithiasis in the paediatric population. radiotherapy (10% vs 18%; p = 0.04) and had higher baseline SF-36 (median score, 95 [IQR, 86-100] vs 90 Renal ultrasound reports indicating presence or [IQR, 70-100]; p < .001). Over a 3-year period, compared absence of TA associated with a single echogenic focus with EBRT, EBRT-LDR was associated with worse in the kidney or ureter were evaluated by the authors. urinary irritative scores (adjusted mean difference at 3 Exclusion criteria were age > 18, multiple echogenic foci years, −5.4; 95% CI, −9.3, −1.6) and bowel function or medullary calcinosis, no follow-up, or TA located scores (−4.1; 95% CI, −7.6, −0.5). The differences were no longer clinically meaningful at 5 years (difference in outside the kidney or ureter. Stone was confirmed urinary irritative scores: −4.5; 95% CI, −8.4, −0.5; either by CT within 3 months of colour Doppler ultrasound, visualisation on ureteroscopy, or patient difference in bowel function scores: −2.1; 95% CI, −5.7, −1.4). However, men who received EBRT-LDR were report of passing the stone. more likely to report moderate or big problems with urinary function bother (adjusted odds ratio, 3.5; 95% Renal twinkling artifact detected using colour Doppler CI, 1.5-8.2) and frequent urination (adjusted odds ratio, ultrasound may be a non-invasive tool to identify 2.6; 95% CI, 1.2-5.6) through 5 years. There were no kidney stones in children. Although this finding is Key articles

March/May 2021

differences in survival or treatment-related regret between treatment groups, although with only 5 years follow-up this is to be expected.

Assoc. Prof. Francesco Sanguedolce Section editor Barcelona (ES)

This study should inform patients considering ERBT-LDR that it comes with a cost in terms of worse urinary irritative and bowel function. It may have a benefit based upon case series, but we await long-term data from this trial.

Source: Five-year outcomes from a prospective comparative effectiveness study evaluating external-beam radiotherapy with or without low-dose-rate brachytherapy boost for localised prostate cancer. Pasalic D, Barocas DA, Huang L-C et al.

fsangue@ hotmail.com

New standard for metastatic papillary renal cell carcinoma

Cancer 2021; doi: 10.1002/cncr.33388.

Future options for mCRPC As standard treatment options for men with metastatic castration-resistant prostate cancer (mCRPC) are used earlier in the disease, there is a need for new options for men escaping androgen deprivation. Cabazitaxel, however, remains an option. It is known to improve survival in men with mCRPC progressing after previous treatment with docetaxel. [177Lu]Lu-PSMA-617 is a radiolabelled small molecule which may also play a role. It delivers high doses of radiation to prostate cancer cells via β-particulate emission with highly specific tumour targeting, thus limiting damage to normal tissues. Encouraging activity and safety has been reported in several non-randomised studies in men with mCRPC that progressed after standard therapies. The TheraP trial compared the activity and safety of [177Lu]Lu-PSMA-617 with cabazitaxel, in men for whom cabazitaxel was considered the next appropriate standard treatment.

… this trial suggests we are at the beginning of radiopharmaceutical therapy for men with prostate cancer.

Papillary renal cell carcinoma (PRCC) is the most frequent subtype of non-clear-cell renal cell carcinoma (RCC); however, it remains a rare and heterogeneous malignancy. PRCC is divided into type 1 and type 2, on the basis of different histological, molecular, and prognostic features. Alterations in the MET pathway are frequent in PRCC, mostly observed in type 1 tumours (80%), but have also been described in up to half of type 2 tumours. Randomised comparisons suggest modestly improved clinical outcomes with sunitinib, a VEGF-directed multikinase inhibitor (when compared with everolimus (mTOR inhibitor)) and it has become the standard of care for patients with metastatic PRCC. SWOG 1500 is a randomised open-label phase 2 trial done at 65 academic and community centres in North America comparing sunitinib (50 mg 4 weeks on and 2 weeks off) to cabozantinib (60 mg od), crizotinib (250 mg bd), and savolitinib (600 mg od), with the aim of determining if MET-directed therapy could improve clinical outcomes in patients with PRCC compared with conventional VEGFdirected agents. Dose reductions were allowed if required. PRCC patients who had received one previous therapy (excluding VEGF and MET-directed agents) were eligible. PRCC subtype was the main stratification criterion, based on local assessment, whereas a post-inclusion central review was mandated. Progression-free survival was the primary endpoint.

TheraP was a multicentre, unblinded randomised phase 2 trial. It enrolled men with mCRPC and previous treatment with docetaxel and PSA progression. Previous treatment with androgen receptor-targeted therapy was … cabazantinib may supplant allowed. Men underwent both a [68Ga]Ga-PMSA-11 and a 2-[18F]FDG PET-CT scan. Only men in whom all sunitinib as standard of care for metastatic deposits were clearly PMSA-positive were patients with metastatic papillary included. Men were randomly assigned (1:1) to [177Lu] Lu-PSMA-617 (6.0–8.5 GBq intravenously every 6 weeks kidney cancer. for up to six cycles) or cabazitaxel (20 mg/ml intravenously every 3 weeks for up to ten cycles). The 152 patients were randomly assigned to one of four primary endpoint was prostate-specific antigen (PSA) study groups. Five patients were identified as response defined by a reduction of at least 50% from ineligible post-randomisation and were excluded baseline. from these analyses, resulting in 147 eligible patients. Assignment to the savolitinib (29 patients) 291 men were screened to identify 200 who were and crizotinib (28 patients) groups was halted after eligible on PET imaging. Study treatment was received a prespecified futility analysis; planned accrual was by 98 (99%) of 99 men randomly assigned to [177Lu] Lu-PSMA-617 versus 85 (84%) of 101 randomly assigned completed for both sunitinib (46 patients) and cabozantinib (44 patients) groups. PFS was longer to cabazitaxel. PSA responses were more frequent among men in the [177Lu]Lu-PSMA-617 group than in the in patients in the cabozantinib group (median 9.0 cabazitaxel group (65 vs 37 PSA responses; 66% vs 37% months, 95% CI 6–12) than in the sunitinib group by intention to treat; difference 29% (95% CI 16–42; p < (5.6 months, 3–7; hazard ratio for progression or death 0.60, 0.37–0.97, one-sided p = 0.019). 0.0001; and 66% vs 44% by treatment received; Response rate for cabozantinib was 23% versus 4% difference 23% [9–37]; p = 0.0016). In addition, they for sunitinib (two-sided p = 0,010). Savolitinib and demonstrated a longer progression-free survival (hazard ratio 0.63 [95% CI 0.46–0·86]; p = 0.0028). They crizotinib did not improve PFS compared with sunitinib. Grade 3 or 4 adverse events occurred in also showed a clinically meaningful improvement in 31 (69%) of 45 patients receiving sunitinib, 32 patient-reported quality of life and symptoms. Grade (74%) of 43 receiving cabozantinib, ten (37%) of 27 3–4 adverse events occurred in 32 (33%) of 98 men in receiving crizotinib, and 11 (39%) of 28 receiving the [177Lu]Lu-PSMA-617 group versus 45 (53%) of 85 savolitinib; one grade 5 thromboembolic event was men in the cabazitaxel group. No deaths were recorded in the cabozantinib group. attributed to [177Lu]Lu-PSMA-617. We await the results of the VISION trial which should report shortly but this trial suggests we are at the beginning of radiopharmaceutical therapy for men with prostate cancer. There are issues around availability of PMSA both for scanning and therapeutics and the cost of doing both a [68Ga]Ga-PMSA-11 and a 2-[18F]FDG PET-CT scan in order to identify the patients most likely to benefit. It is too early for survival outcomes but TheraP showed better activity, safety, and patient-reported outcomes with [177Lu]Lu-PSMA-617 than with cabazitaxel in men with mCRPC progressing after docetaxel.

The discordance rate between central and local review was 37% for PRCC subtyping, and up to 24% of the tumours were ultimately not considered as PRCC after central review. However, they provided a prespecified estimation of the cabozantinib effect within each histological subset according to local or central assessment, which did not seem to modify the favourable results for cabozantinib. As a consequence, cabazantinib may supplant sunitinib as standard of care for patients with metastatic papillary kidney cancer.

Source: [177Lu]Lu-PMSA-617 versus cabazitaxel in patients with metastatic castration-resistant prostate cancer (TheraP): a randomised, openlabel, phase 2 trial. Hofman MS, Emmett L, Sandhu S et al.

Source: A comparison of sunitinib with cabozantinib, crizotinib and savolitinib for treatment of advanced papillary renal cell carcinoma: a randomised open-label, phase 2 trial. Pal SK, Tangen C, Thompson IM, et al.

Lancet 2021; https://doi.org/10.1016/S0140-6736(21)00237-3. Lancet 2021; 397: 695-703.

EAU EU-ACME Office

European Urology Today

Penile reconstruction for genital gender affirmation surgery Best functional and aesthetic outcome following phalloplasty with the radial forearm flap Mr. Wai Gin (Don) Lee St. Peter’s Andrology Centre University College London Hospital London (GB)

waigin.lee@nhs.net

Mr. Nim Christopher St. Peter’s Andrology Centre University College London Hospital London (GB) nim@ andrology.co.uk

Prof. David Ralph St. Peter’s Andrology Centre University College London Hospital London (GB) david@ andrology.co.uk

European centres for gender affirmation surgery Most European centres were invited to contribute their data and thirteen responded in time for publication (see Table 1). Amsterdam (NL) was the first centre established for genital GAS in 1980. They remain the largest centre in Europe for phalloplasty (8 surgeons) and have contributed significant innovations to this field5. London (UK) currently has the highest volume for phalloplasty and was the first to combine two tissue flaps for penile and urethral reconstruction in 2003. The number of centres has increased by 63% in the last 3 years. Most centres offer several different flaps for phalloplasty to accommodate the requirements of each transmasculine individual. Funding Models of funding differed significantly between centres. Centres in the United Kingdom, Germany, France, the Netherlands and Italy offer genital GAS fully funded by the government or health service for residents. Other centres like Belgium require a co-payment by the patient while some others were only available to those who self-fund or are privately insured. Some centres (e.g., London and Belgrade) also offer genital GAS to individuals from abroad on a self-funded or insured basis. Options for penile reconstruction The ideal neophallus should be aesthetically appealing and sensate (to both tactile and erogenous stimulus) while allowing standing micturition and penetrative intercourse6. This should be achieved in a single operation with minimal donor-site morbidity. Disappointingly, there is no single technique that currently meets all the above requirements.

Table 1: Centres in Europe that offer phalloplasty gender affirmation surgery Unit (Country)

Year

Specialty (n)

Amsterdam (Netherlands) Frankfurt (Germany) Lyon (France)

1980

Urology (6) Plastics (2) Urology (2) Plastics (4) Urologist (3) Plastics (1) Urology (2) Plastics (1) Urology (4) Plastics (2) Urology (3) Plastics (1) Urology (2) Plastics (1) General Surg (1) Urologist (1) Plastics (1) Urology (2) Urology (1) Plastics (2) Urology (1)

1989 1990

Belgrade 1 1992 (Serbia) Ghent (Belgium) 1993 London (UK)

2001

Belgrade 2 (Serbia)

2003

Munich (Germany) Turin (Italy) Lille (France)

2016

Warsaw (Poland) Belgrade 3 (Serbia) Freiburg (Germany)

2018

2018 2018

2019 2020

Urology (2) Plastics (1) Urology (2) Plastics (2)

Volume (n/year) Type of flaps for phalloplasty 80 RF, ALT, SCIP, AF, combination flaps 20 RF, ALT

Staged join-up

Yes

RF, MLD, ALT, AF (preexpanded) MLD, ALT, AF

RF, ALT

110

Yes

RF, ALT, AF, combination flaps MLD

100

RF, ALT, SCIP/groin

Yes

20 5

RF, ALT, AF RF, ALT, AF, DIEP

Yes

RF, ALT, AF

Yes

RF, MLD, AF

Both

Yes

No (mostly) No (mostly)

Yes

Abbreviations: RF, radial forearm free flap; ALT, anterolateral thigh flap; SCIP, superficial circumflex iliac artery perforator flap; AF, abdominal flap; MLD, musculocutaneous latissimus dorsi flap; DIEP, deep inferior epigastric artery flap Centres in Europe and the United Kingdom have been Transmasculine individuals can choose between micro * has not started phalloplasty service at the forefront of genital gender affirmation surgery (metoidioplasty) or full-size (phalloplasty) penile (GAS) for transmasculine individuals over the recent reconstruction. Both options offer advantages and Index of gender affirmation surgery units (alphabetical order) decades. Originating from China, the grounddisadvantages, and it is the role of the reconstructive Amsterdam: Amsterdam University Medical Centre breaking use of microvascular free-flap transfer from surgeon to guide and tailor the approach to the Belgrade 1: Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade University the radial forearm (RF) by Chang and Hwang1 for individual. Not all individuals will want, require or Belgrade 2: Sava Perovic Foundation penile reconstruction led to a renaissance in this field qualify for all procedures. Belgrade 3: Andromedic Academy Belgrade, Belgrade University in 1984. Subsequently, significant advances have Frankfurt: Agaplesion Markus Krankenhaus continued predominantly in European centres. Phalloplasty Freiburg: University Medical Centre Freiburg, Department for Urology, Unit for Gender Surgery Phalloplasty offers the most complete genital Alternative tissue flaps and reconstructive Ghent: Ghent University Hospital refinements have been developed and our transformation currently available (see Figs. 1 and 2). Lille: Service d’ Urologie, Andrologie et Transplantation Rénale, Hôpital Claude Huriez understanding of the staging and outcomes of genital A full-size neophallus is necessary to engage in London: St Peter’s Andrology Centre GAS have progressed considerably since that time. penetrative intercourse. Most centres in Europe prefer Lyon: Urology department, Hôpital Lyon Sud. Plastic surgery department, Hôpital de la Croix distant tissue flaps that require microsurgical Rousse techniques (free flaps) or transfer of the flap while This article discusses the role of genital GAS and Munich: Centre for Reconstructive Urogenital Surgery, Urologische Klinik München Planegg summarises some of the centres in Europe and the UK preserving the original blood supply (pedicled flaps). Turin: Urology clinic, Citta della salute e della scienza, University of Turin that offer genital GAS for transmasculine individuals. The primary advantage of free flaps is that the urethra Warsaw: Warsaw/Bydgoszcz The contemporary techniques offered by these centres can be integrated in the flap design resulting in a are briefly discussed, and the functional outcomes single stage, well-vascularised “tube-within-a-tube” Table 2: Comparison of functional and aesthetic outcomes of commonly used flaps for phalloplasty reported. urethra. Several centres (see Table 1) perform urethral join-up (or lengthening) at the time of phalloplasty. Flap Sensation Donor site morbidity Colour match Single stage urethra* Bulky Role of genital GAS RF Best Visible No Yes No Radial forearm free flap Incongruence between the gender identity of an ALT Yes Hidden Yes Some Yes individual and their sex assigned at birth is The most common flap for phalloplasty in Europe MLD Poor Hidden No No Yes distressing with significant repercussions, such as the (and the world) is the RF free flap1 (see Table 1). The risk of self-harm and suicide. Half of transgender and RF flap is considered the gold standard because of the OF Yes Long term weakness No No No and instability gender non-binary (transmasculine) individuals have thin, pliable forearm skin, which is often hairless in attempted suicide2 and they are subject to the urethral segment. Also, the flap has a reliable AF Variable Hidden Yes No Yes stigmatisation, physical abuse and sexual assault. vascular pattern with a long pedicle and multiple Scapular No Hidden No Yes No Most choose to transition physically to align with their sensory cutaneous nerves to facilitate flap transfer. gender identity more closely by use of gender The primary disadvantages are the visible donor site Abbreviations: RF, radial forearm free flap; ALT, anteriolateral thigh flap; MLD, musculocutaneous latissimus affirming hormone therapy and surgery. on the forearm and the neophallus colour mismatch dorsi flap; OF, osteocutaneous fibula free flap; AF, abdominal flap with the surrounding skin. The neophallus may also *single stage/without further flap surgery Genital GAS further ameliorates gender dysphoria lack girth in individuals with less subcutaneous fat. experienced by transmasculine individuals who are results in a generous neophallus (see Table 2). The on gender affirming hormone therapy. Body Alternative tissue flaps The anterolateral thigh (ALT) flap (pedicled or free), neophallus colour match is better than for the RF free satisfaction scores are higher following surgery and flap but hair removal of the urethral segment is gender affirming hormone therapy compared to musculocutaneous latissimus dorsi flap (free) and The abdominal (pedicled) flap (AF) continues to play a hormone therapy alone3. Furthermore, individuals superficial circumflex iliac artery perforator (SCIP) invariably required prior to phalloplasty. The thicker subcutaneous fat in the thigh may also complicate role in phalloplasty and is offered in most centres. The awaiting genital GAS were less satisfied compared to flap (pedicled) are alternatives to the RF flap. In particular, the ALT flap is gaining in popularity tubularisation of the neophallus and urethra in some flap is ideal for those who wish to minimise donor those who did not wish to have genital GAS. Hence, site morbidity or would prefer a shorter operative and transmasculine individuals should not be deprived of because it is a pedicled flap (around 90% of the time) individuals. The donor site wound in the upper thigh that does not require microsurgical anastomosis and remains significant although it is better hidden. recovery time. The AF should also be considered in surgery if they desire it. individuals with multiple co-morbidities that may complicate free flap phalloplasty. Assessment for genital surgery Transmasculine individuals seeking genital GAS Osteocutaneous flaps such as the fibular flap have should meet the World Professional Association for fallen out of favour due to significant donor site Transgender Health Standards of Care4. Revised morbidity and insufficient penile rigidity due to guidelines (version 8) are due for release in 2021. problematic proximal bone fixation. A permanent Individuals should have persistent and documented erection is also less desirable. gender dysphoria and be of adult age in their country. They need to have received 12 months of continuous Combination flaps gender affirmation hormone therapy (unless Some centres combine two different flaps to reduce contraindicated) and have lived in a gender role that the donor-site morbidity and defects resulting from is congruent with their gender identity for a similar the transfer of a single large flap with integrated period. urethra. A free flap urethroplasty is also useful to construct a well-vascularised urethra in a neophallus that would otherwise not have an integrated urethra. EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)

European Urology Today

Figure 1: Radial forearm free flap phalloplasty with deflated penile prosthesis

Figure 2: Phalloplasty with fully inflated penile prosthesis

Continued on page 15

March/May 2021

New guidelines on Non-neurogenic Female LUTS Also addressing female BOO, underactive bladder, nocturia and non-obstetric fistula Early April saw the online publication of the updated 2021 EAU Guidelines, including new Guidelines on Non-neurogenic Female LUTS. This Guideline presents a considerable expansion of the scope of the previous Incontinence Guideline to also address the significant population of women with functional urological conditions not necessarily associated with urinary incontinence that were hitherto not accounted for. The new Panel aimed to align their text more cohesively with the existing Non-neurogenic Male LUTS Guideline and, consequently, several additional sections were added to this Guideline (including non-obstetric fistulae, female bladder outlet obstruction, underactive bladder and nocturia). Over the course of the next couple of years the scope is likely to widen further. The authors just managed to physically meet ahead of the lockdowns, but this multidisciplinary Panel -led by Mr. Chris Harding and Prof. Mela Lapitan (chair and co-chair)- did most of their work virtually. Publication of the findings of a number of systematic reviews addressing overactive bladder syndrome and the diagnosis and treatment of female bladder outlet obstruction is pending, although the outcomes of these reviews informed the 2021 Guidelines publication.

