European Urology Today Vol. 32 - No. 5 – Oct/Dec 2020 by European Association of Urology (EAU)

European Urology Today Official newsletter of the European Association of Urology

Vol. 32 No.5 - October/December 2020

EMUC20 Highlights

Ileal neobladder

Cadaveric workshop

EAU’s largest autumn event took place virtually

Tips and tricks to improve urinary continence

Penile prosthesis surgery training in Bangalore

Prof. F. Burkhard

Prof. I. Moncada

Fig. 1B. In the male patient, to preserve the pelvic plexus situated laterally to the seminal vesicles and its branches close to the critical angle between the seminal vesicle, trigone and base of the prostate, the dissection must be very ventral on the dorsomedial bladder pedicles as indicated by the dotted blue line.

A transformative year for our association As 2020 draws to a close, we look ahead to the possibilities of 2021 Prof. Christopher Chapple EAU Secretary General Sheffield (GB)

c.chapple@ uroweb.org The past year has been an extraordinary year. The pandemic clearly had an enormous effect on our day-to-day working practice. Many of us had to deal with limited access to resources, testing healthcare systems and forcing us to make major changes in the way we managed the treatment of our patients. These quickly deteriorating circumstances in our institutions took a big toll on many colleagues especially in those in the front line. Our EAU Guidelines Offices anticipated swiftly on the changing conditions and set up a Rapid Reaction Group (GORRG) to provide rapid guidance on how to adapt to the current situation. We hope that these recommendations have helped you in the quickly changed daily practice during the first wave, and are still helpful now we seem to have hit a second wave. A number of painful decisions for our Association had to be taken as a logical consequence from the situation. The necessary travel restrictions forced us not only to initially delay our Annual Congress until July, but to eventually convert it to the online EAU20 Virtual Congress. In this context, I would like to acknowledge the efforts made by the Scientific Congress Office led by Prof. Peter Albers and the team in the Central Office of the EAU to switch from a 5-day physical meeting to an interactive online congress in such short time. With attendees from more countries than ever we look back with satisfaction to a successful first fully virtual EAU Congress. Also several Section Meetings were converted to an online equivalent, seeing participant numbers similar to the regular meetings but with a larger global spread. In this edition you will find several reports with the scientific highlights of the PCa Update, ERUS20 and EMUC20. Numerous ESU courses and Masterclasses have also made the transition to the online world proofing to be very popular and successful in knowledge transfer around the globe. Your Online preferences Without doubt, online education is here to stay, but the feedback that we have from many colleagues is that face-to-face meetings will remain to exist. In a recent survey that was disseminated amongst the 18,000 EAU members it became clear that hybrid meetings will be the future. On average, EAU members join one virtual event per month. Interestingly, around two thirds of them have watched online meetings on-demand, not live. As for a physical event, Friday and Saturday are still the best days to participate. Rethinking our strategy Clearly 2020 is a year for future historians to make sense of. With coronavirus isolation, we have changed the way we work, educate, network and communicate- not just for the time being, but

October/December 2020

probably for ever. Although physical meetings remain key for networking, this pandemic has changed our perceptions when it comes to travel (or its necessity), knowledge transfer and work/life balance. COVID-19 caused a shift to new online norms that changes the fundamental expectations and behaviours in a culture, market, industry or process. At the EAU we have adjusted our strategy as well, in order to anticipate these changes and stay committed to providing you with the best evidence-based guidelines Representatives of different European urological national societies in one of the virtual meetings and training in the field of urology and the most up-to-date and highest quality information, with a critical overview of the latest scientific developments. In this context, one of our priorities for the coming transnationally by leading institutions in the MIS years is the advancement of our political activities in field (read more about SISE on page 16-17). This new strategy results in a revision of our academic Brussels. With the launch of our European Policy We are proud of the global outreach of the EAU. This is and scientific programme, meaning that all face-toOffice, chaired by Prof. Hein Van Poppel, we aim to evident by the participation of urologists from across face meetings supported by the EAU and the ESU will make a stronger statement to include urology in the globe in all our activities, very evident recently be cancelled for the remainder of 2020 and into the various European healthcare initiatives by extensive from a review of login data at our virtual events. first half of 2021. As a consequence we have delayed lobbying of the policymakers at the European Conversely, we are delighted to have been able to the Annual EAU Congress in Milan until 9-12 July 2021 Parliament. The initial focus will be on inclusion of maintain our close and long-standing involvement and would hope that you will join us there for what early detection of prostate cancer in the upcoming we hope will be a face-to-face meeting. This allowed EU Beating Cancer Plan, but will be later extended to and contribution to many National and International Societies. Despite the pandemic our members have us to extend some deadlines allowing you some other fields in urology. continued to provide multiple online contributions on additional time to submit your abstracts and send in behalf of the EAU. We look forward to the further your nomination for various awards to be handed out Other important initiatives include the PIONEER development of this important component of our in Milan. project (read more about this on page 3) which has educational and scientific strategy, particularly with the ambition to maximise the way data is analysed New developments and used to improve care for prostate cancer patients the enormous new opportunities provided by effective online involvement and presentations. Certainly, with any crisis situation come some positive across Europe. Data in the PIONEER Platform is developments. With the advances of online coming from sources all over Europe and the world. Future plans technologies, we have seized on potential Of course we will continue with our involvement in As you can see, we have formulated a clear strategy opportunities and innovations available to us to the European Reference Network with eUROGEN, to accumulate data, to analyse it effectively, and to provide online education, prioritising topics and which is now well-established and which interacts use this to underpin our policies, keep our Guidelines allowing us to focus attention on areas of particular closely with the Guidelines Office, the ESU and the as up-to-date as possible, and facilitate education to interest, particularly those areas which are topical. Research Foundation. effectively manage urological patients. New realities have led to new insights, allowing us a more effective Through our previous experiences with webinars Collaboration with national societies through the European School of Urology, we have When it comes to convincing the European Parliament integrated approach for the development of urology over the next few years. seen that attendees appreciate short and focussed about the essential role of urologists in developing webinars. This has inspired us to expand our the highest quality care we can’t do without our I hope that you can see that we had a number of academic programme to incorporate lessons from national societies. Despite the travel restrictions we challenges to overcome in 2020, but that we have these experiences. In close collaboration with the EAU have intensified our collaboration and have hosted been successful in providing an impressive Sections, the European School of Urology and the several webinars with representatives of different programme in academic education. As always we will Guidelines Office, we are currently developing a European national urological societies. continue with the development of the 2021 EAU comprehensive online educational programme for Guidelines and the preparation of what hopefully will next year, encompassing the whole field of urological A topic that is high on the agenda of these meetings be one of the first big physical meetings next year, the practice. From interactive webinars and the surgical is the Standardisation In Surgical Education (SISE) Annual EAU Congress. video of the month, to in-depth sessions like Meet the programme. Many exponential technologies like AI, Experts or updates by international key opinion virtual reality and nanotech are impacting the world On behalf of the EAU Executive, I would like to thank leaders on the latest developments in the field, we of surgery. Incorporation of these technologies in a you sincerely for your continued support to our aim to provide you with a complete and engaging validated, standardised, and high-quality association. Without all the volunteers active in the educational programme. curriculum will enable the urology sector to meet ESU, the Section boards, Scientific Congress Office, the growing demand for skilled surgeons in an Guidelines panels, YUO and steering committees we Clearly, there is enormous potential for the continued exponential way as well. The aim of the SISE wouldn’t be able to pull off all these activities. We use of online educational activities. Not only because programme is to develop a standardised highvery much look forward to meeting you again of the ease of accessing the meeting and eliminating quality curriculum covering several key minimally face-to-face in Milan in July. For now, what I hope for the need for travel but also because this facilitates invasive surgery (MIS) procedures, for urological everyone is a more relaxing end to the year and a review of the data presented at a global scale and at residents, surgeons and their trainers across prosperous and above all healthy 2021! your preferred time of the day and week. Rest Europe. The programme will be developed assured though that we will not be abandoning face-to-face meetings and are looking constructively at the most appropriate format in terms of physical, virtual or hybrid meetings in providing services to the membership. What to expect next year? As we move into the third decade of this century, we remain committed to giving the best possible support for our members and ultimately the best treatment for patients. We recognise the importance of working closely with our patients and the growing importance of shared decision-making and patient involvement. This has led to the establishment of an EAU Patient Information Office, which will be led by Mr. Eamonn Rogers (Galway, IE). We believe that it will be considerably valuable to take into account the patient perspective in the context of what is critical to patients, which is not only a great addition to our Guidelines panels, but also important in our interaction with policymakers across Europe.

Join us in Milan!

9-12 July 2021 Cutting-edge Science at Europe’s largest Urology Congress

Abstract submission now open! Deadline: 1 February 2021

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European Urology Today

Emerging guidelines for imaging and PCa EAU RF and EANM reach consensus on PSMA PET/CT use for PCa patients By Loek Keizer Adoption of prostate-specific membrane antigen (PSMA) PET/CT should be supported by indication for appropriate use and precise criteria for interpretation. PSMA PET/CT criteria should categorise patients as responders or non-responders and specific clinical scenarios deserve special consideration. These are the most important conclusions of a consensus meeting held earlier this year in Amsterdam, the Netherlands. The EAU Research Foundation, together with the European Association of Nuclear Medicine (EANM) held this meeting to examine PET PSMA CT response assessment criteria. As a rapidly growing imaging technique for PCa patients, there is demand for usage guidelines for PSMA PET/CT. There are currently procedure guidelines for performing PSMA PET/CT endorsed by the EANM and it is considered a potentially useful tool for evaluating responses to therapy. However, there is still a lack of data regarding criteria to be used for Expert panel meeting in Amsterdam, 21 February 2020, before COVID-19 made meeting face-to-face impossible evaluating PSMA PET/CT findings in relation to therapy response assessment. disease. However, it should not be performed within 3 months after initiation of systemic therapy in hormone sensitive PCa.”

Prof. Anders Bjartell, EAU RF Chairman and co-author

Five representatives of each body met on 21 February and attempted to answer five relevant questions. The results of the meeting were published as the article ‘Consensus statements on PSMA PET/CT response assessment criteria in prostate cancer’ in the European Journal of Nuclear Medicine and Molecular Imaging on 2 July.

European Urology Today Editor-in-Chief Prof. M. Wirth, Dresden (DE) Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Mr. Ph. Cornford, Liverpool (GB) Prof. O. Hakenberg, Rostock (DE) Dr. D. Karsza, Budapest (HU) Prof. P. Meria, Paris (FR) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) 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.

The authors, Stefano Fanti (Bologna, IT), Karolien Goffin (Leuven, BE), Boris A. Hadaschik (Essen, DE), Ken Herrmann (Essen, DE), Tobias Maurer (Hamburg, DE), Steven MacLennan (Aberdeen, GB), Daniela E. Oprea-Lager (Amsterdam, NL), Wim J.G. Oyen (Milan, IT), Olivier Rouvière (Lyon, FR), Nicolas Mottet (Saint Etienne, FR) and Anders Bjartell (Malmö, SE) represent a mix of experts in nuclear medicine and PCa from across Europe, most of whom attended the Amsterdam meeting. Key questions that were discussed:

Prof. Stefano Fanti, Co-author

“Ideally, PSMA PET/CT criteria should categorise patients as responders or non-responders: categories of responders include patients with stable disease, partial response, and complete response on PSMA PET/CT imaging. Specific clinical scenarios such as oligometastatic or polymetastatic disease deserve special consideration. The use of PSMA PET/CT response assessment should be implemented and evaluated in the context of clinical trials.” The EAU and EANM endorse and promote highquality standards in performing and reporting PSMA PET/CT scans. Speaking to European Urology Today, Prof. Fanti explained that the consensus statement addressed a “shared need” by radiologists and urologists alike:

accomplished with the consensus meeting and article.” “We have no doubt that PSMA PET/CT use will be increasing in the coming years, either due to widespread availability (for example, in the US there are pending FDA dossiers), to an increase in PSMA tracers, and to more clinical indications being recognised (such as staging of high risk patients).” EAU RF Chairman and co-author Prof. Bjartell underlined the need for joint guidelines in the face of increased use of imaging: “Imaging has become extremely important in prostate cancer diagnosis, staging and monitoring and input from the EANM in drawing up guidelines is of utmost importance.”

Fanti: “As it stands, we already have methodological for PSMA PET/CT usage endorsed by the “Can PSMA PET be used before and guidelines EANM. These however do not appropriately cover all after any treatment, considering the clinical indications. At same time we have general Cancer guidelines, but these do not focus on concerns regarding ADT, especially Prostate PSMA PET but rather on individual clinical scenarios, taking into consideration all imaging methods. Maybe in naïve patients?“ in the future we will have guidelines on the appropriate clinical use of PSMA PET, done jointly by “The use of PSMA PET to evaluate response to therapy the EAU and EANM. That would be great!” is not well established as in other indications. Having The recommendations for PSMA PET/CT have been a potentially powerful tool, though expensive, requires proper use: such appropriateness may derive published open access in the European Journal of Nuclear Medicine and Molecular Imaging, in July 2020: from randomised controlled trials, which https://link.springer.com/article/10.1007/s00259-020unfortunately don’t exist, or from expert 04934-4. recommendations, which is essentially what we

Can PSMA PET be used before and after any treatment, considering the concerns regarding ADT, especially in naïve patients? What is the best timing for performing PSMA PET? Which PET criteria should be used to evaluate the PSMA response? Which patients could benefit from a clinical perspective, and how can we handle the different PET tracers? Anonymous voting on a nine-point scale graded PSMA PET/CT consensus statements that concerned utility, best timing for performing, criteria for evaluation of response, patients who could benefit, and handling of radiolabeled PSMA PET tracers. Consensus was reached on all statements.

“Which patients could benefit from a clinical perspective, and how can we handle the different PET tracers?“ The authors conclude that “PSMA PET/CT holds great potential in several clinical situations. Use of PSMA PET/CT should not be considered, if no change of clinical management is expected.” “For evaluation of response to treatment, PSMA PET/ CT can be used before and after any local and systemic treatment in patients with metastatic EAU Research Foundation

European Urology Today

PSMA PET/CT can be used before and after any local and systemic treatment in patients with metastatic disease

October/December 2020

Update from the EAU Guidelines Office IMAGINE project: Impact Assessment of Guidelines Implementation

A transformative year for our association. . . . 1 EAU RF: Emerging guidelines for imaging and PCa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Update from the Guidelines Office . . . . . . . . . 3 News from the European Union. . . . . . . . . . . 5 ERN eUROGEN: Late effects of penile cancer. . 6 Clinical challenge. . . . . . . . . . . . . . . . . . . . . . 7

Quick recap: IMAGINE have launched a Europeanwide multi-centre retrospective observational study in collaboration with European National Urological Societies endorsing the EAU Guidelines. The aim of the study is to map guidelines adherence across Europe. The study will provide a robust map of guideline adherence to prioritised recommendations in Europe as well as a validated platform to map adherence to other recommendations in the future. Update: The first IMAGINE pilot recommendation has been chosen: Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery in men

PIONEER – Prostate Cancer Big Data Platform Big Data in health is defined by the “three Vs": Volume - a large amount of data; Variety - different types of data; and Velocity - data arriving at high speed. The EAU lead PIONEER project will maximise the way data is analysed and used to improve care for prostate cancer patients across Europe. Data in the PIONEER Platform is coming from sources all over Europe and the world. We have identified 82 potential prostate cancer data sources from 16 countries. These include data sets from hospitals, research institutes, biobanks and OMICs consortia, the pharmaceutical industry and biotech companies. Each data source has an associated data fact sheet which allows to assess which data sources contain the most relevant information for a given research question. To date 23 data sources have been catalogued and are ready for conversion and import into the PIONEER Big

(including those with locally advanced or high-risk prostate cancer). Available data suggest 50% receive it inappropriately representing a de-implementation problem. Current status and achievements to date: • Establishment of a Pan-European collaborative research network: • 24 EU member states have joined IMAGINE with discussions ongoing with the remainder. • 12 additional European countries have also joined the project with discussions ongoing with a further 5 countries.

Data Platform. The first two academic datasets have been made available by PIONEER partner Erasmus University Medical Center. Erasmus MC have contributed two of the most well-known European datasets to the PIONEER Big Data platform: The

• Roll out the IMAGINE induction survey. • Development of a user friendly GDPR compliant data capture platform. • To date 113 study sites are enrolled and active in the platform. • Joint authorship IMAGINE editorial accepted for publication in European Urology. Once again we would like to take this opportunity to thank the European National Urological Societies for engaging in this collaborative project; together we can improve patient care.

Prostate Cancer Research International Active Surveillance (PRIAS) study; and The European Randomised study of Screening for Prostate Cancer (ERSPC) Rotterdam. In addition, the first Data Sharing Agreement has been signed with external data contributor Active Biotech AB. Active Biotech AB has now shared data collected in a phase 3 randomised, double blind, placebo controlled study of tasquinimod in men with metastatic castrate-resistant prostate cancer. Furthermore, five industry datasets from three EFPIA partners have been made available in the platform.

Key articles from international medical journals. . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11 EBU Certified programmes and centres . . . . 12 EMUC20: Virtual, but multidisciplinary as always. . . . . . . . . . . . . . . . . . . . . . . . . . . 13 ESFFU: Ileal neobladder after radical cystectomy. . . . . . . . . . . . . . . . . . . . . . . . . . 14 GPC: Advancing endoscopic stone surgery training in Bamako. . . . . . . . . . . . . . . . . . . . 15 ESUO: MRI fusion prostate biopsy in office urology. . . . . . . . . . . . . . . . . . . . . . . . 15 ESU section: ESU bolsters surgical education and standardisation . . . . . . . . . . . . . . . . . . . . . . 16 The changing world of surgical skills training . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 SISE to develop a premium standardised MIS curriculum. . . . . . . . . . . . . . . . . . . . . . . 17 The future of ESU training . . . . . . . . . . . . . . 17 1st virtual ESU-ESFFU Masterclass on Functional Urology. . . . . . . . . . . . . . . . . . . . 18 UUA congress and virtual ESU course commence. . . . . . . . . . . . . . . . . . . . . . . . . . 18 PCa20: A recap of the 1st virtual edition. . . . 19 7th CEUEP: A synergy of east and west. . . . . 19 Obituary Peter Paul Figdor. . . . . . . . . . . . . . 21 ESUT: Incredible but not impossible. . . . . . . 22 EPAD20: PCa on the radar for inclusion in EU Cancer Plan. . . . . . . . . . . . . . . . . . . . . 23 ESGURS: Cadaveric workshop training in penile prosthesis surgery. . . . . . . . . . . . . 24

2020 Guidelines in review Since their launch in March 2020 the EAU Guidelines have been downloaded over 57,000 times! Among the top downloads for 2020 were the oncology Guidelines for Prostate Cancer and Muscle Invasive Bladder Cancer with over 14,000 and 9,000 downloads, respectively. Followed by the non-oncology Guidelines for Urological Infections and Neuro-urology with close to 6,000 downloads each. In addition, the Guidelines Office Rapid Response Group (GORRG) also successfully produced a COVID-19 specific adaptation of all Guidelines at the outset of the pandemic. This was a major collaborative achievement lead by the Guidelines Office and the EAU Section Offices. These COVID-19 specific Guidelines have been downloaded over 9,000 times. Guidelines Office

October/December 2020

The Guidelines Office was also delighted to see that 48% of the 280,000 plus users of the Guidelines online were new users and that online users of the Guidelines generated over 460,000 Guidelines sessions.

ESUT: The most realistic method for learning the EEP technique. . . . . . . . . . . . . . 25

We would like to take this opportunity to thank all users of the EAU Guidelines for their continued support and we look forward to the launch of the updated EAU 2021 Edition of the Guidelines!

Urology Week 2020 recap. . . . . . . . . . . . . . . 28

“...COVID-19 specific Guidelines have been downloaded over 9,000 times.”

Obituary Richard Turner-Warwick. . . . . . . . . 25 EAU PI: “Urologists must ask patients what matters to them”. . . . . . . . . . . . . . . . . 27

YAU: Urothelial Cancer group. . . . . . . . . . . . 29 YUO: Third edition HUCAD: The last course before COVID-19. . . . . . . . . . . . . . . . . . . . . . 29 ERUS-DRUS20: Meeting attracts new global audience. . . . . . . . . . . . . . . . . . . . . . 29 EAUN section: Past EAUN Chair elected AAN Fellow . . . . . . 31 Bile acid loss syndrome . . . . . . . . . . . . . . . . 31 Working together to improve health care through EAUN . . . . . . . . . . . . . . . . . . . . . . . 32 EAUN Fellowship Report . . . . . . . . . . . . . . . 32

European Urology Today

Cutting-edge Science at Europeâ&#x20AC;&#x2122;s largest Urology Congress

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European Urology Today

October/December 2020

News from the European Union EAU repeats core message: The EU must do more to support risk-stratified early detection Mrs. Sarah Collen EAU Policy Coordinator Brussels (BE)

s.collen@uroweb.org The EAU, through its Policy activities, has continued to dedicate a significant amount of time to the policy debate on the European Union’s Cancer Plan. In response to the public consultation by the EU earlier this year, the EAU published an updated ‘White Paper on Prostate Cancer – Recommendations for the EU Cancer Plan to tackle Prostate Cancer’ together with key partner organisations.

approach on prostate cancer can be added to their work in the future. And lastly, we have organised a successful European Prostate Cancer Awareness Day to launch the White Paper, focusing on early detection. A full report can be found on page 23. European Code of Cancer Practice The EAU has also supported and endorsed the European Cancer Organisation’s European Code of Cancer Practice, which is a set of patient rights designed to guide and empower patients throughout their cancer journey. It sets out a series of 10 key overarching rights, and in particular signposts what patients should expect from their health system, in order for them to achieve the best possible outcomes.

PIONEER and digital health and patient empowerment Digital Health PIONEER, the EAU-led Big Data consortium on prostate cancer was also profiled in a As part of these activities, EAU Adjunct Secretary workshop on digital health tools and patient General Hein Van Poppel chaired a Roundtable on empowerment by the European Patients’ Forum. The Prostate Cancer this October for the International contribution from Mieke Van Hemelrijck from King’s Centre for Parliamentary Studies (ICPS), which had College London and part of the PIONEER consortium interventions from a number of EAU members and was mainly about how to engage cancer patients in Europa Uomo. The reports from the Roundtable will digital health. She indicated that we have to also be published in the Government Gazette, a quarterly think carefully about what information we collect magazine which provides quality analytical and using digital health, for example patient-reported politically neutral coverage to 7,500 policy makers and outcomes (PROMs). In PIONEER there is an entire decision makers in the European Union. The EAU was work package looking into which PROMS to use for also represented at the virtual German Presidency men with prostate cancer. In addition, we have to Conference of the European Alliance for Personalised look into feasibility and acceptability when using Medicine. This was another opportunity to focus on digital health, as different age groups, cultures, etc. our priorities for the EU Cancer Plan, repeating the may have different needs. This may be one of the core message that the EU must do more to support rare silver linings of COVID-19, as it provided us with risk-stratified early detection. a situation where we had to embrace digital health from which we can potentially already learn a lot of In achieving the EAU’s political ambitions we can’t do lessons. without the support of MEPs. In the last couple of weeks alone we have met (virtually) with MEPs Bureaucracy of clinical trials Nicolas Casares Gonzales, Juozas Olekas, Peter Liese The EAU has also joined a statement along with and Antonio Lopez Isturiz to make them aware of our fellow medical and scientific societies in the goals. We also met with the Joint Research Centre, the BioMed Alliance on efficiency and affordability of European Commission's science and knowledge clinical trials. We called for a reduction of the service, which employs scientists to carry out research disproportionate bureaucratic demands involved, in order to provide independent scientific advice and which are resulting in rising costs and complexity, support to EU policy. We talked about the approach leading to the stagnation of clinical research in used on the European Commission’s Initiative on Europe, fewer academic clinical trials and limited Breast Cancer in the hope that our evidence based accessibility to innovative treatments. We have

called for three challenges to be urgently addressed: inappropriate and counterproductive safety reporting, inadequate informed consent and re-consent, and over-interpretation of regulations and guidelines. Crucially, excessive administrative demands limit the time that clinical researchers can dedicate to their patients, with potential negative consequences for the quality of studies and with it the quality of future healthcare and, ultimately and most importantly, patient safety. Prof. Anders Bjartell and Sarah Collen will lead the work on General Data Protection Regulation (GDPR) compliance in the working group on regulation and guidelines. If you have relevant expertise to offer, please do get in touch with s.collen@uroweb.org.

“...we have to also think carefully about what information we collect using digital health, for example patient reported outcomes (PROMs).” ERN eUROGEN to double membership after new call for applicants European Reference Networks (ERNs) are cross-border networks bringing together centres of expertise and reference centres of European hospitals to tackle rare or low prevalence and complex diseases and conditions that require highly specialised healthcare. ERNs enable specialists in Europe to share learning and discuss complex patient cases, providing advice on the most appropriate diagnosis and the best treatment. A key principle of ERNs is to let the knowledge travel rather than the patient, leading to economies of scale and more efficient use of costly resources. 24 ERNs covering all major rare disease groups were launched in March 2017, including 956 highly specialised healthcare units from 313 hospitals located in 26 countries (25 EU Member States plus Norway). In 2019 the EC opened a call for new members to apply to join existing ERNs. However, the assessment process was suspended in April this year due to the COVID-19 pandemic. It reopened on 1

September and ERNs have been busy assessing the applicant healthcare providers. Then some applicants will be assessed by an Independent Assessment Body before the Board of Member States for ERNs completes the final assessment. The new members should be formally accepted in the ERNs around June 2021 and most ERNs are expected to double in size. 31 healthcare providers have applied to join the ERN for rare urogenital diseases and complex conditions (ERN eUROGEN) which currently has 29 full members, 12 Associated National Centres and 4 National Coordination Hubs. You can find more information about ERN eUROGEN here: www. eurogen-ern.eu/. EU budget Those of you who are involved in research or other initiatives funded by the EU will be interested to hear that the negotiations continue in earnest on the EU multi-annual budget for 2021-2027. When EU leaders agreed their historic deal on the EU’s recovery package in July this year, they did this at the expense of EU flagship programmes from the EU’s budget. Initiatives such as Horizon Europe (research and innovation), Erasmus (student mobility) and Health4Europe saw their proposed budgets significantly cut. This move had led to a showdown with the European parliamentarians who wanted to protect these shared EU initiatives and ensure adequate resourcing. The beginning of October saw the European Parliament walking out of negotiations with the EU Council citing the Council’s refusal to compromise as the reason. November, however, has seen a successful agreement reached between the EU Council and the European Parliament. This agreement bolsters support for the flagship programmes. For example, the EU4Health programme will now receive 5.1 billion Euros for the 2021-2027 period. This is good news for the EAU and its members as these programmes give necessary support for cross border research and innovation and training that strengthen the field of urology and help us to serve our patients better. All in all, another busy couple of months for the EAU policy team!

‘Our man in Amsterdam’ at the European Medicines Agency (EMA) In March 2019 the headquarters of the EMA moved from London to Amsterdam after the results of the British referendum on the EU became apparent. The Agency's main responsibility is authorising and monitoring medicines (both human and veterinary) in the European Union (EU), similar to, and in collaboration with other regulatory agencies such as the US Food and Drug Administration (FDA) in the WHO. Companies can apply to EMA for a single marketing authorisation, which is issued by the European Commission. If granted, this enables them to market the medicine concerned throughout the EU and the European Economic Area (which includes a number of non-EU countries: Norway, Iceland and Liechtenstein). Most innovative medicines marketed in Europe are authorised by the EMA. Once these medicines are approved by the EMA, individual countries can register these medicines, which is done by their national regulating bodies. On October 22, 2020 EMA celebrated 25 years of its commitment to these goals. EMA does not deal with medical devices, these are regulated by national competent authorities. The EMA: • facilitates the development of medicines & access to them • evaluates applications for marketing authorisations • monitors the safety of medicines throughout their lifecycle • provides information to healthcare professionals & patients The mission of the EMA is to foster scientific excellence in the evaluation and supervision of medicines for the benefit of public and animal health in the EU by facilitating development and access to medicines, by evaluating applications for marketing authorisation, by monitoring the safety of medicines across their life cycle and by providing reliable October/December 2020

information on human and veterinary medicines in lay language. The EMA is governed by a management board whose members are appointed to act in the public interest and should not represent any government, organisation or sector. The EMA has a number of scientific committees (e.g. Pharmacovigilance Risk Assessment Committee [PRAC], Committee for Advanced Therapies [CAT], Committee for Medicinal Products for Human Use [CHMP], Committee for Orphan Medicinal Products [COMP], Committee On Herbal Medicinal Products [HMPC], Paediatric Committee [PDCO], but also a number of working parties and other groups), who provide independent advice. They also enlist the support of thousands of experts from across Europe. The EAU is one of the organisations taking part in the Healthcare Practitioners Working Party (HCPWP) represented by ‘our man in Amsterdam’- Theo De Reijke. Theo De Reijke is a urologist working in the Amsterdam UMC (a recent get together of the Academic Medical Center and the Free University Medical Center). His special interests are bladder and prostate cancer and more in particular improving diagnostics. The HealthCare Professionals Working Party is a platform for exchange of information and discussions on topics of common interest between the EMA and members of the group.

Prof. Theo De Reijke

ensuring that the urological concerns are given full attention. Patients and healthcare professionals understand issues from the inside. They are consulted as experts and provide views on whether the medicine in question can address their needs. They help to define areas on unmet medical need. These external experts (consisting of healthcare practitioners and patients) are consulted in 1 in 4 of the assessments for new medicines, both in the pre-authorisation phase as in the safety monitoring phase. The current work programme of the HCPWP covers a number of important issues which will impact urology, including: medicines development and evaluation, advances in clinical practice, digital health, safety of medicines, product information, access to clinical data (and data privacy), supply issues and availability of medicines, antimicrobial resistance and vaccines. This year, the committee has discussed a number of issues with the working party, such as prevention of medicine shortages, data protection and the use of big data to support regulatory pathways, and guidance on registry based clinical studies.

• assisting the EMA in communicating with healthcare professionals to support their role in the safe and rational use of medicines The HCPWP has a number • contributing to EMA’s scientific work intended to of main activities: continuously improve the benefit-risk assessment • supporting the EMA to of medicines throughout their life-cycle gain a better • enhancing healthcare professionals’ organisations understanding of how understanding of the mandate and work of the If any of these issues are of interest to you and you medicines are being EMA. can offer expertise in any of these areas, please do used in real clinical get in touch with the EU Policy Manager practice and how EU Being a member of this working party is thus s.collen@uroweb.org. regulatory decisions important as it gives the EAU a critical opportunity impact clinical practice to feed in our scientific evidence and expertise, EMA website: www.ema.europa.e European Urology Today

ERN eUROGEN: Late effects of penile cancer Modifications to surgical approach may help reduce lymphoedema risk Mr. Ben Ayres Penile Cancer Disease Area Coordinator for ERN eUROGEN London (UK)

benjamin.ayres@ nhs.net ERN eUROGEN is a European Union initiative. It is a European reference network for rare uro-rectogenital diseases and complex conditions. Its aim is to deliver quick specialist multidisciplinary evaluation and advice to healthcare workers across the European Union and thus promote high-quality diagnosis, treatment and care for patients with rare uro-recto-genital diseases. This is achieved through an online platform called the Clinical Patient Management System, allowing virtual multidisciplinary discussions by experts to take place in a timely fashion for every patient referred. I strongly encourage all European Union-based urologists to use this free-of-charge resource when faced with managing a rare condition such as penile cancer. Education and research Education and research are other important ERN eUROGEN initiatives. There are regular webinars which can also be viewed later if you subscribe to the ERN eUROGEN YouTube channel. One webinar covers the management of lymphoedema in penile cancer patients, a consequence of nodal surgery which can have a significant impact on quality of life1. The lymphatic system plays an important role in protein and fluid haemostasis, cellular drainage from tissues and immune surveillance. Unfortunately, many cancers, including penile cancer, spread via the lymphatic system. In penile cancer we know that inguinal lymph node positivity is the strongest prognostic indicator for cancerspecific survival. The number of nodes involved, extranodal extension, and pelvic node disease are highly associated with worse cancer-specific survival2. As a result, inguinal lymph node surgery is important in the staging and treatment of penile cancer. However, significant genital and lower limb lymphoedema can occur after this surgery, due to the disruption it causes to the lymph drainage and its role in fluid haemostasis. This, in turn, leads to thickening of the skin, lymph blisters, lymphorrhoea and an increased risk of cellulitis. Multidisciplinary approach Modifications to inguinal surgery can reduce the chances of significant lymphoedema, but these adaptations are not possible for all patients, particularly those with more advanced disease. In these men, a multidisciplinary approach to lymphoedema management is required, focusing on good skin care, exercise, elevation, compression, massage and prevention of infection. Modifications to surgical technique In clinically node-negative penile cancer patients, dynamic sentinel lymph node sampling has replaced inguinal lymph node dissection in many large European penile cancer centres. The concept is to identify the first or sentinel inguinal lymph node that the penis drains to in each groin, using dynamic radionucleotide imaging. These are surgically removed and undergo full pathological assessment. If cancer is found, then a completion groin dissection is required. This will not reduce the risk of lymphoedema, but if the sentinel node is negative (about 80% of the time) the patient is saved from a full inguinal node dissection and has been accurately staged. Temporary groin and genital swelling do occur after sentinel node sampling but will resolve unless associated with significant cellulitis. One might argue, though, that if 80% are negative, why not observe clinically node negative patients rather than perform groin surgery in the first place. The reason is that patients who are observed have a significant survival disadvantage3, suggesting treatments for penile cancer are more effective if spread is microscopic rather than macroscopic. Dynamic sentinel lymph node sampling has not become commonplace around the world though due to higher false negative rates than those seen in European specialist centres and patient compliance issues around the need to return for completion lymphadenectomy if positive. 6

European Urology Today

Minimally invasive approach Alternative surgical modifications include a modified inguinal lymph node dissection, focusing dissection medial to sartorius, although if positive nodes are found a completion lymph node dissection is still required, or a minimally invasive approach. The latter is not possible for larger nodes but does show a significant reduction in wound infection and lymphoedema rates4. Modifications to inguinal lymphadenectomy, which include preserving the long saphenous vein and the muscle fascia at the depth of the dissection where possible, are common amongst penile cancer specialists. It is believed these manoeuvres reduce lymphoedema, although evidence of their effectiveness is lacking. Post-operative use of suction drains is also common5. These reduce the risk of lymphocele development. Management of lymphoedema A multidisciplinary approach - working closely with lymphoedema physicians and therapists - is important in the management of lymphoedema. The main aim of treatment is to get the most out of the remaining lymph drainage capacity and to prevent infection, which damages remaining lymphatic channels. Massage, compression, exercise and elevation when resting are all important aspects to this care.

“...if the sentinel node is negative (about 80% of the time) the patient is saved from a full inguinal node dissection and has been accurately staged.” Manual lymphatic drainage is specialist massage performed by lymphoedema therapists. It is commonly used for persistent mons and lower abdominal swelling following penile cancer treatments. Multilayer lymphoedema bandaging can be used to effectively compress lower limb and genital lymphoedema (see figure 1). These dressings often become loose and can fall off, so teaching your patients how to apply the bandaging themselves is important. Off-the-shelf compression garments are also available. These range from scrotal supports or lycra bicycle shorts for genital lymphoedema to specialist compression shorts. The latter have a separate pouch which lifts the genitals away from the body for more effective compression and lymph drainage. Full-length lower limb stockings are also available but require the measurement of leg circumference at several points by a specialist. Adjustable compression garments with Velcro straps are also used to treat leg swelling.

Figure 1: Genital compression bandaging

Impact on quality of life In summary, lymphoedema following penile cancer treatment, especially nodal surgery, can have a significant impact on quality of life. However, inguinal lymph node surgery in penile cancer is important and improves survival. Modifications to the surgical approach should be made to try and reduce the risk of lymphoedema, but in many cases, a full inguinal lymph node dissection is required for optimal treatment. If lymphoedema occurs, a multidisciplinary management approach is important, focusing on good skin care, preventing infection, massage, compression, exercise and elevation when resting. Please remember, ERN eUROGEN exists to give advice from a group of experts in different European healthcare providers to healthcare professionals in the EU who encounter a rare uro-recto-genital disease or complex condition. ERNs are free to access and the knowledge travels, not the patient. Acknowledgements I would like to thank my colleagues Prof. Nick Watkin, Dr. Kristiana Gordon, Mr. Mark Pearson, Chris Backhouse, CNS, Kerry Smith, CNS and ERN eUROGEN for their support with this article.

References 1. Yan S, Minter J, Lam W, Sharma D, Watkin N, Ayres B. P4-11 Impact of lymphoedema on quality of life following radical lymph node dissection for penile cancer. Journal of Clinical Urology 2017;10 (2S):34. 2. Djajadiningrat RS, Graafland NM, van Werkhoven E et al. Contemporary management of regional nodes in penile cancer – improvement of survival? J Urol 2014;191:68-73. 3. Kroon BK, Horenblas S, Lont AP, Tanis PJ, Gallee MPW, Nieweg OE. Patients with penile carcinoma benefit from immediate resection of clinically occult lymph node metastases. J Urol 2005;173:816-9. 4. Kumar V, Sethia KK. Prospective study comparing video-endoscopic radical inguinal lymph node dissection (VEILND) with open radical ILND (OILND) for penile cancer over an 8-year period. BJU Int 2017; 119:530-34. 5. Ayres B, Parnham A, Muneer A et al. What is the extent of variation in inguinal lymph node management by penile cancer specialists? An eUROGEN survey. Eur Urol Open Science 2020; suppl. 2 19: e300. 6. https://www.lymphoedema.org/wp-content/ uploads/2020/01/cellulitis_consensus.pdf. Last accessed 01/11/2020.

EAU Edu Platform The online learning platform for Lower Urinary Tract Symptoms

Exercise is important Some patients with lymphoedema limit exercise as they notice their legs and/or genitals swell more when they are on their feet. This is counterproductive though, as fat and lymph use the same lymphatic channels, so exercising and reducing abdominal fat are important to manage lymphoedema. Using muscles also helps pump lymph to the centre from the peripheries. Exercise will not only also improve general health and well-being, it will also keep the body flexible. This is important when lymphoedema can make the tissues tight. When resting though, patients need to be encouraged to elevate their lymphoedematous limbs to reduce the effect of gravity on the swelling. Skin care Good skin care and reducing infections is important to preserving the lymphatic channels that are left. Assuming skin is intact and not hyperkeratotic, my department recommends Doublebase emollient or Adex gel for skin care. If a patient suffers from 2 or more episodes of cellulitis in a year, we recommend either penicillin V, erythromycin or clindamycin as prophylaxis, in line with the British Lymphology Society and the Lymphoedema Support Network guidelines6. There is limited evidence for the effectiveness of surgery for lymphoedema. Debulking surgery, often in the form of scrotal reduction with penile shaft skin grafting, can be effective in managing genital lymphoedema. Reports of limb liposuction followed by compression exist, but case series are small with no long-term follow-up. Lymphatico-venous anastomosis is also reported but there is limited evidence in penile cancer.

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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. 67

Case study No. 66

Discussion point • Which management and treatment is advisable?

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

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

This 42-year-old man had a traumatic urethral catheter placement with a false passage after surgery for inguinal hernia. Two months later, he had acute urinary retention and it was not possible to pass a catheter beyond the fossa navicularis. A suprapubic catheter was placed. A voiding cystogram suggested bladder neck contracture (Fig. 1). A guidewire was inserted into the suprapubic catheter followed by dilatation which allowed antegrade flexible cystoscopy to be performed. The endoscope could only be passed to the level of the penile base (Fig. 2) where there was a complete obstruction. Distal endoscopy showed complete obstruction at the level of fossa navicularis.

Abscess, lymphoma or RCC – biopsy needed Comments by Prof. Börje Ljungberg Umeå (SE)

type, however with a diffuse demarcation of the renal process. A lymphoma could be an alternative diagnosis.

This patient’s case is challenging with a provisional diagnosis of a renal abscess. However, other diagnosis are alternatives since there only was a moderate CRP elevation, and slightly elevated leucocytes and where the physical examination revealed slight left flank tenderness.

I suggest that this patient will be recommended to have a biopsy for the differentiation of the underlying diagnosis and after that examination a discussion on planning of treatment.

The CT exams (only two scans available) also suggest renal cell carcinoma, possibly of the pRCC

Figure 1

Abscess unlikely – biopsy indicated Comments by Dr. Inga Peters Hannover (DE)

and Prof. Markus Kuczyk Hannover (DE)

History: A 26-year old female had presented with left flank pain and fever (38.6°). The same episode occurred 5 months before. Infection

parameters, i.e. CRP and count of leucocytes were slightly increased. All other parameters as well as physical examination were unremarkable. Images: The CT scan showed a huge renal mass on the left side, with inhomogeneous density values, with contrast enhancement and central necrosis or fluid/abscess formation in the central area. Differential diagnosis: Regarding the medical history of fever, flank pain und elevated laboratory results, a super-infected and in part ruptured cyst or a xanthogranulomatous nephritis (XN) could have been taken into consideration at first sight. However, the CT scan shows a clear definable mass with an in part more or less pronounced contrast enhancement as well as no signs of fat imbibition in addition to an anatomically normal parenchyma in

the rest of the kidney. Therefore, an inflammatory process such as a superinfected haemorrhagic cyst appears to be unlikely. Hence, a renal cell carcinoma has to be taken into account, notwithstanding the young age of the woman. Therapy strategy: Due to the increased leucocyte count and elevated body temperature, we would suggest a percutaneous renal biopsy. Cytology, pathology and microbiology samples have to be taken and investigated. Of course, a primary surgical exploration would be justified as an alternative. In case a nephron-sparing resection of the tumour would appear unsuitable or technically not feasible, this could potentially end up with a nephrectomy.

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Discussion point 1. In this situation, can an MRI reliably assess the urethra and its lumen between the proximal and the distal penile strictures? 2. What treatment is advisable?

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

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Case study No. 66 continued On the basis of the CT scan, we considered this renal lesion to represent malignancy and surgery for partial resection with enucleation of the solid tumour was performed. However, the histopathology of the specimen was reported to represent a nephroblastoma (Wilm’s tumour). Following this result, secondary total nephrectomy with paraaortal lymphadenectomy was performed which showed minimal residual intrarenal tumour and one parahilar lymph node metastasis. Complete staging by CT scan did not show any signs of metastatic disease. Adjuvant radiotherapy to the renal fossa was administered, followed by adjuvant chemotherapy with vincristine, actinomycin D and doxorubicine.

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

tebj@medisin.uio.no

High prevalence of IgA deposits in renal transplants The possibility of recurrence of IgA nephropathy in renal transplants is well known. What is not known is the significance and prevalence of “incidental” IgA deposits in renal transplants generally. Thus, incidental IgA deposits in donor kidneys have unknown sequelae and may predate clinical kidney disease if primed by adverse immunological or hemodynamical stimuli; or they may remain dormant. This study investigated the presence of incidental IgA in post-implantation (T0) biopsies from living (LDK) and deceased donor (DDK) kidneys, and its relationship to post-transplant patient and graft outcomes in large US transplant centres.

It showed a high incidence of incident IgA deposits which was correlated with rejection and rejection-related graft loss. Mesangial IgA was present in 20.4% of 802 T0 biopsies; 13.2% and 24.5% of LDK and DDK, respectively. Donors with incidental IgA deposits were more likely to have hypertension and be of Hispanic or Asian origin. Intensity of IgA staining was 1+ (57.3%), 2+ (26.8%), or 3+ (15.8%) of the T0 IgA+ biopsies. Mesangial pathology correlated with higher-intensity IgA staining with less clearance on follow-up: 53.8% versus 79.2% without mesangial pathology. IgA cleared in 91%, 63%, and 40% of follow-up biopsies with 1+, 2+, and 3+ IgA staining, respectively. Early post-transplant rejection and rejection-related graft loss occurred more frequently in IgA+ kidney recipient. However, 5-year kidney function and graft survival were comparable to kidneys without IgA. This is the first report of incidental IgA in T0 biopsies of LDK and DDK in a US population. It showed a high incidence of incident IgA deposits which was correlated with rejection and rejection-related graft loss. However, there was no adverse association with graft or patient 5-year-survival. Thus, whether IgA deposits in donor kidneys represents latent IgA nephropathy is unclear.

Source: Prevalence, Characteristics, and Outcomes of Incidental IgA Glomerular Deposits in Donor Kidneys. Lillian W Gaber, Faiza N Khan, Edward A Graviss, Duc T Nguyen, Linda W Moore, Luan D Truong, Roberto J Barrios, Wadi N Suki. Kidney Int Rep 2020, 26;5(11):1914-1924. doi:10.1016/j. ekir

Non-donor-specific HLA antibodies related to longterm allograft dysfunction Donor-specific antibodies are associated with high immunological risk and poor allograft outcome. In contrast, the clinical relevance of non-donor-specific HLA antibodies is less clear. A retrospective, single-centre study was conducted in all patients receiving a first kidney transplant at the university hospital of Zürich between January 2006 and February 2015. Patients were stratified into 3 groups, having either no HLA antibodies at all (NoAB), HLA antibodies with donor specificity (DSA) and HLA antibodies without donor specificity (NonDSA). Allograft outcome was assessed using the slope of the estimated glomerular filtration rate Key articles

(eGFR slope), starting at 12 months after transplantation. During a median follow-up of 1,808 days, HLA antibodies were detected in 106 of 238 eligible patients (44%). Out of these, 73 patients (69%) had DSA and 33 patients (31%) had NonDSA only. Medium-term allograft function, as determined by eGFR slope over three years, improved in patients with NoAB (months 12-48: +0.7 ml/min/1.73 m2) but deteriorated significantly in patients with both DSA (months 12-48: -1.5 ml/min per1.73 m2/year, p = 0.015) and NonDSA (months 12-48: -1.8 ml/min per1.73 m2/ year, p = 0.03) as compared to the group with NoAB.

...both donor-specific and nondonor-specific HLA antibodies are associated with medium-term kidney allograft dysfunction…

The main limitations were the short follow-up of the series (12 months) and the lack of robust endpoints, such as metastasis-free or cancer-specific survival. However, the introduction of mpMRI and targeted biopsies in prostate cancer diagnosis undoubtedly improves prognosis assessment. This validation confirms the need for updating risk classifications with the integration of MRI parameters and targeted biopsy features, given the more frequent use of these procedures in daily practice and in our diagnosis recommendations.

Source: Stratifying patients with intermediaterisk prostate cancer: Validation of a new model based on MRI parameters and targeted biopsy and comparison with NCCN and AUA subclassifications. Diamand et al. Urologic Oncology: Seminars and Original Investigations, 2020. ISSN 1078-1439. https://doi. org/10.1016/j.urolonc.2020.08.030.

Follow-up MRI in active

Thus, both donor-specific and non-donor-specific HLA surveillance programmes antibodies are associated with medium-term kidney allograft dysfunction as compared to patients with no Whatever the selection criteria used to define ideal HLA antibodies and are thus likely to be responsible prostate cancer candidates for active surveillance, for long-term loss of allograft function. the risk of misclassification remains and varies from approximately 10% to 30% in the literature. The Source: HLA antibodies are associated with advent of prostate imaging and the widespread use deterioration of kidney allograft function of imaging-directed biopsy aim at decreasing this irrespective of donor specificity. Seraina von risk without drastically reducing the number of Moos , Pietro E Cippà, Rob van Breemen, potential low-risk candidates. MRI may have a Thomas F Mueller. clinically meaningful impact on reassuring patients Hum Immunol 2020, S0198-8859(20)30417-1. and physicians about the safety of active doi:10.1016/j.humimm.2020. surveillance, at diagnosis but also during follow-up, and may reduce the need of unnecessary control biopsies.

MRI and targeted biopsies change prediction models of intermediate risk prostate cancer

Despite a classification proposed by d’Amico et al. to stratify men into low, intermediate and high-risk groups, a significant clinical heterogeneity has been highlighted particularly for patients with intermediate-risk disease. Indeed, some patients harbour aggressive characteristics at final pathology, increasing the risk of early recurrence after local treatment while other patients are affected by indolent PCa despite their initial risk assessment. Several subclassifications of the intermediate risk group (IRC) into favourable and unfavourable disease subsets have been developed. However, these classifications are based on systematic biopsies only. Recently, Roumiguié et al. proposed a new subclassification for patients undergoing pre-biopsy and both systematic and targeted biopsies, i.e. the ideal biopsy strategy to date. In this article, Diamand et al. aims at validating this new subclassification in an external cohort, comparing it to current prediction models. A total of 429 patients was treated with radical prostatectomy after a diagnosis based on MRI, systematic and targeted biopsies. The new model was assessed, as well as the NCCN and AUA subclassifications.

In the present series, the authors assessed the outcomes of 553 active surveillance patients (low and intermediate-risk prostate cancer) who had two or more MRI scans. The timing of MRI was based on both baseline risk (visible lesion or not) and PSA/PSA density changes during follow-up. A second MRI was done after 1 year. Then, MRI was repeated after 2 new years in case of a visible lesion. Otherwise, the decision to perform an MRI was based on PSA. All follow-up biopsies were performed using a transperineal approach. Median follow-up was 76 months.

Prof. Oliver Reich Section editor Munich (DE)

oliver.reich@ klinikum-muenchen.de

use to timely identify patients who progress appears clinically relevant. The avoidance of repeat biopsy in case of MRI stability has to be evaluated in other studies and in non-expert centres. In daily practice or when MRI is not systematically re-reviewed by an expert, PSA density could be an interesting marker to correct a potential imprecise evaluation of progression by MRI.

Source: Natural history of prostate cancer on active surveillance: stratification by MRI using the PRECISE recommendations in a UK cohort. Giganti et al. Eur Radiol 2020 30(4):2082–2090. https://link.springer. com/article/10.1007/s00330-020-07256-z

Trial compares urinary symptom improvement TURP and ThuVARP Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction (BPO). Thulium laser transurethral vaporesection of the prostate (ThuVARP) is a technique with suggested advantages over TURP, including reduced complications and hospital stay. The authors aimed to investigate TURP versus ThuVARP in men with lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO.

In this randomised, blinded trial, men with LUTS or urinary retention secondary to BPO were randomly assigned (1:1) at the point of surgery to receive ThuVARP or TURP. Patients were masked until follow-up completion. Co-primary outcomes were maximum urinary flow rate (Qmax) and IPSS at 12 months post-surgery. Equivalence was defined as a Overall, 2,161 scans were retrospectively re-reported difference of 2.5 points or less for IPSS and 4 mL per by an expert radiologist to give a PI-RADS v2 score. second or less for Qmax. Analysis was done The PRECISE score was given at each follow-up point. according to the intention-to-treat principle. The Clinical progression was defined by histological trial is registered with the ISRCTN registry, progression to ISUP 3-5 cancer and/or by the initiation ISRCTN00788389. of active treatment. A total of 30% of patients experienced this progression.

...MRI characteristics at baseline and during follow-up are correlated with the risk of progression under active surveillance.

PIRADS score 1-2 tended to be associated with PRECISE scores 1-3, whilst patients with baseline PIRADS score 4-5 had more than two-thirds chance being attributed a PRECISE score of 4 or 5 during The main limitations were the short offollow-up. For PRECISE1-2, freedom from clinical progression was 97% at 60 months compared with follow-up and the lack of robust 61% for PRECISE 4-5. There was also a relationship endpoints... between change in PSA density and the PRECISE score. PIRADS at baseline and PRECISE score were The MRI and targeted biopsy subclassification were both predictive for biopsy progression (p < 0.01). Of correlated with unfavourable disease in radical all patients, 57% did not show radiological prostatectomy specimens (defined by a pT3-4 and/or progression, meaning a PRECISE score 1-3. Among pN1 stage and/or ISUP 3-5 grade), with the need of them, only 5% experienced clinical progression. Of adjuvant therapy, and with the risk of biochemical the remaining patients with radiological recurrence after surgery. The main interest of this new progression, 61% experienced clinical progression. model was to decrease the percentage of patients classified as having an unfavourable disease on This prospective study confirms that MRI biopsy (compared with NCCN and AUA classifications), characteristics at baseline and during follow-up are while increasing the proportion of patients correlated with the risk of progression under active harbouring aggressive disease and poor oncologic surveillance. Patients with an initial low PIRADS score outcomes. Its use improved the selection of patients (no visible lesion) have a very low risk of biopsy and/ and could have an impact on de-escalation of or clinical progression. The PRECISE score aiming at unnecessary treatments, such as concomitant identifying radiological progression is strongly androgen therapy with radiotherapy or extensive associated with confirmed histological progression pelvic lymph node dissection in case of surgery. The and may help to avoid unnecessary control biopsy in case of MRI stability. Current active surveillance performance of all models in predicting biochemical protocols have to integrate MRI as follow-up tools. Its recurrence was similar (p > 0.05).

TURP and ThuVARP were equivalent for urinary symptom improvement... 410 men were randomly assigned to ThuVARP or TURP, 205 per study group. TURP was superior for Qmax (mean 23.2 mL per second for TURP and 20.2 mL per second for ThuVARP; adjusted difference in means -3.12, 95% CI -5.79 to -0.45). Equivalence was shown for IPSS (mean 6.3 for TURP and 6.4 for ThuVARP; adjusted difference in means 0.28, -0.92 to 1.49). Mean hospital stay was 48 hours in both groups. 91 (45%) of 204 patients in the TURP group and 96 (47%) of 203 patients in the ThuVARP group had at least one complication. The investigators conclude that TURP and ThuVARP were equivalent for urinary symptom improvement (IPSS) 12 months post-surgery, and TURP was superior for Qmax. Anticipated laser benefits for ThuVARP of reduced hospital stay and complications were not observed.