Mr. Chris Harding (GB), Chair

Prof. Mela Lapitan (PH), Vice-Chair

Prof. Salvador Arlandis (ES)

Prof. Kari Bø (NO)

Mw. Tine Van Den Bos (NL)

Dr. Hanny CobussenBoekhorst (NL)

Prof. Elisabetta Costantini (IT)

Mrs. Monica De Heide (NL)

Dr. Jan Groen (NL)

Mr. Arjun K. Nambiar (GB)

Dr. M. Imran Omar (GB)

Prof. Véronique Phé (FR)

Mrs. Mary Lynne Van Poelgeest-Pomfret (NL)

Prof. Huub Van Der Vaart (NL)

Dr. Fawzy Farag (GB)

Dr. Markos Karavitakis (GR)

Dr. Margarida Manso (PT)

Dr. Serenella Monagas Arteaga (ES)

Ms. Aisling Nic An Riogh (IE)

Ms. Eabhann O'Connor (IE)

Dr. Benoit Peyronnet (FR)

Dr. Vasileios Sakalis (GR)

Ms. Néha Sihra (GB)

Dr. Lazaros Tzelves (GR)

Going forward, the Panel aim to ensure that patient-important outcomes will be driving subsequent updates. The assistance of their patient advocates was invaluable in this respect. Our congratulations to all the Panel members with this achievement! Meet the members of the Non-neurogenic Female LUTS panel:

Guidelines Office

Continued from page 14

In essence, one flap is used to reconstruct the neophallus (e.g., AF or ALT flap) while another is used for urethral reconstruction (e.g., RF or SCIP flap).

outcome. Glans sculpting or glansplasty can be performed using either a variation of the Norfolk technique or the mushroom flap technique, in which the glans is incorporated into the flap design. The clitoris can be buried and scrotoplasty, hysterectomy, salpingo-oophorectomy and vaginectomy can be offered, if requested. Insertion of an erectile device (usually inflatable) and contralateral testicular prosthesis is usually deferred by at least 6 months following scrotoplasty (see Fig. 2).

Combination flaps have disadvantages. The combined flaps can be performed in a single stage, but the operative time is longer and multiple surgical teams are required. The rate of urethral complications may be higher when combined and monitoring the inner flap is challenging. Staging the construction of the neophallus Surgical and functional outcomes and urethra may address some of these concerns but Patient satisfaction would significantly prolong the patient’s journey. Transmasculine individuals are generally satisfied following genital GAS (94-100% satisfaction). They Outcomes depending on choice of flap report a good quality of life and improvement in The best functional and aesthetic outcome following gender dysphoria following surgery, despite the fact phalloplasty is seen with the radial forearm flap (see that the rate of urethral complications approaches Table 2). This phallus has the best chance of 45%8. Outcomes from the UK confirmed that no regret achieving tactile and erogenous sensation (up to was experienced following genital GAS9. All individuals 90% of patients)7. The primary criticism of the radial that could experience orgasm prior to GAS continued to forearm flap is the visible donor site, and some experience orgasm after clitoral transposition. Almost patients choose to cover the scarring with a tattoo or all (> 90%) reported that they could masturbate with undergo further aesthetic refinement procedures. their neophallus. Other sensate flaps include the ALT flap and the SCIP flap. The size of the phallus can be bulky following Penile prosthesis insertion and sexual activity ALT, latissimus dorsi or AF phalloplasty, which may Satisfaction remained high following penile prosthesis be an advantage depending on the individual’s insertion. The majority of transmasculine individuals preference. are satisfied with the aesthetic appearance and are able to engage in penetrative intercourse (> 80%)10. Adjunctive procedures Further procedures can be performed in addition to The most common reason for not engaging in phalloplasty to improve functional and aesthetic penetrative intercourse was the lack of a partner. However, rates of mechanical failure, device infection and erosion are significantly higher when compared to devices implanted in men with corpora cavernosa. The 5-year device survival was 78% in the UK10. Metoidioplasty The alternative to phalloplasty is metoidioplasty. Metoidioplasty is performed by lengthening the hypertrophied clitoris following testosterone stimulation to form a micropenis. The metoidioplasty normally measures between 4 cm and 10 cm (median 5.7 cm) making it best suited for those of smaller build (body mass index < 25kg/m2)11. Most will be able to void while standing (87-100%) but most individuals will continue to void in a cubicle (rather than at a Figure 3: Patient following completion of metoidioplasty gender urinal). Penetrative intercourse is rarely possible affirmation surgery (see Fig. 3). March/May 2021

Technique for metoidioplasty Metoidioplasty is performed in one or more stages depending on the centre. If staged, the clitoral ligaments and urethral plate are first divided to lengthen the clitoris and the extended portion augmented by buccal mucosa onlay graft (similar to first-stage urethroplasty). The metoidioplasty is completed in the second stage by urethral tubularisation and lengthening, micropenis construction, scrotoplasty and removal of the “female” reproductive organs (if desired). Testicular prostheses are inserted in the third stage and mons resection can be offered to improve the relative size of the metoidioplasty. Why metoidioplasty? Metoidioplasty is preferred by some transmasculine individuals because recovery is significantly quicker (3 weeks off work compared to 6-12 weeks for free flap phalloplasty) while the micropenis retains full erogenous and tactile sensation with natural erections. The procedure also causes less local scarring and avoids a large donor site scar that some individuals find stigmatising. Finally, urethral complications are less common because the tissues are better vascularised. Summary Genital GAS is offered in specialised centres in Europe and the UK. The volume of surgery in each centre is generally small due to the complexity and duration of surgery. Free flap phalloplasty is the penile reconstruction of choice and despite significant morbidity and rate of complications, patient satisfaction remains high. Acknowledgement The authors would like to thank all the European centres that contributed to this article: Prof. Rados Djinovic, Belgrade (RS) Prof. Miroslav Djordevic, Belgrade (RS) Dr. Marco Falcone, Turin (IT) Prof. Piet Hoebeke, Ghent (BE) Dr. Vladimir Kojovic, Belgrade (RS) Dr. Francois Marcelli, Lille (FR) Dr. Saskia Morgenstern, Frankfurt (DE) Dr. Paul Neuville, Lyon (FR)

Dr. Daniel Schlager, Freiburg (DE) Dr. Piotr Swiniarski, Warsaw (PL) Dr. Wouter Van Der Sluis, Amsterdam (NL) Dr. Jens Willmichrath, Munich (DE) References 1. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74(2):251-258. 2. Hass AP, Rodgers PL, Herman JL. Suicide Attempts among Transgender and Gender Non-Corming Adults - Findings of the National Transgender Discrimination Survey. American Foundation for Suicide Prevention and the Williams Institute;2014. 3. Van De Grift TC, Elaut E, Cerwenka SC, et al. Effects of Medical Interventions on Gender Dysphoria and Body Image: A Follow-Up Study. Psychosomatic Medicine. 2017;79(7):815-823. 4. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism. 2012;13(4):165-232. 5. Al-Tamimi M, Pigot GL, Elfering L, et al. Genital Gender-Affirming Surgery in Transgender Men in The Netherlands from 1989 to 2018: The Evolution of Surgical Care. Plastic and reconstructive surgery. 2020;145(1):153e-161e. 6. Lee WG, Christopher N, Ralph DJ. Penile Reconstruction and the Role of Surgery in Gender Dysphoria. Eur Urol Focus. 2019;5(3):337-339. 7. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57(4):715-722. 8. Lee WG, Li V, Ralph D, Christopher N. Novel classification of urethral complications in female to male gender affirming surgery. BJU Int. 2020;125 (Supplement 1):4. 9. Garcia MM, Christopher NA, De Luca F, Spilotros M, Ralph DJ. Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience. Transl. 2014;3(2):156-162. 10. Falcone M, Garaffa G, Gillo A, Dente D, Christopher AN, Ralph DJ. Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery. BJU Int. 2018;121(1):139144. 11. Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: Techniques and outcomes. Translational Andrology and Urology. 2019;8(3):248-253.

European Urology Today

A highly successful meeting amidst a pandemic Prof. Nikolaos Sofikitis represented EAU at one of the few physical meetings in 2020 Prof. Nikolaos Sofikitis Dept. of Urology Ioannina University (GR)

b) demonstrate larger quantitative and qualitative sperm motility c) have a better epididymal sperm reservoir function d) show more optimal intratesticular testosterone concentration e) are characterised by a smaller percentage of genetic alterations in haploid cells

v.sofikitis@ hotmail.com

Males with testicles located within a large, colourful, wrinkled scrotum are prone to polygamy. Males without scrotal sacs are prone to monogamy. Thus, testicular descent in the male influences the male sexual behaviour. A colourful, wrinkled scrotum is always attractive for the females.

I would like to thank the Executive Committee of the European Association of Urology (EAU) and its Secretary General Prof. Christopher Chapple (Sheffield, GB) very much for giving me the unique opportunity to participate in the 108th Annual Meeting of the Japanese Urological Association (JUA 2020) and give three invited lectures here. The meeting took place in Kobe (JP) from 22 to 24 December 2020. It was one of the few physical meetings in 2020. Japan is closed for foreigners during the Covid-19 pandemic. I was able to visit Japan because I have a permanent resident status here. I had undergone my first SARS-CoV-2 PCR test in Greece prior to my departure. Immediately after my arrival in Tokyo, I underwent a rapid SARS -COVID 2 test. After that, I could not travel to the venue of the meeting; according to the rules of the Japanese government, I had to isolate myself in a hotel for two weeks. At the end of the isolation period, I travelled to Kobe. In this city, I immediately saw that Japanese citizens protected themselves from the coronavirus by carefully adopting the suggestions of their government. In the venue, the body temperature of each participant was measured. Sweets and liquids were offered in specific places of the venue. Although JUA 2020 was held amidst a pandemic, I consider its organisation highly successful. A high-level scientific programme was offered to the participants, and additionally the highly developed sense of kindness and responsibility inherent in the nature of the Japanese people coupled with the unique Japanese hospitality offered a uniquely friendly atmosphere.

“The highly developed sense of kindness and responsibility inherent in the nature of the Japanese people offered a uniquely friendly atmosphere.” A significant number of urologists participated in JUA 2020. All Japanese medical universities (more than 100) had asked their urologists to be physically present at the meeting. As a result, many young urologists were there; in contrast, most urologists from public hospitals and private practice urologists attended virtually. Several invited lectures were given by professors in person, mainly from Japanese medical universities, whereas some invited lectures were presented online; most of which were delivered by international speakers. The scientific atmosphere was exciting and the scientific messages that were offered to the participants were significant and remarkable. Testicular descent in mammals and humans I gave three invited lectures. One of them, named "Philosophical, financial, and physiological consequences of testicular descent in mammals and in the human", attempted to answer many unanswered questions, such as "what is the benefit for the male to have its testicles descended within a scrotum?”, “why did nature decide that thousands of calories should be consumed during testicular descent?", “is it correct to state that during the evolution of species, testicular descent remains an important feature for the maintenance of the testes in a low-temperature environment?", and "if this last hypothesis is correct, how can we explain the presence of adequate testicular spermatogenesis in species with intraabdominal testes such as the Asiatic elephant and the turkey?" The take-home messages of this lecture supported the thesis that the testicular descent does offer benefits to males, since males with scrotal sacs: a) attract females more easily and efficiently International Relations Office

European Urology Today

“These observations may make young urologists realise that basic research in urology is exciting and can provide interesting explanations.” In addition, my lecture provided evidence that female sexual behaviour, too, influences male sexual behaviour. For example, species in which females commonly have multiple male partners, such as the chimpanzees and bonobos, tend to have higher rates of sperm competition within the female reproductive tract. Thus, female infidelity increases the competition between spermatozoa ejaculated by different males that try to fertilise the oocyte of a given female animal. The overall result is the need for the male to develop larger testicles in order to produce a larger number of spermatozoa, aiming to win in the sperm competition race. However, large testicles are accompanied by the need for a large, well-developed scrotum that will host these large testicles. This will, in turn, attract many females. Thus, female infidelity leads to male infidelity. Finally, the lecture described physiological mechanisms explaining the mystery why species with scrotal sacs (i.e. humans) have larger quantitative and qualitative sperm motility but lower sperm counts compared with ascrotal species. Testicular descent is accompanied with a longer course of testicular artery compared with ascrotal species, which offers the opportunity for incomplete testicular torsions in the species with scrotal sacs. This may lead to the development of episodes of testicular ischemia. The spermatozoa in scrotal species are thus trained in anaerobic glycolysis, in addition to their ability to utilize the metabolic pathway of aerobic glycolysis. The overall result is a larger potential for motility of the spermatozoa of scrotal species. Thus, spermatozoa of scrotal species are better and more efficiently ‘trained’ for their future endeavour in the rigorous female environment. To sum up, scrotal species: a) develop metabolic advantages in the sperm physiology compared with ascrotal species and thus b) demonstrate a larger quantitative and qualitative sperm motility Male elephants and turkeys with intraabdominal testicles have internal mechanisms to lower testicular temperature, thereby securing optimal sperm production and maintenance of sperm reproductive potential.

Prof. Nikolaos Sofikitis (bottom row, second from the left) together with the other participants in the International Journal of Urology editorial board meeting

publication. Furthermore, we have developed a schedule for publishing a debate on an andrology topic between a member of the ESAU board and an andrology expert from JUA in European Urology Today (EUT) one or two times per year. This plan has been accepted by the Secretary General of EAU and the Executive Committee of EAU. With the support from the leaders of JUA, we anticipate exciting debates in the topics erectile dysfunction, penile surgery, male infertility, and male endocrinology. My participation in the two sessions has given me the possibility to reconfirm the wish of JUA to collaborate with EAU in several types of educational activities. My personal feeling is that a close collaboration between JUA and EAU will promote education of urologists for the great benefit of urologists of both organisations. Personal exchange of knowledge Overall, I feel that a physical meeting amidst a pandemic is more attractive to participants – provided that the rules for the safety and health of those participants are strictly followed. I enjoyed the direct

interactions and thus meaningful discussions I had with participants after each lecture. If the period for discussion during a session wasn’t sufficient to allow for all the questions to be answered, personal exchange of scientific information, knowledge, and experience was possible. The obvious cons of a physical meeting are the risks to the health of the participants. I was only able to visit Japan because I have a permanent resident status, and traveling during a pandemic is not easy. In the long run, I would prefer a physical meeting – and let’s hope this will be possible for all delegates again soon.

“We developed a schedule for publishing a debate on an andrology topic between a member of the ESAU board and an andrology expert from JUA in EUT one or two times per year.”

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

N ew dates!

Registration deadline: 1 October 2021

The above observations may make young urologists realise that basic research in urology is exciting and can provide interesting explanations about the development of species during evolution and about several features in the physiology of the genital tract that provide certain advantages to the reproduction and the survival of some species. International Journal of Urology I also had the honour to participate in two sessions of the editorial board of the International Journal of Urology. I also had the great honour to be invited to become a member of this editorial board. The International Journal of Urology has a significant impact factor and attracts many manuscripts from all over the world for consideration for publication. The journal contributes to the promotion of research and education in urology worldwide. We agreed that EAU Section of Andrological Urology (ESAU) board members are going to submit articles on various topics in andrology to the International Journal of Urology Review Studies for consideration for

www.eurep21.org March/May 2021

Virtual

ESU Update

10-11 MC June on 2021 Partial nephrectomy New ESU-ESUT-ERUS Virtual Top renal tumour management, new technologies and controversies

www.esupartialnephrectomy.org

By Erika De Groot

Additionally, the masterclass will address issues of management of complications and surgical margins, giving a very useful perspective for clinicians in their daily practice.

The newest addition to the popular masterclass of the European School of Urology (ESU), the ESU-ESUTERUS Virtual Masterclass on Partial nephrectomy aims to enrich the participants’ knowledge on partial nephrectomy (PN) for improved management of renal tumours. This much-awaited masterclass set to take place from 10 to 11 June 2021 will also explore the latest PN advancements in terms of precision surgery for optimal oncological and functional results. The masterclass’ stellar programme was organised through the collaborative efforts of the ESU, the EAU Section of Uro-Technology (ESUT) and the EAU Robotic Urology Section (ERUS). Internationallyknown experts will lead the masterclass: ESU Chairman Prof. Joan Palou (ES), ESUT Chairman Prof. Ali Serdar Gözen (DE) and the three Course Directors Prof. Francesco Porpiglia (IT), Dr. Alberto Breda (ES) and ESU Chair Elect Prof. Evangelos Liatsikos (GR). In this article, we interviewed the esteemed Prof. Porpiglia who shared his expert insights on the relevance of PN knowledge; how the masterclass aspires to boost the participants’ clinical practice; and the process of how the programme was developed. Why is it important that urologists know more about PN? FP: The partial nephrectomy scenario continues to evolve. The paradigm of PN has changed completely after the introduction of robotics. In the last 10 years, many innovations were introduced to increase the precision of each surgery irrespective of the approach; from new intraoperative image guidance modalities (e.g. indocyanine green and augmented reality) to new intraoperative tools to optimise all the surgical steps (sutures and new haemostatic agents). The indication to PN has been

Will the masterclass examine any controversies and/or current challenges? FP: Yes, indeed one of the main goals of this masterclass is to tackle current controversies. There will be sessions dedicated to the issue of ischemia time and extension; a comprehensive coverage of PN literature; the surgical access where advantages and disadvantages of trans- and retroperitoneoscopy; and innovations about nephrometry scores. In terms of challenges, the masterclass will cover the limit for a safe enucleation, the study of perfusion areas of the kidney to plan a selective clamp, and many others.

experienced urologists who have keen interest in kidney surgery. This masterclass is for seasoned urologists who perform this kind of interventions in their daily practice. Participating in this masterclass can be a great opportunity for them to update their knowledge of technical innovations and future perspectives. The masterclass is also where young urologists become more familiarised with PN: milestones, current indications, emerging technologies, and identification of patients best suited for such intervention.

“This masterclass will feature PN advancements in precision surgery for optimal oncological and functional results.”

Prof. Porpiglia, one of the Course Directors and interviewee

pushed forward, changing the challenges and the surgical strategies of surgeons. Through the masterclass, we aim to update participants with contemporary knowledge on PN. In what ways will the masterclass enhance the participants' clinical practice? FP: The masterclass’ well-structured programme will not only include the PN milestones and main principles in all the different PN approaches (e.g. open and pure laparoscopy, robotic, etc.) but also the current innovative strategies that can aid surgeons in maximising intraoperative results.

Please take us through the process of how the programme for this masterclass was developed. FP: The programme was developed by taking into account the importance of PN cornerstones but with the anticipation of what’s to come in terms of future innovations. For this very reason and to give the participants the best overview on PN scenario, top European PN experts were selected based on their specific surgical skills and expertise; PN approaches and technologies they are familiar with; and their scientific background on the masterclass topics. Who is the masterclass’ target audience and why? FB: The target audience includes both novice and

Selection criteria The number of representatives per country is a factor in the selection. To offer equal opportunity to participate in this masterclass, the number of representatives per country will be limited. Additionally, priority is given to those who did not participate in a previous masterclass (this year). An EAU membership is mandator, and application is on a first-come, first served basis. The ESU offers diverse masterclasses on a myriad of topics. These masterclasses are designed to bolster urological clinical practice and to raise patient care. For an overview of all ESU masterclasses, please visit www.esu-masterclasses.org and apply.