Source: Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): A randomised controlled trial. Hashim Hashim, Jo Worthington, Paul Abrams, Grace Young, Hilary Taylor, Sian M Noble, Sara T Brookes, Nikki Cotterill, Tobias Page, K Satchi Swami, J Athene Lane, UNBLOCS Trial Group. The Lancet, Volume 396, Issue 10243, 4–10 July 2020, Pages 50-61.

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European Urology Today

October/December 2020

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

fsangue@ hotmail.com

How to define aggressive prostate cancer? There are several definitions aiming at defining aggressive prostate cancer, mainly based on tumour grade, PSA values, clinical stage. Genomic classifiers are also used in some settings. However, in spite of these currently used prognostic stratifications, it remains hard to precisely identify a lethal prostate cancer. Such an identification is important from a clinical point of view, but also from an aetiological and prevention perspective in order to study risk factors and to use it in aetiologic epidemiology research. In this article, the authors used data from the SEER database. They compared the performance of multiple aggressive cancer definitions in discriminating fatal prostate cancer within 10 years of diagnosis. The definition of fatal prostate cancer was chosen arbitrarily, given that there is no gold standard. The authors also chose to place most emphasis on sensitivity as a positive predictive value (PPV).

prostatectomy (OP) (n = 3,651) between 2011 and 2013 were identified in pseudonymised claims and core data of the German local health care funds (AOK) and followed for 5 years. Surgical re-interventions for LUTS, urethral stricture or bladder neck contracture were evaluated. Surgical approach was related to re-intervention risk using the Kaplan-Meier method and Cox proportional-hazards models. 5,050 first re-interventions occurred within 5 years of primary surgery (Kaplan-Meier survival without re-intervention: 87.5%, 95%-CI: 87.2%-87.8%). PV carried an increased hazard of re-intervention (HR 1.31, 95%-CI: 1.17-1.46, p < 0.001) relative to TURP, OP carried a lower hazard (HR 0.43, 95%-CI: 0.37-0.50, p < 0.001) and LEP did not differ significantly (HR 0.84, 95%-CI: 0.66-1.08, p = 0.2). This pattern was more pronounced regarding re-intervention for LUTS recurrence (PV: HR 1.52, 95%-CI: 1.35-1.72, p < 0.001; LEP: HR 0.84, 95%-CI: 0.63-1.14, p = 0.3; OP: HR 0.38, 95%-CI: 0.31-0.46, p < 0.001; relative to TURP).

...5-year re-intervention rates of transurethral resection and laser enucleation did not differ significantly... The authors conclude that the 5-year re-intervention rates of transurethral resection and laser enucleation did not differ significantly, while photoselective vaporisation had a substantially higher rate. Open simple prostatectomy remains superior to transurethral resection with respect to long-term efficacy.

The competing causes of death were not considered...

Source: Surgical re-intervention rates after invasive treatment for lower urinary tract symptoms due to benign prostatic syndrome: a comparative study of more than 43,000 patients From the initial population of 55,900 men, 3,073 died with long-term follow-up. Gilfrich C, May M, of prostate cancer within 10 years. The performance of Fahlenbrach C, Günster C, Jeschke E, Popken G, clinical stage (TNM) and Gleason score was analysed. Stolzenburg J, Weißbach L, von Zastrow C, PSA was left out of the definitions. Gleason score was Leicht H. the primary determinant of the sensitivity and PPV of each definition. Definitions including Gleason score 3+4 or more had the highest sensitivity while those including 8 or more had highest PPVs. Definitions often performed similarly across subgroups based on race/ethnicity and age at diagnosis. Finally, the evidence-based consensus recommended to define aggressive prostate cancer as diagnosis of T4 or N1 or M1 or Gleason score 8-10 prostate cancer. Such definition may be adequate for epidemiology studies. However, it may be irrelevant for outcomes studies, especially because of the 10-year window. The competing causes of death were not considered and a not negligible proportion of patients with aggressive prostate cancer may have died from other causes. The estimated percentage of these patients was relatively high in the cohort (31%). The definition was subjective. Moreover, the outcomes of patients after the diagnosis of aggressive prostate cancer highly depend on the received treatment which influences the cancer-specific mortality and the natural course of the diagnosed disease.

Source: Recommended definitions of aggressive prostate cancer for etiologic epidemiologic research. Hurwitz et al. on behalf of the Prostate Cancer Cohort Consortium (PC3) Working Group. JNCI: Journal of the National Cancer Institute, 2020, djaa154. https://doi.org/10.1093/jnci/djaa154

Large-scale comparison of surgical re-intervention rates after LUTS surgery No large-scale comparison of the four most established surgical approaches for LUTS due to benign prostate obstruction in terms of long-term efficacy is available. The investigators from Germany compared photoselective vaporisation, laser enucleation and open simple prostatectomy to transurethral resection with regard to 5-year surgical re-intervention rates. 43,041 male patients with LUTS who underwent transurethral resection (TURP) (n = 34,526), photoselective vaporization (PV) (n = 3,050), laser enucleation (LEP) (n = 1,814) or open simple Key articles

October/December 2020

J Urol. 2020 Oct 26;101097JU0000000000001463. doi: 10.1097/JU.0000000000001463.

Impaired spermatogenesis in COVID-19 patients The current study aimed to determine the impact of SARS-CoV-2 infection on male fertility. This is a single-centre, hospital-based observational study that included autopsied testicular and epididymal specimens of deceased COVID-19 male patients (n = 6) and recruited recovering COVID-19 inpatients (n = 23) with an equal number of age-matched controls, respectively. The investigators performed histopathological examinations on testicular and epididymal specimens, and also performed TUNEL assay and immunohistochemistry. Also, semen specimen were evaluated for sperm parameters and immune factors.

...impairment of spermatogenesis was observed in COVID-19 patients... Autopsied testicular and epididymal specimens of COVID-19 showed the presence of interstitial oedema, congestion, red blood cell exudation in testes, and epididymides. Thinning of seminiferous tubules was observed. The number of apoptotic cells within seminiferous tubules was significantly higher in COVID-19 compared to control cases. It also showed an increased concentration of CD3+ and CD68+ in the interstitial cells of testicular tissue and the presence of IgG within seminiferous tubules. Semen from COVID-19 inpatients showed that 39.1% (n = 9) of them have oligozoospermia, and 60.9% (n = 14) showed a significant increase in leucocytes in semen. Decreased sperm concentration and increased seminal levels of IL-6, TNF-α, and MCP-1 compared to control males were observed. The authors conclude that impairment of spermatogenesis was observed in COVID-19 patients, which could be partially explained as a result of an elevated immune response in testis. Additionally, autoimmune orchitis occurred in some COVID-19 patients. Further research on the reversibility of impairment and developing treatment are warranted.

Source: Impaired spermatogenesis in COVID-19 patients. Honggang Li, Xingyuan Xiao, Jie Zhang, Mohammad Ishraq Zafar, Chunlin Wu, Yuting Long, et al. eClinicalMedicine by The Lancet, EClinicalMedicine: Open Access published: October 23, 2020. Doi: https:// doi.org/10.1016/j.eclinm.2020.100604

Mini vs. Standard PCNL for 20-40 mm renal stones: Results from a large randomised controlled trial New technologies need to be tested in an appropriate way before to be claimed as more efficient than standard interventions.

Dr. Guillaume Ploussard Section editor Toulouse (FR)

g.ploussard@ gmail.com

Source: Mini Percutaneous Nephrolithotomy Is a Noninferior Modality to Standard Percutaneous Nephrolithotomy for the Management of 20–40 mm Renal Calculi: A Multicenter Randomized Controlled Trial. Guohua Zeng, Chao Cai, Xianzhong Duan, et al. Eur Urol doi.org/10.1016/j.eururo.2020.09.026, in press

Nevertheless, in most of the cases new devices are introduced onto the market without having passed through the scrutiny of robust studies to prove their alleged advantages. In the field of renal stones interventions, a revival of the percutaneous nephrolithotomy (PCNL) was seen after the introduction of flexible ureteroscopes (fURS). Smaller scopes that could rival with fURS in terms of comorbidities became increasingly popular for the treatment of medium-size renal stones; they simultaneously maintained the higher stone-free rates (SFR) of standard PCNL.

...the space between the Amplatz sheath and the scope was wider in the case of mPCNL than in sPCNL... In order to appropriately address the clinical question of whether miniPCNL (mPCNL) could be a non-inferior treatment modality compared to standard PCNL (sPCNL) for renal stones of 20 to 40 mm in size, a large randomised controlled trial has been undertaken recently in 20 high-volume Chinese centres, with the recruitment running from 2016 to 2019. The non-inferiority margin was set within a 10% of lower stone-free rate (SFR) with respect to sPCNL, so that the sample size accounted for 2,000 patients, making it one of the largest (if not the largest) RCT for renal stone interventions.

Best treatment for lower pole renal stones: Shared decision with the patient Since the introduction of the shock-wave lithotripsy (SWL) in the ‘80s and the diffusion of retrograde intrarenal surgery (RIRS) in the last two decades, the treatment of lower pole stones (LPS) has been a matter of eternal discussion. This subgroup of kidney stones is considered a separate category when it comes to providing practitioners with recommendations and guidelines, as the anatomy plays a major role in the outcomes. A steep renal pelvis-infundibulum angle, a narrow and/or long infundibulum are widely accepted as anatomical factors that add additional issues, especially to SWL and RIRS. On the other hand, side effects such as invasiveness or higher complication rates may counterbalance higher stone-free rates, especially for percutaneous lithotripsy (PCNL). As a result, several studies and systematic reviews have been undertaken in the last years to shed some more light on the best treatment option to offer patients in the challenging setting of lower-pole stones < 2cm. A recent systematic review could implement evidence by selecting more randomised controlled trials in this setting of patients than in the past, so that the outcomes are of interest as the trials also included more up-to-date technologies.

The size of the tracts was 18ch for mPCNL and 24 for sPCNL, which corresponds to an increase in the ...PCNL and RIRS were shown to be surface area of 77.8% from the former to the latter. Interestingly, the authors highlighted that the space the most efficient treatment options, between the Amplatz sheath and the scope was wider the latter especially in the case of in the case of mPCNL than in sPCNL, which provides a better visibility and outflow of fragments for the LPS < 1 cm... former modality. Renal access was performed in the majority of cases under US guidance and in the supracostal 11th rib space. The systematic review was methodologically sound. A total of 15 studies was selected to test the primary Baseline evaluation was done by CT scan and SFR and secondary endpoints, being the first assessment of assessment was performed with X-ray + ultrasound stone-free rate (SFR) within 3 months from the scan before discharge and at 1 month after removal of treatment, while the second endpoints included the the JJ stent. In the follow-up, the CT scan was only operative time, the hospitalisation time, the used in case of doubtful clinical circumstances. The complication and retreatment rates. Furthermore, SFR status was defined as residual fragments ≤ 4 subgroup analysis was undertaken for LPS < 1 cm and mm, if any. The authors explained that Chinese of 1-2 cm. The results confirmed the already known patients are accustomed to being discharged once all superiority of PCNL on RIRS and SWL in terms of SFR; the urinary derivation tubes are removed, so that the some points raised by the authors are worth data of hospitalisation do not reflect those published mentioning. First and foremost, most of the trials were elsewhere. Furthermore, in most of the patients small in size, with only one counting for more than 100 harbouring stone fragments between 4 to 6 mm the patients. There is a consistent selection bias in all the conservative management was the preferred option. trials as SWL –and in some cases RIRS as wellrecipients was assigned to the relevant treatment as No differences were reported in terms of baseline long as adverse anatomical factors were not present. patients’ demographics; the conversion from one As a consequence, the pooled SFRs reported probably modality to another happened in few cases and the best possible outcomes for SWL and RIRS. This symmetrically, in such a way that the intention-toissue may partly explain why there were no statistically treat and per-population analysis overlapped entirely. significant differences in terms of the SFRs between the PCNL and RIRS groups of patients. Both treatments The primary endpoint was achieved, as the SFR was showed significantly better SFRs with respect to SWL nearly the same between the two groups of patients, (PCNL vs. SWL: OR 6.7; RIRS vs. SWL: OR 2.85. p < 0.01). with a difference of SFR at one session of just 0.5% Interestingly, in the subgroup of patients with < 1 cm, (overall 86%). On the contrary, the group of patients no trial included PCNL as an option, so that all results undertaking a mPCNL had a lower drop of involved a comparison between RIRS and SWL with the haemoglobin, higher rate of tubeless procedure, former showing higher, although not statistically lower post-op pain, and shorter hospitalisation. The significant, SFR overall complications were comparable, also when (p = 0.08). The studies testing the PCNL included stratifying for the Clavien-Dindo grades. different calibres of renal tracts, so there was a certain heterogeneity in the outcomes involving this group of The main limitations include the somehow limited patients. generalisation and clinical application of the outcomes as the procedures were performed by Operative and hospitalisation times favoured SWL highly skilled surgeons and the need of disposing a with respect to both PCNL and RIRS. However, the second set of instrumentation, respectively. retreatment rate was significantly higher for the SWL,

EAU EU-ACME Office

European Urology Today

Prof. Serdar Tekgül Section Editor Ankara (TR)

serdartekgul@ gmail.com so the former advantages are diluted if not nullified by the cumulative effect of the repeated interventions. As expected, complication rate was the main unfavourable adverse outcome for PCNL, although there might be a trend in the future of more comparable outcomes with respect to RIRS and SWL, with the increasing popularisation of miniPCNL approaches. Overall, PCNL and RIRS were shown to be the most efficient treatment options, the latter especially in the case of LPS < 1 cm, even though patients should always be informed of the effectiveness of SWL as soon as they need to undergo a longer and repeated treatment process.

Source: Systematic Review and Meta-Analysis Comparing Percutaneous Nephrolithotomy, Retrograde Intrarenal Surgery and Shock Wave Lithotripsy for Lower Pole Renal Stones Less Than 2 cm in Maximum Diameter. Panagiotis Kallidonis,* Panteleimon Ntasiotis, Bhaskar Somani, Constantinos Adamou, Esteban Emiliani, Thomas Knoll, Andreas Skolarikos and Thomas Tailly. The Journal of Urology: Vol. 204, 427-433, September 2020.

The suture-stent: Revival of an old concept to reduce stentrelated symptoms Nowadays, the insertion of ureteric stents is one of the most common interventions in urology. Stents are usually indicated to temporarily drain an obstructed upper urinary tract, in preparation of an endoscopic procedure (passive dilatation of the ureter) or after an endoscopic surgery to prevent post-operative complications. Nevertheless, most practitioners are aware these devices may have a high impact on the patient’s quality of life, especially in terms of pain and lower urinary tract symptoms (LUTS). This issue was addressed first and foremost by the introduction of a standardised patient reported outcomes measure, such as the Ureteric Stent Symptom Questionnaire (USSQ) which has been validated in multiple languages in the last 10-15 years.

The trial outcome was positive as the primary endpoint showed satisfying results, i.e. a substantial reduction in urinary symptoms scores (difference -6.6, p < 0.001) in the suture stent group... In order to improve patients’ experience, different materials and stent designs have been tested in the last years. A randomised controlled trial, single-blind, has recently been published to test a hand-made suture-stent inserted in ureteric stone patients, either electively (preparation of URS) or in emergency setting (decompression of urinary tract). The study and device designs were based on former evidence that string/suture stent could reduce the symptoms suffered by patients because of the lack of distal coil. The latter aspect has been investigated previously, as factors such as long distal coil –especially if crossing the trigone midline- were identified among the main causes of LUTS.

estimated on the fluoroscopy images) and shaped as a “tail coat”. A 4-0 non-absorbable stitch was applied to the distal edge at the equivalent length necessary for it to curl in the bladder. Patients were unaware about the type of stent they were having. USSQ scores were recorded at three time points: one week after the stent insertion, the day prior surgery (i.e. ureteroscopy; 2-6 weeks later) and finally 2-6 weeks after stent removal. The latter measurement was a surrogate of the basic condition, as it is estimated that the stent-related symptoms should remit after 2 weeks. It was used as reference against scores recorded on the first two time points. The trial outcome was positive as the primary endpoint showed satisfying results, i.e. a substantial reduction in urinary symptoms scores (difference -6.6, p < 0.001) in the suture stent group compared to the standard stent group of patients at both the baselineadjusted Visit 1 (i.e. one week post stent insertion) and Visit 2 (just prior URS). Pain was reduced in the intervention group when comparison was performed between baseline and Visit 2 scores (difference -6.1, p = 0.004). On the other hand, patients from the suture-stent group were affected by a higher percentage of failed URS (23.9 vs. 6.5%), mostly due to unnegotiable ureteric orifice. Moreover, in a significant proportion of patients (14.6%) the suture was found dislocated up in the distal ureter, although this issue did not translate into any complication at the time of URS. Overall, this is a pivotal study showing benefit of suture-stent in terms of better patient tolerance, as a new model of this kind is going to be introduced on the market. However, the manufactured one will be produced in just two lengths. Thus it is impossible to fully reproduce the study’s conditions where the length of the suture-stents were tailored according to the actual site of the stone.

Source: Reduction of stent-associated morbidity by minimizing stent material: A prospective, randomized, single-blind superiority trial assessing a customized "Suture-Stent". Patrick Betschart, Alberto Piller, Valentin Zumstein, Hans-Peter Schmid, Daniel S Engeler, Sabine Güsewell, Manolis Pratsinis, Dominik Abt. BJU Int. 2020 Nov 5. doi: 10.1111/bju.15290. Online ahead of print.

Can contralateral testicular hypertrophy predict monorchidism in boys with nonpalpable testicles? In up to 20% of patients presenting with undescended testes, testes are non-palpable. In this patient group, the role of imaging in detecting an abdominal testis has not been shown to be reliable; the most reliable means to exclude an abdominal testis is still laparoscopy. In boys with unilateral nonpalpable testis (NPT) contralateral testicular hypertrophy is considered to be a predictor of absence of the testis. However, its implication in clinical practice is not well-defined. Studies which looked at the size of the testis to define a cut-off value as a possible predictor of monorchidism have given variable results, mostly due to different methods used for testicular measurement. Apart from measurement tools several additional factors such as age range, ethnicity, and selection bias of cohorts may account for the huge differences among cut-off values and predictive accuracy.

group A (p < 0.01) and group B (p < 0.01), whereas the differences between groups were small. Among patients with NPT, a receiver operating characteristic curve was used to determine the optimal cut-off value. It revealed that both a testicular length of 17.5 mm and a volume of 1.05 ml provided the highest Youden’s index for prediction of monorchidism. The sensitivity and specificity for testicular length were 34.1% and 94.7%, and volume were 34.1% and 93%, respectively. The predictive accuracy for testicular length and volume were 69.4% and 65.7%, respectively. Even though the negative predictive value was merely 66.6% (54/81) and 66.2% (53/80), the positive predictive value (PPV) reaches to 82.3% (14/17) and77.7% (14/18) for testicular length and volume.

In boys with non-palpable testis, laparoscopic evaluation to exclude abdominal testis is the gold standard. In this study the diagnostic value of contralateral testicular size in prediction of monorchidism in patients with NPT was not high, as it was in many other previous studies. But because the positive predictive value is relatively higher, evaluating the contralateral size gives valuable preliminary information about the presence of abdominal testis but can still not be considered a definitive indicator. Therefore, contralateral testicular hypertrophy can provide information about preoperative counselling and may serve as a reference, without being a complete replacement of laparoscopic evaluation. There is a need of prospective studies with standard and objective measurement of contralateral testicular size to be able to define a cut-off size to define an established role of this evaluation.

Source: Detection of monorchidism in boys with unilateral undescended testes: clinical benefits and limitations of contralateral testicular size. Huang Y, Liu P, Sun N, Zhang W, Song H. J Pediatr Urol. 2020 Jun;16(3):356.e1-356.e6. doi: 10.1016/j.jpurol.2020.02.006. Epub 2020 Feb 17. PMID: 32165086.

This paper reports a comprehensive search of current literature, investigating the association between age at initiation of toilet training, approach used for toilet training, and bladder bowel dysfunction. A total of 10 studies with 24,121 participants (aged 5-17) were included for pooled analysis. Overall, the odds ratio (OR) with 95% confidence interval (95% CI) of lower urinary tract dysfunction in children who initiated toilet training at a younger age when compared to those who initiated toilet training at an older age, was 0.71 (0.63-0.81), (p < 0.001), irrespective of the approach used for toilet training. Subgroup analysis for day-time incontinence (persistent daytime wetting) was 0.77 (0.62-0.95), p = 0.014; although the outcomes for enuresis fluctuated, favourable results were still observed in the earlier training group (OR: 0.63, 95% CI: 0.43-0.94, p = 0.023). Subgroup analysis for age at initiating toilet training vs LUT dysfunction also showed favourable results in children who were trained earlier, i.e. before 24 months (OR:0.77, 95% CI 0.63-0.94, P Z = 0.009). Sensitivity analysis confirmed that the results were strong. This meta-analysis presents preliminary findings that show the incidence of bowel and bladder dysfunction may be decreased by initiating toilet training in children at a younger age - prior to the age of 24 months. Although the definition about the age of initial toilet training varied greatly in studies, findings from the current study suggested that the optimal time for initiating toilet training may be prior to the age of 24 months. If toilet training was initiated after 24 months or later, it may result in increased prevalence of LUT dysfunction. Since no RCTs studies were included in the current meta-analysis, well-designed longitudinal studies with larger sample size and from different cultural backgrounds are needed to confirm these results.

Source: Delayed in toilet training association with paediatric lower urinary tract dysfunction: A systematic review and meta-analysis. Li X, Wen JG, Xie H, Wu XD, Shen T, Yang XQ, Wang XZ, Chen GX, Yang MF, Du YK. J Pediatr Urol. 2020 Jun;16(3):352.e1-352.e8. doi: 10.1016/j.jpurol.2020.02.016. Epub 2020 Mar 10. PMID: 32241587.

Transperineal vs. transrectal Does delayed toilet training in prostate biopsy significantly reduces infectious children cause lower urinary complications tract dysfunction? Since the recognition of bowel and bladder emptying problems in children, many theories have been put forward regarding the development of bladder bowel dysfunction (BBD) in children. The current understanding is that the dyscoordination of the external sphincter (pelvic floor) during bladder and rectal emptying is the main mechanism of this dysfunction. The causative factor for pelvic floor dyscoordination is still controversial. There has been ample amount of literature examining toilet training and dysfunctional elimination association and suggesting that late toilet training with bladder overactivity may be a leading factor. However, no clear hypothesis has been put forward or tested as to why this would occur. Some hypothesise that changing attitudes and practices towards toilet training causes toilet training to be completed at a later age compared to previous generations. Concomitantly, there has been an increase in the incidence of paediatric bladder bowel dysfunction.

The purpose of this study was to identify which non-antibiotic strategies could reduce the risk of infectious complications following prostate biopsy. The EAU Guidelines Panel on Infections in Urology performed a literature search on MEDLINE, Embase and Cochrane Database for randomised controlled trials (RCTs) (Inception to May 2020) assessing non-antibiotic interventions in prostate biopsy. Primary outcome was pooled infectious complications (fever, sepsis and symptomatic UTI) and secondary outcome was hospitalisation. Cochrane risk of bias tool and GRADE approach were used to assess the bias and the certainty of evidence.

Rectal preparation with povidoneiodine was also shown to reduce infectious complications...

Ninety RCTs (16,941 participants) were included in the analysis with 83 RCTs being categorised into one of ten different interventions. Transperineal biopsy was associated with significantly reduced infectious In boys with non-palpable testis, laparoscopic complications as compared to transrectal biopsy (RR Bowel and bladder dysfunction evaluation to exclude abdominal testis is the gold 0.55, 95% CI 0.33–0.92, p = 0.02, I2 = 0%, participants standard. Although presence of contralateral testicular in children may be due = 1,330, studies = 7). Rectal preparation with hypertrophy (CTH) in patients with monorchidism is a was also shown to reduce infectious to delayed toilet training. However, povidone-iodine well-known phenomenon, its implication in clinical complications (RR 0.50, 95% CI 0.38–0.65, p < practice is still controversial. there is no clear explanation about 0.000001, I2 = 27%, participants = 1,686, studies = 8) as well as hospitalisation (RR 0.38, 95% CI 0.21–0.69, how this happens. Authors evaluate a large cohort of 707 patients aged p = 0.002, I2 = 0%, participants = 620; studies = 4). between 9 and 48 months with unilateral The authors found no difference in infectious undescended testes (UDT); palpable UDT (group A, n = Another theory suggests that the symptoms of complications/hospitalisation for six other The study - methodologically sound - aimed at testing 609), non-palpable but viable testes (group B, n = 57) dysfunctional voiding are more common when toilet interventions: number of biopsy cores, periprostatic the superiority of a customised suture-stent versus a and monorchidism (group C, n = 41). Contralateral training starts early, as immature children may be less nerve block (PPNB), number of injections for PPNB, standard one in terms of better quality of life, assessed testicular length and volume were evaluated with likely to empty in a timely manner, or when training needle guide type, needle type, and rectal by means of the German-USSQ. The manufactured starts late due to (or in association with) constipation. preparation with enema. In two interventions (needle ultrasonography. Comparison of contralateral stent – initially the same type of the standard group diameter, rectal preparation with chlorhexidine) testicular size between three groups and calculation meta-analysis was not possible. Finally, seven studies - was manipulated by the operator on the surgical of optimal cut-off value and diagnostic performance Bowel and bladder dysfunction in children may be had unique interventions. The certainty of evidence table according to the site of the targeted ureteric due to delayed toilet training. However, there is no among NPT were performed. The length and volume stone, with the lower-end cut below the stone (length of contralateral testes of group C were larger than of clear explanation about how this happens. was rated as low/very low for all interventions. Key articles

EAU EU-ACME Office

European Urology Today

October/December 2020

Prof. Oliver Hakenberg Section Editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de The panel concluded that transperineal biopsy significantly reduces infectious complications compared to transrectal biopsy and should therefore be preferred. If transrectal biopsy is performed, rectal preparation with povidone-iodine is highly recommended. The other investigated non-antibiotic strategies did not significantly influence infection and hospitalisation after prostate biopsy.

as is augmented prophylaxis, although no established standard combination exists to date. The section editor of EUT would like to comment that several findings in this review need further consideration as regards the principles of antimicrobial stewardship and the role of transperineal biopsies.