The masterclass will also consider specific categories of patients, such as the elderly and those harbouring application been clinical stage T2 (cT2)Anrenal tumourshas or local ® madeindication to the EACCME for CME recurrences, to illustrate and surgical strategies presently available. accreditation of this event

ESU-ESUI Masterclass on Prostate biopsy Virtual

ESU-ESUT-ERUS Masterclass on Partial nephrectomy

3-4 June 2021

Virtual

www.esuprostatebiopsy.org

10-11 June 2021 www.esupartialnephrectomy.org

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

March/May 2021

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

European Urology Today

Report

ESU-ESOU Virtual Masterclass on MIBC Essential treatment updates, diagnosis and histology Amassing an attendance of 50 participants from 22 countries across the world, the ESU-ESOU Virtual Masterclass on Muscle-invasive bladder cancer took place on 8 and 9 April 2021. The masterclass faculty was comprised of esteemed experts led by Course Director Prof. Fred Witjes (NL), ESU Chair Prof. Joan Palou (ES), and ESOU Chairman Prof. Morgan Rouprêt (FR). This masterclass was organised through the collaborative efforts of the European School of Urology (ESU) and the EAU Section of Oncological Urology (ESOU). Day one commences The first session “Diagnosis and Initial Treatment” kickstarted with a comprehensive presentation by Prof. Valeria Panebianco (IT) on diagnostic tools for muscle invasive bladder cancer (MIBC) with an emphasis on nodes comparing CT, MRI, PET-CT scans. This was followed by the lecture of Dr. Erik Veskimäe (FI) which was entitled “Histological variant bladder cancers and clinical consequences for treatment (invasive and metastatic disease)”. According to Dr. Veskimäe, the 2016 World Health Organization (WHO) classification of the urinary system enables pathologists, urologists and oncologists to improve understanding about variant histology of bladder cancer (BCa). Furthermore, preliminary data suggests that patients with MIBC could benefit from tailored treatment based on histological variant. He added that patients with metastatic variant histology BCa should receive chemotherapy and the role of immunotherapy remains to be seen. The session concluded with a semi-live video demonstrating radical transurethral resection (TUR) for small invasive BCa. The “Cystectomy and Node Dissection” session commenced with the presentation of Prof. Bas Van Rhijn (NL) “ERAS in Cystectomy: What has to be done

and what is the impact”. He explained that Enhanced Recovery After Surgery (ERAS) is a concept of a multidisciplinary, fast-track pathway including pre-operative, per-operative and post-operative measures that was first introduced in the ‘90s by Scandinavian surgeons in colorectal surgery. “The same ERAS-concept has subsequently also been applied to cystectomy. The ERAS society has formulated recommendations in 2013 showing the impact of specific interventions for cystectomy. However, the level of evidence in favour of ERAS is still low and the ERAS protocols and items used in studies are very different between these studies. This indicates the need for multiple (randomised) studies to specifically determine which ERAS items are associated with the highest benefit for our patients,” stated Prof. Van Rhijn. His presentation was followed by a lecture by Prof. Maria Ribal on the extent and survival of a node dissection with videos demonstrating open and lap/robot technique of node dissection, as well as, videos on robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC).

Coverage of day two Prof. Witjes welcomed participants on Friday morning with a recap of day one. A presentation on bladdersparing options by Prof. Nicholas James (GB) followed, then deliberations during “Point Counterpoint: T2/3N0M0, 4 cm, MMT or RC” between Prof. Van Rhijn for multimodality treatments (MMT) and Prof. Marek Babjuk (CZ) for RC. A semi-live surgical video presentation by Prof. Witjes on prostate-sparing RC took place after.

Virtual 18-19 June 2021 www.esuurolithiasis.org

European Urology Today

20% have complications that are classified grade III in the Clavien-Dindo System. Prof. Palou added that patients should be aware that complications in radical cystectomy do happen. He said, “The most important about complications is to detect them as soon as possible and to treat them immediately.”

The final session of the masterclass, “Recurrent or Metastatic Disease” commenced with the lecture of Dr. Richard Cathomas (CH) on systemic therapy “The question is ultimately not what is the best diversion, but rather, what is the best diversion for the updates covering chemotherapy and immune therapy. patient. This depends on many factors and should be Afterwards, the faculty discussed patient cases which determined in a shared decision-making process include clinical cases prepared by participants, then taking into account the patient’s situation, needs, and the masterclass came to a close. hopes to provide the best quality of life possible in their individual situation,” said Prof. Thalmann. You can access or review the masterclass presentations via www.urosource.org. Feel free to check out the conversations on Twitter by using the In the lecture “Complications after RC and management, what to expect and how to prevent and hashtag #esumibc21. Interested in participating in solve”, Prof. Joan Palou (ES) stated that about 60% of upcoming ESU masterclasses? Visit www.esuthe patients present one complication and that 10 to masterclasses.org for the overview and apply now!

The first day ended with lively discussions and participant presentations during the Journal Club segment where four papers were presented by the participants and discussed by all.

ESU-ESUT Masterclass on Urolithiasis

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

Further into the masterclass, the session on diversion kickstarted with videos on the “W” and “S” type neobladders by Prof. Babjuk and Prof. George Thalmann (CH), respectively. This was followed by the video presentation “Uni or bilateral uretero cutaneostomy” by Dr. Antoine Van Der Heijden (NL). Afterwards, Prof. Thalmann shared his insights in his lecture “Neobladdder: What is the best diversion?”.

Prof. Ribal discusses mapping studies of lymph node metastasis

ESU - Weill Cornell Masterclass in General urology 12-16 July 2021, Salzburg, Austria www.esusalzburg.org

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

March/May 2021

Report

Virtual masterclass elicits confidence in NMIBC treatment Impact on clinical practice, key messages and participants' impressions The 4th ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer commenced from 4 to 5 February 2021. Its first virtual edition attracted participants from 26 countries across the globe, and elicited positive feedback on content quality, scientific level, and overall interactivity despite the digital format. Organised by the European School of Urology (ESU) and the EAU Section of Oncological Urology (ESOU), field experts such as Course Directors Prof. Marek Babjuk (CZ) and ESU Chair Prof. Joan Palou (ES) together with ESOU Chair Prof. Morgan Roupret (FR) and ESU Chair Elect Prof. Evangelos Liatsikos (GR), spearheaded the masterclass. In this article, Prof. Babjuk imparts some of the masterclass’ key messages. In addition, participants Dr. Ikhlas Arief Bramono (ID), Dr. Magne Dimmen (NO), Dr. Chantal Ducret (IT), Dr. Pierre Einwaller (DE), and Dr. Matthew Liew (GB) share their experiences and what they think will be the masterclass’ impact on their clinical practice. Fundamental messages on treatment Prof. Babjuk highlighted the following take-home messages:

• At present, several new treatment modalities are being evaluated in patients with NMIBC that is unresponsive to Bacillus Calmette-Guérin (BCG). Results of systemic immunotherapies or intravesical treatments such as gene therapies, device-assisted instillations or combinations of cytotoxic drugs are promising and may replace radical cystectomy in selected patients in the future. Future impact on clinical practice When asked about the potential impact of masterclass in their practice, the participants’ responses were optimistic. Dr. Ducret stated, “One never stops learning. This experience gave me the opportunity to improve myself and become a better urologist. Discussing a clinical case with the faculty helped dissipate some doubts I encounter in my daily practice.”

base underpinning various treatment options, as well as excellent tips and tricks, having attended this masterclass. He would also like to congratulate the brilliant organising team. “After attending this masterclass, I was pleased to know that most of what my colleagues and I do is in accordance with the guidelines,” Dr. Dimmen disclosed. “I could adopt a few new learned techniques and focus on delivering treatment at a high standard even more.” “I will definitely try more en-bloc resections,” said Dr. Einwaller. “I won't do genetic sampling just yet due to the costs involved but will use more instillation.” Dr. Bramono stated, “I'll apply what I’ve learned to optimise my patients' treatment.”

Reasons for applying According to Dr. Liew, he felt more confident to use the When asked what drew them in to join the masterclass, the participants shared their reasons, as latest techniques for treating NMIBC in his clinical practice. He now has a full appreciation of the evidence well as, other ESU masterclasses they would like to apply to. “NMIBC is one of the most prevalent conditions that I deal with in my daily practice. I applied because I wanted to receive comprehensive and evidence-based updates on NMIBC treatment,” said Dr. Dimmen. “I’ll keep an eye out for other ESU masterclasses. I also already encouraged some of my colleagues to apply.”

• The most important step in NMIBC treatment is transurethral resection of the bladder (TURB), which must be followed with precise pathological evaluation of resected tissue. The quality of the whole procedure is crucial for patient outcome. The masterclass introduced new modalities of advanced tumour imaging, modern equipment and new surgical strategies including en-bloc resection. • Patients should be stratified according to prognostic factors into risk groups. This helps select optimal adjuvant treatment for individual patients.

Smile, you’re on Zoom. Some faculty and attendees at the masterclass

For Dr. Liew, he joined the masterclass because he wanted to have more in-depth knowledge, particularly with en-bloc bladder resection, as he aims to develop a specialist interest in NMIBC. He added, “I have already applied for the ESU-ESUI Virtual Masterclass on Prostate Biopsy and I hope to join more”. “I applied for the masterclass because activities like these are great opportunities for sharing knowledge, tips & tricks, and receiving updates from the experts,” stated Dr. Ducret who hopes to join the ESU masterclasses on urolithiasis and MIBC as well. Dr. Einwaller said, “I always liked learning. I like receiving education from advanced trainings to practical workshops. I’m interested in applying for the ESU masterclasses on MIBC and prostate biopsy.” Dr. Bramono signed up for the masterclass because he wanted to learn about NMIBC management from the experts based on the latest EAU Guidelines. He added, “I hope to participate in more ESU masterclasses focused on onco-urology so I could have broader insight when I work in a cancer centre in the future.” Masterclass resources Access and/or review the presentations of the NMIBC masterclass via UROsource, the EAU learning library for urologists which is comprised of over 50,000 items of scientific content. To watch the presentations of day one, please visit www.urosource.org/?session_id=11007#show. For day two, please go to www.urosource.org/ ?session_id=11008#show. Interested to participating at ESU masterclasses? Feel free to explore www.esu-masterclasses.org and apply.

Curriculum

Personalised management of Prostate Cancer patients with risk of CVD events

Current challenges for optimal individualised management of LUTS/BPE patients

Module 1 CVD in Prostate Cancer Patients Increased risks & comorbidities

Module 3

February

Tolerability and safety barriers for optimal medical treatment of Male LUTS/BPE

Module 2

Faculty

How to manage risk in PCa patients during COVID-19 April/May

Prof. F. Porpiglia & Prof. K. Tikkinen

Date Tuesday 1 June 2021, 18:30 PM CET

Module 3 Advances in safety in the treatment of PCa

Brought to you by

September

Module 4 Future directions in PCa management

Previous modules

November

January 2021 - Challenges in Differential Diagnosis of Male LUTS/BPE

Brought to you by

March 2021 - Outstanding challenges in medical treatment of Male LUTS/BPE

uroweb.org/educationonline

March/May 2021

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European Urology Today

ESU Updates

Your guide to ESU courses at EAU21 A handy overview of what to expect and how to register Choose from an array of highly-informative and popular courses organised by the European School of Urology (ESU) for the EAU21 congress. This article provides a sneak peek of some of the in-demand courses, as well as, a guide in selecting the ESU courses for your educational and professional needs. Register now to secure your virtual seat! Please note that this is only the preliminary programme. Visit www.eau2021.org/programme for the latest schedule. The ESU courses will take place in the online room Zoom Webinar 1. ESU Course 2 Practical aspects of cancer pathology for urologists The 2021 WHO novelties 8 July 2021, 11:00 to 13:00 Chair and presenter: Prof. Eva Compérat (FR) Presenter: Prof. Ferran Algaba (ES) Enrich what you know and receive valuable insights straight from the experts themselves on specific aspects of cancer pathologies of the following: • Prostate: Recent developments in Gleason grading, contemporary reporting issues (i.e. Gleason Grade 4) • Bladder: Overlap between histopathology and molecular pathology, and recent recommendations for T1 staging • Kidney: Urological impact of major changes in the upcoming WHO classification of renal carcinomas (i.e. new entities or categories and their relevance) • Testicle: Current classification of testicular germ cell tumours, and value of histological tumour type in predicting post-chemotherapy residual metastasis

“You will have plenty of opportunities for interaction with the faculty of experts and fellow participants...”

ESU Course 5 Renal transplantation: Technical aspects, diagnosis and management of early and late urological complications 9 July 2021, 08:00 to 10:00 Chair and presenter: Prof. F. Javier Burgos Revilla (ES) Presenters: Dr. Alberto Breda (ES) and Prof. Arnaldo José Figueiredo (PT) For a complete vision of kidney transplantation (KT), join this course and enhance your knowledge on organ procurement, resolution of postoperative and late potential complications developed after kidney implantation. This ESU course will highlight surgical details, tips and tricks of each video presentation. The course’s coverage of the transplantation process will include the following: • Medical and surgical recipient evaluation • Deceased donor procurement techniques depending on different scenarios: Brain death or non-heart-beating donor • Approaches to live donor nephrectomy: Laparoscopic (conventional, mini-lap, single-port, robotic, transvaginal) or open • Renal implantation options: Open or robotassisted laparoscopy • Diagnosis and treatment of complications associated to KT

international guidelines, the controversies at present, and what lies in the future. This ESU course will cover the who, when and how often to screen and the use of "smart screening", as well as, the current role of MRI, genetics and biomarkers. AS is a widely accepted management option for low-risk prostate cancer and is also now considered in the treatment of select patients with favourable intermediate risk disease. As clinical and pathological factors influence the risk of disease progression, this ESU course will also discuss surveillance strategies which will include the role of MRI, repeat biopsy, and recent changes in management. You will have plenty of opportunities for interaction with the faculty of experts and fellow participants; illustrative and practical clinical case discussions; use of chat and poll functions. ESU Course 21 Laparoscopy for beginners 12 July 2021, 11:00 to 13:00 Chair and presenter: Prof. Xavier Cathelineau (FR) Presenters: Dr. Tiago Ribeiro De Oliveira (PT) and Prof. Bhaskar Somani (GB)

ESU Course 12 Prostate cancer screening and active surveillance: Where are we now? 10 July 2021, 13:00 to 15:00 Chair and presenter: Prof. Alexandre Zlotta (CA) Presenters: Assoc. Prof. Sigrid Carlsson (US) and Assoc. Prof. Martin Eklund (SE)

Taking into account the large widespread of miniinvasive surgery in urology, improving one’s knowledge of the practical aspects of laparoscopy becomes mandatory. The aim of this ESU course is to provide you with bases together with the tips and tricks on:

In this course, you can expect a practical overview of the current status of screening and active surveillance (AS) for prostate cancer which will include

• Indications and contraindications of the laparoscopic approach • How to choose and use the best instrumentation

Complete overview and schedule of all ESU courses on page 6 • Managing air parameters and optimal access • How to prevent and manage complications The video and lively discussions will aid beginners in shortening their learning curve and optimising the success of their laparoscopic procedures.

How to register Participation to the ESU courses is subject to availability and only limited virtual seats are available! Don’t miss out and sign up for the courses now. Please go to www.eau2021.org/registration to register for EAU21 and enrol for the ESU courses of your choice. The registration fees* for the courses are as follows: EAU members Non-members Residents/nurses

€ 23 € 35 € 15

* Fees Include 7.7% VAT.

EAU Edu Platform

The online learning platform for GU cancers

The online learning platform for Lower Urinary Tract Symptoms

PROSTATE CANCER

KIDNEY CANCER

Webcasts

Articles with expert comments

Video interviews with key opinion leaders

Webinars on hot topics

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BLADDER CANCER

European Urology Today

March/May 2021

Natural 3D visual technologies for minimally invasive surgery A big step towards laparoscopic or robotic operating with a similar natural visual system as in open surgery Prof. Ali-Serdar Gözen Chair, ESUT Heilbronn (DE)

asgozen@yahoo.com Many visualisation systems are designed to help us seek new information that can then be rapidly interpreted, if presented well. Pathologies become more visible than ever before with these new visual system technologies. The endoscopic surgeon might be able to operate faster and safer even with less training than before if we have a certain visualisation tool. Three-dimensional world The new visualisation systems we are using during laparoscopic and robotic surgery include highresolution video cameras (Full HD, 4K or 8K), and improve the perception of surgical anatomy and pathologies. We are living in a three-dimensional world. By nature, we perceive and conceptualise the world in three special dimensions. Consequently, the laparoscopic 3D viewing systems can be considered the closest ones to habitual natural vision conditions. 3D view helps the surgeon during laparoscopic operations, particularly with tasks such as the spatial manipulation of structures and understanding and comprehending complex pathological anatomy. Improvement across various tasks utilising 3D visualisations was evidenced with increases in speed and accuracy of task performance.

EAU Section of Uro-Technology (ESUT)

The use of 3D imaging has been proven as also beneficial to surgical training by shortening the learning curve, as well as being more effective in the acquisition of more complex laparoscopic skills. Superior to natural vision Novel stereoscopic displays are capable of displaying even more information than our natural vision can perceive. This is most relevant to visualisation applications in which complex 3D data must be studied, analysed, utilised or interacted with in precise ways. Stereoscopic 3D displays are capable of providing all of the rich monocular depth cues available in modern 2D imaginary with the addition of an important spatial depth cue: binocular disparity.

“Novel stereoscopic displays are capable of displaying even more information than our natural vision can perceive.” Active eyewear or polarised glasses surgeons need to wear are cumbersome and simply unnatural. This factor can become even more important during complex and long procedures. Eyestrain, fatigue, and discomfort during the operation (effects from 3D display viewing) can also adversely affect the surgical performance. Every laparoscopic and robotic surgeon should be able to profit from the benefits of 3D vision technologies without having to deal with visual discomfort and other fatigue-related symptoms. Modification of visual function 3D laparoscopic surgery is associated with significant modification of visual function, which appears to be evident after 2 hours of surgery already. A significant

Join our free UROwebinars! • Different topics every month • Up to date in 30 to 60 minutes • Great interaction with Polls and Q&A • Developed in collaboration with EAU Section and Guidelines Offices

increase in visual stress has been shown after the use of conventional 3D monitors with polarised filtersglasses. One solution to this issue might be the employment of auto-stereoscopic displays, which maintain the features of 3D visualisation solutions without the need for additional polarised filters (glasses), leading to a more comfortable viewing experience. By utilising 3D visual systems capable of satisfying all visual depth cues and representing reality with high fidelity without affecting visual function, significant performance benefits can be achieved when a precise and real perception of digitalised information is required. The time has come to revolutionise surgery utilising a 3D connected environment that will also improve surgical training, procedure planning, efficiency and ultimately, patient health outcomes. 2D image As photons travel through the optical components of the eye, they create a two-dimensional representation on the retina, one for each eye. The human brain uses the planar picture from both eyes to reconstruct a three-dimensional model of our environment, which is possible because the images are disparate. Even monocular depth cues can help our brain reconstruct a three-dimensional representation of a scene using the best available information of a 2D image. The current 2D imaginary is unable to portray a highly informative depth cue through binocular disparity. Autostereoscopic 3D displays In modern 3D display technologies, we can neglect most of the monocular cues, since binocular and oculomotor cues predominate for object distances below 10 m. Autostereoscopic 3D displays can be distinguished as:

Operating with the aid of 3D visual technologies

multi-view 3D displays, Volumetric 3D displays and digital hologram displays. A multi-view Autostereoscopic 3D display system can produce different images in multiple (different) angular positions, thus evoking both stereo parallax and motion parallax depth cues to the surgeon, without the need for any special eyewear. The display can be also connected with a camera, which will track your eyes constantly and find the optimal spot according to your head position without losing the 3D image. The multi-view display is based on 2D display technologies and uses additional optical layers in front of a 2D display to create autostereoscopic images. A multi-view display system comprises a flat-panel display - which shows 2D information - and an optical device, which converts the 2D information into view images that produce a 3D effect. One of the most important aspects of 3D imaging is to facilitate a natural interaction between surgeons and operating field. The autostereoscopic 3D displays without the need of polarised glasses can be a big step towards natural laparoscopic or robotic operating similar to open surgery.

Check your understanding of the EAU Guidelines New courses on the EAU Guidelines are available now. • Understand the diverse natures of subjects such as Paediatric Urology, Bladder Stones and Testicular Cancer • Arrive at the right diagnoses • Make risk assessments of cases • Decide on a treatment and follow-up strategy Dr. Nicolaos Grivas Dr. Panagiotis Kallidonis Dr. Henk Van Der Poel

CME cre

Free access with MyEAU account

dits

All courses are in line with EAU Guidelines 2020.

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European Urology Today

This article is written and funded by Telix Pharmaceuticals

Telix Pharmaceuticals Developing advanced technologies for patients with kidney cancer Telix is a late-stage radiopharmaceutical company developing a broad portfolio of diagnostic and therapeutic assets using Molecularly Targeted Radiation (MTR). Telix’s research pipeline aims to address significant unmet medical needs in prostate, kidney, glioblastoma and hematologic cancers as well as a range of immunologic and rare diseases.

WHAT IS MTR? An MTR drug comprises of a radioactive pay1oad attached to a targeting agent such as a small mo1ecule or antibody,

elix’s lead investigational product for prostate cancer imaging has been accepted for filing by the U.S. Food and Drug Administration (FDA), and has been granted Priority Review status by the Australian Therapeutic Goods Administration (TGA). The Company’s second product for kidney cancer imaging has been granted Breakthrough Therapy (BT) designation by the FDA and is nearing completion of Phase III development.

which binds selectively to cancer cells. An MTR drug attaches to unique cancer cell targets that are typically expressed only on the surface of the cancer cell, thus sparing normal tissues.

To maximise patient access to molecularly targeted radiation, Telix is committed to clinical development of its research pipeline that is fully integrated with the current standard of care. Once administered into the blood

Some important facts on renal cancer WORLDWIDE 430.000 PEOPLE WERE DIAGNOSED WITH KIDNEY CANCER IN 2020

MORE THAN 175.000 PEOPLE DIED FROM KIDNEY CANCER GLOBALLY IN 2020

stream the MTR drug circulates throughout the body and attaches

CLEAR CELL RENAL CELL CARCINOMA (ccRCC) IS THE MOST COMMON FORM OF KIDNEY CANCER

to the cancer cells, including small

ccRCC HAS A HIGH RISK OF METASTASIS

metastases, wherever they are located in the body. This is differentiated from traditional radiation therapy, which is typically highly localised.

Crucial role of advanced imaging methods to assess treatment modalities and to avoid misstaging of disease

Short half-life radioisotopes may be used to image the cancer, for diagnosis and staging purposes.

High sensitivity of current standard of diagnostic care such as ce-CT and MRI for detecting small renal masses but low specificity.(1) With conventional imaging methods, the ability to distinguish ccRCC from non-ccRCC is debatable.(2) The low relative predictive value of biopsies is an issue, and because biopsies are often restricted to a single site, they can fail to provide information on the extent of the disease.(3)

α- and β- emitting radioisotopes are suitable to kill cancer cells.

Better informed treatment decisions and personalised therapy may lead to improved outcomes for patients.

“For urologists, there is an unmet need to see if the tumor is benign or not and it’s important to know if the patient has a ccRCC or a non ccRCC.” Prof. Peter Mulders, Dept of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands

New imaging and therapeutic radiopharmaceuticals New imaging and therapeutic radiopharmaceuticals are being developed to target a cell-surface antigen called Carbonic Anhydrase IX (CAIX), a cancer target that is overexpressed in ccRCC due to a mutation of the von Hippel-Lindau (VHL) protein. CAIX is present on 90+% of ccRCC cells but is absent from normal

“Because of the bone metastases seen by the PET Scan imaging, we were able to change the therapeutic approach in a patient where surgery was the initial option.” Prof. Peter Mulders, Dept of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands

kidney tissues and is therefore an attractive target for diagnosis and therapeutics.

Case report from Merkx et al 2021(3)

Improved detection of ccRCC (including metastatic disease, which also expresses CAIX) with PET/CT imaging could lead to more accurate staging. This could reduce the need for renal biopsy and the proportion of partial or radical nephrectomies performed to remove localized renal masses that are subsequently shown to have benign or indolent histopathology.

New imaging technology can be used to more accurately detect whole body disease sites Whole body scan of a 57-year-old male patient revealing 3 lesions. Only the ones at renal and adrenal level (black arrows) were also detected on CT.(3) See full paper here: https://doi.org/10.1007/ s00259-021-05271-w

For more information, please visit our website telixpharma.com and clinicaltrials.gov NCT03849118 Adapted from Merkx 2021

1) Jae Heon Kim et al, World Journal of Surgical Oncology, 2016 - 2) Sanchez A et al, Journal of Clinical Oncology. 2018 - 3) Merkx et al, European Journal of Nuclear Medicine and Molecular Imaging, 2021

European Urology Today

www.telixpharma.com

March/May 2021

The e-informed patient An emerging responsibility of the EAU and the national urological societies Dr. Markos Karavitakis Member EAU Patient Information Working Group Assoc. Member EAU Guidelines Office Athens (GR) markoskaravitakis@ yahoo.gr

Dr. Gerasimos Alivizatos President of the Hellenic Urological Association Athens (GR)

gali@outlook.com.gr

Dr. Andreas Skolarikos Prof. of Urology, University of Athens President Professional and Scientific Services, HUA Athens (GR) andskol@yahoo.com Informing a patient about their medical problem and the way they could be treated was, is, and will forever be a sacred obligation to the attending physician1. For many decades, the rules of bioethics have required the development of "autonomy" of the patient, i.e. the right of the patient to be informed about their condition and to decide on their treatment after having received correct and thorough information and after any questions have been answered2. Very early in its discovery and its widespread use by the public worldwide, the internet began to be a source of medical information for the patient. For the past twenty years, patients and the general public have had access to a huge amount of information3, which they consult extremely often3-6. The rapid expansion of the use of the web and of the health information derived here has been termed the e-patient revolution6. In addition, in our era patients can easily find information on television, in print, and in online magazines.

“The majority of patients claim that the information they find on the internet, even in cases of malignancy, helps them make a decision about their treatment and strengthens their relationship with the doctor.” The bibliography at the end of this article indicates that patients use this information rather correctly. The majority of patients claim that the information they find on the internet, even in cases of malignancy, helps them make a decision about their treatment and strengthens their relationship with the doctor. Most patients who search for information on the internet do not try to replace their doctor, since the search for this information is done, most of the time, after they have first contacted the specialist. They aim to confirm the information received from the specialist and to search for additional information to answer some of their questions3,7. Also, the information patients acquire on the internet does not seem to increase their anxiety and stress about their health problem8. Conversely, many physicians consider the internet to be damaging to their traditional role as a medical authority8 and consider it to be a serious waste of time to explain the information gathered from the internet to the patient9. Simultaneously, they believe EAU Patient Information

March/May 2021

that patients are misinformed on the internet, which often leads to wrong decisions and requirements10. Furthermore, it is shown that in some occasions an increasingly large number of potential patients are utilising Direct-to-Consumer (DTC), internet-based prescribing platforms for the diagnosis and treatment of diseases that do not require physical exams11. Online misinformation We believe that the growing use of the internet has implications for people seeking information on health matters. The internet can be helpful for patient-physician communication, but this depends on the quality of health information found and whether the information is discussed during the medical visits12. We also believe that there is indeed online misinformation in the medical field, a problem that is part of the era of “fake news” in which intentional or unintentional misinformation spreads rapidly, a fact that has worsened during the Covid-19 period10,13.

“Conversely, many physicians consider the internet to be damaging to their traditional role as a medical authority and consider it to be a serious waste of time to explain the information gathered from the internet to the patient.” A recent study revealed that online health information on prostate cancer (PCa) lacks concordance to current guidelines. Certified websites or websites created by medical experts showed a significantly higher quality and accordance with guidelines14. Many popular YouTube videos about prostate cancer contained biased or poor-quality information. A greater number of views and thumbs up on YouTube does not mean that the information is trustworthy15. Media coverage on and marketing of robot-assisted radical prostatectomy (RARP) on the internet is more widespread compared to laparoscopic prostatectomy (LP) and open radical prostatectomy (ORP). Disturbingly, the quality of websites featuring any technique for prostatectomy was of poor quality while these websites claimed to present honest information, and this finding needs to be discussed when obtaining informed consent from patients16. Most videos on the surgical treatment of LUTS/benign prostatic hyperplasia (BPH) on YouTube had a low quality of content, provided misinformation, were subject to commercial bias and did not report on conflicts of interest. These findings emphasise the importance of thorough doctor-patient communication and active recommendation of unbiased patient education materials17. There are countless examples of misleading information on the internet in our specialty. This means that we should do better. Even large associations release information difficult to comprehend. Currently available online InternetBased Patient Education Materials (IPEMs) pertaining to benign prostatic hyperplasia treatment options are written at a level that is too difficult for the average patient to understand. Physicians and health networks should take the United States Department of Health and Human Services recommendations into consideration when designing IPEMs to optimise accessibility to health information to improve patient compliance and outcomes18.

advertising is not allowed, no exception for anyone is made. In most countries that allow advertising, materials can be submitted to specific central regulations. These must comply with ethical standards, and the information provided must be truthful, accurate, and not create false expectations. In Germany, Italy, Switzerland, and the UK, for instance, advertising is regulated and controlled by state agencies, peer reviewed by national associations. In Austria, regulations are issued by the Austrian Medical Chamber and entail restrictions on advertising channels: no advertising is allowed on television or other mass media platforms. There are issues caused by the non-uniform approach to advertising medical services in Europe. Physicians working in countries where advertising is not allowed suffer from the competition of neighbouring countries where it is allowed. There is quite an outflow of patients going abroad for treatment, not because the same treatment is not offered at home or is not equally good at home, but simply because they are attracted to a different country by commercials. Since their own doctors cannot promote themselves, patients may not even know that they offer the same services for the same or even better price. Therefore, we need European regulations to prevent unfair competition19. What should the position of the EAU be? The European Association of Urology (EAU) needs to better educate its members and the public, especially those who do not have access to English literature. The EAU recently released an update of their practical guidelines for effective and professional use of social media communication technologies by urologists20, and it is also providing carefully worked-out patient education materials (PEM) on 24 urological topics. Although these materials have a better readability compared to similar sources, a simplification of certain chapters might be helpful to facilitate better patient understanding. The EAU Patient Information website is a central web portal covering 18 European languages, with free access to information collected from its own sources such as the EAU Guidelines and other high-quality sources. Our aim for this web portal is to provide useful, accurate, unbiased, high-quality, and evidence-based information pertaining to all urological diseases. As computer literacy and internet access are continuously increasing, there is an emerging responsibility of the EAU and the national medical societies to address this important issue. We owe this to our patients, to our colleagues, and to our urological community.

“A greater number of views and thumbs up on YouTube does not mean that the information is trustworthy1.” The EAU Patient Information website can be found at patients.uroweb.org/

References 1. Akerkar, S.M. and L.S. Bichile, Doctor patient relationship: changing dynamics in the information age. J Postgrad Med, 2004. 50(2): p. 120-2. 2. Ahmad, F., et al., Are physicians ready for patients with Internet-based health information? J Med Internet Res, 2006. 8(3): p. e22. 3. Chen, X. and L.L. Siu, Impact of the media and the internet on oncology: survey of cancer patients and oncologists in Canada. J Clin Oncol, 2001. 19(23): p. 4291-7. 4. Basch, E.M., et al., Use of information resources by patients with cancer and their companions. Cancer, 2004. 100(11): p. 2476-83. 5. Eysenbach, G., The impact of the Internet on cancer outcomes. CA Cancer J Clin, 2003. 53(6): p. 356-71. 6. Asafu-Adjei, D., et al., Misinformation on the Internet regarding Ablative Therapies for Prostate Cancer. Urology, 2019. 133: p. 182-186. 7. Wang, Y., et al., Systematic Literature Review on the Spread of Health-related Misinformation on Social Media. Social science & medicine (1982), 2019. 240: p. 112552-112552. 8. Fox, S. and L. Rainie, The Online Health Care Revolution: How the Web Helps Americans Take Better Care of Themselves. 1999. 9. Hart, A., F. Henwood, and S. Wyatt, The role of the Internet in patient-practitioner relationships: findings from a qualitative research study. Journal of medical Internet research, 2004. 6(3): p. e36-e36. 10. Loeb, S., et al., Quality of Bladder Cancer Information on YouTube. Eur Urol, 2021. 79(1): p. 56-59. 11. Wackerbarth, J.J., et al., Examining Online Traffic Patterns to Popular Direct-To-Consumer Websites for Evaluation and Treatment of Erectile Dysfunction. Sex Med, 2021. 9(1): p. 100289. 12. Langford, A.T., et al., Impact of the Internet on PatientPhysician Communication. Eur Urol Focus, 2020. 6(3): p. 440-444. 13. Gonzalez-Padilla, D.A. and L. Tortolero-Blanco, Social media influence in the COVID-19 Pandemic. Int Braz J Urol, 2020. 46(suppl.1): p. 120-124. 14. Bruendl, J., et al., Accordance of Online Health Information on Prostate Cancer with the European Association of Urology Guidelines. Urol Int, 2018. 100(3): p. 288-293. 15. Loeb, S., et al., Dissemination of Misinformative and Biased Information about Prostate Cancer on YouTube. Eur Urol, 2019. 75(4): p. 564-567. 16. Alkhateeb, S. and N. Lawrentschuk, Consumerism and its impact on robotic-assisted radical prostatectomy. BJU Int, 2011. 108(11): p. 1874-8. 17. Betschart, P., et al., Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading. BJU Int, 2020. 125(4): p. 595-601. 18. Sare, A., et al., Readability Assessment of Internet-based Patient Education Materials Related to Treatment Options for Benign Prostatic Hyperplasia. Acad Radiol, 2020. 27(11): p. 1549-1554. 19. Hawlina, M., Lack of uniform regulations for advertising medical services leads to unfair competition in Europe Occular Surgery News 2015. May 1(Available online upon the search by the title). 20. Borgmann, H., et al., Online Professionalism-2018 Update of European Association of Urology (@Uroweb) Recommendations on the Appropriate Use of Social Media. Eur Urol, 2018. 74(5): p. 644-650.

Legal framework Things get even more confusing as there is no universal legal framework in Europe for advertising medical services. Results of a recent survey administered by the European Union of Medical Specialists (UEMS) show that advertising medical services is currently allowed in more than half of the EU countries. The lack of uniform regulations and guidelines across Europe creates legal inconsistencies and leads to unfair competition. Advertising is still not allowed in Belgium, Croatia, France, Luxembourg, Greece, Cyprus, Estonia, and Slovenia, while in Bulgaria and Slovakia there is no legislation covering this specific matter. Regarding who can advertise, no differentiation among individuals, corporations, and medical doctors is made in most countries. In countries where European Urology Today

EUSP’s knowledge exchange during the pandemic & after Redesigned programmes, more accredited centres and new projects Prof. Vincenzo Mirone Chairman EUSP Napels (IT)

mirone@unina.it

Prof. Axel Merseburger Chairman Elect EUSP Lübeck (DE)

axel.merseburger@ uksh.de The advent of the COVID-19 pandemic imposed restrictions on our daily lives. However, it did not dissuade the pursuit for learning. We at the European Urological Scholarship Programme (EUSP) recognise that stimulating clinical research and skills development during this time is crucial. Learning and scientific exchange should not come to a halt but we’d rather use these challenging times as a catalyst to equip young urologists with new and improved knowledge for better patient care and clinical practice. Since the majority of international urological events are held virtually this year, face-to-face deliberations and comprehensive coverage of highly-specific topics are put on hold (e.g. discussions after a poster session). Thanks to the newly-adapted EUSP scholarship programmes, the personal interaction will continue and important topics not usually covered in Plenary Sessions will still be covered in-depth. Newly-adapted EUSP programmes The EUSP recently redesigned its two scholarship programmes Clinical Visit and 1-Year Scholarship in order for young urologists to still refine their skills in the time of the pandemic, this time, at leading certified host centres in their own countries. • The redesigned Clinical Visit programme will offer scholars observership and opportunities to finetune their skills under the guidance of experts at certified local host centres. The duration of this programme is from six weeks to three months. • For the 1-year Scholarship, the EUSP scholars will search for and contact local host centres where they can set up basic research projects. In the future when the number of host centres further increases, the EUSP plans to establish a platform where host centres and the EUSP can publish upcoming projects. Interested scholars can then choose which projects they would like to participate in. For more information on the requirements and how to apply for the scholarship programmes, please visit https://uroweb.org/education/scholarship/how-toapply/. Certified EUSP host centres In order to guarantee the highest educational level, EUSP host centres need to meet a certain number of criteria. Thanks to the Certification Programme of EUSP host centres, the certification process for training centres hosting the scholarship programmes is streamlined. At present, there are 56 outstanding European institutions that are certified EUSP host centres (please refer to the list found on this page). Prof. Merseburger’s institution, the University Hospital Schleswig-Holstein, Campus Lübeck (UKSH), is one of them. UKSH is generally focused on understanding urologic cancer including prostate cancer and performing clinical work from localised treatment to clinical trials in advanced disease. Last year, the UKSH co-authored and published a paper for the New England Journal of Medicine and their paper on advanced metastatic European Urological Scholarship Programme Office

European Urology Today

Company

Specialty

Country City

Medical University of Vienna Medical University of Vienna Medical University of Vienna Medical University of Vienna OLV Ziekenhuis Aalst-Asse-Ninove OLV Ziekenhuis Aalst-Asse-Ninove OLV Ziekenhuis Aalst-Asse-Ninove OLV Ziekenhuis Aalst-Asse-Ninove OLV Ziekenhuis Aalst-Asse-Ninove KU Leuven KU Leuven KU Leuven KU Leuven Institut Paoli-Calmettes Institut Paoli-Calmettes Institut Paoli-Calmettes University Hospital La Pitié-Salpêtrière University Hospital La Pitié-Salpêtrière University Hospital La Pitié-Salpêtrière Eberhard-Karls-University Heinrich-Heine-University Heinrich-Heine-University Heinrich-Heine-University Heinrich-Heine-University Ludwig Maximilians University Munich Ludwig Maximilians University Munich University of Bonn Universitätsklinikum Carl Gustav Carus University Hospital Cologne University of Leipzig University Hospital Schleswig-holstein, Campus Lübeck General University Hospital of Patras Ospedale Pediatrico Bambino Gesù Istituto Europeo di Oncologia Istituto Europeo di Oncologia Istituto Europeo di Oncologia National Cancer Institute Sava Perovic Foundation Fundació Puigvert Fundació Puigvert Fundació Puigvert Fundació Puigvert Fundació Puigvert Fundació Puigvert Hospital Universitario Ramón y Cajal IOR Institute of Oncology Research Canisius-Wilhelmina Ziekenhuis Máxima Medisch Centrum Radboud University Medical Centre Radboud University Medical Centre Radboud University Medical Centre Radboud University Medical Centre St. Antonius Ziekenhuis St. Antonius Ziekenhuis St. Antonius Ziekenhuis Hacettepe University Faculty of Medicine North Bristol NHS TRUST North Bristol NHS TRUST Sheffield Teaching Hospitals NHS Foundation University College Hospitals London