Source: Antibiotic Prophylaxis for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and MetaAnalysis. Adrian Pilatz, Konstantinos Dimitropoulos, Rajan Veeratterapillay, Yuhong Yuan, Muhammad Imran Omar, Steven MacLennan, Tommaso Cai, Franck Bruyere, Riccardo Bartoletti, Bela Koves, Florian Wagenlehner, Gernot Bonkat and Benjamin Pradere. J Urol. 2020 Aug;204(2):224-230. doi: 10.1097/ JU.0000000000000814. Epub 2020 Feb 27. PMID: 32105195.

Source: Non-antibiotic Strategies for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and MetaAnalysis. Benjamin Pradere, Rajan Do decision support tools lead Veeratterapillay, Konstantinos Dimitropoulos, to the correct choice? Yuhong Yuan, Muhammad Imran Omar, Steven MacLennan, Tommaso Cai, Franck Bruyère, Riccardo Bartoletti, Bela Köves, Florian Wagenlehner, Gernot Bonkat and Adrian Pilatz. For men with localised prostate cancer, decision J Urol. 2020 Oct 7:101097JU0000000000001399. doi: 10.1097/JU.0000000000001399. Online ahead of print.

Fosfomycin trometamol can replace fluoroquinolone to reduce the rate of infectious complications after prostate biopsy Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been banned by the European Commission. In this systematic review, the EAU guidelines panel on infections in urology summarises the evidence for different antibiotic prophylaxis regimens. They searched MEDLINE, Embase and the Cochrane Database for randomised controlled trials (inception to October 2019) assessing antimicrobial interventions in prostate biopsy. Primary outcome was infectious complications. Exclusion criteria were simultaneous interfering interventions. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used to assess the certainty of evidence.

No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. Overall 59 randomised controlled trials (14,153 participants) and 7 different antimicrobial interventions were included. Antibiotic prophylaxis reduced infectious complications compared to no prophylaxis (RR 0.56, 95% CI 0.40e0.77, p[0.0005, I2[15%, participants 1,753, studies 11). A short-term prophylaxis (single shot to 3 days) was inferior to a long-term prophylaxis (1 to 7 days) with fluoroquinolone (RR 1.89, 95% CI 1.37e2.61, p[0.0001, I2[0%, participants 3,999, studies 17). Fosfomycin trometamol was an alternative to fluoroquinolone with reduced rates of infectious complications (RR 0.49, 95 CI 0.27e0.87, p[0.02, I2[54%, participants 1,239, studies 3). Empiric prophylaxis was inferior to targeted prophylaxis (RR 1.81, 95% CI 1.28e2.55, p[0.0008, I2[48%, participants 1,511, studies 6). Standard prophylaxis was inferior to augmented prophylaxis (using multiple rather than single agent) using a fixed model (RR 2.10, 95% CI 1.53e2.88, p < 0.0001, I2[71%, participants 2,597, studies 9), but not using a random model (p[0.07). No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. The certainty of evidence was rated as low/very low. The panel concluded that in countries where fluoroquinolones are allowed as antibiotic prophylaxis, a minimum of a full 1-day administration as well as targeted therapy in case of fluoroquinolone resistance is recommended. In countries with a ban on fluoroquinolones, fosfomycin is a good alternative, Key articles

October/December 2020

making regarding management options can be difficult and is highly sensitive to personal preferences. Multiple factors, including tumour risk, life expectancy, baseline sexual and urinary function, and anxiety surrounding cancer progression, contribute to the basis of any treatment choice. Decision support tools have the potential to foster a shared decision-making process surrounding prostate cancer treatment. Understanding how decision support tools influence uptake of guidelineconcordant care may optimise delivery of aggressive treatment to the patients with prostate cancer who need it most.

Source: Decision support for men with prostate cancer: concordance between treatment choice and tumour risk. Filson CP, Hong F, Xiong N et al. Cancer 2020 doi: 10.1002/cncr.33241

Life prolonging treatment for mCPRC Men with deleterious alterations in genes involved in homologous recombination repair, such as BRAC1 and BRAC2, have more aggressive prostate cancer and a higher mortality. However, tumours with gene alterations that affect homologous recombination repair are sensitive to poly(adenosine diphosphate– ribose) polymerase (PARP) inhibitors. This has caused great excitement as it raises the possibility of targeted treatment for men with prostate cancer. The PROfound trial has previously reported an improvement in imaging-based progression-free survival with olaparib. The study recruited men with metastatic castration-resistant prostate cancer and alterations in at least 1 of 15 prespecified genes with a direct or indirect role in homologous recombination repair, who had progressed during treatment with either enzalutamide or abiraterone plus prednisolone. Patients were randomised 2:1 to receive olaparib 300mg b.d. or the alternative next generational hormonal agent. The overall population comprised patients who had at least one alteration in BRCA1, BRCA2, or ATM (cohort A) and patients with at least one alteration in any of the other 12 prespecified genes (cohort B). Crossover to olaparib was allowed after imaging-based disease progression for patients who met the criteria. This paper presents the overall survival data.

At the time of the final analysis, 148 of 245 patient (60%) in cohort A had died. The median duration of overall survival in cohort A was 19.1 months with olaparib and 14.7 months with control therapy This paper identified men enrolled in a prospective (hazard ratio for death, 0.69; 95% confidence randomised controlled trial assessing the P3P decision interval [CI], 0.50 to 0.97; p = 0.02). In cohort B, support intervention and its impact on decision 70% have died. The median duration of overall conflict. For this post-hoc analysis only men with low survival was 14.1 months with olaparib and 11.5 or intermediate-risk disease were considered. Only months with control therapy. In the overall participants with complete data allowing risk population (cohorts A and B), the corresponding classification and those with a documented final durations were 17.3 months and 14.0 months. treatment choice were included. Participants Overall, 86 of 131 patients (66%) in the control randomised to P3P used the web-based tool, which group crossed over to receive olaparib (56 of 83 generated a 1-page summary of patient reported patients [67%] in cohort A). A sensitivity analysis information which was used by the provider to that adjusted for crossover to olaparib showed highlight symptom issues, concerns and preferences. hazard ratios for death of 0.42 (95% CI, 0.19 to 0.91) Active surveillance was considered guideline in cohort A, 0.83 (95% CI, 0.11 to 5.98) in cohort B, concordant for men with low and favourable and 0.55 (95% CI, 0.29 to 1.06) in the overall intermediate-risk tumours. Similarly, active treatment population. The most common adverse event in was considered guideline concordant for men with those who received olaparib were anaemia, unfavourable intermediate-risk prostate cancer. It was nausea, fatigue or asthenia. also assessed whether providers recommended against any treatment options (i.e. restricted).

…men with low-risk prostate cancer often fail to choose active surveillance because clinicians advise against this option. This study identified 295 men in the cohort: 113 (38%) had low-risk disease, 119 (40%) had favourable intermediate-risk disease, and 63 (21%) had unfavourable intermediate-risk disease.144 men received usual care and 151 used the P3P decision support intervention. Ninety-seven men (33%) had their treatment options restricted by their provider. Among low-risk patients, more men pursued active surveillance after using P3P whether they were given unrestricted (62% vs. 54% with usual care; p = 0.54) or restricted options (71% vs. 59% with usual care; p = 0.34). After adjustments, only black race (odds ratio [OR], 0.31; 95% CI, 0.11-0.89) and restricted options (OR, 0.23; 95% CI, 0.08-0.65) had an inverse association with the receipt of surveillance for patients with low-risk prostate cancer. An impact associated with P3P versus usual care (OR, 0.89; 95% CI, 0.36-2.20) was not observed.

Mr. Philip Cornford Section editor Liverpool (GB)

Those patients with an alteration in BRCA1, BRCA2, or ATM and who received olaparib had a significantly improved overall survival and a prolonged time to second progression. Those patients with an alteration in BRCA1, BRCA2, or ATM and who received olaparib had a significantly improved overall survival and a prolonged time to second progression. It should be noted this study used rechallenge with a next generational hormone agent in the control arm rather than either docetaxel or cabazitaxel dependent upon previous treatments. As a consequence, issues about sequencing remain. It is clear that olaparib is effective against an ineffective treatment. The question remains should such patients have a taxane first?

Source: Survival with Olaparib in metastatic castration-resistant prostate cancer. Hussain M, Mateo J, Fizazi F, et al. NEJM 2020 doi: 10.1056/NEJMoa2022485

As is seen in community data from the US, black men Radiotherapy after radical and those of younger age are less likely to pursue active surveillance. In addition, this study showed that prostatectomy, adjuvant or men with low-risk prostate cancer often fail to choose salvage therapy active surveillance because clinicians advise against this option. Consequently, although the P3P instrument ameliorates decisional conflict, its use was Previous prospective, randomised clinical trials not associated with more appropriate alignment of showing that adjuvant radiotherapy was treatment with disease risk. associated with a reduced risk of recurrence in

philip.cornford@ rlbuht.nhs.uk

patients at risk (i.e. positive surgical margins, pathological T-stage 3 disease, Gleason score 8–10) were confounded by either late use of salvage radiotherapy or no use of post-radical prostatectomy PSA monitoring or both. In addition, results were inconsistent regarding the longer-term outcomes of metastases-free survival and overall survival. As a consequence, three randomised trials (RAVES, GETUG-AFU 17 and RADICALS-RT) have compared adjuvant radiotherapy with a policy of early salvage radiotherapy in cases of PSA progression. The ARTISTIC collaboration curated a prospective plan to create a systematic review of these 3 studies. Using a prospective framework for adaptive meta-analysis, starting the review process whilst the trials were ongoing, they developed a protocol before the trial results were available. They agreed a harmonised definition of event-free survival as the time from randomisation until the first evidence of either biochemical progression (PSA ≥ 0.4 ng/mL and rising after completion of any postoperative radiotherapy), clinical or radiological progression, initiation of a non-trial treatment, death from prostate cancer, or a PSA level of at least 2.0 ng/mL at any time after randomisation. Investigators supplied results for event-free survival, both overall and within predefined patient subgroups. Hazard ratios (HRs) for the effects of radiotherapy timing on event-free survival and subgroup interactions were combined using fixed-effect meta-analysis.

…early salvage rather than adjuvant radiotherapy should be considered standard of care. They obtained updated results for event-free survival for 2,153 patients recruited between November 2007 and December 2016. Median follow-up ranged from 60 months to 78 months, with a maximum follow-up of 132 months. 1,075 patients were randomly assigned to receive adjuvant radiotherapy and 1,078 to a policy of early salvage radiotherapy, of whom 421 (39.1%) had commenced treatment at the time of analysis. Patient characteristics were balanced within trials and overall. The majority of patients had either stage pT3a or b disease (1,719 [79.8%]), positive surgical margins (1,526 [70.9%]), and extracapsular extension (1,656 [76.9%]. Most patients (1,671 [77.6%]) had a Gleason score of 7. The radiotherapy schedule was similar in all trials: 64 Gy in 32 fractions or 66 Gy in 33 fractions; RADICALS-RT also permitted 52.5 Gy in 20 fractions. Based on 270 events, the meta-analysis showed no evidence that event-free survival was improved with adjuvant radiotherapy compared with early salvage radiotherapy (HR 0.95, 95% CI 0.75–1.21; p = 0.70), with only a 1 percentage point (95% CI −2 to 3) change in 5-year event-free survival (89% vs. 88%). Results were consistent across trials (heterogeneity p = 0.18; I² = 42%). At the time of reporting only 421 (39.1%) of those in the salvage arm had received radiotherapy. The authors concluded that early salvage rather than adjuvant radiotherapy should be considered standard of care. Subgroup analysis was hampered by a lack of events but there was no suggestion of a benefit for adjuvant radiotherapy even in the highest risk groups. It is clear that for many patients early salvage should be considered. However, for those patients with Gleason 8-10 and pT3b or higher (< 20% of the study) who have a particularly high rate of biochemical recurrence, shared patient and clinician decision making should be employed.

Source: Adjuvant or early salvage radiotherapy for the treatment of localised and locally advanced prostate cancer: a prospectively planned systematic review and meta-analysis of aggregate data. Vale CL, Fisher D, Kneebone A et al. Lancet. 2020; 396: 1422-31.

EAU EU-ACME Office

European Urology Today

Frequently Asked Questions

Announcement

When can I take the assessment, and how much time does it take? The assessment is organised on Thursday, 11 & Friday, 12 March 2021. You can take it any time of the day or night within a timeframe of maximum 2 hours.

In-Service Assessment 2021 As EBU we are very happy to announce that we have further developed the assessment into a learning tool. You do not only get feedback on your results, but learn at the same time!

• The in-depth analysis offers a comparison of your level of knowledge against your peers within your country and worldwide.

How do I take the assessment? The assessment is offered online in collaboration with Pearson VUE. It can be taken anywhere, even from the comfort of your home.

The format of the assessment remains unchanged and consists of 100 single correct answer MCQs covering all urology fields. However, the analysis will now be more insightful:

• You can compare your performance over the years, which allows an objective assessment of your improvement.

Do I receive CME credits? Participation qualifies for 10 CME credits.

• This objective and comparative data will bring many rational approaches to improve training. As trainee you will obtain information about your knowledge at different levels of your training. With this data you can regulate your own training process and become more motivated. The institute may benefit as well as their trainees’ results can guide them to regulate and make rational changes in the training programme.

How much do I pay? The regular fee is € 60. A reduced fee of € 50 is applicable for applicants from EBU Certified Training Centres, as listed on www.ebu.com/ebu-certified-centres.

• Until 7 days after announcement of your result, the MCQs, including detailed validation comments on each question, will be available in our examination management system “Examfolio”. This allows you to review the assessment and improve your knowledge. The assessment is thus a learning tool as well.

EBU Certified Residency Training Programmes in Urology Austria Hanusch-Krankenhaus. Vienna Krankenhaus der Barmherzigen Brüder, Vienna Landeskrankenhaus Leoben Medical University of Vienna SMZ Ost - Donauspital, Vienna SMZ Süd - Kaiser-Franz-Josef-Spital, Vienna Uniklinikum Salzburg

Hungary Semmelweis University, Budapest

Belgium AZ Maria Middelares, Ghent AZ Nikolaas, Ghent AZ St Lucas, Ghent OLV Ziekenhuis Aalst-Asse-Ninove U.L.B. Hôpital Erasme, Brussels Universitair ziekenhuis, Ghent UZ Leuven

The Netherlands Onze Lieve Vrouwen Gasthuis, Amsterdam VU Medisch Centrum, Amsterdam

Croatia KBC Sestre Milosrdnice, Zagreb Czech Rep Faculty Hospital Plzen and Faculty of Medicine in Plzen, Charles University 1st Faculty of Medicine, Charles University and General University Hospital Prague 2nd Faculty of Medicine, Charles University and Motol University Hospital Prague Estonia North Estonia Medical Centre Foundation, Tallinn Tartu University Hospital Finland Helsinki University Hospital Turku University Hospital Germany Helios Marien Klinik, Duisburg Justus-Liebig-Universität Gießen Klinikum Bamberg Klinikum der Stadt Ludwigshafen am Rhein Klinikum Garmisch-Partenkirchen Klinikum Ludwigsburg Klinikum rechts der Isar der Technischen Universität München SLK-Kliniken Heilbronn St. Antonius-Hospital Gronau Städtisches Klinikum Braunschweig UKH Universitätsklinikum Halle (Saale) Uniklinik RWTH Aachen Universitätsklinikum Hamburg-Eppendorf Universitätsklinikum Carl Gustav Carus, Dresden Universitätsklinikum Düsseldorf Universitätsklinikum Jena Universitätsklinikum Schleswig-Holstein, Kiel University Hospital Schleswig-Holstein - Campus Lübeck Klinikum Nürnberg Universität Regensburg - Caritas Krankenhaus St. Josef Greece Sismanoglio General Hospital, Athens University General Hospital of Heraklion

I am a trainee, why should I take the assessment? Self-assessment is considered a powerful tool. It allows you to evaluate your knowledge against European standards.

European Urology Today

Italy General Hospital of Bolzano Malta Mater Dei Hospital Malta, Msida

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

EBU Certified Sub-Speciality Centres Institute Sub-Specialty Germany University Hospital Cologne

Testicular Cancer

United Kingdom Oxford University

Stone Treatment

Certified EBU-EAU Host Centres Institute Specialty Belgium Onze-Lieve-Vrouwziekenhuis Aalst UZ Leuven

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

France Pitié-Salpétrière Hospital, Paris

Prostate Cancer, Neuro-urology, Renal Cancer

Germany Eberhard Karls University Tuebingen Heinrich-Heine University, Medical Faculty, Düsseldorf Ludwig-Maximilians-Universität München University Hospital Bonn University Hospital Carl Gustav Carus, Dresden University Hospital Leipzig University Hospital of Cologne

Urothelial Cancer Prostate Cancer, Renal Cancer, Testicular Cancer, Urothelial Cancer Prostate cancer, Urothelial Cancer Neuro-urology Prostate Cancer Prostate Cancer Urothelial Cancer

Italy Bambino Gesu Hospital, Rome

Paediatric Urology

Lithuania National Cancer Institute, Vilnius

Prostate Cancer

Sweden Örebro University Hospital

Spain Universitary Hospital Ramon y Cajal, Madrid

Transplantation

Switzerland HUG - Hôpitaux Universitaires Genève Inselspital - Universitätsspital Bern Kantonsspital St. Gallen Kantonsspital Winterthur UniversitätsSpital Zürich

Switzerland Ospedale Regionale Bellinzona e Valli, Bellinzona

Prostate Cancer

The Netherlands Canisius-Wilhelmina Hospital, Nijmegen Maxima Medisch Centrum, Veldhoven Radboud University Medical Center, Nijmegen St. Antonius Ziekenhuis, Nieuwegein

Prostate Cancer Prostate Cancer Female Urology & Incontinence, Neuro-Urology, Paediatric Urology, Prostate Cancer Renal Cancer, Prostate Cancer, Urothelial Cancer

Turkey Hacettepe University Faculty of Medicine, Ankara

Paediatric Urology

United Kingdom North Bristol NHS Trust Sheffield Teaching Hospitals NHS Foundation

Female Urology & Incontinence, Stone disease Reconstructive Urology

Norway Sorlandet Sykehus HF Arendal Sorlandet Sykehus HF Kristiansand Sykehuset i Vestfold, Tønsberg Poland European Health Centre Otwock Gdansk Medical University Interdisciplinary Hospital Miedzylesie MCPE, Warsaw Medical University of Warsaw Pomeranian Medical University, Szczecin University Hospital Kraków Portugal Centro Hospitalar e Universitário de Coimbra Slovenia University Clinical Centre Ljubljana Spain Clínica Universidad de Navarra, Pamplona Fundació Puigvert, Barcelona Hospital Del Mar, Barcelona Hospital Universitari Clínic de Barcelona Hospital Universitari de Bellvitge, Barcelona Hospital Universitari Germans Trias i Pujol, Badalona Hospital Universitari Vall d'Hebron, Barcelona Hospital Universitario La Paz, Madrid

Turkey Ankara University, School of Medicine Bagcilar Hospital, Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul Cukurova University, Adana Ege University School of Medicine, Istanbul Hacettepe University - Faculty of Medicine, Ankara Istanbul Üniversitesi Istanbul Tıp Fakültesi Istanbul University- Cerrahpasa, Cerrahpasa Medical Faculty Marmara University School of Medicine, Istanbul Uludag Üniversitesi Tıp Fakültesi, Bursa

October/December 2020

EMUC20: Virtual, but multidisciplinary as always Advances in GU cancer treatment and imaging open up new options for specialists By Loek Keizer and Juul Seesing On 13 and 14 November, the 12th edition of the European Multidisciplinary Congress on Urological Cancers, EMUC20 went ahead on slightly different footing than usual. Instead of a very broad four-day event that also includes (hands-on training) courses by the European School of Urology and the annual meeting of the EAU Section of Urological Imaging, the event hosted by ESMO, ESTRO and the EAU was transformed to a streamlined, two-day online programme. The planned Athens congress was postponed to 25-28 November 2021. The scientific programme was designed to cover every major onco-urological topic, with moderators and speakers coming from urologists, radiologists and medical and radiation oncologists. Bringing together experts from these different but complementary disciplines has been the driving force for EMUC congresses since their conception, helping make multidisciplinary teams a widespread reality across Europe. Over 1,900 people from all around the world registered to attend EMUC20, with nearly 1,200 joining live and even more on demand. Participants came from 104 countries, from New Zealand to the west coast of the USA, and from Norway to Namibia. Most participants were members of the three organising societies.

drug, but quality of life should always be an endpoint, too.” In the same session, Prof. Jonathan Epstein (Baltimore, US) addressed the controversies and uncertainty that persist in prostate cancer grading and the first prostate cancer grading recommendations from the Genitourinary Pathology Society (GUPS) that focuses on these areas. These recommendations were published in the 2019 GUPS White Paper on Contemporary Grading of Prostate Cancer.

One of the highlights of the first day was the session “Highlights in GU cancers.” Mr. André Deschamps (Antwerp, BE) presented the results of the EUPROMS study, a Patient-Reported Outcomes (PRO) study conducted by the patient advocacy organisation Europa Uomo. The key message of the study was unmistakable: active surveillance should be considered the first treatment for prostate cancer in order to ensure the best quality of life. The EUPROMS results revealed that active surveillance had the best average Expanded Prostate Cancer Index Composite (EPIC) score in incontinence (100) and sexual function (57, see figure 1). The respondents, 2,943 prostate cancer patients from 24 European countries who received treatment, also experienced less tiredness, insomnia, and pain or discomfort while under active surveillance in comparison with other treatments. This led to Mr. Deschamps’ logical conclusion: “When it can be applied safely, active surveillance should be considered the first treatment for prostate cancer.” During the discussion, via the interactive feature of the congress platform, Mr. Deschamps received a couple of questions about the difference between the EUPROMS study and a clinical study. “It is a different kind of survey that we did. We wanted to have a picture of what the real quality of life of men is after treatment,” he clarified. “I think that clinical studies should be taking the quality of life into account as well: as a primary endpoint, in fact. Of course it is also important to consider life extension when deciding to spend a lot of money on a new October/December 2020

Implementing multidisciplinary strategies in genito-urinary cancers

VIRTUAL 13-14 NOVEMBER 2020

Prof. Anders Bjartell (Malmö, SE), chairman of the EAU Research Foundation (EAU RF), gave an update on the EAU RF trials in progress such as the PEGASUS study. He also touched on the PRECISION study, which became a game-changing trial showing the value of MRI before a prostate biopsy. The NIMBUS study, which was stopped early for safety reasons, was further discussed in the later session “New trials update,” during which Prof. Axel Merseburger (Lübeck, DE) described it as “a game-changing trial,” ending with a firm recommendation based on its outcome: “Please give BCG in a standard dose to patients with high-risk NMIBC.” COVID-19 Speakers in other sessions also identified optimal therapies for patients with urological malignancies. Prof. Declan Murphy (Melbourne, AU), in his talk “PSMA PET for upfront staging in high-risk disease,” presented the primary outcome of the ProPSMA study: “PSMA PET/CT should replace conventional imaging in high-risk and unfavourable intermediate-risk prostate cancer.” PSMA PET/CT showed 27% greater accuracy than conventional imaging, the study reported. In the same session on individualised approaches in advanced prostate cancer, Dr. Gerhardt Attard (Sutton, GB) stated evidence that suggests that 90% of castrate-resistant prostate cancer (CRPC) cases have actionable genomic aberrations and that HRR mutations are truncal and present at diagnosis. “We now have agents that could potentially be used (…) to treat patients harbouring a number of these tumour mutations. The DNA repair pathway has the highest potential for impacting your current clinical practice.”

Fig. 1: From Mr. Deschamps's presentation: "Highlights in Europa Uomo Patient Reported Outcomes Study (EUPROMS)" (Plenary Session 3: Highlights in GU Cancers)

Active surveillance The first day of EMUC20 covered a broad spectrum of topics in genitourinary malignancies: from the refinement of bladder cancer treatment to updates on trials, and from individualised approaches in advanced prostate cancer to a multidisciplinary case discussion on kidney cancer. Due to the obvious major changes the COVID-19 epidemic has caused for urological practice, EMUC20 featured a roundtable about the impact of the epidemic on the management of GU cancers.

12th European Multidisciplinary Congress on Urological Cancers

Exemplifying 2020, EMUC20 featured a roundtable about the COVID-19 epidemic in relation to GU cancers. Dr. Saskia Biskup (Tübingen, DE), MD PhD in human genetics, tried to answer the question whether a COVID-19 infection interferes with the immune status of oncological patients, a question that does not have a definitive answer at present: “If I have to summarise COVID and cancer, this summary is going to be very short. We have to collect data.” Dr. Biskup went on to summarise the current data available, but she emphasised that “there’s no recommendation possible at this point.” “It’s interesting that so far there’s no evidence that COVID causes a more severe disease in immunocompromised subjects,” she described. “However, there is a potential rationale supporting an increased risk of COVID-19 morbidity in patients treated with immunotherapy. Publications suggest that hyper-inflammatory responses together with T-cells consumption play a major role in SARS-CoV-2 pathogenesis as observed in SARS-CoV and MERS-CoV infections. SARS-CoV-2 infection is characterised by persistent antigenic T cells’ activation leading to an exhaustive status rather than a failure to activate T cells’ responses. Patients treated with immunotherapy may therefore be at high risk.” “It is suggested that the risk is different depending on the oncology treatment. But my biggest and greatest recommendation is that we need data to better interpret the risk for our oncological patients.” And thus, for the time being, the EAU Guidelines recommendations for the COVID-19 era by the EAU Guidelines Office Rapid Reaction Group (GORRG)

Group discussion during Plenary Session 10: Fragments of Imaging, with Assoc. Prof. Sanguedolce, Prof. Salomon, Prof. Barentsz, Mr. Mannaerts and Prof. Panebianco

remains applicable. Prof. Maria Ribal (Barcelona, ES) presented the criteria for diagnosis, therapy, and follow-up prioritisation as indicated by GORRG. “Most of you will realise that in Europe we are facing the second wave of the pandemic, so those recommendations we felt we could reverse perhaps should be applied again,” she said. “Fragments of imaging” The second day of EMUC20 covered a lot of ground in its seven hours. Five plenary sessions covered bladder and testicular cancers, organ preservation in difficult cases, oligometastatic cancers and a session devoted to imaging techniques. Additionally, an abstract session was held, where a selection of the best submitted abstracts were presented. The winner of the best oral abstract was Dr. Eduard Roussel (Leuven, BE) for “Molecular subtypes of fully resected clear renal carcinoma are prognostic for risk of relapse and may impact adjuvant treatment.” EMUC congresses are typically organised to coincide with the Annual Meeting of the EAU Section for Urological Imaging (ESUI), as well as other imagingspecific workshops and meetings. With the move to an online congress, the wide imaging scientific programme was streamlined somewhat and integrated into the EMUC20 Virtual Congress.