Stone Disease Prostate Cancer Renal Cancer Urothelial Cancer Female urology and incontinence BPH Prostate Cancer Renal Cancer Urothelial Cancer Neuro-urology Female urology and incontinence Prostate Cancer Paediatric Urology Urothelial Cancer Renal Cancer Prostate Cancer Neuro-urology Prostate Cancer Renal Cancer Urothelial Cancer Prostate Cancer Renal Cancer Testicular Cancer Urothelial Cancer Prostate Cancer Urothelial Cancer Neuro-urology Prostate Cancer Urothelial Cancer Prostate Cancer Prostate Cancer Stone disease Paediatric Urology Prostate Cancer Renal Cancer Urothelial Cancer Prostate Cancer Reconstructive urology Prostate Cancer Female urology and incontinence Stone disease Urothelial Cancer Transplantation Renal Cancer Transplantation Prostate Cancer Prostate Cancer Prostate Cancer Prostate Cancer Paediatric Urology Neuro-urology Female urology and incontinence Renal Cancer Prostate Cancer Urothelial Cancer Paediatric Urology Female urology and incontinence Stone disease Reconstructive urology Andrology

Austria Austria Austria Austria Belgium Belgium Belgium Belgium Belgium Belgium Belgium Belgium Belgium France France France France France France Germany Germany Germany Germany Germany Germany Germany Germany Germany Germany Germany Germany Greece Italy Italy Italy Italy Lithuania Serbia Spain Spain Spain Spain Spain Spain Spain Switzerland The Netherlands The Netherlands The Netherlands The Netherlands The Netherlands The Netherlands The Netherlands The Netherlands The Netherlands Turkey United Kingdom United Kingdom United Kingdom United Kingdom

prostate cancer was recently accepted by the Journal of Clinical Oncology. Having this profile is an ideal basis for the Department of Urology at the University of Lübeck to welcome and accommodate EUSP scholars in the future. The newly-certified host centres also include the distinguished institutions General University Hospital of Patras in Patras, Greece and the Institut PaoliCalmettes in Marseille, France. For more information on all the host centres, please visit https://uroweb.org/education/scholarship/ certified-host-centres/ Further EUSP programmes The EUSP also offers fellowships such as the European Robotic Curriculum, ESTU Fellowship on Kidney Transplant, and EULIS Fellowship in Endourology. The latest addition to the EUSP fellowship programme involves two COVID-themed projects.

Vienna Vienna Vienna Vienna Aalst Aalst Aalst Aalst Aalst Leuven Leuven Leuven Leuven Marseille Marseille Marseille Paris Paris Paris Tübingen Düsseldorf Düsseldorf Düsseldorf Düsseldorf Munich Munich Bonn Dresden Cologne Leipzig Lübeck Patras Rome Milan Milan Milan Vilnius Belgrade Barcelona Barcelona Barcelona Barcelona Barcelona Barcelona Madrid Bellinzona Nijmegen Veldhoven Nijmegen Nijmegen Nijmegen Nijmegen Nieuwegein Nieuwegein Nieuwegein Ankara Bristol Bristol Sheffield London

The EUSP recently collaborated with the EAU Section of Andrological Urology (ESAU) and ReproUnion to bolster pioneering research on the effects of COVID-19 on urological patients. The consortium is searching for two residents/ post-doc/PhD fellows to take part in one of the two projects themed “Impact of the human virome on male reproductive health – lessons learned from COVID-19 pandemic”. The projects will focus on research with the possibility of clinical/surgical training in andrology. The deadline for applications is 15 May 2021. The projects will commence on 1 September 2021. For more information, please go to https://uroweb. org/call-for-applications-scholarship-for-pioneercovid-19-projects/. More EUSP aims and aspirations We at the EUSP plan to establish a series of topic-based curricula with long-term scholarship

programmes to train young urologists in various fields of urology and in other aspects as well such as leadership. For this, we aim to forge collaborations with the Young Urologist Office, the European School of Urology, the EAU Guidelines Office, and the EAU Research Foundation to name a few, and further develop programmes in urological subspecialties. We also aspire to build strong relations with national representatives and develop a solid platform to further stimulate progress of urological science and care. Our credo at EUSP is to help forge young urologists of today to become key opinion leaders of tomorrow. To learn more about us and all our programmes, please visit https://uroweb.org/education/scholarship/. March/May 2021

Progressive prostate cancer therapy in outpatient setting Sufficiently experienced team makes metastatic prostate cancer therapy in office possible Dr. Horst Brenneis ESUO board member Urologie im Zentrum Pirmasens (DE)

brenneis-dr@gmx.de

Prof. Helmut Haas Chairman ESUO Heppenheim (DE)

hf.haas-hp@ t-online.de Even in the early 2000s, progression in prostate cancer was associated with short survival time and poor prognosis. The introduction of taxanes and the second generation of androgen deprivation therapies, e.g. abiraterone, enzalutamide, apalutamide, darolutamid, led to a significant prolongation of survival and a much better prognosis. Since these are partly oral and ambulatory therapies, there has been a shift of these therapies to the outpatient setting. Only the application of nuclear medicine therapies (alpharadin223 and PSMA-lutetium) still require mandatory inpatient treatment. Oncology Agreement The prerequisite for progressive prostate cancer therapy in Germany is participation in the ’Oncology Agreement’ within the framework of the statutory health insurance. Furthermore, corresponding additional training (additional qualification: ‘drug-based tumour therapy’) and clinical experience should be available. In addition, the office staff (medical assistants) must complete an oncology continuing education course. Both physicians and staff are required to undergo continuous education, e.g. in the CME programme of the EAU. A network of clinics, regional general practitioners and specialists, e.g. via tumour boards, is also essential. Profound knowledge In addition, profound knowledge of the approval status of especially novel hormonal treatments (NHT) is important, since not all substances are approved in all stages of prostate carcinoma (hormone-sensitive, castration-resistant, metastatic, M0CRPC, M1CRPC). Incorrect prescribing can lead to expensive recourse, at least in Germany. M0CRPC is defined by PSA increase in combination with testosterone at castration level under androgen deprivation therapy (ADT) and the absence of metastases in conventional imaging (technetium99m bone scan and computed tomography (CT) of the pelvis, abdomen, chest, and head). PSA doubling time can be calculated using a calculator (e.g. www.mskcc.org/nomograms/prostate/psa_ doubling_time). Androgen receptor inhibitors In patients with nonmetastatic castration-resistant prostate cancer (nmCRPC or M0CRPC) at high risk of progression (defined as prostate-specific antigen [PSA] doubling time ≤ 10 months), new androgen receptor inhibitors (ARI) in combination with continued androgen deprivation therapy (ADT) are considered the new standard of care. Apalutamide, enzalutamide, and darolutamide have been approved on the basis of improved metastasis-free survival (MFS) in the respective large pivotal studies SPARTAN, PROSPER and ARAMIS. After a longer follow-up period, they were able to show a statistically significant and clinically relevant overall survival advantage. Close patient control All substances are administered orally and easy to handle in office. A close control of the patients is necessary, especially at the beginning of the therapy. In the first phase, blood count, liver and EAU Section for Urologists in Office (ESUO)

March/May 2021

kidney function should be checked every 2 weeks. In the further course, this interval can be extended to 4 weeks. This laboratory control is easily done together with a clinical control when the drug is re-prescribed. We also perform a PSA check at the same interval. Imaging is sufficient every 6-12 months if the PSA course/decline is stable. According to literature and experience of the authors, the substances are well tolerated. In most cases only moderate fatigue occurs. With apalutamide, eczema develops relatively frequently (Rush, see Fig.1,2), which may be perceived as very disturbing by the patient and can force him to discontinue therapy or reduce the dose. Topical or systemic corticosteroids are helpful in this case. It is important to educate the patient well and to inform the primary care physician. Compliance In daily practice the use of abiraterone requires good patient education regarding the intake of the medication (2 hours before meals) and compliance regarding cortisone substitution. The author remembers a case of an 81-year-old patient who had already been on abiraterone for over a year. In the course of networking, the general practitioner noticed distinct hypokalaemia. The reason was the independent discontinuation of the corticosteroid therapy in the context of a respiratory tract infection. His wife had advised him to do this because “cortisone is not good for the immune system”. Such situations are also conceivable in the context of the current COVID-19 situation. Once again, the importance of a good network of physicians must be emphasised. Particularly in rural areas, the necessary laboratory tests (see above) can be performed by a general practitioner close to the patient's home. This can save the patient long journeys.

“…, there has been a shift of these therapies to the outpatient setting.”

Fig. 1: Eczema developed in the posterior surface of the trunk after apalutamide administration

Fig. 2: Eczema developed in the anterior surface of the trunk after apalutamide administration

Especially blood count control is necessary due to the risk of anaemia. Because this drug has only been approved recently, the authors do not yet have personal experience in its use. In summary, the modern therapy of metastatic prostate cancer is possible without problems in an outpatient setting in the office, provided a

sufficiently experienced and trained team is present. In palliative situations, it saves hospitalisation and thus improves the patient’s quality of life.

ANNOUNCEMENT

FEBU Part 1 Written Exam Determine & demonstrate your level of knowledge

Intravenous chemotherapy with taxanes Intravenous chemotherapy with taxanes is the longest established therapy for metastatic prostate cancer. It is approved for both hormone-sensitive and castration-resistant stages. In practice, this requires a team experienced in intravenous chemotherapy. Close monitoring of the patient is required regarding laboratory tests (especially blood count/leukocytes), neuropathy and susceptibility to infection. The patient should be encouraged to have regular weight and blood pressure checks and documentation. Onycholysis can be prevented by cooling the acra. Docetaxel, especially at the 50 mg dosage every 2 weeks, is generally well tolerated. With cabazitaxel, particular attention should be paid to neutropenia. As a preventive measure, a GM-CSF preparation (e.g. filgrastin) can be given 48 hours after infusion. Personalised medicine A new challenge for practice urology lies in the introduction of personalised medicine in the therapy of CRCP. In early 2021, the first PARPP inhibitor (olaparib) was approved in Europe. The prerequisite for the effect of this substance is the presence of a defect in the DNA repair genes BrCa1 and BrCA2. As condition to use the substance, this genetic defect must be detected either in the tumour tissue (somatic mutation in the primary tumour or metastatic tissue) or as a germline mutation in the peripheral blood. The probability of this defect is estimated at approx.10-15% in the literature. Testing possible genetic alterations requires a detailed discussion and explanation to the patient at the time of arranging the test with the molecular pathologist. In particular, the presence of a germline mutation means a significantly increased risk of BrCa-associated tumours for close relatives of the patient. In this respect, the risk of breast carcinoma in female relatives (sister, daughter) is also important for the urologist. Accordingly, a human geneticist needs to be consulted here specifically. Qualification for genetic counselling In Germany, a special qualification for genetic counselling is necessary, which can also be acquired by urologists. Monitoring the well-tolerated therapy in the office is possible without any problems.

Date: Local time: Venues:

Thursday, 23 September 2021 14:30 – 16:30 Pearson VUE test centres

FORMAT The exam consists of 100 single correct answer MCQs. COMPUTER BASED EXAM The exam is organised in collaboration with Pearson VUE. The candidate takes the exam at one of Pearson VUEs secured test centres. CME/CPD CREDITS Participation qualifies for 20 credits.

Visit our website www.ebu.com for information and registration

European Urology Today

Urodynamics for male lower urinary tract symptoms Review of the UPSTREAM study Prof. Marcus Drake Bristol Randomised Trial Centre University of Bristol (GB)

Marcus.Drake@ bristol.ac.uk

Dr. Amanda Lewis Bristol Randomised Trial Centre University of Bristol (GB)

amanda.lewis@ bristol.ac.uk For men who remain bothered by voiding symptoms despite initial treatment, surgery to relieve bladder outlet obstruction (BOO) is commonly considered. Urodynamics (UDS) aims to decide whether an individual would realistically benefit from such surgery, by diagnosing BOO formally, and looking for risk factors for bad outcome. For example, detrusor underactivity during voiding (DUA) may mean that symptoms will not improve even if BOO is treated. Alternatively, detrusor overactivity (DO) during storage might cause subsequent problems such as incontinence. Value of urodynamics Until recently, it was not clear whether urodynamics truly made a difference to outcomes beyond influencing clinical decision making1. Hence there was a split of opinions among urologists2. Some supported routine use of urodynamics, feeling that surgery to relieve BOO risks bringing more harm than benefit if BOO is not present. In contrast, supporters of selective use of urodynamics point to the lack of evidence, and the costs of providing the service. There was also a presumption about what the patients wanted, with an assumption that undergoing the test would not be popular. UPSTREAM UPSTREAM (Urodynamics for Prostate Surgery: Randomised Evaluation of Assessment Methods) is a randomised controlled trial (ISRCTN56164274) in men with bothersome lower urinary tract symptoms (LUTS), in whom surgery was an option3. Participants were randomised to either routine care (RC) diagnostic tests including uroflowmetry, symptom score and bladder diary or RC plus urodynamics (UDS). 820 men were randomised in 26 hospitals in England. The primary outcome was the International Prostate Symptom Score (IPSS) 18 months after randomisation. The UDS arm demonstrated noninferiority relative to RC, with a difference in the mean IPSS of 0.33. Overall IPSS fell from 19 to 13 in both arms. The median BOO index for the UDS arm was 48 and DO was seen in around half of the men4.

It is vital, however, that urologists understand some key points: • Any indication of neurological disease or a condition that increases the prevalence of DUA (such as diabetes mellitus) makes UDS an important test; • Individual choice by the patient may justify the use of UDS; • Some men suffered a deterioration in symptoms as a result of surgery. The UPSTREAM team is evaluating this further to derive predictors of outcome, and that work will yield the individual patient clinical indications for UDS; • It is essential to consider what type of LUTS the man is experiencing. To have a good chance of benefit from surgery, voiding LUTS must be present, and they should also be causing a substantial degree of bother. If storage LUTS are the principal cause of bad quality of life, outcome of BOO surgery is not good. ICIQ-MLUTS Alongside the IPSS, the study used the International Consultation on Incontinence Questionnaire (ICIQ). The additional information that this brings compared with only IPSS turned out to be very influential for understanding the quality of life impact of LUTS5. In particular, ICIQ-MLUTS measures the presence of dribble and incontinence, which are absent from the IPSS. Furthermore, it reports the bother associated with each individual symptom. Overall, this symptom score provided a quick and efficient way to capture which symptoms are present and bothersome. It is thus more valuable than IPSS in prioritising the therapy for an individual patient. Quality of testing The study was careful to ensure proper quality of testing, joining the UNBLOCS study6 in reviewing standards of flow rate testing and urodynamics for a proportion of tests during the set-up phase of the studies7. We identified wrongly-diagnosed BOO in 6%, which has to be considered a serious error since it could lead to unnecessary surgery being done. We also found that 28% of urodynamic centres did not record calibration checks and equipment servicing, meaning that the equipment may not measure accurately. Furthermore, centres sometimes failed to identify a potential recording problem at the crucial moment of maximum flow rate. This is crucial, since the tracing has to be scrutinised to make sure the correct data is used when diagnosing BOO [see Fig. 1]. Hence, centres were at risk of making an error of diagnosis, and again this could place the patient at risk of inappropriate surgery.

“…UDS did not actually reduce surgery rates” Effect on surgery rate The study looked to see whether UDS reduced the surgery rates, arguing that DUA could be identified with this additional test, and that this would mean the men would not undergo surgery to relieve BOO. 38% (153/408) in the UDS arm received surgery during the 18-month-period, compared with 36% (138/384) in the routine care arm. Hence it was clear that UDS did not actually reduce surgery rates. Conclusion The basic conclusion of the USPTREAM study is that UDS was non-inferior to RC for the IPSS but did not reduce surgical rates in this population. Hence, routine use of UDS in the evaluation of uncomplicated LUTS has a limited role and should be used selectively3.

EAU Section of Female and Functional Urology

European Urology Today

Fig. 1: A spike is present on the flow trace (red arrow). The machine interpreted this as being the patient’s maximum flow rate, and so erroneously derived the bladder outlet obstruction index from here. In fact, such spikes are not generated by bladder contraction, and the patient’s actual function is best indicated by the peak of the phasic flow curve (purple arrow). This is the point where the index should have been calculated.

Additional study results Extensive qualitative research was undertaken, and this established that Urodynamics is acceptable to men with LUTS and generally well tolerated8, in contrast to the clinicians’ generally held assumptions. We found evidence of clinicians and patients negotiating treatment decisions between them and of patients disagreeing with clinicians’ recommendations9. We also identified that consultations were sometimes rushed, with incomplete discussions of test results and treatment options, as well as misperceptions about LUTS and its treatment. Hence there is some need for units to

evaluate the service delivery in this area, which is a crucial component of any urology service. It is increasingly clear that men prefer conservative and less risky treatment options, but the preference varies depending on baseline symptom severity and the risk/benefit characteristics of the treatment. Men prefer reducing the risk of surgery1, and hence the role of UDS in potentially achieving this is valuable for individual patients. However, UPSTREAM found that UDS does not reduce surgery rates overall, and hence it should not be routine practice in otherwise healthy men with voiding LUTS. Over the next few years, the study will continue to report features to optimise the diagnostic pathway for LUTS in men. Acknowledgement This project was funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project number 12/140/01). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. This study was designed and delivered in collaboration with the BRTC, a UKCRC Registered Clinical Trials Unit (CTU), which, as part of the Bristol Trials Centre (BTC), is in receipt of NIHR CTU support funding. The UPSTREAM trial was sponsored by North Bristol NHS Trust (NBT), Bristol, UK. Study data were collected and managed using REDCap (Research Electronic Data Capture, Harris PA, et al. J Biomed Inform. 2009 Apr;42(2):377-81) hosted at the University of Bristol. References 1. Clement KD, Burden H, Warren K, Lapitan MCM, Omar MI, Drake MJ. Invasive urodynamic studies for the management of lower urinary tract symptoms (LUTS) in men with voiding dysfunction. Cochrane Database of Systematic Reviews: John Wiley & Sons, Ltd; 2015. 2. Drake MJ, Lewis AL, Lane JA. Urodynamic Testing for Men with Voiding Symptoms Considering Interventional Therapy: The Merits of a Properly Constructed Randomised Trial. Eur Urol. 2016;69(5):759-60.