“Possible benefits of the use of (improved) ultrasound in urology include reduced costs, better accessibility and easier lesion targeting.” It was in the tenth plenary session, ‘Fragments of Imaging’ that most of the latest developments in oncological urology-related imaging were presented. The Saturday afternoon session was chaired by ESUI Chairman Prof. Salomon (Hamburg, DE) and Assoc. Prof. Sanguedolce (Barcelona, ES) and at its peak attracted some 470 simultaneous viewers (or 630 unique viewers spread out over the entire session). Many questions for the speakers were submitted through the Q&A system, several of which were covered in the discussion following the presentations. Mr. Christophe Mannaerts (Nijmegen, NL) presented the latest developments in ultrasound, specifically when compared to the mpMRI pathway. The latter poses some challenges, including “costs and accessibility, inter-reader reproducibility, inter-operator reproducibility with the necessity of cross-modality registration, and the variability in results from different centres of expertise,” said Mr. Mannaerts, citing several recent publications. Possible benefits of the use of (improved) ultrasound in urology include reduced costs, better accessibility and easier lesion targeting. This makes ultrasound a field that is worth further developing and refining, according to Mr. Mannaerts. Improvements can be found in the use of micro-ultrasound, working at 29MHz instead of the more traditional 8-12MHz. Mannaerts: “The use of this increased frequency has

led to 300% improved resolution, revealing microstructures and tissue patterns. The PRI-MUS protocol has been developed for this case.” Other potential developments include novel modalities in ultrasound, like contrast ultrasound dispersion imaging (CUDI). Mr. Mannaerts concluded that ultrasound imaging for PCa detection and localisation is improving, and it can become a more accessible and viable modality for targeted biopsy if improvements are made in developing a standardised acquisition and reporting scheme, and high-quality benchmarking with the mpMRI pathway in the same patient group. Other presenters in the busy session were Prof. Jurgen Futterer (Nijmegen, NL), Prof. Frederik Giesel (Heidelberg, DE), Prof. Jelle Barentsz (Nijmegen, NL), and Prof. Valeria Panebianco (Rome, IT). Promising new developments in imaging Prof. Futterer summarised developments in imaging in the past thirty years, indicating that abbreviated (or “fast”) MRI prostate protocols might make for an appealing option, depending on indications, cost, experience, and the development of smart algorithms and AI. Prof. Giesel discussed the “rising star” of imaging, the new fibroblast activation protein inhibitors (FAPI-)PET/CT. Advantages compared to FDG include no need for diet or fasting for patients and quicker image acquisition after tracer application. “FAPI opens a new application for PSMA-negative PCa patients,” Prof. Giesel concluded. Prof. Barentsz, introduced by the moderators as “the father of the PI-RADS” presented some first results on the use of nanoparticles, and the perspective of their use as a contrast agent. Nano-MRI guided RT shows “promising results” in detecting small positive lymph nodes that PLND and PSMA PET/CT have trouble finding. Prof. Barentsz expects approval for the agent, MR-Linac, in the next two years. “Can VI-RADS avoid TUR-B prior to radical cystectomy?” asked Prof. Panebianco in the final talk of the session. “Yes we can,” she concluded. Her presentation on the Vesical Imaging-Reporting and Data System proposed an MRI pathway for bladder cancer patient stratification: NMIBC vs. MIBC, and MIBC-T2 vs. Locally Advanced BC -T3–T4, only then sampling TUR for confirmatory pathology in VI-RADS 5. The session closed with an unfortunately brief panel discussion on delegate’s questions. Considering the enthusiasm for the session, and the hotly anticipated new imaging technologies on display, urological cancer specialists can expect big changes in their imaging options in the near future. The congress organisers are pleased with the attendance and scientific content of EMUC20, but nevertheless look forward to welcoming Europe’s urological cancer experts to Athens in 2021 for a more conventional congress. • Missed a session? All EMUC20 webcasts, ePosters, and full-text abstracts are available in the Resource Centre at www.emuc.org European Urology Today

Ileal neobladder after radical cystectomy Tips and tricks to improve urinary continence Asst. Prof. Bernhard Kiss Dept. of Urology University Hospital Bern (CH)

the seminal vesicles are anatomic landmarks for preservation of the distal fibres of the pelvic plexus. The angle between the bladder neck and the prostate close to the seminal vesicles is characterised by nerve fibre condensation. The anterolateral periprostatic nerves are deemed important for smooth muscle innervation of the proximal urethra.

bernhard.kiss@ insel.ch

During surgery, particular attention must be paid to preserving the critical angle between the uterine cervix, trigone, and lateral vaginal wall in females (Fig. 1a). Tip: Dissection is carried out along the anterolateral wall of the vagina (one or eleven oÂ´clock).

Prof. Fiona Burkhard Dept. of Urology University Hospital Bern (CH)

fiona.burkhard@ insel.ch

Maintaining a good Quality of Life (QoL) in cancer survivors has become a focus of interest as the number of cancer survivors is growing steadily. Following cystectomy for bladder cancer or for other forms of bladder dysfunction and following urinary diversion with an orthotopic bladder substitution (OBS), urinary continence and sexual function are the main factors determining QoL. Published results on continence vary strongly, often due to different treatment methods, different definitions of continence, and different methods of evaluation (e.g. questionnaires vs. follow-up examinations). Reported daytime continence rates range from 90% to 92%, with better results reported in men than women. Night-time continence rates are lower at approx. 80%1,2. Careful patient selection, a meticulous surgical technique, and good postoperative patient education are of utmost importance to ensure good outcomes.

â&#x20AC;&#x153;The preservation of the autonomic nerves to the urethra is essential for urinary continence, complete bladder emptying, and sexual function.â&#x20AC;? Continence after OBS is dependent on specific characteristics of the OBS (such as a cross-folded intestinal segment with transection of circular fibres, type of bowel, spheroidal shape, and functional capacity), resulting in low pressure and high volume combined with a functioning outlet mechanism. Nerve-sparing surgery Autonomic nerves to the urethra maintain urethral closing pressure at rest. Their preservation is essential for urinary continence, complete bladder emptying, and sexual function in both males and females following cystectomy. Sympathetic innervation (L1 and L2) of the pelvic organs originates from either the singular superior hypogastric plexus (located at the aortic bifurcation), which is bilaterally connected to the pelvic plexus, or the sacral splanchnic nerves (3). Parasympathetic innervation originates from the sacral spinal cord (S2 to S4). The pelvic plexus receives parasympathetic fibres through the pelvic splanchnic nerves. The ventral part of the pelvic plexus is responsible for innervation of the urogenital tract, the dorsal part for visceral (rectal) innervation.

In the male patient, to preserve the pelvic plexus situated laterally to the seminal vesicles and its branches close to the critical angle between the seminal vesicle, trigone, and base of the prostate, the dissection must be very ventral on the dorsomedial bladder pedicles (Fig. 1b). Tip: Dissection is anterolateral from the seminal vesicles to the base of the prostate. The neurovascular bundle is freed from the prostate. In select cases, preservation of one or both seminal vesicles may be considered if there is a safe distance from the primary tumour. No electrocautery or other heat-emitting devices should be used near these heat-sensitive structures.

Fig. 1B: In the male patient, to preserve the pelvic plexus situated laterally to the seminal vesicles and its branches close to the Fig. 1B. the male patient, to trigone preserve theofpelvic plexus situatedmust laterally to theonseminal critical angleInbetween the seminal vesicle, and base the prostate, the dissection be very ventral the vesicles and itspedicles branches closebytothethe critical angle between the seminal vesicle, trigone and dorsomedial bladder as indicated dotted blue line

base of the prostate, the dissection must be very ventral on the dorsomedial bladder pedicles as indicated by the dotted blue line. pelvic floor muscles and prevent urinary incontinence, three hours (later to four hours) in order to increase particularly during coughing, sneezing, getting up, or the functional capacity of the OBS to ultimately 500 ml. sitting down. The patient should train the isometric Tip: The patient has to understand that he/she should not empty the OBS as soon as he/she starts dribbling sphincter regularly by squeezing for six seconds and then relaxing with ten repetitions a couple of times a in order to allow for the highest achievable pressure in the OBS to promote its distension. Larger volume and day. Tip: By placing a finger in the rectum or vagina and asking the patient to contract the pelvic floor lower pressure within the OBS result in better continence, especially at night. Therefore, in the first Kessler et al. assessed 381 consecutive men undergoing (without contracting the gluteus or abdominal wall), you can make sure the exercises are performed postoperative period it is inevitable that the patient cystectomy and OBS in a multivariate analysis and correctly. loses urine while expanding his/her OBS. found that attempted nerve sparing significantly affected daytime continence, whereas age significantly After voiding, a few drops of urine and/or mucus As the neural feedback between the bladder and the affected night-time continence4. remain in the bulbar urethra because the autonomic brain no longer exists after cystectomy, the detrusorIn a more recent study evaluating no vs. unilateral vs. milking of the urethra is missing due to loss of the sphincter reflex that raises the urethral closing bilateral nerve sparing, any degree of nerve sparing autonomic bulbospongiosus reflex7. While sitting down pressure when the intravesical pressure rises is no was associated with both day- and night-time longer present. Therefore, patients do not wake up at or during physical exertion with contraction of the continence, which became even more apparent over night when the bladder is full. Tip: Instruct the patient pelvic floor muscles, this fluid is expelled. Tip: By time5. In women, a uterus- and vagina-sparing to use an alarm clock at night: first set it at threetechnique not only maintains the reproductive function milking out the urethra manually after voiding, this hourly intervals and later at four-to-five-hourly but also allows for a less extended dissection around post-micturition dribble incontinence can be avoided. intervals. the vagina and better preservation of the autonomic Residual urine has to be expelled after catheter nerves, thereby improving continence rates6. As sleeping pills and alcoholic drinks relax the removal on a daily basis by ultrasonography or Postoperative patient management in-and-out catheterisation until residual-free voiding is sphincter and make the patient sleep more deeply, this should be avoided before going to bed to prevent Unlike a normal bladder, the reservoir has no repeatedly assured. Besides the risk of serious coordinated contraction to increase pressure and expel complications such as pyelonephritis and septicaemia, uncontrolled urine loss at night. urine. Gravitational force alone empties the bladder severe metabolic acidosis and salt loss syndrome, bringing about full relaxation of the pelvic floor. In the pouch leakage, fistulas, and pouch rupture, residual Conclusion To achieve continence after OBS, reservoir early postoperative phase, this is easier in a sitting urine can also cause infections that lead to increased characteristics (low pressure, high volume), position. There should be no intensive abdominal mucus production and intensified wall contractions of straining, because this may trigger the spinal reflex, the OBS, which in turn results in urinary incontinence. intraoperative nerve sparing, and postoperative patient education are of utmost importance. Sphincter function which causes counter-active external sphincter has to be intact, the reservoir has to have a low contraction. If a patient is unable to void spontaneously without residual urine after two to three days (20-30 ml may be pressure with a high volume of approximately 500 ml and the patient needs to empty completely at After removal of the transurethral catheter, the patient acceptable), then a mechanical outlet obstruction four-hourly intervals, including setting the alarm clock should be ruled out. should be instructed to void at two-hourly intervals at night to avoid overdistension of the reservoir and during the day and at three-hourly intervals overnight. overflow incontinence. As soon as the patient is able to retain urine for two Training the isometric sphincter can help build up the hours, the voiding interval should be prolonged to References Preservation of these nerves is generally possible on the non-tumour-bearing side and should always be attempted if an OBS is planned. In patients with tumours located at the bladder dome and anterior bladder wall or in patients with multifocal T1HG urothelial cancer, bilateral nerve sparing can be considered.

Knowledge of pelvic innervation in both sexes is a precondition for nerve-sparing cystectomy. The pelvic plexus is located medial to the internal iliac arteries on both sides. In women, the plexus extends from the lateral aspects of the rectum and vagina to the bladder neck. The rectouterine fold is an excellent anatomic landmark for locating and preserving neural structures. Due to the close proximity of the pelvic plexus to the lateral vaginal wall (paracolpium) caudally and the cervix uteri (parametrium) cranially, recognising these structures is important in nerve-sparing radical pelvic surgery. In men, the pelvic plexus is located lateral to the rectum on both sides. The tip and the lateral aspect of EAU Section of Female and Functional Urology

European Urology Today

Fig. 1A: In the female patient, to preserve the pelvic plexus and its branches the dissection must be very anterolateral on the dorsomedial bladder pedicles as indicated by the dotted blue line

Fig. 1A. In the female patient, to preserve the pelvic plexus and its branches the dissection must be very anterolateral on the dorsomedial bladder pedicles as indicated by the dotted blue line.

1. U. E. Studer et al., Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned. J Urol 176, 161-166 (2006). 2. R. E. Hautmann, B. G. Volkmer, M. C. Schumacher, J. E. Gschwend, U. E. Studer, Long-term results of standard procedures in urology: the ileal neobladder. World J Urol 24, 305-314 (2006). 3. B. Baader, M. Herrmann, Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat 16, 119-130 (2003). 4. T. M. Kessler et al., Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. J Urol 172, 1323-1327 (2004). 5. M. A. Furrer et al., Nerve-sparing radical cystectomy has a beneficial impact on urinary continence after orthotopic bladder substitution, which becomes even more apparent over time. BJU Int 121, 935-944 (2018). 6. T. Gross et al., Reproductive organ-sparing cystectomy significantly improves continence in women after orthotopic bladder substitution without affecting oncological outcome. BJU Int, (2018). 7. P. Bader, C. L. Hugonnet, F. C. Burkhard, U. E. Studer, Inefficient urethral milking secondary to urethral dysfunction as an additional risk factor for incontinence after radical prostatectomy. J Urol 166, 2247-2252 (2001).

October/December 2020

Advancing endoscopic stone surgery training in Bamako GPC support for Prof. Alain Le Duc’s unwavering efforts to train surgeons in West Africa Bamako is the capital and most populous city of Mali. It is now the seventh-largest West African urban centre and is estimated to be the fastest growing city in Africa. As such, the need for trained surgeons is paramount. In 2018, Professor Alain Le Duc of the University of Paris requested aid from the Global Philanthropic Committee (GPC) to help Point G Hospital in Bamako advance training in endoscopic stone surgery. More specifically, the proposal aimed to teach endoscopic management of the upper urinary tract using percutaneous and ureteroscopic techniques, as well as to equip the department with the proper equipment to perform these surgeries. To assist in this endeavour, Olympus Corporation generously donated a large number of endoscopic equipment to the hospital.

The Point G Hospital is a civilian hospital that overlooks Bamako. The Department of Urology is located in a completely rebuilt section of the hospital and has 40 beds dedicated to conventional urology of the upper urinary tract and endoscopic treatment of the lower urinary tract. This university department has an excellent reputation in West Africa and is an official training centre for the whole country. Professor Le Duc is committed to supporting this project's educational mission and will spearhead a Train the Trainer programme, which consists of several targeted workshops. Each workshop will be kept to 3 to 5 participants to ensure active participation, enabling a rigorous training. In turn, the trained surgeons will train their colleagues according to local needs. In addition, nurses will be invited to actively participate in these sessions. The objective is to train at least 30 young urologists in endourology over 3 years.

Prof. Le Duc demonstrating stone surgery in Point G Hospital in Bamako

Due to the country's political unrest and the COVID-19 pandemic, the project has faced some immense challenges and setbacks. The goal is to commence the training programme in the second half of 2021, if the situation permits. We wish Prof. Le Duc and the urological department at Point G Hospital great success and growth and offer our continued support for this important endeavour. Stay tuned for project updates. Prof. Le Duc demonstrating stone surgery in Point G Hospital in Bamako.

Prof. Alain Le Duc is an International Consultant for the United Nations Population Fund (UNFPA) since 2008 and Co-Chairman of Urology Speciality Courses, Medical Faculty at the University of Bamako in Mali. He is a member of Equilibre et Population, an organisation committed to improving the living conditions and status of women and girls in West Africa, and Vice President of Chirurgie Solidaire, an association dedicated to providing surgical training in developing countries. In addition, Prof. Le Duc is an Administrative Council member of two NGOs involved in educating and training young surgeons in West Africa, focusing on urology and obstetric fistulas. The SIU is honoured to have presented Prof. Le Duc with the SIU-Albert Schweitzer International Teaching Award in 2018.

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

MRI fusion prostate biopsy in office urology Is this recommended procedure an illusion for most patients in Germany? Dr. Timur H. Kuru Urologie am Ebertplatz Cologne (DE)

of interest to educated urologists who treat predominantly outpatients in an own professional profile. In this light, we would like to give our European readers a quick overview of the situation in Germany.

thkuru@gmail.com

“We have to fight for a fair reimbursement of the outpatient setting.”

Dr. Johannes Salem CUROS Köln Cologne (DE)

johannes.salem@ googlemail.com Co-author: Dr. Tobias Kohl, Leverkusen (DE)

Unfortunately, not all institutions accept the benefits of MRI fusion as a fact. The German Institute for Quality and Efficiency in Health Care (IQWiG) published a Health Technology Assessment (HTA) report this summer. In their statement, the authors of the report see no benefit in prostate fusion biopsies with regard to mortality, number of biopsy sessions needed, and patients' quality of life compared to standard TRUS biopsies. It must be said that this process of HTA evaluation is not yet complete, but it already reveals the first big obstacle to overcome if we are to bring fusion biopsy into more widespread clinical practice.

Reimbursements One of the main limitations to the spread of this There are several possibilities for performing MRI procedure is the low rate of reimbursement, at least fusion biopsies. Regardless of which system is used, in Germany. The current reimbursement rate of an even if one "simply" performs a cognitive fusion, outpatient prostate biopsy is €18.79 (EBM 26341) for a everything is better than a standard TRUS biopsy patient with public health insurance (GKV). without any MRI information. This fact has been Consequently, this procedure is mainly performed in recognised by nearly all national and European large hospitals and university clinics, which are either guidelines on prostate biopsy. MRI diagnostics are able to compensate the negative reimbursement with now recommended before both primary and other procedures or turn the case into an inpatient re-biopsy of the prostate in the EAU Guidelines on setting. The rate for inpatient reimbursements, Prostate Cancer. The German S3-guideline on prostate depending on the Diagnosis Related Group (DRG) cancer will be updated this year, and it is expected to system, can be as high as €1000 per case. implement European recommendations on this point. Therefore, it has to be decided whether prostate The EAU Section of Outpatient and Office Urology biopsies are to become an outpatient procedure in (ESUO) aims to address core issues that affect and are Germany. There are strong reasons for this, not least that it is a typical outpatient procedure with low morbidity. There is no need for an inpatient setting EAU Section of Outpatient and Office Urology (ESUO) (see table 1). This would also allow beds to be kept October/December 2020

Fig. 1: Outpatient setting of MRI Fusion Prostate Biopsy

free for more severe procedures, especially in times of a pandemic.

“MRI fusion biopsies are firmly in the patient's interest.” Starting here, in Germany, all urologists should work on establishing high-quality prostate biopsies by

integrating MRI information into their biopsy template. Our data show a clear benefit to patients. Thus, MRI fusion biopsies are firmly in the patient's interest. Our cohort of patients confirms that there is no need for an inpatient setting. Instead, we have to fight for a fair reimbursement of the outpatient setting. This would still save money, which could be invested more effectively elsewhere. Its high cost, of course, is a principal obstacle to spreading the MRI fusion technique more widely.

Pros

Cons

Outpatient setting

Lower costs, higher availability, higher patient acceptance, lower infection rates

No observation of the patient

Inpatient setting

Continuous observation, immediate treatment of complications

Higher costs, utilisation of hospital beds

Table 1: The pros and cons of the outpatient and inpatient setting in prostate biopsy European Urology Today

ESU Updates

ESU bolsters surgical education and standardisation School stimulates advancements in urological training The European School of Urology (ESU) has successfully developed and implemented surgical training programmes for many years. New technologies, more collaborations, and more highly-specialised training will be integrated in these programmes. The ESU acknowledges that the early years of one’s clinical or surgical practice are critical in establishing the foundation for its success, and training is an integral part of this foundation.

The changing world of surgical skills training The inception, milestones and adaptations By Prof. Ben Van Cleynenbreugel Excellence in surgical patient care and reduction in complications are relative to the capabilities of the surgeon involved. The foundation of what makes a good surgeon is his/her training and mentorship. This article traces back the history of surgical training and how it influenced the hands-on training (HOT) programme of the European School of Urology (ESU) as we know now. History Apprenticeship could well be the oldest form of education in crafts and trades. The master served “in loco parentis”; he taught the craft to his apprentice and set a good example. This master-apprentice model changed into a more structured education at the end of the 19th century, thanks to Dr. William Halsted, American pioneer of scientific surgery to whom the infamous credo "see one, do one, teach one" is attributed. He developed a formal surgical training programme with a strong emphasis on gradually increasing the responsibility and autonomy of the surgeon in training. This system was a noticeable improvement, but created excesses which allowed overtired, unsupervised residents and interns to treat seriously ill patients without proper training, skills or supervision. This has led to the “European Working Time Directive” which unintentionally reduced the caseload and training opportunities of surgical residents.

focused on laparoscopic skills training as laparoscopy was an emerging technology. The training was given as an introductory course during Annual EAU Congresses, with little visibility and ad hoc training programme. The trainers were recruited based on their surgical case load and (inter)national exposure. However, there was no structured training to become a HOT trainer. It was up to a trainer to adapt the training to the level of a trainee. Over time, the HOTs became stand-alone courses and no longer appendices to meetings and congresses. Dedicated training centres were established with help of the industry, the necessary equipment and funding became available. The HOTs expanded into trainings in endoscopy, open surgical skills and non-technical skills to improve the education of aspiring surgeons and ultimately, improve patient care. Boosting trainer capabilities Numerous studies have shown that the quality of teaching influences student performance. Students with faculty, who received poor teaching evaluations, performed more poorly on Objective Structured Clinical Examination (OSCE) data-gathering stations, than did students with teachers that rated average or good [1]. Teaching quality has an impact on student performance, as measured by increases in pre- and postclerkship National Board of Medical Examiners (NBME) medicine subject examination scores and clerkship scores [2].

To ensure trainers quality of the ESU surgical curriculum, the “Train the Trainer” programme was launched. This programme aims to further increase the capabilities of potential and existing trainers; to guarantee the quality of the training provided; and to standardise the training pathway for different procedures. The programme is designed to develop practical techniques and skills through mastery of modules in simulation, dry lab (e.g. training models, scoring systems) and wet lab (e.g. cadaver training, animal models). The programme also provides the necessary tools to improve non-technical skills such as adopting suitable coaching styles and the principles of proctoring and mentoring. SISE: Ensuring quality The Standardisation In Surgical Education (SISE) project was initiated in line with the mission statement to raise the level of urological care throughout Europe and beyond. The goal of SISE is to set up a standardised, validated training programme for HOT to produce surgeons who are highly competent and confident in performing surgical procedures, and thereby mitigate the risk of complications.

Cluj-Napoca (RO), Uniwersytet Mikołaja Kopernika w Toruniu (PL), Univerzita Karlova (CZ) and Panepistimio Patron (GR). Through SISE, national societies will receive support in the organisation of national training courses with an international standard and certification. The aim is to provide basic skill training which will be made available to all residents. This support will consist of: - Access to validated training curriculums, including all the needed protocols for the execution - Access to the validated training materials - Train the trainer programme for national trainers - Official SISE certification for course participants - Assistance from an international network of societies This is an important and crucial step, as standardisation improves the quality of training programmes. Good programmes produce physicians who take care of their patients well, and better programmes produce physicians who take care of their patients better. References

SISE is co-funded by the Erasmus + Programme of the European Union. An official Erasmus + grant proposal was written by the ESU Training and Research group of EAU’s education office together with Academisch Medisch Centrum (NL), SLK-Kliniken Heilbronn (DE), Institutul oncologic

1. AV Blue et al, Surgical teaching quality makes a difference, Am J Surg. 1999 Jan;177(1):86-9 2. CH III Griffith et al, Relationships of how well attending physicians teach to their students’ performances and residency choices, Acad Med. 1997;72(suppl 1):S118 –S120

The introduction of laparoscopy as a treatment modality was the tipping point to fundamentally change the way surgeons are trained. As the surgical skills required to excel as a laparoscopic surgeon are fundamentally different for the required skills set to be an outstanding open surgeon, the number of avoidable perioperative complications during laparoscopic surgeries skyrocketed. The above factors caused a paradigm shift in surgeon training. Teaching surgical skills in an operating theatre has now shifted to training centres where skills are honed in a controlled, stress-free environment. The first HOTs The primary HOTs of the ESU were mainly

50 UROwebinars: A milestone achievement This year marks a milestone for the UROwebinars. At present, a total of 50 highly-informative presentations have attracted 14,365 attendees from 160 countries and garnered a cumulative 102,734 views on YouTube. Through the collaboration of the European School of Urology (ESU), the Guidelines Office of the European Association of Urology (EAU) and various EAU Sections, the popularity and demand for UROwebinars rose since their initial livestream in 2016. The first UROwebinar was presented by Prof. Morgan Rouprêt (FR) which was entitled “Update on bladder cancer management: what are we doing wrong?” wherein he addressed contemporary concepts and controversies in bladder cancer.

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European Urology Today

HOTs evolved from an introductory course to an integral element of EAU and ESU activities. Shown here are HOTs at European Urology Residents Education Programme in 2019.

Each hour-long UROwebinar features highlyspecialised and contemporary topics delivered by key opinion leaders in the field. All UROwebinars are recorded and can be reviewed at a later stage. Urologists of varying specialties and experience can enjoy these webinars. Attending the UROwebinars requires no registration fees. The current top three most popular UROwebinars viewed live by attendees are namely: • “Flexible ureterorenoscopy and retrograde intrarenal surgery: Instrumentation, technique, tips, tricks and indications” by Prof. Palle Osther (DK) and Prof. Dr Olivier Traxer (FR) on 7 July 2020 with 665 attendees • “Surgical anatomy for laparoscopic and roboticassisted radical prostatectomy and cystectomy” by Ms. Jo Cresswell (GB) Mr. Hasan Qazi (GB) on 14 July 2020 with 662 attendees

• “Radical cystectomy: The urologist’s nightmare” by Prof. Joan Palou (ES) on 29 September 2020 with 630 attendees. The announcement of this UROwebinar on Twitter amassed 6,843 impressions, making it the most popular tweet about the UROwebinars.

For the full list of upcoming UROwebinars, please visit www.uroweb.org/education/online-education/ webinars/. View the full playlist of previous UROwebinars through ESU’s YouTube channel via this link: https://bit.ly/354GE5P.