3. Drake MJ, Lewis AL, Young GJ, Abrams P, Blair PS, Chapple C, et al. Diagnostic Assessment of Lower Urinary Tract Symptoms in Men Considering Prostate Surgery: A Noninferiority Randomised Controlled Trial of Urodynamics in 26 Hospitals. Eur Urol. 2020;78(5):701-10. 4. Lewis AL, Young GJ, Abrams P, Blair PS, Chapple C, Glazener CMA, et al. Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). Eur Urol Focus. 2019;5(3):340-50. 5. Ito H, Young G, Lewis A, Blair PS, Cotterill N, Lane A, et al. Grading severity and bother using the IPSS and ICIQ-MLUTS scores in men seeking lower urinary tract symptoms therapy. Journal of Urology. 2020. 6. Hashim H, Worthington J, Abrams P, Young G, Taylor H, Noble SM, et al. Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): a randomised controlled trial. Lancet. 2020;396(10243):50-61. 7. Aiello M, Jelski J, Lewis A, Worthington J, McDonald C, Abrams P, et al. Quality control of uroflowmetry and urodynamic data from two large multicenter studies of male lower urinary tract symptoms. Neurourol Urodyn. 2020;39(4):1170-7. 8. Selman LE, Ochieng CA, Lewis AL, Drake MJ, Horwood J. Recommendations for conducting invasive urodynamics for men with lower urinary tract symptoms: Qualitative interview findings from a large randomized controlled trial (UPSTREAM). Neurourol Urodyn. 2019;38(1):320-9. 9. Selman LE, Clement C, Ochieng CA, Lewis AL, Chapple C, Abrams P, et al. Treatment decision-making among men with lower urinary tract symptoms: A qualitative study of men's experiences with recommendations for patient-centred practice. Neurourol Urodyn. 2021;40(1):201-10. 10. Malde S, Umbach R, Wheeler JR, Lytvyn L, Cornu JN, Gacci M, et al. A Systematic Review of Patients' Values, Preferences, and Expectations for the Diagnosis and Treatment of Male Lower Urinary Tract Symptoms. Eur Urol. 2021.

EAU21 Industry Sessions Thursday, 8 July

Friday, 9 July

12.00 - 13.00 Intuitive 19.00 - 20.00 Boston Scientific 19.00 - 20.00 Laborie

12.45 - 13.45 12.45 - 13.45 18.00 - 19.00 18.00 - 19.00

Saturday, 10 July

Sunday, 11 July

09.30 - 10.30 09.30 - 10.30 14.15 - 15.15 14.15 - 15.15 18.30 - 19.30

10.15 - 11.15 10.15 - 11.15 14.00 - 15.00 18.00 - 19.00 18.00 - 18.30

Ipsen MedscapeLive Bristol-Myers Squibb IBSA Astellas

Astellas Janssen AstraZeneca GSK

Astellas Pierre Fabre Bayer Bio Techne Recordati

This overview of the Industry Sessions planned during EAU21 Virtual, 8-12 July 2021 is tentative and subject to be changed. For the latest and most up-to-date programme, visit eau2021.org.

March/May 2021

Digital uropathology in times of COVID-19 Remote diagnosis, consultation and distant teaching Prof. Rodolfo Montironi ESUP Chairman Section of Pathological Anatomy School of Medicine Ancona (IT)

Prof. Liang Cheng Dept. of Pathology and Laboratory Medicine Indiana University School of Medicine Indianapolis (US)

r.montironi@ staff.univpm.it

lcheng@iupui.edu

Dr. Alessia Cimadamore ESUP Board Member Section of Pathological Anatomy School of Medicine Ancona (IT)

Prof. Antonio LopezBeltran ESUP Honorary member Dept. of Surgery Cordoba University Medical School Cordoba (ES)

a.cimadamore@ staff.univpm.it

em1lobea@gmail.com

Prof. Marina Scarpelli Section of Pathological Anatomy School of Medicine Ancona (IT) m.scarpelli@ univpm.it

Slide 1: Virtual slide of a whole mount section of the prostate (Size: 1.42 GB). The cancer area was dotted on the surface of the glass slide before digitalisation. The user can navigate and change magnification in order to define the lesion and its nature.

In this period of COVID-19 pandemic, uropathologists, and pathologists in general, are reconsidering the approach in examining glass slides with conventional light microscopy (CLM). There are constrains linked to the issues uropathologists are facing, including the need of physical distance with laboratory professionals and colleagues and loss of social interaction.

2019;475(1):77–83. Implementation of AI-based algorithms The use of DM will allow the routine implementation 9. Bera K, Schalper KA, Rimm DL, Velcheti V, Madabhushi A. Artificial intelligence in digital pathology - new tools for of artificial AI-based algorithms5-12. Algorithms are diagnosis and precision oncology. Nat Rev Clin Oncol. based on DM as “learn and input associations and 2019;16(11):703-715. links between items such as a diagnosis made by a 10. Bulten W, Balkenhol M, Belinga JA, et al. Artificial uropathologist, underlying molecular features and intelligence assistance significantly improves Gleason patients’ survival or response to adjuvant/neoadjuvant therapy”7. Such algorithms have the capability of After the pandemic going beyond the visual evaluation of morphological The question is what uropathology will be like after patterns in order to identify tissue features not the resolution of this pandemic. Since medical perceived by human recognition. Nagpal et al13 practices, including pathology, are moving towards an adopted “a supervised learning method to develop a era of global digitalisation, the uropathology practice deep learning system for PCa grading” on radical might not return to what CLM routine was before the prostatectomy specimens. Accuracy was assessed for pandemic. In particular, uropathologists are the assignment of PCa grade groups by generalists, in becoming more and more enthusiastic about the comparison to specialists. adoption and application of digital microscopy (DM). The process of merging data from multiple sources, including DM, diagnostic imaging13 and robotic DM originated approximately 40 years ago1. Dr. Peter H. Bartels (US) contributed to the development of DM. surgery, “is defined as multi-criteria decision making and information fusion”4,14. The resulting information, Together with others, he developed its theoretical background as well as applications. The recording and including the diagnostic, prognostic and therapeutic decisions when applied to men with PCa examined merging processes were extended over a large area, with whole slide imaging, and with biomarkers using a so-called multi-megapixel array. It deriving from tissue, urine and blood samples, is far corresponds to what we call virtual slide. This more accurate than when the various sources are included case based reasoning and machine vision, i.e. the current bases of the artificial intelligence (AI)2. considered separately”. All this requires the utilisation of AI. Distant teaching using DM will also grow into a Bartels’ fields of interest focused on digitalisation in mainstream mode of pathology teaching, something uropathology. One of his studies included the cribriformity index of prostate cancer (PCa). This might that is reinforced by COVID-19. have appeared of little clinical significance. Nowadays, PCa with a cribriform architecture is considered as the References 1. Cimadamore A, Lopez-Beltran A, Scarpelli M, Cheng L, most aggressive form of Gleason pattern 43.

grading of prostate biopsies by pathologists. Mod Pathol. 2021;34(3):660-671 11. Goldenberg SL, Nir G, Salcudean SE. A new era: artificial intelligence and machine learning in prostate cancer. Nat Rev Urol. 2019;16(7):391-403. 12. Montironi R, Cheng L, Lopez-Beltran A, et al. Decision support systems for morphology-based diagnosis and prognosis of prostate neoplasms: a methodological approach. Cancer. 2009 Jul 1;115(13 Suppl):3068-77. 13. Nagpal K, Foote D, Tan F, Liu Y,et al. Development and Validation of a Deep Learning Algorithm for Gleason Grading of Prostate Cancer From Biopsy Specimens. JAMA Oncol. 2020;6(9):1372-1380. 14. Antonelli M, Johnston EW, Dikaios N, et al. Machine learning classifiers can predict Gleason pattern 4 prostate cancer with greater accuracy than experienced radiologists. Eur Radiol. 2019;29(9):4754-4764. 15. Montironi MA. From image analysis in pathology to robotics and artificial intelligence. Anal Quant Cytopathol Histol. 2016;38, 268–269

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Montironi R. Digital pathology and COVID-19 and future crises: pathologists can safely diagnose cases from home Virtual slides using a consumer monitor and a mini PC. J Clin Pathol. A glass slide scanner, a computer with webcam, a TV 2020;73(11):695-696 monitor, an internet connection are pieces of 2. Montironi R, Cimadamore A, Lopez-Beltran A, Cheng L, equipment we use to reach in real time the goals of Scarpelli. Exciting experiences in the 'Rocky road to digital sharing images for consultation, teaching, and diagnostics'. J Clin Pathol. 2021;74(1):5-6 communication with clinicians, patients and students. Modern equipment can scan whole mount sections (see 3. Montironi R, Cimadamore A, Scarpelli M, Cheng L, Lopez-Beltran A, Mikuz G. Pathology without microscope: Figure 1)4. Virtual slides are shared among us or sent From a projection screen to a virtual slide. Pathol Res over the internet to other colleagues. The procedure is Pract. 2020;216(11):153196. doi: 10.1016/j.prp.2020.153196. quite fast and simple, considering that the size of a virtual whole mount section is in the range of gigabits. 4. Montironi R, Cimadamore A, Massari F, et al. Whole Slide

The goals can also be met through ‘smart working from home’1. Virtual slides are exchanged via a home internet connection and, in real time, shown on a TV home screen, linked to a PC. The examining uropathologist does not feel isolated because he/she, when analysing the slide(s), can simultaneously communicate with others by using one of the platforms available. Such communication and interaction include voice and image of a colleague and/or student, shown, at the same time as the virtual slide, in a window in a corner of the TV.

8. EAU Section of Uropathology (ESUP)

March/May 2021

Imaging of Large Format Histology in Prostate Pathology: Potential for Information Fusion. Arch Pathol Lab Med. 2017;141:1460-1461 Rakha EA, Toss M, Shiino S, et al. Current and future applications of artificial intelligence in pathology: A clinical perspective. J Clin Pathol. 2020;jclinpath-2020-206908 Moradi M, Salcudean SE, Chang SD, et al. Multiparametric MRI maps for detection and grading of dominant prostate tumors. J Magn Reson Imaging. 2012;35(6):1403–13. Janowczyk A, Madabhushi A. Deep learning for digital pathology image analysis: A comprehensive tutorial with selected use cases. J Pathol Inform. 2016;7(1). Lucas M, Jansen I, Savci-Heijink CD, et al. Deep learning for automatic Gleason pattern classification for grade group determination of prostate biopsies. Virchows Arch.

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

European Urology Today

Young Urologists/Residents Corner YAU Sexual and Reproductive Health Group YAU Men's Health Working Party will continue activities and cooperations under a new name Assoc. Prof. Giorgio Russo Consulting Editor for European Urology Editor for Int J Impot Res University of Catania (IT) giorgioivan1987@ gmail.com

Konya (TR), Ioannis Sokolakis, Nuremberg (DE), Ahmet Ürkmez, Istanbul (TR) and Borat Garcia Gómez, Madrid (ES), Andrey O. Morozov, Moscow (RU and Selcuk Sarikaya, Ankara (TR) - Associate members. The group actively collaborates with the Guidelines office of sexual and reproductive health and with the Male sexual health and dysfunction scientific committee of the European Society for Sexual Medicine (ESSM), demonstrating its involvement with scientific societies in order to promote every aspect of interest in sexuality.

Giorgio Ivan Russo, Maarten Albersen, Catania (IT), Leuven (BE) Chairman

Paolo Capogrosso, Marco Falcone, Varese (IT) Turin (IT)

Mikkel M. Fode, Herlev (DK)

Murat Gül, Konya (TR)

"Sexuality is a fundamental component of our being, even when we do not engage in any sexual activity” (Anne Dickson).

Google Sexuality represents an aspect of daily life of substantial importance to each of us. The term "sex" in Google has a relative search volume (RSV) equal Inspired by a global vision on sexuality, the Men's Health group will change its look shortly and will be to 73, which is considered to be a high value. In fact, the value 100 indicates the highest search frequency named "Sexual and Reproductive Health Group". of a given term, while 50 indicates half of the searches. In addition, over the last months our group Aspects of sexual health has focused its attention on the impact of the Since its foundation (2012), our group has been COVID-19 pandemic on people’s sexual habits by studying with scientific rigor all aspects of sexual exploring the impact of the COVID-19 pandemic on health, from the point of view of medical problems, from a psychological vision, sexual dysfunctions after sexual behaviour in the population of three different surgery and finally a special look at new technologies. countries: Iran, Italy and Spain. The group is currently formed by Giorgio Ivan Russo, Catania (IT), Chairman, Maarten Albersen, Leuven (BE), Paolo Capogrosso, Varese (IT), Marco Falcone, Turin (IT), Mikkel M. Fode, Herlev (DK), Murat Gül,

Major changes For example, during COVID-19 quarantine, traffic on Pornhub increased significantly. As most people were forced to stay inside, major changes were observed in

Ioannis Sokolakis, Nuremberg (DE)

Ahmet Ürkmez, Istanbul (TR)

Borja García Gómez, Andrey O. Morozov, Selcuk Sarikaya, Madrid (ES), Moscow (RU), Ankara (TR), Associate Member Associate Member Associate Member

The members of the YAU Sexual and Reproductive Health Group

Italy’s hourly traffic. On 11 March, traffic at 2 am was 47% higher than normal and remained 25% above average even at 5 am. Evening traffic at 9 pm was 12% higher than at 9 pm on an average day. Traffic in Spain was 6.1% higher than normal on 12 March. After midnight, traffic increased up to 10.1% at 3 am. Early morning traffic was much lower than average, followed by a slight increase in the afternoon and a

6.5% increase at 7 pm. Certainly, the pandemic is an exceptional situation in all our lives. The research above merely demonstrates the continued and actual interest of our group in all aspects that may concern sexuality. Finally, we would be delighted to receive your application to be part of our research team.

YAU Trauma and Reconstructive Working Party A plea for evidence-based medicine in reconstructive urology Ass. Prof. Luis Alex Kluth Dept. of Urology University Hospital Frankfurt (DE)

Luis.kluth@kgu.de I had the pleasure of spending my residency at one of the most renowned urethral reconstruction centres in Europe: the University Medical Centre HamburgEppendorf (Hamburg (GE)), under the supervision of Margit Fisch and Roland Dahlem. After finishing a uro-oncologic fellowship with Shahrokh Shariat at Weill Medical College of Cornell University (New York, US) during my residency, everything seemed to turn around evidence-based medicine. Researchers would aim for the highest level of evidence, thoughtful randomised prospective study designs, well established NMIBC and MIBC EAU guidelines etc. No recommendations After returning from this fellowship, I was searching for this quality of evidence-based medicine in reconstructive urology, especially in urethral reconstruction. However, I had no idea where to look. At the time, no guidelines-based recommendations

existed. Consequently, I started to think about ways to bring more evidence-based medicine into reconstructive urology.

Reconstructive urologists follow an own institutional standard, a so-called surgical school - it is important to publish them.

In March 2017, I presented a proposal for a new Trauma The literature in reconstructive urology is mainly and Reconstructive working party at the Annual EAU outcome-driven. I mean the surgical outcome, about Congress in London (UK) and was often asked: why? which different surgical techniques and surgical success rates are described and compared. However, Questions a publication on a urethral stricture-free survival rate I remember that when I was in the operating room of 90% gives you little insight into how this excellent with Roland Dahlem, I could not stop asking him success rate has been achieved. In contrast, we rarely questions, such as: why are you using that suture now, find literature on perioperative diagnostic algorithms, why continuously, why not interrupted, why do we keep antibiotic treatment, types and lengths of the catheter for that time? He never needed more than a catheterisation, standardised reporting on peri and second to respond, but even though he always had a postoperative complications, donor site (oral) very reasonable argument, in the end it often sounded morbidity and quality of life measured by patientlike he was saying: we just do it this way (always). reported outcomes (PROMS). Therefore, the new released EAU guidelines on urethral stricture disease I truly think this is what reconstructive urology is about, are a milestones in reconstructive urology. Are we a field which is highly based on surgical experience. It done? No, we just started! is about doing things the same way as you have learned them. And only after I started doing Having our new guidelines for urethral stricture reconstructive surgeries myself, I realized that diseases is a milestone in reconstructive urology. The everything reconstructive surgeons do both inside and relevance of these guidelines cannot be overestimated especially outside the operating room (e.g. and the panel deserves congratulations. Three panel preoperative diagnostic retrograde urethrogram, use of members are also member of our YAU group, which antibiotic prophylaxis, urine culture control, underlines the expertise of our members and the postoperative voiding micturition control) follows an importance of fruitful collaborations. Our group institutional standard, you could also say a ‘surgical actively supports the EAU guidelines section on school’. However, usually these institutional standards urethral stricture disease by providing systematic are not published. reviews and meta-analyses on topics which lack evidence. But we need to keep in mind that these guidelines have been and will be based on research, publications, systematic reviews and meta-analyses, performed by dedicated academic reconstructive surgeons. The need for young academic urologists In the beginning, when I was looking for YAU group members in Europe, it was quite difficult to identify urologists who are both interested in reconstructive urology and research. I believe it has something to do with age.

Members of the YAU Trauma and Reconstructive Working Party

European Urology Today

The most productive time of an academic urologist is in the earlier years of her/his residency. But at that time, you most likely do not have the surgical skills and expertise to (1) deeply understand and thus address clinical problems in reconstructive urology and (2) provide sufficient data on patients you operated on. Once you do have the clinical expertise, you realise you are too old to do research!

As an academic reconstructive urologist, you have to manage the balancing act between gaining surgical (clinical) experience and keeping the fire for doing research - in other words, you need a long breath. Starting with two members in the first year, our YAU Trauma and Reconstructive Urology working party has constantly grown and currently includes 10 members with different expertise in the broad field of reconstructive urology. This includes urethroplasty, trauma surgery, incontinence surgery, fistula repair, ureteral repair, pyeloplasty, penile reconstructive surgery, corporoplasty, urinary diversion, transgender surgery, 3D modelling, tissue engineering, robotic surgery, andrology, and sexual medicine. One of our main projects is to merge existing retrospective institutional databases and create prospective multi-institutional registries. Based on these datasets, we develop new risk models on different surgical outcomes and validate PROMS for urethral stricture disease. Collaborations Within the EAU, we collaborate with different disciplines such as the European School of Urology (ESU) and the European Society of Genital Urinary Reconstructive Surgeons (ESGURS). We believe in the importance of international collaborations with existing research groups such as the American Trauma Urologic Reconstructive Network Surgeons (TURNS) and the European Society of Sexual Medicine (ESSM) Scientific Collaboration and Partnership (ESCAP) to create high-quality projects. We embrace the heterogeneity and diversity of our group, which widens the spectrum of research interest and allows views from different angles on each project. Running and future projects Some of our running and future projects address some important clinical questions, thereby reflecting the broad spectrum of reconstructive urology: • Prospective randomised controlled trial comparing surgical outcomes and donor site morbidity between buccal mucosa and lingual mucosa graft urethroplasty for anterior urethral strictures using the European Association of Urology quality criteria for standardised reporting; Continued on page 29

March/May 2021

Young Urologists/Residents Corner Urology fellowship in Heilbronn during the pandemic Unique training experience at successful German clinic Dr. Fatih Sandikçi HSU, Yıldırım Beyazıt Dıskapı Training and Research Hospital ESRU, National Communication Officer for Turkey Ankara (TR) @DrSANDIKCI For over a year now, the COVID-19 pandemic has been blocking the world. During this period urologic education has especially been affected in a negative way. Moreover, face-to-face training and fellowship programmes have been stopped in many parts of the world. Online platforms Training programmes have moved to online platforms in many countries. However, online virtual training cannot replace a real surgical training. Performing surgical training on real models, real patients and developing real surgical skills is still necessary. I had applied for a robotic and laparoscopic surgery fellowship training programme at SLK-Kliniken-Heilbronn (DE), one of the pioneer minimally invasive training centres in Europe, before the pandemic begun. After a long mail correspondence and accomplishing the necessary formalities, I was allowed to come to Germany in pandemic times.