The top three most re-watched UROwebinars on YouTube are the following: • “How to interpret a urodynamic study; fact and artefact” by Prof. Marcus Drake (GB) on 24 May 2020 with 35,168 views. • “PCNL approaches: Prone” by Prof. Evangelos Liatsikos (GR) on with 6 September 2019 with 8,934 views • “PCNL approaches: Supine” by Dr. Guido Giusti (IT) on 18 July 2019 with 5,618 views A slide from the UROwebinar of Profs. Osther and Traxer

October/December 2020

ESU Updates

SISE to develop a premium standardised MIS curriculum Increase in skilled surgeons boosts urological care in Europe Many exponential technologies are impacting the world of surgery. Incorporation of these technologies in a validated, standardised, and high-quality curriculum will enable the urology sector to meet the growing demand for skilled surgeons in an exponential way as well. The Standardization In Surgical Education (SISE) programme was developed to address this need. History and relevance of MIS Since its introduction in the 1980s, minimally invasive surgery (MIS) has caused a paradigm shift in surgery. Compared to open surgery, MIS has shown to cause less tissue trauma and triggers fewer adhesions. Patients experience reduced postoperative pain and shorter hospitalization time. Many surgeons and educators have embraced MIS techniques due to its positive impact on the EU healthcare system and the enormous patient demand for MIS. Unfortunately, sufficient numbers of skilled MIS surgeons are lacking because of high training costs; unequal distribution of training programmes in Europe; and variation in competences and quality. Furthermore, significant complication rates from surgeons performing MIS procedures early in their learning curve have been reported. A standardised training MIS programme is urgently needed. About SISE The aim of the SISE programme is to develop a standardised high-quality curriculum covering several

key MIS procedures, for urological residents, surgeons developed methodologies can be adapted for one and another. During SISE, the developed programmes will and their trainers across Europe. be implemented and validated by all consortium The programme will be developed transnationally by partners. leading institutions in the MIS field: Academisch Expected results Medisch Centrum (NL), SLK-Kliniken Heilbronn (DE), The SISE programme is expected to yield high impact Institutul Oncologic Cluj-Napoca (RO), Uniwersytet Mikołaja Kopernika w Toruniu (PL), Univerzita Karlova and deliver the following results at different levels: (CZ) and Panepistimio Patron (GR). SISE is co-funded by the Erasmus+ Programme of the European Union. 1. Validated training material Training material will be developed for each of the different courses for both trainers and students. As The EAU will act as the coordinator and will be such, online training material for endoscopic stone responsible for the development of the training treatment courses (ESTs1, ESRs2a, ESTs3), programme, project management and dissemination laparoscopy courses (LUSs1/E-BLUS, LUSs2 and of the project results. LUSs3) and transurethral treatment course will become available for both trainers and students. In Activities and methodology addition, the courses will be validated to ensure As part of SISE, two educational programmes will be dissemination to other European hospitals and developed for the three most common types of MIS universities. which are endoscopic stone treatment, laparoscopy and transurethral treatment. The educational 2. Increased number of trained trainers and trainees programmes will be the following: Since the courses address the needs of the • A Train the Trainer programme to ensure that trainees, more students will be motivated to follow sufficient number of well-trained trainers are the courses and become an MIS surgeon. available to teach residents; • A high-quality, standardised programme including the required examination and certification for training of residents (to be provided by the trained trainers). The development of these two programmes for each MIS type will be performed in parallel since

3. Increased number of surgeons and improved urological care Upon completion, the SISE consortium will ensure implementation of the courses across Europe to further enhance urological care in Europe. It is expected that at least five hospitals/universities will implement the programme every year.

The future of ESU training:

“Now is the time to globalise going virtual. There’s certainly a need for it. We at the ESU are evaluating live surgeries, webinars, meet-the-experts, online platforms and many more to find the new balance. Technology will give us the possibility to continue to teach, disseminate essential updates, and push innovation. This pandemic will end at a certain point and even after the crisis, our ESU ambassadors will continue to pass on the knowledge virtually. Our aims include standardisation of virtual training,” stated ESU Chair Elect Prof. Evangelos Liatsikos (GR). Teletraining Finding new ways to deliver hands-on trainings (HOTs) in the time of the pandemic is crucial as funding for the HOTs is reduced and travel restrictions prohibits faculty and participants from attending. The implication of these is the need for local HOT initiatives and to instruct without the need to physically be onsite. This is where online monitoring/ mentoring and technology step in.

One of the notable innovations in HOT is teletraining. “Teletraining is a digital transposition of the classic HOT. Each tutor and trainee use the same equipment (e.g. laparoscopy box and training tasks) during the training which allows everyone to perform the procedure in real time. This way, the tutor has the chance to teach multiple trainees at the same time and still offer individualised suggestions,” explained ESUT Training Group Chair Dr. Domenico Veneziano (IT). According to Dr. Veneziano, the reason behind teletraining was mainly to make surgical training exponential. “In the time of the pandemic, teletraining is not only a good option to optimise costs and efficiency, and probably one of the few options to pursue in terms of practical surgical training,” said Dr. Veneziano.

October/December 2020

Conclusion Through the SISE programme, future implementation of a standardised curriculum will lead to an increase in skilled trainers and residents. This will ultimately result to better clinical outcomes with less surgical errors, lower re-admission and re-operation rates and an associated decrease in healthcare costs.

fitting content following a machine-learning pattern. It may sound like science fiction, but I can assure you that the prospect of virtual-reality (VR) autonomous tutors are much closer to materialising than it seems,” stated Dr. Veneziano. Virtual MRI-reading course The first virtual “MRI-reading course” of the ESU took place on the 9 October 2020. Spearheaded by Dr. Jochen Walz (FR), the course provided vital insights on the role of magnetic resonance imaging (MRI) in the management of prostate cancer patients, and how to use the information gathered from the prostate MRI.

During the virtual course, the participants learned how to use an imaging workstation. The course offered basic concepts/principles behind different MRI sequences e.g. T2-weighted imaging, diffusionweighted imaging (DWI) and dynamic contrast enhanced (DCE) imaging. This was to familiarise Future solutions and methodologies “The current standardisation in teaching provides the participants with the sequences when interpreting prostate MRI. The participants also learned how to same tips and tricks that produce equally valid use the PI-RADS scoring system when evaluating results, at least when it comes to basic skills. However, as a consequence, the standardisation may MRIs. The course provided information on the not push individual skills enough but bring trainees to standards and quality criteria for a prostate MRI. an average improvement in their performance. This is The participants performed a hands-on reading and the reason why we’re already working on further assessment of prostate MRI scans on their computers advancements such as the possible use of artificial intelligence to adapt standardised methodologies to a via the MIM-software, a practical imaging solution single trainee. The online tutor would be replaced by that provides advanced visualisation, image analysis, and report sharing. This was followed by a reference autonomous systems that deliver the best and most reading provided by expert radiologists and pathological verification. The teletraining and the virtual course are a few notable online activities of the ESU that represent exciting new programmes and activities.

During a simultaneous teletraining session

Like many European countries that will benefit from SISE, esteemed urologist Dr. Marcin Jarzemski shared his perspective on how urologists in Poland will benefit from the programme. “The SISE programme will help enable Polish urologists to learn and practice at the highest level. Many Polish centres are equipped with modern endoscopic equipment but have limited access to high-level dry lab models. Although urology training programme in Poland is well-planned, verified and adapted to the standards of the EAU, there is always insufficiency of practical training, especially within minimally-invasive techniques. The development and introduction of SISE will not only help solve this issue but also improve the verification of knowledge and skill level of future operators, ” stated Dr. Jarzemski.

EAU and Orsi Academy to innovate robotic surgical training

Digital HOTs, VR tutors, and standardisation aims The current pandemic may have a negative impact on education but along with COVID-19’s emergence also sprung adaption and innovation. The advent of virtual events and activities of the European School of Urology (ESU) is a testament to that. What does the ESU already offer in this field? What lies in the future of ESU training? Will these new teaching methodologies become staple?

4. Increase in MIS by cross-over to other surgical disciplines The SISE consortium aims to further advance MIS and implement standardised training on MIS in other surgical disciplines, such as gynaecology and cardiology, to help patients and the European healthcare system fully benefit from MIS.

“Technology is booming day by day. One excellent example of this is telecommunication. Five years ago, an online event would not be plausible. The capacity of the technology at the time would not be able to support it. Time lag alone was already a huge issue. Nowadays we’re streaming congresses, live surgeries, masterclasses, and courses to name a few, and then there’s 5G. The future holds so many possibilities. One of the main goals of the ESU is to continue to embrace technological revolution, integrate developments and make them our own,” concluded Prof. Liatsikos.

A rapid evolution of cutting-edge technologies, specifically in robotic surgery, is taking place. New knowledge to use and optimise these technologies, as well as, standardised and validated training programmes are required. This year on the 10th of August, the European Association of Urology (EAU) and the Orsi Academy announced their collaboration for the continued development of a surgical training programme utilising the academy’s robotic curriculum and well-equipped facilities. The first partnership of the EAU and the Orsi Academy was established in 2014. The academy became the official EAU Robotic Urology Section (ERUS) robotic training centre and hosted the first ERUS curriculum programme. One of their most successful training programmes is the Certified Curriculum of ERUS (CC-ERUS), which is a structured and validated modular curriculum for RARP (robot-assisted radical prostatectomy). Novel programme The new EAU-Orsi Academy training programme is based on a systematic framework of the teaching pyramid and the system of proficiencybased progression training. The programme involves training against a set of clearly-defined objective metrics to achieve a proficiency benchmark. Prof. Dr. Alexandre Mottrie, CEO of the Orsi Academy, stated “The EAU and the academy share the same core mission to improve healthcare. Both aim to offer top-quality training, innovate, and back it up with big-data analysis. We both aspire to offer first-rate training with certified training pathways at a European level for safer surgery and better patient outcomes. In addition, working together with the EAU will bring more academic prowess and diversification to the academy.”

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1st virtual ESU-ESFFU Masterclass on Functional Urology A recap of expert insights, videos, cases & breakout sessions By Erika De Groot With a packed, highly-informative programme allotted into two half-days, the ESU-ESFFU Masterclass on Functional Urology commenced on 28 October and concluded on the 29th. This year’s edition was a virtual first for the masterclass which was attended by 34 dedicated attendees from 22 countries; notably, a participant from Guyana even followed the masterclass at 3 AM his time. Through the collaborative efforts of the European School of Urology (ESU) and EAU Section of Female and Functional Urology (ESFFU), the masterclass offered contemporary updates, detailed step-by-step videos of procedures, and lively case discussions during the breakout sessions. The faculty members were comprised of highlyregarded experts in the field such as Course Director Prof. John Heesakkers (NL), Prof. Emmanuel ChartierKastler (FR), Prof. Elisabetta Costantini (IT), Prof. Hashim Hashim (GB), Prof. George Kasyan (RU), Mr. Nikesh Thiruchelvam (GB) and Prof. Frank Van Der Aa (BE). This article capsulizes some of the expert insights and key messages shared during the masterclass, together with overall impressions from both faculty and attendees.

sub-specialists in female and functional urology who have been adequately trained and have transferrable skills dealing with complications in the bladder, urethra and vagina. Bladder pain syndrome (BPS) is probably the most controversial topic in functional urology, according to Prof. Kasyan. During his lectures on BPS/interstitial cystitis, he presented the main practical skills in diagnostics and surgical treatment of this complex disease. He shared step-by-step videos which demonstrated the management of stress urinary incontinence. The troubleshooting of complications of urinary diversions is another important issue discussed during the masterclass. Prof. Hashim added, “Urinary diversion is major surgery and complications can arise that need to be dealt with in a methodical approach.” Mr. Thiruchelvam presented the technical aspects of sacral nerve stimulation, particularly the new MRI compatible lead and rechargeable devices; the urological consequences and management of the neuropathic bladder; and the complexity and complications associated with ileal conduit urinary diversion. Prof. Heesakkers shared sound, practical advice when dealing with complicated cases: “Check every step that

Core messages In his presentation “Urodynamics made simple in 20 minutes”, Prof. Hashim concluded that good quality urodynamics should be performed according to the standards of the International Continence Society to obtain results that can be interpreted and used to treat patients. Tackling the topic on mesh removal, Prof. Hashim stated that mesh complications are becoming more prevalent and apparent resulting in the need for the holistic treatment of patients by a multidisciplinary team. Mesh removal needs to be performed by

Masterclass faculty, participants and organisers

you make, know the alternatives to opt for if needed, and if possible, keep it simple. Moreover, inform your patients about the possible outcomes and stay modest with your promises.” Memorable cases When asked which of the patient cases featured during the breakout sessions left an impression, Prof. Kasyan said, “Dr. Vanessa Fenner (CH) presented a very interesting case on pelvic pain related to urethral diverticula. The standard treatment, followed by the management of rare post-operative complications, refers to all aspects of pelvic disorders and surgery.” To Prof. Hashim, the most memorable case was the infected artificial urinary sphincter resulting in osteomyelitis. “It is extremely rare. The patient case also highlighted the importance of a multidisciplinary team working together.”

Prof. Constantini demonstrates robotic sacrocolpopexia

Overall impressions “It was impressive and commendable that the masterclass took place, albeit online, in the time of the pandemic. The faculty was able to come together and discuss the course, and a large number of participants were able to deliberate on difficult complex cases and interact via Zoom,” said Mr. Thiruchelvam.

“What I appreciated the most were the cases prepared and presented by the participants, and the discussions that followed, as well as, the high-quality instructive videos on operative techniques from the faculty,” said Prof. Heesakkers. Excerpts from participant feedback have shown that all participants thought that the masterclass will help increase their professional knowledge and improve their patient care. Due to more interest gained, the participants requested for more surgical videos, clinical cases and extra time for questions after each presentation in future editions of the masterclass. The participants stated that the masterclass was wellorganised with a professional yet friendly atmosphere. Access the scientific content Rewatch the presentations and look back on insights shared during the masterclass via UROsource (www.urosource.org), the single largest knowledge base available today in the field of urology. Interested in joining other ESU masterclasses? Please visit www.esu-masterclasses.org to know more about upcoming masterclasses. We look forward to your participation.

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UUA congress and virtual ESU course commence First hybrid urology event takes place in Kiev By Prof. Alexander Shulyak The three-day congress of the Ukrainian Urological Association (UUA) kicked off in Kiev, Ukraine on 10 September 2020. During this well-attended event, the virtual ESU course “Trauma in urology and reconstructive urology” of the European School of Urology (ESU) commenced on 11 September wherein 230 delegates onsite and 1,400 online participants viewed the course. In this report, I have included insights and impressions of the ESU course’s well-respected faculty members, Prof. Luis Martínez Piñeiro and Asst. Prof. Luis Alex Kluth. Congress launches Originally set to take place in June, the congress was rescheduled in September due to the emergence of COVID-19. Thanks to ESU’s help, the congress was reorganised and the course was restructured into a virtual event. The presentations were either pre-recorded, in online format, or delivered live at the congress. This adapted setup made it possible to ensure quarantine measures, maintain live communication, and carry

out a scientific programme packed with essential updates. On day one, UUA President and Corresponding Member of the National Academy of Medical Sciences of Ukraine (NAMS), Prof. Sergey Vozianov welcomed the delegates on behalf of the NAMS President Prof. Tsymbalyuk Vitaly Ivanovich. The thematic sessions centred on key issues and challenges in urology, and explored contemporary research. During the symposium "Modern looks and features in treatment of lower urinary tract symptoms/benign prostatic hyperplasia", Prof. Vozianov, Prof. James Van Hasselt and I disseminated information on sexual dysfunction in relation to combined treatment for LUTS in BPH. We emphasised that combination therapy affects sexual function, especially in terms of ejaculation. The main recommendation was to express caution with regard to combination therapy. The plenary session "Urolithiasis and UTI" was chaired by Prof. Vozianov, Prof. Vasily Chernenko and Prof. Victor Stus. During this session, Prof. Alexander Borisov discussed the pathogenetic features of acute pyelonephritis. Afterwards, Prof. Vozianov underscored the rules for choosing the tactics in treating ureteral stones. Conducted by a group of Ukrainian scientists and led by Prof. O.V. Romashchenko, the school dedicated to female sexology delivered informative lectures and discussions on erectile dysfunction, the Skene glands, erogenous zones in women, and diagnostics of female sexual dysfunction.

Adhering to social distancing and safety protocols onsite

European Urology Today

Popular virtual course Spearheaded by Prof. Martínez Piñeiro and Prof. Kluth

of the ESU, together with Prof. Vozianov, Dr. Sergey Volkov and I, the virtual ESU course covered topics on renal, ureteral, bladder and external genitalia traumas; anterior and posterior urethra strictures, and female strictures. Presentations and insights shared, such as the tactics and methods of treating kidney injuries and the discussions that followed, were How we presented in a hybrid setup enlightening. The role of super selective embolization of renal vessels in the treatment of the severe category and conversing with friends and peers in person. But of patients was clearly defined. there is no reason to wait until things get back to the way they were; there are just too many important The interaction, participation and overall organisation developments in urology we need to talk about now.” of the congress and course were outstanding, according to Prof. Martínez Piñeiro. Prof. Kluth Congress continues agreed, “The UUA and the ESU did an excellent job; Another esteemed expert, Prof. Walter Ludwig the livestreamed lectures went smoothly and there Strohmaier, presented his lecture devoted to modern were plenty of fruitful discussions. It was truly a approaches to treatment and prevention of pleasure to be part of this experience.” urolithiasis at the congress which was entitled “Urolithiasis Update on Pathogenesis and When asked if the online format is a viable alternative Metaphylaxis”. due to current COVID-19 situation, Prof. Martínez Piñeiro said, “Although I’ll always prefer the onsite This was followed by the plenary session format because I can see the audience’s reaction and "Reconstructive urology and oncourology” which was the interaction is better, this is what we have at the chaired by Prof. Sergey Shamraev. moment.” Prof. Shamraev, Dr. Daria Shamraeva, and Dr. Maria Prof. Kluth shared, “When I was presenting, I missed Rydchenko provided the results of their analysis of the real-time feedback, such as eye contact, and the urethroplasties in patients with complicated urethral audience’s reactions to certain slides. So when I was strictures. finished and was asked the first question, I felt some sort of relief as there was live interaction.” Prof. Vyacheslav Grigorenko, Dr. Rostislav Danilets and Dr. Volkov offered key points in the optimization Prof. Kluth added, “Of course, everyone misses the of patient selection in clinical, locally-distributed urology meetings, the large crowds that they attract, prostate cancer for radical prostatectomy. October/December 2020

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PCa20: A recap of the 1st virtual edition Staging, treatment of recurrent disease, mHSPC and CRPC By Erika De Groot The EAU Virtual Update on Prostate Cancer (PCa20) commenced on 17 October 2020 as an online event, a first for the specialised meeting. PCa20 drew in more than 500 unique viewers during its almost five-hour programme which was moderated by esteemed experts Prof. Morgan Rouprêt (FR) and Prof. Arnulf Stenzl (DE). The PCa20 scientific programme was comprised of four main topics centred on updates on prostate cancer (PCa) staging, treatments of recurrent disease, de novo low-volume metastatic hormone-sensitive prostate cancer (mHSPC), and castration-resistant prostate cancer (CRPC). Highly-regarded experts in the field presented insights and developments at the meeting: Prof. Joaquim Bellmunt (US), Prof. Alberto Briganti (IT), Mr. Philip Cornford (GB), Prof. Gert De Meerleer (BE), Dr. Nicola Fossati (IT), Prof. Steven Joniau (BE), Prof. Axel Merseburger (DE), Prof. Nicolas Mottet (FR) who presented “Breaking News from the 2020 EAU Guidelines” updates, Asst. Prof. Jan Philipp Radtke (DE), Prof. Derya Tilki (DE), Prof. Jeroen Van Moorselaar (NL) and Dr. Jochen Walz (FR). Some of the PCa20 highlights and key messages are shared in this report. On PCa imaging Dr. Walz summarised the differences between the biparametric magnetic resonance imaging (MRI) and multiparametric MRI. The advantages of biparametric MRI included efficiency in the use of resources and scanning time, while providing good diagnostic performance. However, it was observed that

biparametric MRI is mainly for the experts as less experienced readers lose diagnostic reliability. Following Dr. Walz’s presentation, Prof. Radtke discussed prostate-specific membrane antigen (PSMA) PET imaging, which is currently the most sensitive staging tool for PCa independent of the disease stage (localised, recurring or metastatic). The information provided in these presentations was put into clinical context during the interactive case discussions, which focused on the current staging options, highlighting their drawbacks and limitations, as well as, the resulting clinical consequences. On BCR In his presentation “BCR after surgery: early or late salvage RT” Prof. De Meerleer said, “Concerning biochemical recurrence (BCR) of PCa, opt for salvage radiotherapy. You have to refer the patient to the radiation oncology department as soon as possible which means at a PSA is 0.15 to 0.20. Waiting for PSMA scan results to be positive is not the way to go. We need to combine early salvage radiotherapy (RT) with hormonal treatment. However, it is not yet known how long the hormonal treatment is to be administered, but a period of at least six months is mandatory.” Prof. De Meerleer added that randomised trials would prove helpful such as the LOBSTER trial, which compares six and 24 months of androgen deprivation therapy (ADT) in case of salvage RT. On nmCRPC According to Prof. Merseburger, the treatment of non-metastatic castration-resistant prostate cancer (nmCRPC) has significantly changed in recent years.

Three positive studies show a metastasis-free survival (MFS) and overall survival (OS) benefit when ADT was combined with novel hormonal therapy (NHT), namely apalutamide, enzalutamide or darolutamide. The latest EAU Guidelines recommend intensification of the treatment in a high-risk situation. The same applies to the clinical situation mHSPC where ADT alone is not enough and NHT or docetaxel should be given upfront instead of at the point of progression. With sequencing data from the CARD study, the role of chemotherapy in metastatic castration-resistant prostate cancer (mCRPC) Polls on cases were part of the programme to boost interaction was strengthened. Cabazitaxel should be the next and brainstorming treatment after NHT and docetaxel failure. On genomic profiling Concerning mCRPC, recent advances in precision oncology are about to be introduced into the clinics. Promising data from clinical trials with poly-ADP ribose polymerase (PARP)-inhibitors demonstrate clinical meaningful activity in patients harbouring BRCA1 or BRCA2 mutations. In his presentation “New developments in the management of mCRPC”, Prof. Bellmunt presented the results of two important trials, one of which was the Profound trial which studied olaparib in genomically-selected patients who had enzalutamide or abiraterone failure. This trial demonstrated a survival benefit in patients with specific DNA repair genes such as BRCA1, BRCA2 and ATM, as well as, and how patients with DNA damage repair (DDR) mutation also benefitted. “This will be a new option for PCa patients; to implement genomic profiling to see if they have DNA repair alterations which can be seen in somatic tissue up to 23% and in the germline up to 12%. This means that the future for PCa management will move towards a more personalised approach,” stated Prof. Bellmunt.

Prof. Bellmunt also presented the results of a trial using ipatasertib, which is an AKT inhibitor in patients having phosphatase and tensin homolog (PTEN) loss. “In that PTEN loss, they have activation of AKT. The trial also showed radiological progression-free survival benefit which means that there’s another subgroup of profiled patients who might require specific treatment.” He stated that fellow-presenter Prof. Marc-Oliver Grimm (DE) mentioned that in addition to profiling the patient, one should look for other alterations such as patients who have microsatellite instability–high (MSI-H) as they might be candidates for pembrolizumab. Prof. Bellmunt added that future treatment with lutetium PSMA PET–CT is a promising tool for PCa patients. Access PCa20 scientific content Rewatch the PCa20 presentations via UROsource (www.urosource.org), the single largest knowledge base available today in the field of urology.

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7th CEUEP: A synergy of east and west Expert insights on urolithiasis, kidney cancer and UTUC The 7th Chinese European Urology Education Programme (CEUEP) was held from 27 to 29 October 2020 and was co-organised with the European Association of Urology (EAU), the European School of Urology (ESU) and the Wu Jieping Medical Foundation. CEUEP was livestreamed to and from the venues in Beijing, Shanghai and Guangzhou wherein 60 participants took part in the courses simultaneously. More than half of the participants were from primary hospitals or remote areas. As a non-profit organisation, Wu Jieping Medical Foundation offered free registration and covered traveling accommodation costs for the participants who were from other cities. This programme aimed to promote Prof. Wu’s “gracious medical ethics, excellent medical skills and specific services” and to develop China’s urology with more qualified professionals. The hands-on training (HOT) on October 27 included 12 laparoscopic animal surgeries demonstrating partial nephrectomy, laparoscopic nephrectomy and ureter suture. For most of the participants, performing HOT on animals was a rare opportunity. Additionally, basic laparoscopic skills on box trainers were offered to 10 participants in Shanghai. The HOT tutors were Dr. Wenfeng Zhao (Peking University Wu Jieping Urology Center), Dr. Wei Chen and Dr. Shuai Jiang (Zhongshan Hospital Fudan University), as well as, Dr. Cheng Hu (Third Affiliated Hospital, Sun Yat-Sen University).

Opening speech from Prof. Chapple, Secretary General of EAU

October/December 2020

The programme on October 28 began with a welcome speech from Mrs. Yang Ren, Director of International Communication & Education Department at the Wu Jieping Medical Foundation. She was followed by pre-recorded welcome speeches and well wishes from Secretary General of the EAU Prof. Christopher Chapple, ESU Chairman Prof. Joan Palou, ESU Chairman Elect Prof. Evangelos Liatsikos, other ESU faculty members Prof. Andrea Minervini and Prof. Alberto Breda, as well as, the local faculty members. This year’s courses consisted of modules on urolithiasis, kidney cancer and upper urinary tract urothelial carcinoma (UTUC). The presentations of the ESU faculty in each modules were pre-recorded. The urolithiasis module included presentations on the complications of endourology procedures by Prof. Liatsikos (University Hospital of Patras); tips and tricks for PCNL by Prof. Gang Wang (Peking University First Hospital); tips and tricks for flexible ureteroscopy by Prof. Yi Zhang (Peking University International Hospital). Prof. Xiaofeng Gao (Shanghai Changhai Hospital) and Prof. Wenqi Wu (First Affiliated Hospital of Guangzhou Medical University) interpreted the key points of the ESU lecture and moderated discussions among all the participants. The kidney cancer module featured presentations on surgery treatment of localised and advanced renal cell carcinoma by Prof. Minervini (Careggi Hospital); on active surveillance and minimally-invasive treatment by Prof. Ningchen Li (Peking University Wu Jieping Urology Center); and on medical treatment by Prof. Xinan Sheng (Peking University Cancer Hospital). Prof. Jiahua Pan (Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine) and Prof. Rongpei Wu (First Affiliated Hospital, Sun Yat-sen University) interpreted the key points of the ESU lecture and moderated discussions among all the participants. The UTUC modules included presentations by Prof. Breda (Fundació Puigvert) from diagnosis to conservative management and follow up of UTUC; by Prof. Gang Zhu (Beijing United Family Hospital) on the surgical treatment of UTUC and more; and by Prof.

Group photos from the Beijing, Shanghai and Guangzhou venues

Kexin Xu (Peking University People’s Hospital) on the latest updates on neoadjuvant versus adjuvant treatment of locally advanced UTUC. Prof. Yuan Shao (Ruijin Hospital) and Prof. Di Gu (First Affiliated Hospital of Guangzhou Medical University) interpreted the key points of ESU lecture and moderated discussions among all the participants. Feedback from the participants showed that 85% of them rated the CEUEP with a score of “9” and higher

on a scale from “1” to “10”. The participants stated that the programme was well-organised; the lectures were informative, and interactions with top experts have broadened their vision and enlightened them with regard to their clinical practice. In addition, the participants have expressed their appreciation for the hard work of the faculty members and for the opportunity to boost their confidence in performing surgeries. The participants stated that they look forward to next year’s CEUEP. European Urology Today

ESU-ESOU Masterclass on Non-Muscle-Invasive Bladder Cancer

ESU-ESOU Masterclass on Muscle-Invasive Bladder Cancer

Virtual meeting

8-9 April 2021, Amsterdam, The Netherlands

4-5 February 2021

www.esumibc.org

www.esunmibc.org

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

Education Online

ESU ESTs2 Workshop Endoscopic stone treatment step 2 6-8 May, 2021, Prague, Czech Republic www.esuests2.org

e-learning at your own convenience

EAU Education Online course

Advanced Prostate Cancer: Metastatic Hormone-Sensitive Prostate Cancer The Third course in the Advanced Prostate Cancer series The new Advanced Prosate Cancer series is

Registration deadline: 29 March 2021

comprised of 5 courses which offer clinicians a complete view on clinical aspects, diagnosis and treatments of prostate cancer.

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

2 CME c

Free access with MyEAU account

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

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

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redits

Each course will be individually accredited by EACCME

uroweb.org/education October/December 2020

EAUN21 10-11 July 2021, Milan

Join us in Milan!

Join our free UROwebinars! • Different topics every month • Up to date in 30 to 60 minutes

22nd International EAUN Meeting

• Great interaction with Polls and Q&A

www.eaun21.org

• Developed in collaboration with EAU Section and Guidelines Ofﬁces

Abstract and Video Submission, Difficult Case Submission Research Project Plan Submission Deadline: 1 March 2021

in conjunction with

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Peter Paul Figdor 1926-2020 “Whenever an old man dies, it is as though a library were burning down” -Amadou Hampâté Bâ

This quote by Malian writer, historian and ethnologist Amadou Hampâté Bâ (1900-1991) was the deepest of our feelings when Univ. Doz. Dr. Peter Paul Figdor passed away in August 2020. He was a real library and an encyclopaedia on the History of Urology. Peter Paul Figdor was a very humble and kind man. After completing his medical studies at the University of Vienna he started his training in urology in 1950 under the famous Prof. Dr. Richard Übelhör at the Hospital in Lainz. At that time his main interest was in nephrology, especially the use of artificial kidney and peritoneal dialysis and later also in kidney transplantation. Figdor was involved in the establishment of the first unit for haemodialysis at the Lainz Hospital in 1953, at that time one of the first in Central Europe. For further training in this field he was a long term guest resident with Prof. Alwall in Lund, Sweden, and Prof. Borst in Amsterdam, The Netherlands. During his further urological training he focused on oncological surgery, reconstructive surgery, paediatric urology and hospital hygiene. In 1962 he followed his teacher and chief Prof. Übelhör to his new position as

October/December 2020

published in the EAU’s Europe, The Cradle of Urology is a superb example of his knowledge.

University Chair at the Allgemeine Krankenhaus (AKH) in Vienna and finished his PhD degree in 1969. In 1974 he became head of the urological department at the Kaiser-Franz-Joseph-Hospital in Vienna. His long term interest in functional kidney problems resulted in the book publication Urologische Nephrologie (‘Urological nephrology’, Urban & Schwarzenberg, 1976). In 1986 and 1987 he was President of the Austrian Society of Urology (ÖGU). Among many positions he was a member of the Gesellschaft der Ärzte in Vienna and of the Royal Society of Medicine in London. Archivist When he retired from active urology in 1992 he was appointed archivist of the Austrian Society of Urology (ÖGU) and dedicated all his enthusiasm to the

research of the history of urology. This resulted in a variety of publications and three reference works: Philipp Bozzini - The Beginning of Modern Endoscopy (Endopress, 2002); The Development of Endoscopy (Endopress, 2004); and Biographien Österreichischer Urologen (‘Biographies of Austrian Urologists’, Universimed, 2007). His work as an archivist was huge, but unfortunately most of his work was in a pre-digital age and the archive mainly consists of thousands of photocopies from the original books and archives he found in the libraries in Paris, London, Madrid, etc.

In 1998 he joined the EAU History Office (at that time Historical Committee of the EAU) and became one of our most knowledgeable, active and scientific members. His profound expertise in all facets in the history of European urology was overwhelming and he contributed to our activities for almost two decades. After the earlier death of his beloved wife he became more secluded from our activities but we will always remember him as a good friend and an outstanding historian. Hilary Mantel wrote: "The writer of history is a walking anachronism, a displaced person, using today’s techniques to try to know things about yesterday that yesterday didn’t know itself. He must try to work authentically, hearing the words of the past, but communicating in a language the present understands." Such a writer of history was Peter Paul Figdor.

His knowledge on the history of urology was enormous. His chapter “Transurethral access to the bladder – endoscopy and lithotripsy” that he

Prof. Dirk Schultheiss - Dr. Johan Mattelaer Former Chairmen of the EAU History Office

European Urology Today

Incredible but not impossible Ultrasound bursts for stone propulsion and lithotripsy Dr. Nariman Gadzhiev The Federal State Institute of Public Health Saint Petersburg (RU) nariman.gadjiev@ gmail.com For more than a century, open stone surgery, with its inherent morbidity, was the standard treatment for kidney stones. The introduction of the first extracorporeal shock wave lithotripsy (ESWL) machine, the Dornier HM-3, in 1980 by Chaussy et al., has revolutionised the treatment for urolithiasis1. Stone comminution during ESWL is achieved by two means. The first is direct application of acoustic energy focused on the stone surface. The energy is generated by an electrohydraulic, electromagnetic, or piezoelectric source. The second is indirect energy from the collapse of cavitation bubbles that are generated on the stone surface2. However, stones consisting of brushite, calcium oxalate monohydrate, and cystine remain refractory to ESWL3.

“In search of better outcomes for extracorporeal stone treatment, ultrasound-based alternatives have been investigated.” The first ESWL machine’s success was mainly attributed to the delivery of broadly focused shocks with relatively low-pressure amplitudes4. However, that lithotripter was quite cumbersome and not without inconveniences such as the water bath, the need for regional or general anaesthesia, the need for two expensive X-ray units, and the requirement for expensive electrodes with a short lifespan. Fundamental design changes led to treatment optimisation, and later ESWL machines delivered high-peak pressures (30–100 MPa) in a single-cycle pulse at a slow rate (≤ 2 Hz). Such high-peak pressures led to excessive bubble production that occurred during cavitation. In turn, excessive bubbles shielded subsequent waves from making contact with the stone. This inevitably resulted in inferior outcomes of lithotripsy, such as poorly predictable stone fragmentation and high retreatment rates. This led to a change in preference from ESWL to endoscopic techniques such as flexible ureteroscopy and percutaneous nephrolithotomy5. Ultrasound-based alternatives In search of better outcomes for extracorporeal stone treatment, ultrasound-based alternatives with similar acoustic output have been investigated. The first ultrasound-based solution was presented by Shah and colleagues in 20106. They demonstrated a prototype device that utilised ultrasound force to move stones within a tissue phantom. In the beginning, the prototype device consisted of a large 2-MHz, 8-cm, annular probe around a separate imaging probe and was working under the following parameters: an acoustic power of 5–40 W, a duty cycle of 50% with 2-5 pulses per second, and a peak negative pressure of 20 MPa. In later years, this system was modified to a single-hand-held probe that was 6 cm in diameter and had a frequency of 350 kHz. It was used for stone visualisation and stone repositioning. The working parameters were upgraded as well: 3-sec bursts at a 50% duty cycle with a 2.4-MPa peak negative pressure applied for 10 minutes. Ultrasonic stone repositioning (called propulsion up to now) has been used safely 65 times on subjects with successful stone repositioning from different locations in different settings, including emergencies. The method was tested both with and without anaesthesia. In the anesthetised patients, Burst Wave Lithotripsy (BWL) was monitored with ultrasound and with endoscopic control during ureteroscopy. BWL was capable of moving stones of up to 7 mm in 95% of the cases for a distance of more than 3 mm. Human studies are currently underway (NCT02028559) to explore various clinical applications and are eagerly awaited7. EAU Section of Uro-Technology (ESUT)

European Urology Today

Another ultrasound-based technology appeared in 2015 and was based on the studies that utilised pulses of High Intensity Focused Ultrasound (HIFU) for artificial stone comminution into dust by generating a cloud of cavitation bubbles8. No heating of surrounding tissues was observed due to pulsing the ultrasound with a sufficiently low duty cycle. Sinusoidal short bursts of focused ultrasonic pulses of lower amplitude pressure eliminated the blocking effect of surface cavitation and improved stone fragmentation. In vitro experiments demonstrated that stones of varying compositions were successfully comminuted to < 4 mm fragments at peak pressures of 6.5 MPa. Uric acid stones were treated most rapidly (0.17-1.40 minutes), followed by struvite (0.07-2.02 minutes), COM (8.0-18.1 minutes), and cystine stones (10.3-21.3 minutes). Finer fragments were generated by higher frequency treatment. In an animal model, COM stones implanted beforehand were treated with BWL for 30 minutes with a 350 kHz transducer and peak negative focal pressures of 6.5-7 MPa. Results showed that 82% of the treated stone mass was disintegrated into fragments less than 2 mm9.

“During in vitro experiments, BWL alone treated 5.9% ± 1.3% of the total stone mass.”

accumulation of cavitation bubbles and debris that may provide a shielding effect; fourth, ultrasonic propulsion forms stress fractures and helps oscillate formed cavitation bubbles, further damaging the targeted stone13.

“New ultrasound burst technology seems like a real game-changer in the field of extracorporeal lithotripsy.” Clinical trials with BWL in humans have been approved by the Food and Drug Administration and are currently underway (NCT03873259). Recently, the first successful interim result of BWL combined with ultrasonic propulsion was published. Treatment was performed under the following parameters: 20 cycles at 350 kHz frequency, 6 MPa peak negative pressure, and 17 Hz pulse repetition frequency for less than 10 minutes in an awake patient who experienced mild discomfort and transient haematuria14.

In conclusion, new ultrasound burst technology seems like a real game-changer in the field of extracorporeal lithotripsy. There is huge potential for this procedure to win back its position from retrograde intrarenal surgery for small and mediumThe safety of BWL was studied in animal models. They sized stones. demonstrated a pattern of haemorrhagic renal injury that was similar to what was previously found in References ESWL, with total renal injury estimated to be less than 1. Elmansy HE, Lingeman JE. Recent advances in lithotripsy technology and treatment strategies: A systematic review 0.1% measured with a 335-kHz transducer, in contrast to 5% with ESWL10. This pattern is thought to be update. Int J Surg [Internet]. 2016;36(PD):676–80. formed from cavitation bubbles rapidly forming and Available from: http://dx.doi.org/10.1016/j.ijsu.2016.11.097 collapsing during BWL pulses, causing mechanical 2. Large T, Krambeck AE. Emerging Technologies in trauma to small vessels. In a porcine survival safety Lithotripsy. Urol Clin North Am [Internet]. 2019;46(2):215– 23. Available from: https://doi.org/10.1016/j. study, human calcium oxalate monohydrate stones were implanted beforehand and then exposed to BWL ucl.2018.12.012 at 6.5–7 MPa, 350 kHz, 10 Hz PRF for 30 minutes. 87 3. C. Türk (Chair), A. Neisius, A. Petrik, C. Seitz, A. Skolarikos (Vice-chair) KT, Guidelines Associates: N.F. percent of the exposed stones were reduced to fragments of less than 2 mm. Subsequent MRI, Davis, J.F. Donaldson, R. Lombardo, N. Grivas YR. EAU Guidelines. Edn. presented at the EAU Annual Congress histology, and gross examination demonstrated no injury in the renal parenchyma, although there was Amsterdam 2020. ISBN 978-94-92671-07-3. [Internet]. evidence of petechial haemorrhage and surface Available from: https://uroweb.org/guidelines/ erosion of the immediate urothelium circumscribing 4. Maxwell AD, Cunitz BW, Kreider W, Sapozhnikov OA, Hsi the stone11. RS, Harper JD, et al. Fragmentation of Urinary Calculi In Vitro by Burst Wave Lithotripsy. J Urol [Internet].

Ultrasonic propulsion 2015;193(1):338–44. Available from: http://dx.doi. During both BWL and ESWL, not all stones tend to org/10.1016/j.juro.2014.08.009 break apart immediately. If it were possible to confirm 5. Rassweiler J, Rieker P, Rassweiler-Seyfried MC. the stone breakage, the duration of the procedure Extracorporeal shock-wave lithotripsy: Is it still valid in could be reduced. To overcome this barrier and the era of robotic endourology? Can it be more efficient? complement the BWL efficiency, ultrasonic propulsion Curr Opin Urol. 2020;30(2):120–9. technology was incorporated12. During in vitro 6. Shah A, Owen NR, Lu W, Cunitz BW, Kaczkowski PJ, experiments, BWL alone treated 5.9% ± 1.3% of the Harper JD, et al. Novel ultrasound method to reposition total stone mass. When propulsion was administered kidney stones. Urol Res. 2010;38(6):491–5. sequentially after BWL, this led to a 1.9-fold increase in stone fragmentation. However, when BWL and ultrasonic propulsion were interleaved, a 4.6-fold increase in stone fragmentation was observed compared to BWL alone. There are some plausible explanations for this correlation: first, ultrasonic propulsion facilitates the release of loose, weakened fragments from the stone surface; second, the reorientation of stone redistributes stress and leads to new stress fractures; third, ultrasonic propulsion prevents the

Burst Wave Lithotripsy prototype system

7. Bailey MR, Wang Y-N, Kreider W, Dai JC, Cunitz BW, Harper JD, et al. Update on clinical trials of kidney stone repositioning and preclinical results of stone breaking with one system. 2018;020004:020004. 8. Ikeda T, Yoshizawa S, Tosaki M, Allen JS, Takagi S, Ohta N, et al. Cloud cavitation control for lithotripsy using high intensity focused ultrasound. Ultrasound Med Biol. 2006;32(9):1383–97. 9. Dai JC, Bailey MR, Sorensen MD, Harper JD. Innovations in Ultrasound Technology in the Management of Kidney Stones. Urol Clin North Am [Internet]. 2019;46(2):273–85. Available from: https://doi.org/10.1016/j.ucl.2018.12.009 10. Chen TT, Samson PC, Sorensen MD, Bailey MR. Burst wave lithotripsy and acoustic manipulation of stones. Curr Opin Urol. 2020;30(2):149–56. 11. Wang Y-N, Kreider W, Hunter C, Cunitz BW, Thiel J, Starr F, et al. An in vivo demonstration of efficacy and acute safety of burst wave lithotripsy using a porcine model. 2019;020009:020009. 12. Ramesh S, Chen TT, Maxwell AD, Cunitz BW, Dunmire B, Thiel J, et al. In Vitro Evaluation of Urinary Stone Comminution with a Clinical Burst Wave Lithotripsy System . J Endourol. 2020;1–20. 13. Zwaschka TA, Ahn JS, Cunitz BW, Bailey MR, Dunmire B, Sorensen MD, et al. Combined Burst Wave Lithotripsy and Ultrasonic Propulsion for Improved Urinary Stone Fragmentation. J Endourol. 2018;32(4):344–9. 14. Lashin AM, Attya M, Elbaz R, Sheir K, Maxwell A, Cunitz B, et al. Stone Disease : Shock Wave Lithotripsy Podium 15 Copyright © 2020 American Urological Association Education and Research , Inc . Unauthorized reproduction of this article is prohibited . 2020;203(4):43881.

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

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October/December 2020

EPAD20: PCa on the radar for inclusion in EU Cancer Plan EPAD20 partners highlight the necessity of early detection and awareness raising of prostate cancer By Juul Seesing Europe’s Beating Cancer Plan (EU Cancer Plan) and the EU’s Mission on cancer could offer a number of opportunities for early detection and awareness raising of prostate cancer (PCa). This became clear during the presentations of Dr. Paolo Guglielmetti (IT), principal administrator of the EU Cancer Plan taskforce of the European Commission, and Prof. Christine Chomienne (FR), vice-chair of the Mission’s board, at the European Prostate Cancer Awareness Day (EPAD20). EPAD20, being held virtually in the middle of ‘Movember’ on 17 November 2020, was hosted by the MEPs Tiemo Wölken (DE) and Tomislav Sokol (HR), both members of the European Parliament’s Special Committee on Beating Cancer. This year a collaboration between the European Association of Urology (EAU), Europa Uomo, the European Cancer Patient Coalition (ECPC), Movember, the European Alliance for Personalised Medicine (EAPM), COCIR, and the Challenge Cancer Intergroup, EPAD20 aimed to call on the EU to address the important issues of early detection and awareness raising of PCa in the EU Cancer Plan, a draft of which is planned for release in January 2021. Nearly 400 unique viewers attended a programme featuring high-level influencers from various fields: oncology specialists, patient advocates, representatives from charities and foundations, and policymakers.

stated. “Especially the recent documents you have produced are going in the right direction.”

based algorithm as a potential way forward for risk-stratified early detection of PCa: an algorithm which will prevent over- and underdiagnosis and overtreatment. Awareness among men is an essential part to achieve early detection. Ms. Sarah Coghlan (GB) from Movember gave a presentation about the successful awareness-raising campaigns of the foundation. The characteristic grow-a-moustache-in-November movement has borne fruits. “With 48% of our Movember community over the age of 45 taking action to speak to their doctor about the risks of prostate cancer versus less than 20 percent of the general male population, we have learned that our Mo Bros are more aware of these risks,” Ms. Coghlan said, referring to the ‘Movember Is Good For You’ survey. “Helping men understand the risks they face is probably the first step in getting them to take action.”

Dr. Guglielmetti’s presentation was followed by Prof. Chomienne’s about what the EU’s Mission on cancer “can bring to research and innovation to fight against cancer and, of course for all of you here today, to fight against prostate cancer.” She referred to the Mission's thirteen recommendations for bold actions (see figure 1). “All these recommendations are in line with what you wish for prostate cancer." She went on to highlight a few recommendations, among which the fourth one on cancer screening and early detection: “We have listened to all you have been wishing and working on so far.” About the sixth recommendation: “We want to stress how important it is to develop an EU-wide research programme on early diagnostic and minimally invasive treatment and technologies in line with what you also wish.”

the EU Cancer Plan to ensure that prostate cancer gets the attention it deserves.” Other presenters at EPAD20 were Prof. Monique Roobol (NL), who reported the latest results of the European Randomized study of Screening for Prostate Cancer (ERSPC), Prof. Jelle Barentsz (NL), who demonstrated how MRI is the game changer for early detection and for monitoring active surveillance, Mr. André Deschamps (BE), whose presentation on the results of the Patient-Reported Outcomes EUPROMS study is highlighted in the EMUC report on page 13 of this issue, and Dr. Gregor Thörmer (DE), who gave the industry perspective on establishing high-quality MRI pathways.

(Re)watch EPAD20? On www.epad.uroweb.org, under The attention PCa deserves “Programme”, you can find a recording of the entire MEP Wölken delivered the closing remarks, event and download the presentations. summarising the meeting. “I think it is fair to say from what we have heard today that the scientific evidence points to a review of the early detection “All these recommendations are in guidelines for prostate line with what you wish for prostate cancer across the EU in order to save lives and cancer.” raise the quality of life Mo Bros of prostate cancer Prof. Hein Van Poppel (BE) opened the meeting by Recommendations for bold actions patients. We hope this describing the current landscape of early detection of In the second panel “How can this be supported at EU will be an area the PCa. “After PSA had been introduced, prostate cancer level?” Dr. Guglielmetti gave a talk about the European Commission was detected early and thus mortality declined. Yet, will be able to include PSA testing was discouraged, because prostate cancer opportunities for PCa under the framework of the EU Cancer Plan. He underlined that early detection is one in its cancer plan. I diagnosis automatically led to active treatment. We myself, being a were not able to discriminate between significant and of the most important targets of the plan and that insignificant cancer. But times have changed.” He cited “new elements to strengthen the recommendations on substitute member in cancer screening” across the EU are being monitored. the beating cancer the ability to avoid overdiagnosis and overtreatment, “The potential benefit of prostate cancer early committee, will closely two arguments used against PSA testing. In his later detection is on the radar of the plan,” Dr. Guglielmetti follow the debate on Figure 1: The EU Mission on cancer’s thirteen “Recommendations for bold actions.” presentation, Prof. Van Poppel proposed a science-

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October/December 2020

European Urology Today

Cadaveric workshop training in penile prosthesis surgery Simulation training may overcome limited clinical surgical training opportunities Dr. Pramod Krishnappa Nu Hospitals Dept. of Urology Bangalore (IN)

and repeated requests, the registration was increased and finally stopped at 72 due to space limitations at the cadaver lab. The workshop involved 4 hours of lectures and 2 hours of hands-on experience with 3-piece PP (AMS 700) in a cadaveric lab. Each participant had predefined steps to follow during the insertion of 3-piece PP in the cadavers.

pramod23dr@ gmail.com

Happy European faculty members The European faculty members had been tutors in several other cadaver workshops held in Europe before and commented on a few things that particularly made an impression on them. First the outstanding quality of the facilities, they saw no real differences compared to the European ones. They were also impressed by the high level of respect paid to the cadavers; Before starting the hands-on cadaver lab, all participants stood up and observed a moment of silence in gratitude and respect for those offering their bodies to science.

Prof. Juan MartinezSalamanca University Hospital Puerta de HierroMajadahonda Dept. of Urology Majadahonda (ES) jims09@me.com

Prof. Ignacio Moncada University Hospital La Zarzuela Dept. of Urology Madrid (ES) imoncada3@ gmail.com Training in penile prosthesis (PP) surgery is not common during urology residency, as not many institutes around the world have trained faculty in PP surgery. Only 15% of urology training programmes in the US have a dedicated prosthetic urologist. This percentage is even smaller in developing countries. The relatively high costs and lack of insurance cover for PP surgeries in many countries are some of the additional barriers for PP surgery1. Simulation and aviation industry With the strict adherence to European Working Time Directive (EWTD) on surgical training, the majority of published studies conclude that training opportunities and operative exposure for trainees have decreased dramatically2,3. Some of the scientific associations feel that such surgical training is inadequate. Having assessed these gaps in surgical training, simulation training may be a suitable option to train residents or young urologists in PP surgery. Much of the progress in simulation training over the past century was accomplished by the aviation industry, with the flight simulator created in 1910. Simulation training in healthcare such as the cadaveric workshop has many advantages (such as the opportunity to train many urologists at once in one place, pressure-free learning environment compared to the operation theatre, real feel of the anatomy) and hence may increase the confidence levels of urologists.

An online survey questionnaire was issued to all participants prior to the start of the workshop and later after the workshop. Significant improvements were noted in procedural knowledge test scores and surgical confidence levels of the participants after the completion of the workshop. During the workshop, they could also feel the level of excitement and satisfaction among the attendees. The workshop was very well appreciated and received appreciation from sexual medicine societies around the globe. What comes next? The training in PP surgery does not end here. The next step would be to have limited participants and to have a live surgery alongside the cadaveric workshop, to gain more confidence. The third and the final step in training would be to help these participants through live or online (audio-video) support in the operation theatre during the PP surgeries at their home institutes. The next few big questions arise: who should take this initiative forward and help training these participants at their home institutes? Should the PP manufacturing companies take this initiative forward? Or should the scientific societies (EAU, ESGURS, ..) take responsibility for this training?

From left to right: Rupin Shah (IN), Vasan Srini (IN), Giulio Garaffa (GB), Juan Martinez-Salamanca (ES), Ignacio Moncada (ES), and Pramod Krishnappa (IN)

the industry, should come forward more strongly in training urologists in prosthetic urology.

“I fear not the man who has practised 10,000 kicks once, but I fear the man who has practised one kick 10,000 times” - Bruce Lee. With the increase in medical lawsuits in the last two decades and a reduced residency training period, it may be inevitable that we come to depend on cadaveric models for training in the near future. We need a globally accepted, structured programme in simulation training. This may soon be officially included in the residency training programme, in order to overcome the limited clinical surgical training opportunities. References

The British Association of Urological Surgeons (BAUS) evaluated the human cadaveric training programme (fresh-frozen) for three modules (core operative urology, endourology and trauma urology) and concluded it is an effective procedural training in urology6. Simulation training programme There is a large void in the training of PP surgery. The experts, represented in both the scientific societies and

1. Kovac JR. Centers of excellence for penile prosthetics are a novel concept that will likely prove difficult to implement. Transl. Androl. Urol. 2017; 6 (Suppl 5): S898–S899. 2. Marron CD, Byrnes CK, Kirk SJ. An EWTD-compliant shift rota decreases training opportunities. Bull R Coll Surg Engl. 2005;87(7):246–248. 3. Association of Surgeons in Training, Optimising Working Hours to Provide Quality in Training and Patient Safety: A Position Statement by the Association of Surgeons in Training, Association of Surgeons in Training 2009. http://

Urgency

urinary The disease, urological incontinence in MS patients treatment and therapeutic guidelines

Vol. 32 No.1

- January/Feb

The Europea

Dr. S. Charalampous

ruary 2020

n robotic curriculu How do you prepare m fellowsh to get the most ip out of it

Dr. J. Vicente

in Amsterda m

ry Sessions

The upcoming 35th Annual EAU is its Plenary Sessions. In this Congress (EAU20) will bring article, seven practice-changing respected and prominent urologists,updates to the forefront when it commence who will chair s in Amsterdam the sessions, this March. One offer a glimpse of the exemplary of the novel scientific content that constitute elements of EAU20’s the Plenary Sessions. Scientific Programm e

New frontie rs in infections

Dr. John Heesakker s (NL), Plenary New frontiers Session 1: in infections, 21 March Views on the diagnosis and treatment of tract infections urinary (UTIs) substantial country. In some, ly vary the use of antibiotics per treatment is extensive in UTI and tailor-mad patient. In others, e to the on the restriction disease management is based of antibiotics antibiotic resistance. usage to overcome What are the consequences of these contrasting assessments? Is one possible to create better than the other? Is it guidelines on situations concerning infections when local bacteria load resistance differ and antibiotic from Session will investigateregion to region? This to find the answers Plenary questions. to these

Testis cance r and surgical andro logy

Modern PCa imaging in daily practice

LUTS and storag e symptoms

The role of innovation in stone mana gement

Dr. Jochen Walz (FR), Plenary prostate cancer Session 3: Modern imaging in daily Prof. Jean-Nicol practice, 22 March as Bladder dysfunctioCornu (FR), Plenary Session Modern imaging is Prof. Thomas prostatic disease, n, storage symptoms and 6: how we diagnose substantially changing the Knoll (DE), benign The 23 March way role of innovation Plenary Session 7 Stones: Multiparametric and treat prostate cancer (PCa). , 24 March MRI improved Lower urinary disease but the the tract symptoms new MRI pathways detection of the The removal include storage (LUTS) in men problems, i.e. of stones, which often symptoms (e.g. decisions to biopsy generate new is a daily business most urologists, and/or nocturia. overactive bladder) favour treatment or whether to is for Whilst the underlying or surveillanc has shifted from driven by innovation. Treatment pathophysiology and put into e need to be open and shock context of adapted endoscopic wave is more understood non-neurogenic storage such as biomarkers with regard to new developme symptoms percutaneo approaches; and ureteroscolithotripsy to and mainly relying and genomics. nts dysfunction py and us nephrolitho on bladder , their tomy became However, safety clinical practice. management remains complex This Plenary the standard. aspects have Session will address This to be respected reduction of septic prostatic obstruction is especially so when benignin detail and offer for the complications answers on how these issues in is present. pressure or antibiotic such as intrarenal also a major integrated in imaging can cause of persistent Mixed symptoms are new clinical pathways prophylaxis be . which are a daily LUTS after surgery decision-making. and clinical challenge for Since fluoroscop the urologist. y modality, radiationis used as a standard imaging The discussants Moreover, molecular safety will deliver key practical includes both imaging provides and the surgical how to identify improvements the patient messages on substantial team. the symptoms in detection and Session will determine The second part of the and logical origin. disease. The Plenary Through real-life rule out a neurochallenge is how location of recurrent when and if new ballistic lithotripter discuss the best cases, panels information into to integrate lasers, will medical treatment the clinical decision-m this will be followed s, and scopes are required. bladder (OAB) stratification. for overactive This aking and risk by a round-tabl in men; the best Perhaps experts on a option between ablative will be the solution the use of artificial intelligence challenging stone e deliberation among resection, vaporizatio surgical Plenary Session case. and aquablatio will give answers in the future. The last presentatio 7 n in case of concomitann, enucleation to this hypothesis n symptoms intervention to will raise your knowledge t storage . on stone and proven obstruction the next level. Don’t miss it! about minimally ; invasive, day-case and an update surgical strategies.