Permission from airport police The flights to many European countries were stopped or cancelled in this period. I was continuously following the latest news about the situation in Germany without losing hope. I contacted the German Embassy directly via an email and was informed that I needed permission from the airport police. The mail from the airport police unit stated: "You can come, but we will check your documents before you enter the country and the final decision is made by the police”. I quickly finished my preparations, including all my CCOVID-19-related documents and PCR test results. Finding a place to stay was also a big problem then, but it was solved thanks to the help of the host clinic. Finally, I could enter Germany after a very detailed document check by the airport police. First day As soon as I reached the urology department, I directly went to the secretary Mrs. Reuter and handed in the required documents. Then, I met with Prof. Jens Rassweiler, one of the pioneers of laparoscopic and robotic surgery, whose name I had heard frequently over the years. Prof. Ali Gözen, who is responsible for the training programme in Heilbronn informed me about the daily workflow in the operating theatre. On the first day, I met the team members one by one and entered the operating room for endourological operations. It was my first day in an operating room in a different country. Da Vinci The following days, I continued to work in legendary operating room 7 in the new building. Before coming

to Heilbronn I watched many surgery videos related to robotic surgery. However, assisting in robotic surgery and working very closely with the Da Vinci Xi Robotic System was another hard experience. This experience involved taking an active role in many ablative and reconstructive robotic and laparoscopic operations. This was a very important and valuable opportunity for me. We have performed 6-12 robotic and laparoscopic cases and 45-50 endoscopic cases per week, which was a high number during the COVID-19 pandemic period. All the cases were prepared very carefully under the special pandemic regulations in the hospital. The COVID-19-positive or CCOVID-19suspected emergency cases were operated in a dedicated separate operating theatre. During my 3-month fellowship training period, I joined in about 70 robotic and 42 laparoscopic surgeries. The clinic has a well-equipped training room with laparoscopic and endoscopic simulators and computers with educational training videos. Scientific study projects Another important aspect for me was to join the two scientific study projects and learn how to write a scientific paper from the experts. All these important experiences have made this training into a very valuable achievement for me. During the same period, operations were postponed in many urology clinics. However, despite the COVID-19 pandemic many operations continued to be performed with devotion, knowledge and high-level surgical skills in

Posing with Profs. A. Gözen (left) and J. Rassweiler (right)

Heilbronn. Successful management of this situation is the result of the knowledge and experience of the clinic over the years. Its scientific power and skills provide confidence and belief to surgeons who are trained like me. Prof. Jens Rassweiler and Prof. Ali Serdar Gözen's efforts and the non-stop work of the entire team is an undeniable necessity to run this successful and prestigious clinic. I am grateful to them for giving me this wonderful educational opportunity.

Urology Cheat Sheets: A new way to study urology? Studying urology has never been so easy! Dr. Esther García Rojo HM Hospitales and Roc Clinic Board RAEU Madrid (ES)

Scientific advisor The Urology Cheat Sheets family has not stopped growing. We now have a renowned urologist as scientific advisor (Javier Romero Otero) and several permanent collaborators, both residents and young urologists (Manuel Alonso Isa, Pablo Abad López and Celeste Manfredi). We are all interested in evidence-

based medicine and the dissemination of knowledge through social media. With this project, we address all those people who are interested in learning about urology in a different, fun and simple way. From urologists who seek to consolidate knowledge or to have an easy access

esthergrojo@ hotmail.com Image 3: Urology Cheat Sheets website

In August 2020, in the absence of urology-related, schematic and easy to understand material for studying and consultation, I started creating “cheat sheets” about specific topics, with algorithms, diagrams, summaries, etc. After the initial acceptance and popularity in my hospital, I decided to share them on my Twitter account weekly (see Image 1).

clinical practice guide, to students and residents who are studying or reviewing all aspects of the specialty for the preparation of exams. New material Our objective is to release new material twice a month, to cover the most relevant topics in order to study for board examinations or for a quick review before performing an in-patient round or working in an out-patient clinic.

Urology cheat sheets platform From the beginning, the urological community accepted the sheets and the circulation on social media was phenomenal. There were pictures of the sheets in hospital study rooms around the world and each sheet had between 20,000 and 50,000 views on Twitter. Following this initial success, Urology Cheat Sheets was established as a serious platform with a proper Twitter account (@CheatUrology), dedicated entirely to provide schematic scientific content, based on the latest scientific evidence, reviewing the most important urological topics, both the basics and the most complex subjects, always in a simple and practical way.

Continued from page 28

• Prospective study on the main therapy for Peyronie's disease including the use of all injection therapies (including Clostridium collagenase histolyticum) by measuring success, recurrence, shift to surgery and surgical reports; • (Recurrent) anastomotic strictures, comparing Holmium Laser Incision vs. cold knife incision in vesicourethral anastomotic stenoses in patients who underwent radical prostatectomy for prostate cancer; March/May 2021

More recently, we are collaborating with the Residents and Young Urologist Working Group of the Spanish Association of Urology (@ResidentesAEU), who will be participating in the development of scientific content (see Image 2).

Image 1: Examples of #urologycheatsheets

• Consequences of bulbar urethroplasty surgery on erectile function; • Intraurethral application of platelet-rich plasma after internal urethrotomy to reduce stricture recurrence; • Primary urethral realignment vs suprapubic catheter for posterior urethral (traumatic) injuries; • The impact of preoperative double-J stent on perioperative complications, recurrence and quality of life in adult patients undergoing pyeloplasty; • Stoma complications and quality of life after ileal

Image 2: Examples of #urologycheatsheets collaboration with the @ResidentesAEU

conduit diversion; • Cold knife versus hot knife Direct Vision Internal urethrotomy (DVIU) in the treatment of male urethral strictures; • Tissue engineering in reconstructive urology – the current status and critical insights into future directions; • Long-term follow-up for patients operated by paediatric surgeons for distal hypospadias. Evidence-based medicine And last but not least, YAU aims at bringing evidence-

You can find all Urology Cheat Sheets on the official website: http://urologycheatsheets.org/ (see Image 3) and remember that everyone is welcome to collaborate on this project!

based medicine to the table. Our YAU group was founded in March 2017 and is thus the ‘youngest’, together with the Urotech group. We are proud to have added 13 original articles on behalf of the Trauma and Reconstructive Urology working party. We need young practising urologists in Europe with a major interest in trauma and reconstructive urology, who are dedicated to academia. We would like you to actively collaborate in order to create a group of young ’key opinion leaders’ in the field of trauma and reconstructive urology in Europe. European Urology Today

25-28 November 2021, Athens, Greece

Working together to improve patient care 13th European Multidisciplinary Congress on Urological Cancers In conjunction with the • 9th Meeting on the EAU Section on Urological Imaging (ESUI) • European School of Urology (ESU) • EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) • Young Academic Urologists Meeting (YAU)

www.emuc21.org

ESUI21 9th Meeting of the EAU Section of Urological Imaging 25 November 2021, Athens, Greece

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

www.eu-acme.org

www.esui21.org In conjunction with the 13th European Multidisciplinary Congress on Urological Cancers

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

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

European Urological Scholarship Programme (EUSP) Do not forget to submit your online applications for Short Visit, Clinical Visit, Clinical and Lab Scholarship, and Visiting Professor Programme before 1 September.

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

European Urology Today

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

March/May 2021

ESOU21 zeroes in on most pressing onco-urology topics Online edition reports best outcomes, resolutions & COVID-19 By Erika De Groot The virtual 18th Meeting of the EAU Section of Oncological Urology (ESOU21) delivered the most pressing onco-urological topics from 29 to 31 January 2021, under the leadership of esteemed ESOU Chair, Prof. Morgan Rouprêt (FR). About 740 delegates from 40 countries from across the globe attended ESOU21. The meeting garnered an impressive total of 62,880 page views on its digital platform, 4.4 million Twitter impressions and 772 tweets. The meeting begins ESOU21 commenced on Friday morning with an enthusiastic welcome from Prof. Roupret followed by lively deliberations on the diagnosis and staging of prostate cancer (PCa) covering systematic biopsy, as well as, prostate-specific membrane antigen (PSMA) - positron emission tomography (PET). This session was followed by the renal cell cancer (RCC) session which highlighted key points on partial nephrectomy such as use of fluorescence in preparing renal hilum, resection techniques and more. The session on upper tract urothelial carcinoma (UTUC) and bladder cancer (BCa) followed, wherein Dr. Alberto Breda (ES) stated that the emergence of new technologies and urinary biomarkers aid urologists in breaking limitations of standard techniques. Dr. Evanguelos Xylinas (FR) shared that with regard to primary diagnosis, urinary markers are not yet ready for primetime. Prof. Marek Babjuk (CZ) underscored the EAU Guidelines recommendation of offering radical cystectomy to patients with Bacillus Calmette-Guérin (BCG)-unresponsive tumours. In the subsequent session on rare tumours, Dr. Oscar Brouwer (NL) said that invasive staging remains necessary in intermediate/high-risk clinically node negative (cN0) patients. According to Prof. Peter Albers (DE), the percentage of mortality in testicular cancer

(TC) has significantly reduced to 5% at present. He added that reduction of burden of treatment should be further discussed. The key points of Dr. Julien Van Damme’s (BE) presentation included the TC pathway for the best oncological outcome and maximal fertility preservation e.g. TC diagnosis, fertility planning, etc. ESOU21’s first day concluded with clinical case discussions on improving risk stratification in men with intermediate PCa, and weighing whether pelvic lymph node dissection will change in the PSMA-PET era. ESOU21’s second day Day two commenced with the joint session of the ESOU and its official scientific journal European Urology Oncology (EUO) focusing on RCC which comprised of the EUO presentation on systemic treatment of metastatic RCC (mRCC); surgical and perioperative challenges of large renal tumours; and case deliberations on perioperative care of geriatric RCC patients.

and one-year maintenance for patients with high-risk non-muscle-invasive bladder cancer (NMIBC); upfront systemic therapy for mRCC patients, and more.

Following this session, the educational session of the European School of Urology (ESU), ESOU and EAU Robotic Urology Section (ERUS) covered topics on tumours operable using robotic technology, and variants of robotic partial nephrectomy, to name a few.

In his presentation "Impact of COVID-19 outbreak on oncological robotic-assisted surgeries: Risk assessment of the pandemic", Dr. Alexandre Ingels (FR) listed challenges such as how first-wave studies show no systemic pre- and post-operative tests and most asymptomatic cases were missed; overestimation of Case discussions ensued during the next session on COVID-19 mortality; and underestimation of nosocomial advanced and oligometastatic PCa such as deliberations contaminations. on the contrast between adjuvant and salvage radiation therapy after radical prostatectomy for patients with Further into the session, Prof. Maria Ribal (ES) high-risk PCa. These were followed by more lectures on explained the establishment, aims and process of the high-risk UTUC such as by Assoc. Prof. Andrea Necchi EAU Guidelines Office Rapid Reaction Group on (IT) who tackled current issues and controversies in adapted guidelines recommendations. systemic perioperative treatment, and Prof. Shahrokh Shariat (AT) who compared open or robotic Dr. Riccardo Campi (IT) offered his expert insights on nephroureterectomy. virtual tumour boards (vTBs). He stated that research is needed on the impact of vTB on patient outcomes and A multidisciplinary panel of experts discussed the costs; and vTBs should foster evidence-based, impact of COVID-19 during the session “Setting the patient-centred care and value-based care. scene: Impact of COVID-19 on cancer treatment”. Dr. Louis Lenfant (FR) enumerated treatment strategies for ESOU21’s second day concluded with the STEPS patients with urological cancers such as induction BCG (Sessions To Evaluate ProgresS) programme.

ESOU22 19th Meeting of the EAU Section of Oncological Urology 21-23 January 2022, Madrid, Spain www.esou22.org

In-depth panel discussions during oligometastatic PCa session

Day three The meeting’s final day kickstarted with a video session dedicated to penile and testicular cancers demonstrating procedures such as glansectomy and partial orchiectomy. Afterwards, the PCa session on metastatic disease took place and provided insights on using prostate biomarkers to guide targeted treatment in advanced PCa. The RCC session on advanced and mRCC followed with lectures on histological classification, cytoreductive nephrectomy, if immunotherapy is necessary in a first-line setting, and more. The highly-anticipated ESOU21 meeting came to a close with the must-read papers in onco-urology in 2020. Explore these and the rest of ESOU21 presentations via the Resource Centre https://resource-centre.uroweb. org/resource-centre/ESOU21.

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March/May 2021

European Urology Today

Introducing the newest member of our family of journals: European Urology Open Science

We are pleased to announce the launch of European Urology Open Science, a member of the European Urology family of journals. The journal is dedicated to the publication of high quality, innovative research that will benefit patients with urological conditions and will serve the world-wide community of urologists in academia and practice. European Urology Open Science is a broad-scope, gold open access (OA) journal published on behalf of the European Association of Urology (EAU) and the European Board of Urology (EBU). All OA articles will be immediately and permanently accessible online-only for everyone to read, download, copy and distribute.

European Urology Today

March/May 2021

Global Philanthropic Committee Milestones ICS joins the GPC The International Continence Society (ICS) joins the GPC

GPC initiated by Dr. Robert Flanigan Unite forces to support educational initiatives in areas where needs are important and resources limited

Haiti GPC branches out to support upcoming urologists in Haiti via the Global Association for the Support of Haitian Urology (GASHU). Seminars, workshops, and two-day conferences in Port-au-Prince (2013, 2014).

Ongoing Equipment Donations Thanks to the GPC programme several companies donate technical equipment to projects in Rwanda, Senegal, Mali, Haiti and Jamaica

2016

2010 2018

2013 AUA, EAU, SIU join the GPC American Urological Association, European Association of Urology and the Société Internationale d’Urologie join the committee

2015

2012

PIUTA initiative launch PAUSA Initiative for Urology Training in Africa. Support the development of Urology in Sub Saharan Africa: Dakar, Senegal and Ibadan, Nigeria.

Tanzania GPC establishes major training programme at the Kilimanjaro Christian Medical Centre, Tanzania

TUNISIA

MOROCCO

ALGERIA

LIBYA

WESTERN SAHARA

MAURITANIA

MALI

GUINEA-BISSAU

CHAD

LIBERIA

ERITREA

SUDAN

BURKINA FASO

GUINEA SIERRA LEONE

EGYPT

NIGER

SENEGAL

BENIN

IVORY COAST

NIGERIA

ETHIOPIA

GHANA

CENTRAL AFRICA REPUBLIC

TOGO

CAMEROON EQUATORIAL GUINEA

GABON

UGANDA REPUBLIC OF THE CONGO

DEMOCRATIC REPUBLIC OF THE CONGO

Sudan First workshop for surgical repair of vaginal ﬁstula and urinary incontinence hosted in Sudan

SOMALIA KENYA

RWANDA BURUNDI

TANZANIA

ANGOLA ZAMBIA

MALAWI

MOZAMBIQUE ZINBABWE NAMIBIA

BOTSWANA

MADAGASCAR

SOUTH AFRICA

Philanthropic support in the developing world AUA, EAU, ICS and SIU continue support of new project initiatives The Global Philanthropic Committee (GPC) consists of multi-national urology organisations including the American Urological Association (AUA), European Association of Urology (EAU), International Continence Society (ICS) and the Société Internationale d’Urologie (SIU), with the goal of supporting proposals for worthy projects to improve urologic care throughout the world. The GPC allows organisations to pool their resources to fund larger-scale philanthropic projects as a collaborative effort.

“The GPC’s mission is to provide philanthropic support to improve urological education in the developing world.” The GPC’s mission is to provide philanthropic support to improve urological education in the

developing world. The GPC strives to provide funding mainly for education and generally will not provide funds for purchasing expensive equipment. The GPC will selectively provide funds for educators to travel for the purpose of providing training in various regions of the world, within the parameters of an approved funding request. Milestones Dr. John Denstedt (CA), American Urological Association (AUA): “In 2013, at the GPC Meeting held during the AUA Annual Meeting in San Diego, Prof. Olapade-Olaopa noted that since the GPC had begun its support and equipment donations to his institution in Ibadan, Nigeria, they had a 30-40% increase in procedures. He mentioned that they also had more multidisciplinary interactions between urologists, nurses and general surgeons, which was an unexpected benefit from the GPC’s support. It’s clear that GPC support has led to long-term improvements in urology care in

underserved areas – which is exactly the goal of this collaborative effort.” Prof. Christopher Chapple (GB), European Association of Urology (EAU): “The GPC is an initiative which we are very proud to support. We believe it is an important initiative as it allows us to channel resources from all four organisations to support colleagues practising in less advantaged areas of the world. In particular, the EAU has been proud to support the unit at the Kilimanjaro Christian Medical Centre in Arusha, Tanzania, and its training programme for young urologists, who are very grateful for the philanthropic support that provides equipment to facilitate this programme.” Mr. Daniel Snowdon (GB), International Continence Society (ICS): “ICS, as a registered charitable organisation, shared the philanthropic goals of the GPC. We also greatly valued the partnership

opportunities the group offered in uniting like-minded societies in an international effort to ease the suffering caused by urological health issues.” Ms. Susie Petrusa (GB), Société Internationale d'Urologie (SIU): “When Dr. Robert C. Flanigan, the AUA secretary, approached the SIU in 2010 to support an initiative for a global philanthropic group, SIU leadership immediately recognized the significant potential for valuable assistance this initiative could bring to underserved countries. As an international organization with a philanthropic mission, this project was a natural fit for the SIU. The SIU’s mission is further demonstrated by the activities of the GPC: supporting cooperation in urological care and education.” Urology organizations can support a project through monetary funds and/or in-kind donations, including volunteer time.

For more information about the GPC, please contact: GPC@siu-urology.org.

March/May 2021

European Urology Today

"Spot-on" evidence-based nursing care New research and developments Dear EAUN members,

Selected from PubMed

The growing evidence in urology nursing care is amazing!

Continence

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

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

• Lachance CC, Grobelna A. Management of Patients with Long-Term Indwelling Urinary Catheters: A Review of Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 May 14. PMID: 31449368. https://pubmed.ncbi.nlm.nih.gov/31449368/ • Davis NF, Bhatt NR, MacCraith E, Flood HD, Mooney R, Leonard G, Walsh MT. Long-term outcomes of urethral catheterisation injuries: a prospective multi-institutional study. World J Urol. 2020 Feb;38(2):473-480. doi: 10.1007/ s00345-019-02775-x. Epub 2019 Apr 24. PMID: 31020421. https://pubmed.ncbi.nlm.nih.gov/31020421/ • Zavodnick J, Harley C, Zabriskie K, Brahmbhatt Y. Effect of a Female External Urinary Catheter on Incidence of Catheter-Associated Urinary Tract Infection. Cureus. 2020 Oct 23;12(10):e11113. doi: 10.7759/cureus.11113. PMID: 33240709; PMCID: PMC7682542. https://pubmed.ncbi.nlm.nih.gov/33240709/ • Jin Y, Jin T, Lee SM. Development and Evaluation of the Automated Risk Assessment System for CatheterAssociated Urinary Tract Infection. Comput Inform Nurs. 2019;37(9):463-472. doi:10.1097/CIN.0000000000000506. https://pubmed.ncbi.nlm.nih.gov/30807296/

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

• Kranz J, Schmidt S, Wagenlehner F, Schneidewind L. Catheter-Associated Urinary Tract Infections in Adult Patients. Dtsch Arztebl Int. 2020;117(6):83-88. doi:10.3238/ arztebl.2020.0083. https://pubmed.ncbi.nlm.nih.gov/32102727/

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

• Schmudde Y, Olson-Sitki K, Bond J, Chamberlain J. Navel to Knees With Chlorhexidine Gluconate: Preventing Catheter-Associated Urinary Tract Infections. Dimens Crit Care Nurs. 2019;38(5):236-240. doi:10.1097/ DCC.0000000000000371. https://pubmed.ncbi.nlm.nih.gov/31369441/

• Hariati H, Suza DE, Tarigan R. Risk Factors Analysis for Catheter-Associated Urinary Tract Infection in Medan, Indonesia. Open Access Maced J Med Sci. 2019;7(19):31893194. Published 2019 Sep 12. doi:10.3889/ oamjms.2019.798. https://pubmed.ncbi.nlm.nih.gov/31949514/ • Meddings J, Manojlovich M, Fowler KE, et al. A Tiered Approach for Preventing Catheter-Associated Urinary Tract Infection. Ann Intern Med. 2019;171(7_ Suppl):S30-S37. doi:10.7326/M18-3471. https://pubmed.ncbi.nlm.nih.gov/31569226/ • Tyson AF, Campbell EF, Spangler LR, et al. Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU. J Intensive Care Med. 2020;35(8):738-744. doi:10.1177/0885066618781304. https://pubmed.ncbi.nlm.nih.gov/29886788/

Endourology • Farinha R, Rosiello G, Paludo AO, et al. Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis. Eur Urol Focus. 2021 Mar 25:S24054569(21)00098-5. doi: 10.1016/j.euf.2021.03.019. Epub ahead of print. PMID: 33775611., Peter Schatteman, Geert De Naeyer, Frederiek D’Hondt, Alexandre Mottrie. https://pubmed.ncbi.nlm.nih.gov/33775611/ • Piazza P, Rosiello G, Chacon VT, et al. Robot-assisted Cystectomy with Intracorporeal Urinary Diversion After Pelvic Irradiation for Prostate Cancer: Technique and Results from a Single High-volume Center. Eur Urol. 2021 Apr 7:S0302-2838(21)00229-3. doi: 10.1016/j. eururo.2021.03.023. Epub ahead of print. PMID: 33838960. https://pubmed.ncbi.nlm.nih.gov/33838960/ • Geraghty RM, Cook P, Roderick P, Somani B. Risk of Metabolic Syndrome in Kidney Stone Formers: A Comparative Cohort Study with a Median Follow-Up of 19 Years. J Clin Med. 2021 Mar 2;10(5):978. doi: 10.3390/ jcm10050978. PMID: 33801183; PMCID: PMC7957897. https://pubmed.ncbi.nlm.nih.gov/33801183/ • Reesink DJ, Gerritsen SL, Kelder H, van Melick HHE, Stijns PEF. Evaluation of Ureteroenteric Anastomotic

Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center. J Urol. 2021 Apr;205(4):1119-1125. doi: 10.1097/ JU.0000000000001518. Epub 2020 Nov 30. PMID: 33249976. https://pubmed.ncbi.nlm.nih.gov/33249976/ • Batagello CA, Vicentini FC, Monga M, et al. Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomized, double-blinded, placebo-controlled trial. BJU Int. 2021 Feb 25. doi: 10.1111/bju.15378. Epub ahead of print. PMID: 33630393. https://pubmed.ncbi.nlm.nih.gov/33630393/

Bladder cancer • McConkey R & Dowling M. Supportive Care Needs of Patients on Surveillance and Treatment for Non-MuscleInvasive Bladder Cancer. Seminars in Oncology Nursing vol 37, issue 1, Feb 2021. https://pubmed.ncbi.nlm.nih.gov/33431233/ • Bente Thoft Jensen. Organization Factors in the ERAS Bladder Cancer Pathway: The Multifarious Role of the ERAS Nurse, Why and What Is Important? Seminars in Oncology Nursing Vol 37, issue 1 feb 2021 https://pubmed.ncbi.nlm.nih.gov/33431234/ • Mostafid et al. Best Practices to Optimise Quality and Outcomes of Transurethral Resection of Bladder Tumours. European Urology Oncology vol 4, issue 1 pg 12-19 Feb 2021. https://pubmed.ncbi.nlm.nih.gov/32684515/ • Sari Motlagh R, Mori K, Laukhtina E, et al. Impact of enhanced optical techniques at time of TURBT with or without single immediate intravesical chemotherapy on recurrence rate of NMIBC, a systematic review and network meta-analysis of randomized trials. BJU Int. 2021 Mar 8. doi: 10.1111/bju.15383. Epub ahead of print. PMID: 33683778. https://pubmed.ncbi.nlm.nih.gov/33683778/ • Valenberg et al. Validation of an mRNA-based Urine Test for the Detection of Bladder Cancer in Patients with Haematuria. European Urology Oncology vol 4, issue 1. https://pubmed.ncbi.nlm.nih.gov/33004290/

European Association of Urology Nurses

Apply for your EAUN membership online! Would you like to receive all the benefits of EAUN membership, but have no time for tedious paperwork?

www.eaun.uroweb.org

Fellowship Programme

Becoming a member is now fast and easy! Go to www.eaun.uroweb.org and click EAUN membership to apply online. It will only take you a couple of minutes to submit your application, the rest - is for you to enjoy!

Visit a hospital abroad! 1 or 2 weeks - expenses paid Application deadline: 31 August 2021 • Only EAUN members can apply • Host hospitals in Belgium, Denmark, France, the Netherlands, Sweden, Switzerland and the United Kingdom • A great way of widening your horizon For Fellowship application forms, rules and regulations and information on which specialities the hosting hospitals can offer please visit the EAUN website. T +31 (0)26 389 0680 F +31 (0)26 389 0674 eaun@uroweb.org www.eaun.uroweb.org

European Urology Today

European Association of Urology Nurses

March/May 2021

Adolphe Steg 1926-2021 Professor Adolphe Steg passed away on April 11, 2021, aged 96 years. For the young generation this may ring a faint and distant bell, but this name definitely deserves to be remembered and honoured. Born in 1925, Adolphe Steg, son of poor Jewish immigrants, arrived in France aged 6 speaking only Yiddish. He soon became a star pupil of the French education system. Having narrowly escaped the tragic round-up of the Paris Jews in 1942, he later escaped prison, survived thanks to a Catholic priest and joined the French Resistance. After the war, reunited with his family (his father survived the Holocaust) he joined the Paris Medical school. On the occasion of a rotation in Urology as a resident, he met the man who was to be his mentor and would change his life: Prof. Pierre Aboulker. Aboulker recognised his potential and had him join the faculty of his department as Assistant Professor. Ady Steg rose to full professorship and served as Aboulker’s adjunct for over a decade. In this period he assisted his mentor when he operated President De Gaulle with open prostatectomy for BPH in 1965.

“Visionary, open-minded Humanist Urologist”

for open BPH, which in his hands almost never required blood transfusion, which was quite an achievement in this period. At the same time he had the vision to leave his faculty free to explore new avenues in urology: endo-urology developed by Thierry Flam, reconstructive surgery, urethral In 1976, Steg became Chief of Urology after the strictures, artificial sphincters, and radical death of Aboulker and ran for 20 years an prostatectomy, where I recall him observing me extremely successful department of Urology at the negotiating my learning curves with great generosity. Hospital Cochin in Paris. Here he operated with Ady Steg was definitely a ‘Humanist Urologist’: his the same dedication on the famous (including President Mitterrand) and the poor. Residents extraordinary mix of French and Jewish cultures rotating in Steg’s department were taught that allowed him to be a visionary. Exceptionally curious the satisfaction and well-being of the patient had and openminded, always on the lookout for new priority over the surgeon’s satisfaction, a things beyond his teaching at the bedside and in the message not always easily heard by young, eager operating room. He introduced and popularised surgeons in training. Steg performed with great major innovations that were controversial at the time. skill and taught the then-current urological Franzen’s Cytoaspiration of the prostate when the procedures, particularly the Hryntschak procedure diagnosis of cancer relied on DRE, LHRH agonists to

replace the cardiotoxic DES, endo-vesical BCG to treat high-risk superficial bladder tumours, x-ray guided percutaneous kidney cysts puncture to avoid open surgery (which was current practice at the time), and was instrumental in developing ESWL in France. All these achievements seem far away in times of robotic surgery, augmented reality, and various ‘omics’ but what remains today as one of Steg’s major achievements is his seminal role in the development of the EAU. In 1984 Steg became the second Secretary General of the EAU, succeeding Willy Gregoir. At this time the EAU, created in the early 1970s,was a kind of ‘old boys’ group counting 200 members, with a congress every other year. During his ten-year mandate, Steg increased, from meeting to meeting, the visibility of the EAU to the initially indifferent Urological Societies of ‘big’ countries who took their time to accept the added value of the

Association. Finally, in the first issue of European Urology Today published in April of 1991 he was able to underline the success of the EAU in bringing together more and more Urologists from all over Europe, free to travel since the fall of the Berlin Wall. At this time the dialectically minded Secretary General realised that the future spectacular increase of the EAU membership required a profound overhaul of the organisation (modification of quantity induces transformation in quality). He also realised that the Secretary General to achieve it should belong to the younger generation and gifted with excellent organisational skills. One name came on top of the list: Frans Debruyne. Debruyne had spectacularly organised the EAU’s Amsterdam congress in 1990, and, as the saying goes, the rest is history. On top of these multiple achievements, and having received numerous honours (member of the French National Academy of Medicine, Grand Officer of the Légion d’Honneur to name but two), Ady Steg devoted a considerable amount of his time to the Jewish community, serving as President of several national and international institutions and gaining here again respect, gratitude and a wide recognition for his achievements. Ady Steg is survived by his wife Gilberte, the love of his life, his two sons (one of them a Professor of Cardiology) and six grandchildren. With them we mourn a truly great man, the mentor I had the chance to meet, who accepted me as his pupil and changed my life, the way Pierre Aboulker changed his. Laurent Boccon-Gibod

Join us! Help us increase awareness of incontinence and treatment options. Become an ambassador for Urology Week 2021.

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urologyweek.org March/May 2021

European Urology Today

EAUN restructured after strategic change COVID-19 encouraged reviewing educational activities and communication platforms Mrs. Paula Allchorne, RN, Executive MBA – Health Service Management EAUN Chair Elect London (GB) p.allchorne@ eaun.org The world has changed over the last eighteen months. The global pandemic hit us hard and suddenly affected each and every one of us. Many health professionals were redeployed to assist in controlling the pandemic, often far away from their ‘comfort zones’. They had to work in hastily formed teams to deliver the best care they could under such challenging and diverse circumstances. Many of us fell ill ourselves and sadly some much-valued colleagues or family members died. We had to learn to adapt to a different way of thinking and doing things, both in our everyday lives and in our professional lives and practices. The pandemic has influenced us to adapt to challenges most of us never thought we would experience in our career or lifetime. And the determination and resilience of colleagues, trainees and volunteers was humbling. Consider the changes But at some point, we also need to find time to pause and reflect on the last eighteen months. To consider the changes we have all experienced in our work and how we all managed to become a more cohesive group of professionals, which goes well above and beyond our own expectations. As we move on, we need to try and use our newly found skills and empowerment to develop more innovative ways of caring for our patients and our work force, in urology.

During this period of time, as urology health care professionals, we still had urology patients to manage in the COVID-period, especially newly diagnosed cancer patients or patients that were waiting for organ-saving surgery due to renal stones and sepsis. We all learnt how to manage these patients differently, and hopefully in some cases more efficiently, during COVID-19. Sometimes COVID-19 even helped streamline services, making them more efficient and patient-centred (as discussed in the EAUN bladder cancer webinar of which the recording is available on the EAUN website at https://nurses. uroweb.org/nurses/education-2/webinars/).

“The pandemic also allowed us to focus on aspects that seemed less urgent before…” IT platforms The pandemic also allowed us to focus on aspects that seemed less urgent before, in the frantic pace of the 21st century. We have re-learnt how important it is to spend time with our friends, families and colleagues regularly. And how important it is to share different experiences and practices with the entire world, using different IT platforms to support each other. These advances have allowed us all to keep in touch with people, to ‘check in’ and ensure people are safe and being looked after to the best of our ability under difficult circumstances. Change our strategy No one could anticipate how long this would last but the EAUN board acknowledged that, because of travel restrictions and the fact that different countries experiencing different pressures, we needed to change our strategy and reach out to you, support our members better and support members globally. The EAUN Board has been busy working behind the scenes to restructure the responsibilities of our board members and refresh our long-term strategy plan. Our overall aim is to continue supporting you all in

your educational needs, updating everyone on new evidence-based practice, and to support each other better, using a wider range of social media platforms. Restructuring and refreshing A key area in which the EAUN restructured is education. This core responsibility ensures the EAUN continues to support its members in providing educational programmes, sharing practices, encouraging a conduit of communication to our members and standardising care across Europe and globally. The aim is to ensure that we can continue to deliver to our members, even during challenging times. The EAUN has approximately 3,000 members worldwide and The Philippines Urology Society recently signed up to join the EAUN, allowing the Association to reach Urology Teams and patients far beyond Europe. Education The education group ha designed a plan to ensure a state-of-the-art educational programme is delivered to its members regularly. In 2021 we have already delivered 2 webinars and plan to continue delivering these at least every quarter. Visit the EAUN webpage to view recordings and find out which webinars are scheduled at www.eaun.org/ nurses/education-2/webinars/. Using webinars as a new way of educating and sharing best practices allowed twenty-four different countries to access valuable up-to-date knowledge and support. The webinars are based on the requests and feedback from previous questionnaires sent to EAUN members. The first session was titled Managing bladder cancer during the COVID-19 pandemic and the March webinar focuses on prostate cancer - the feedback has been excellent! We are aiming at running two ESUN courses. If the COVID-19 restrictions are still in place, these will be virtual but

with the same key principle: to give you tools to advance your knowledge and improve your practice in your workplace. New course We have also launched a new course to improve patient care, our online Pigtail Nephrostomy Course. This e-course consists of the following modules: Background, The pigtail nephrostomy catheter, Placement of the catheter, How and when to change the catheter and Flushing, cleansing and dressing of the catheter. The 1-hour e-learning programme primarily shows and explains how to take care of a pigtail nephrostomy catheter. Special Interest Groups (SIGs) Despite the extreme pressures of COVID-19, the SIGs still managed to deliver their webinars. Without their support we would not be able to deliver such amazing state-of-the-art educational programmes, which include webinars and ESUN courses, which are all accredited now. So a massive thank you to them for their continuing support to the EAUN. If anyone is interested in joining a SIG group, please contact the Chair of the group. More details can be found at www.eaun.org/about-eaun/special-interestgroups-sigs/.

EAUN21 goes virtual Top scientific content delivered by leading experts The upcoming 21st International EAUN Meeting (EAUN21) will remain Europe’s biggest urological nursing event that will centre on critical assessment of clinical practices and key research developments regardless of the online format. Restrictions may have been imposed due to the current COVID-19 situation but the EAUN’s pursuit for knowledge and offering this knowledge will endure. Mark 3 and 4 September in your calendars and join us! What EAUN21 entails This anticipated meeting presents the latest in science and education in various formats to suit the needs of all participants (e.g. continence nurses, stoma care nurses, oncology nurses, operating room nurses, etc.). EAUN21’s scientific programme will include plenary and specialty sessions, challenging state-of-the-art lectures, poster sessions, thematic sessions and an ESU course. Expect nothing less than the newest and most relevant developments beneficial to your daily practice. Sessions may be compact but they will remain highly-informative, interesting and inspiring.

Register now for the early fee! Deadline: 2 August 2021 The programme is organised so that you will be able to attend all EAUN21 sessions and not miss out on the essentials.

Urological Nursing (EFUN) and the role of ANP” will centre on the development of the Advanced Nurse Practitioner (ANP) role, which has advanced in a variety of ways across Europe. Experiences with the ANP role and the link to the current Guidelines will be shared with the audience, as well as, the progress on the development of the EFUN. We highly encourage you to share your insights and participate in the lively discussions during this session.

For the complete Scientific Programme visit www.eaun21.org Exciting programme content You would be pleased to know that the Nursing Research Competition, the Difficult Cases, and the poster and video sessions will remain in the EAUN21 programme. Presenters will showcase their original research work which will comprise of lectures and videos. Afterwards, attendees will then ask their questions and discuss with the presenters directly. The Special Interest Groups (SIGs) will present sessions on continence care, endourology (i.e. coverage on stone disease, benign prostatic hyperplasia, and technologies such as robotics), and skeletal issues in metastatic prostate cancer. EAUN21 will also feature two new topics: palliative and end-of-life care in urology and the effects of COVID-19 on urology care.

The virtual meeting begins EAUN21 will commence with a warm and enthusiastic welcome from EAUN Chair Ms. Susanne Vahr. This will be followed by bestowal of the prestigious Ronny Pieters Award to a urology nurse for his/her exceptional contribution in urology and to the EAUN.

Courtesy of the European School of Urology, the new and highly-recommended ESU course on Peyronie’s disease will be scheduled at the end of the day. Peyronie’s disease and its management are interesting topics which are not typically discussed. Incorporating these in the programme adds to the dynamism of the meeting.

Developments and controversies The Plenary Session “Educational Framework for

Before EAUN21 concludes, an award session will take place honouring the best in the poster session and

European Urology Today

research competition. Then the congress will conclude with the Annual General Meeting. All participants are welcome and encouraged to attend this part of the programme as well. For an overview of the EAUN21 scientific programme, please visit www.eaun21.org/scientific-programme/. Special sessions The Patient Information session on prostate cancer and Androgen Deprivation Therapy will now take place during the 36th Annual EAU Congress (EAU21) this July. A train-the-trainers workshop on the same topic will be organised separately. Please note that nurses that are registered for EAUN21 in September will have free access to EAU21, 8-13 July! Sessions that cannot be included in the condensed EAUN21 programme will be incorporated in the education programme in the future.

Access to EAU21 Nurses and EAUN Members registered for EAUN21 are automatically registered to EAU21. Make sure to register for EAUN21 before 12 July to be able to attend the Virtual EAU Congress for free!. Feel free to explore the EAU Congress' scientific programme via www.eau2021.org/programme.

Save the date!

How to register Keep an eye on the registration webpage of the meeting www.eaun21.org/registration/ and sign up! If you register before 12 July you will also be able to attend the Virtual EAU Congress for free! We look forward to welcoming you at EAU21 and EAUN21!

Join us!

3-4 September 2021

21st International EAUN Meeting

March/May 2021

European Urology Today Vol. 33 No.2 - March/May 2021

Articles inside

EAUN restructured after strategy change

ESFFU: Urodynamics for male lower urinary tract symptoms

Philanthropic support in the developing world

ESUO: Progressive prostate cancer therapy in outpatient setting

EUSP’s knowledge exchange during the pandemic & after

The e-informed patient

ESU-ESOU Virtual Masterclass on MIBC

Key articles from international medical journals

New guidelines on Non-neurogenic Female LUTS

ESGURS: Penile reconstruction for genital gender affirmation surgery

A highly successful meeting amidst a pandemic

Update from the EAU Guidelines Office

EAU meets the EU’s health chief, Commissioner Kyriakides

Get ready for the EAU21 Virtual Congress

Clinical challenge