If complicatio n cases came to court. ..

Challenges across the BCa spect rum

You are invit

ed!

Join us for the Opening Ceremo on Friday 20 ny March, 18.00-1 9.30, in eURO Auditor ium 1*

*) Including prestigio

us EAU Awards

The Opening Ceremony will be followed by a Networki ng Reception in the foyer of eURO Auditoriu m 1 until 21.00 hrs.

www.eau20.org

More informat

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4-5

Notification:

Promoting your (online) activities Also in these times of COVID-19, the EAU executive is pleased to help promote any (online) scientific activities. Due to the large number of requests we received in the past, we have been forced to set up some rules and regulations related to the circulation of promotional material. All EAU-related activities and activities from national societies with which we have a special alliance, may be promoted through the EAU's e-mail channels (e-mail newsletter or separate e-mail communication), in addition to the other available channels. All other urological activities may be included in our Uroweb online calendar.

Overwhelming response The workshop included 3 international (European) tutors, 9 national (Indian) tutors and 72 hands-on participants. There was a total of 12 cadaveric stations. Each cadaveric station had 1 tutor and 6 participants. The initial registration target was to have only 30 participants but due to the overwhelming response

European Urology Today

of the Europ ean Association of Urology

Prof. M. Wirth after 16 years says goodbye

EAU Executive responsible for and Communica Finance tions

EAU20: Eur 27 ope’s finest Novel scien in urology tific updates to expect at premieres the Plena

European Urology Today

One such cadaveric workshop was conducted by the South Asian Society for Sexual Medicine (SASSM) in Bangalore (IN) and was supported by ESGURS. The international (European) faculty for the workshop were the ESGURS members: Ignacio Moncada (ES), Juan Ignacio Martinez-Salamanca (ES) and Giulio Garaffa (UK). Rupin Shah, Vasan Srini and Pramod Krishnappa formed the local organising team in Bangalore. It was the first hands-on cadaveric workshop in PP surgery in South Asia guided by the European faculty.

European U rology Toda y

Official news letter

Dr. Maarten Albersen (BE), Plenary Session #Testis cancer 2: and surgical andrology, 21 March Plenary Session 2 will kickstart andrology and with updates on surgical a review of the new Guidelines on Peyronie’s disease. 2020 EAU focus on diseases The session will that dysgenesis syndrome, result from the testicular also and review Mr. Tim O’Brien carcinoma in situ, and invasive the links with fertility, (GB), Plenary Nightmare on Session 4: addition, the testicular cancer. robotics, 22 esteemed Prof. In Prof. Morgan March Kyle Orwig present pioneering Rouprêt (FR), research in fertility (US) will Plenary Session Challenges across Plenary Session preservation. 5: the spectrum 4 23 March of bladder cancer, robotic surgery will explore the complicatio To reduce treatment ns of through the prism burden in testis Leading medico-leg Plenary Session of the law courts. cancer, the will explore the The landscape back for his fourth al lawyer, Mr. Bertie Leigh micro RNAs in promising role for novelties (GB), is has patient EAU congress of in bladder cancer urologists accountabl not changed and ready case-based discussion selection, and conduct (BCa) as a e for their decisions. to hold years. Molecular quickly as it did in the past complex retroperito on the role of robotic-ass few pathway, description isted neal surgery. biological mechanism The session will of new feature three s, markers in and several drugs scenarios: Should proceed to perform blood and urine, in the pipeline I open surgery extremely appealing. make this topic failure during after machine robotic-assisted (RARP)? Was radical prostatecto I ready We aim to find cava (IVC) surgery for the transition to inferior my more solutions to challenges responsible for in renal cell carcinoma? Who vena preservation, personalise table-side errors? is d medicine, proper in organ tools, a wise indication of usage of cystectomy, follow-up schedule, and The Plenary Session implementation will be raw the manageme of immunoth entertaining. erapy in nt of local and It will challenge and likely, locally-advanced assumptions decision-making, concerning BCa. consent and BCa is at the safety during crossroads of surgery. endoscopic minimally invasive January/February surgery; the use , open and generations of of new 2020 drugs such as immunotherapy; medical strategy and development.

Few cadaveric workshops Cadavers are high-fidelity models where exact tissue relationships exist, and tissue ‘feel’ is preserved. Fresh-frozen cadavers are preferred over the formaldehyde embalmed cadavers as the tissue planes are much better. Few cadaveric workshops in PP surgery were conducted across the globe since last decade4,5.

EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)

www.asit.org/assets/documents/ASiT_EWTD_Position_ Statement.pdf. 4. Lentz AC, Rodríguez D, Davis LG, Apoj M, Kerfoot BP, Perito P, Henry G, Jones L, Carrion R, Mulcahy JJ, Munarriz R. Simulation Training in Penile Implant Surgery: Assessment of Surgical Confidence and Knowledge With Cadaveric Laboratory Training. Sex Med. 2018 Dec;6(4):332-338. 5. Krishnappa P, Srini VS, Shah R, Lentz AC, Garaffa G, Martinez-Salamanca JI, Moncada I. Cadaveric Penile Prosthesis Workshop training improves surgical confidence levels of urologists: South Asian Society for Sexual Medicine course survey. Int J Urol. 2020 Aug 9. doi: 10.1111/iju.14338. Epub ahead of print. 6. Ahmed K, Aydin A, Dasgupta P, Khan MS, McCabe JE. A novel cadaveric simulation program in urology. J Surg Educ. 2015 Jul-Aug;72(4):556-65.

Please feel free to contact us (EUT@uroweb. org) in case there are any queries or remarks related to this notice.

The lectures were followed by hands-on training sessions in the lab

October/December 2020

The most realistic method for learning the EEP technique Using fresh frozen cadavers in prostate laser enucleation training Prof. Lutfi Tunc ESUT Endoscopic Enucleation of Prostate (EEP) Study Group Ankara (TR)

lutfitunc@gmail.com It has been more than 20 years since the laser enucleation of the prostate was defined using anatomic endoscopic enucleation of prostate (EEP). The technique has gained more popularity in recent years and has found a wider place in endoscopic BPH therapy. EEP shows higher haemostasis and intraoperative safety compared to TURP and open prostatectomy, peri-operative parameters such as catheterisation time and hospital stay are in favour of

EEP training

EEP, and the long-term functional results are comparable to those of open prostatectomy.

programme with different models. We have deployed different techniques in fresh frozen cadaver models and found it very realistic and useful for EEP training.

The EAU Guidelines recommend laser enucleation of the prostate using a Ho: YAG laser (HoLEP) for men with moderate to severe LUTS as an alternative to transurethral resection of the prostate or open prostatectomy. Despite its aforementioned advantages, HoLEP has not yet become as widespread as it deserves due to its steep learning curve and also its limitations in access to equipment. Due to the lack of a globally accepted and applied programme in EEP training, urologists start to perform this surgery directly under mentorship in the operation theatre. However, a standard training programme and training models are needed before starting with procedures. Bench or virtual reality – non-biologic - simulator models have also been reported on this subject. However, these models are accompanied by inherent limitations. Fresh frozen cadavers have previously been used in the training of various urological interventions. The first prostate enucleation course that used a fresh cadaveric model was reported in 2015. However, the model couldn't become popular due to financial reasons and the lack of demand and enthusiasm at that time. Cadaver models can mimic the real-life environment in an optimal way and they are better in reflecting the real anatomy and tissue than computer-based simulators, dry lab, and animal models. The ESUT Endoscopic Enucleation of Prostate (EEP) Study Group is currently working on a training

We have started a pilot study with cadaver models, in which we used a 100 W holmium laser source a 26 Char. continuous flow resectoscope and a tissue morcellator as standard HoLEP equipment. We found that the cadaver model is more decent for EEP training than other models. It has the potential to teach real-life anatomy beyond merely simulating the surgical technique. The prostate capsule colour and tissue appearance from adenoma were easy to distinguish and anatomical enucleation could be performed smoothly in a teaching setting.

Final view

The fact that the fresh cadaveric training model is more expensive than other models seems to be the biggest obstacle. This obstacle can be overcome by using the same cadaver pelvic part together with other branches.

We feel that the fresh cadaver model is the best training model for prostate laser enucleation technique. Unlike other training models, training in the cadaver model seems to be the most effective and realistic method of demonstrating and learning the true laser EEP technique.

5 o’clock incision

Lateral lobe enucleation

Richard Turner-Warwick, CBE A pioneer of functional reconstruction in urology On Saturday 19 September 2020, Richard Turner-Warwick, MSc. MCh, DM (Oxon), DSc (Hon), FRCP, FRCS, FRCOG, FACS (Hon), FRACS (Hon), one of urology’s most famous innovators, passed away at the great age of 95.

1925-2020

RTW’s honours and awards were many. He served on the Council of both the Royal College of Surgeons and also the Royal College of Obstetricians and Gynaecologists. He was President of the British Association of Urological Surgeons 1982-1984 and was an instigator of the third part specialist examination in urology. He received honorary fellowship of many academic societies. In 1992 he was made a Commander of the Order of the British Empire, by HM The Queen, for his services to medicine.

Richard Trevor Turner-Warwick (RTW) was born on 21st February 1925. His father, William Warwick, was a consultant vascular surgeon at the Middlesex Hospital. His mother, Joan (nee Harris), was also a doctor, and specialised in women and children's welfare clinics in the poorer quarter of London’s East End. In 1942, Turner-Warwick started his medical training at Oriel College, Oxford. His future wife Margaret (Moore) was a medical scholar in the year below at Lady Margaret Hall. So, after a third year Final Honours School Degree in Natural Sciences, he stayed on for a fourth research BSc year in neuroanatomy. RTW rowed in the first Oxford eight for three years. In 1946, as President of the Oxford University Boat Club, he was instrumental in bringing the Boat Race back from Henley to the Thames tideway, captaining the victorious Oxford crew that year. The challenges involved in competitive rowing had a lasting impact on him; whenever a task required strength and endurance he would just grit his teeth and ‘think of Cambridge’!

was appointed RSO (Resident Surgical Officer) at the Institute of Urology, working with Sir David Innes Williams (the father of paediatric urology). In 1960, he was appointed Consultant Surgeon at the Middlesex Hospital in charge of the thyroid clinic and in 1964 he established the urology department following the retirement of his mentor Sir Eric Riches. His passion was in harnessing every combination of surgical and modern radiological expertise to

He completed his clinical studies at the Middlesex Hospital London. Post-graduation he was fortunate to be working with a number of eminent surgeons resulting in an exceptionally broad spectrum of experience. He was one of a very small number of medical ‘polymaths’ to qualify by study and experience in, not just one, but three of the Royal Colleges as FRCS, FRCOG and MRCP. In 1958 he undertook a research fellowship in the USA and visited a number of specialist centres, establishing contacts, many of whom became life-long friends. Margaret, by then his wife, was able to join him and together they toured the USA in an ancient bright red Ford V8 convertible. Following his return to the United Kingdom, he completed his MCh (Master of Surgery) thesis and

October/December 2020

2005 he undertook over 300 operating surgical teaching visits in America, Australia, New Zealand as well as Europe and the UK.

understand how the bladder worked, in order to optimise the surgical management of incontinence. With other key innovators he developed the then-novel techniques of video-urodynamics and set up a new diagnostic ‘urodynamic clinic’. These early advances in urological practice were critical to restoring urinary continence and so transforming the lives of many thousands of patients. He was one of the founding members of the International Continence Society. RTW’s broad surgical training provided him with the expertise to develop innovative surgical techniques to reconstruct and restore function to the urinary tract and adjacent organs in the abdomen and pelvis. He devised his own surgical instruments manufacturing the prototypes himself in his home workshop.

An early meeting of enthusiasts in functional urology - the name "The Humpty Dumpty Club" emphasising the importance of 'a word means what I mean it to mean, no more, no less'. L-R: John Gosling, Mike Torrence, Tage Hald, Tim Stevenson, Alan Brown, Graham Whiteside, Patrick Bates, Richard Turner Warwick, Paul Abrams, David Thomas, Peter Wirth, Derek Griffiths, Euan Milroy

RTW devoted a significant amount of his personal income to supporting research and visiting surgical fellows, and many of these now hold eminent positions in the field of functional and reconstructive urology worldwide. As well as his extraordinary surgical talent, a major legacy of RTW was his teaching. He was renowned as a visiting expert ‘coming into town bearing slides’, cinefilms and later videos and often travelled with his own portable generator. Between 1965 and

In 2002 we together published his seminal work, Functional Reconstruction of the Urinary Tract and Gynaenco-urology: an exposition of functional principles and surgical procedures. Many of the 1600 illustrations were based on his own diagrams. The book and his other writings include his sayings such as “there are no such things as brave surgeons, just brave patients”; “the bladder is an unreliable witness” referring to problems with overreliance on symptoms to make a diagnosis and ‘Any reconstructive procedure is a TITBAPIT – you take it to bits and you put it together again – do not TITB it if you cannot PIT again!’ RTW and his wife, Professor Dame Margaret Turner-Warwick, Professor of Medicine at the Royal Brompton Hospital (the first female President of the Royal College of Physicians) married in 1950 and were a devoted couple. Always something of an eccentric, both in dress and other interests, in retirement in Devon Richard continued his reconstructive works on the garden with a 14-ton digger and a tractor! He delighted in fly fishing, with Margaret frequently accompanying him to paint one of her fine watercolour landscapes. Margaret sadly predeceased him in 2017. They are survived by two daughters, one a Professor of Medicine and the other a senior art teacher, six grandchildren (two of them doctors), and eight greatgrandchildren. By Prof. Chris Chapple EAU Secretary General

European Urology Today

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EAU Crystal Matula Award 2021 For a young promising European urologist The EAU Crystal Matula Award 2021 is the most prestigious prize given to a young promising European urologist aged 40 or under who has the potential to become one of the future leaders in academic European urology. The award will be presented at the Opening Ceremony of the upcoming 36th Annual EAU Congress in Milan from 9-12 July 2021. The list of previous awardees includes many well-known names: D. Tilki (2020), M. Albersen (2019), S. Silay (2018), C. Gratzke (2017), A. Briganti (2016), M. Rouprêt (2015), S. Shariat (2014), P. Boström (2013), P. Bastian (2012), S. Joniau (2011), J. Catto (2010), M. Ribal (2009), V. Ficarra (2008), M. Michel (2007), A. De La Taille (2006), M. Matikainen (2005), P. Mulders (2004), B. Malavaud (2003), M. Kuczyk (2002), B. Djavan (2001), A. Zlotta (2000), G. Thalmann (1999), F. Montorsi (1998), F. Hamdy (1996). Nomination Process National Societies can nominate a candidate by supplying the following documents: • Letter of endorsement • Motivation letter • Complete curriculum vitae

• List of publications in the below sequence: 1. Peer reviewed papers (including the impact factors of the journals) • Original articles • Reviews • Case reports 2. Book chapters or editor of books • Overview of grants received from (inter-)national institutions or from the industry • List of received Awards • The deadline for nomination is 1 February 2021. Please note that eligible candidates can also apply for this award by contacting their national urological society directly. The candidate is then expected to supply his/ her national society with a CV and the above mentioned documents, requesting a letter of endorsement. How to apply Please send your nominations to the EAU Central Office at m.smink@uroweb.org and mention “EAU Crystal Matula Award 2021” in the subject line of your e-mail.

The EAU Crystal Matula Award is supported by a grant of €10,000 from LABORIE.

Apply now!

LABORIE

EAU Prostate Cancer Research Award 2021 For the best paper published on clinical or experimental studies in prostate cancer With the goal to encourage innovative, high-quality research in prostate cancer, the EAU has launched the EAU Prostate Cancer Research Award. Supported by the Fritz H. Schröder Foundation, an expert jury will select the best paper dealing with clinical or experimental studies in prostate cancer. The award will be handed over at the 36th Annual EAU Congress in Milan, 9-12 July 2021 during the Opening Ceremony. Join this competitive search and help boost the quality of prostate cancer research in Europe! Rules and Eligibility • The topic of the paper should deal with clinical or experimental prostate cancer research.

• The paper must have been published or accepted for publication in a high-ranking international journal between 1 July 2019 and 30 September 2020, and submitted in English. • Applicants must be a member of the EAU. • The submitting author must be the first author of the paper or, by exception, the corresponding senior last author. • Applicants should only submit one paper. • Deadline for submission by e-mail is 1 February 2021. A review committee will screen all entries and an independent jury will select the best paper based on quality and merits. How to apply Inquiries and correspondence should be addressed to the EAU Central Office, at m.smink@uroweb.org, with “EAU Prostate Cancer Research Award 2021” in the subject line of your e-mail.

The award is supported by a grant of €5,000 from the FRITZ H. SCHRÖDER FOUNDATION. www.fhsfoundation.eu

European Urology Today

October/December 2020

“Urologists must ask patients what matters to them” EAU Patient Information’s new Chairman shares his vision on patient empowerment Ms. Patricia Chang EAU Patient Information Website & Social Media Coordinator Arnhem (NL) p.chang@ uroweb.org EAU Patient Information (EAU PI), the patient initiative of the European Association of Urology (EAU), is pleased to introduce its new Chairman: Mr. Eamonn T. Rogers. Mr. Rogers (Galway, IE) recently took over as Chairman from Dr. Mark Behrendt (Amsterdam, NL) who chaired EAU PI from June 2019 to September 2020 and headed the EAU PI Working Group. This group is an expert team of healthcare professionals consisting of urologists, specialist nurses and a uropathologist from several European countries who contribute to developing and updating EAU Guidelines-based content about urological cancers and diseases as provided on EAU PI’s website (patients.uroweb.org), and explore new ways to further develop EAU PI. In the following sections, you will find highlights of Mr. Rogers’ vision and strategy on improved patient care and empowerment. Vision of our new Chairman “In the future, urologists must continue to provide high quality patient care and improved patient access to urological services at an affordable cost to health providers. This will be particularly challenging as European urologists manage highly prevalent, chronic conditions including prostate cancer, benign prostatic hyperplasia, urinary incontinence and erectile dysfunction that consume financial resources, and are projected to increase in incidence as patients live longer.

EAU PI must address and innovate its approach to communication from multiple perspectives, the individual, interpersonal, institutional, community based, and policy level, all at the same time. This is likely to be far more effective than using a single approach, e.g. to the individual patient. This necessitates simultaneous communication and the development of links with multiple institutional and individual stakeholders, such as healthcare providers, patients, multidisciplinary health professionals and public health officials.

manner as the EAU lobbies the EU and statutory healthcare providers regarding cancer care, EAU PI should assist the EAU Executive to also lobby healthcare providers to provide patients with the tools and information to participate in their own care. Urologists must not just ask patients what’s the matter with them, but also what matters to them. Urologists enhance patient advocacy by empowering patients to become their own advocates, raising awareness about urological disease and focusing political attention.”

We welcome Mr. Rogers to EAU PI and wish him success in his role as Chairman. We are convinced In order to be influential, EAU PI must employ strategies developed by communication experts and behavioural economists, targeting those populations of urological patients that require the greatest support A track record in urology and engagement.” spanning over 25 years Collaboration with national societies “While EAU PI is strategically positioned to inform and advocate for patients, its approach must recognise Europe’s unique multiculturalism, reflecting cultural sensitivity among patients and healthcare providers. EAU PI must formally collaborate with the national societies, seeking linkages with their websites.” Mr. Eamonn T. Rogers

Mission within the scope of the EAU “The mission of the EAU is to raise the level of urological care in Europe, and for many years this has been done through educational and scientific programmes aimed at urologists. Patient expectations of healthcare delivery and outcomes are changing as technology permeates society and the healthcare economy. The EAU must reach out to urological patients, empowering them as allies to further enhance the quality of their care, raise patient awareness, educate urologists and patients, and demonstrate cost effectiveness.” Evolvement of patient empowerment “I feel the role of EAU PI in the next three to five years must evolve beyond information provision and act to empower patients to assist urologists in the management of their urinary conditions. In the same

Eamonn T. Rogers is an experienced and award-winning urologist and clinical advisor. In 1999, in conjunction with his colleagues, he received the Aneurin Bevan Award for exemplary management of urology patients at Central Middlesex Hospital, London. He is a former president of the Irish Society of Urology (20172018). His current positions are: National Clinical Advisor in Urology to Irish Healthcare System (HSE), Lead Urologist in the National Cancer Control Programme (Ireland), and Consultant Urologist at the University College Hospital Galway (Ireland). He recently received an adjunct appointment to the Department of Urology, University of Illinois at Chicago (UIC) College of Medicine, USA.

that Mr. Rogers’ contributions will bring the EAU patient information initiative to new heights. Questions or interested? If you would like to learn more about EAU Patient Information and its activities, or if you have any suggestions to improve our patient information, please do not hesitate to e-mail us at: info.patientinformation@uroweb.org. Please feel free to visit our website (patients.uroweb.org), and follow us on Twitter (@EauPatient) and Facebook (@EAUPatientInformation).

He is a member of the following Societies: Irish Society of Urology, European Association of Urology, American Urological Association, and Société Internationale d’Urologie. His track record includes more than 40 peer-reviewed publications. Throughout his career, he was responsible for formal and informal tuition of both undergraduates and fellow postgraduates at University College Hospital Galway, Royal College of Surgeons in Ireland, Baylor College of Medicine and University of Dublin, Trinity College. He presented at regular surgical meetings and was responsible for unit presentations at clinical, radiological and histopathology conferences. His vision on the future endeavours of EAU PI includes the following: “There will be challenges for EAU PI over the next three to five years. Urologists can help patients understand the important role patients have in managing their own health challenges. The role of EAU PI is to enable this link. EAU PI must educate clinicians as to how data empower their patients to achieve improved yet efficient health outcomes, nurturing relationships with existing patients while reaching out to new patients. Furthermore, EAU PI initiatives must reflect sensitivity to patients’ gender, age and vulnerability.”

ESOU21: To infinity and beyond! Virtual congress offers ‘the best of the best’ in genitourinary cancer “When I was in Dublin (IE) for my first ESOU meeting as chairman of the section on 20 January 2020, I could never have imagined the massive impact the COVID-19 outbreak would have on cancer diagnosis and treatment”, says Professor Morgan Rouprêt. Indeed, oncology was (and still is) ‘collateral damage’ of the pandemic crisis. Oncological care greatly hampered The clinical resources of hospitals were focused on COVID-19 patients. Cancer diagnosis and treatment was difficult. Patients already diagnosed with cancer were reluctant to come to the hospital to get their treatment or to follow up on their disease as scheduled initially. Consequently, more advanced and metastatic cases were diagnosed after the lockdown compared to the same period a year before.

Register now! Deadline: 31 January 2021 Ongoing research trials were delayed as the enrolment of patients slowed down massively, thus disturbing huge investments aimed at answering important scientific questions in the field of oncourology. Lastly, all physical congress and scientific events became virtual. Scientific education is still there, but there is less networking and social interaction. Prof. Rouprêt: “Nobody knows what the effects will be. How will important new data be spread in the onco-urological community?” The COVID-19 situation seems lasting and as it continues, we need to be flexible and adapt to this ‘new world’ as much as we can. “The COVID-19 outbreak has not only changed our view of the world and our organisation, but also our behaviour and the way we will continue to raise the level of knowledge in the field of onco-urology”, according to Rouprêt. Before all this happened, the ESOU launched a very timely programme (as it appears now) called October/December 2020

Prof. Morgan Rouprêt ESOU chairman

ESOU online. The first part of this online educational programme was launched during ESOU20 in Ireland: a bladder cancer module and a prostate cancer module. The typical length of an ESOU online module is 45 minutes at maximum and it consists of 3 parts: one state-of-the-art lecture, one lecture looking ahead (what is in the pipeline) and one clinical case evidence-based discussion. The faculty is always multidisciplinary and involves urologists, medical oncologists and radiation oncologists. The format is more or less the same. Prof. Rouprêt: “We had the opportunity to record another module about prostate cancer during the lockdown. There is more to come! An increasing number of colleagues dealing with oncology is interested in and attracted by our multidisciplinary vision of oncology.”

For the complete ESOU21 Scientific Programme visit www.esou21.org One chairman from the ESOU board is always leading the discussion. The videos are announced on Twitter and Facebook. They are visible on the EAU YouTube channel (https://www.youtube.com/c/uroweb), on the onco-urological platform of the EAU https:// uroonco.uroweb.org/ and soon on the platform of European Urology Oncology, our official ESOU scientific journal (https://euoncology. europeanurology.com)

Fully virtual ESOU21 congress Obviously, our ESOU21 congress will be a fully virtual event organised from 29 to 31 January 2021. The ESOU board came up with a wonderful and eclectic programme about new insights obtained in onco-urology in 2020. Several 1-hour sessions will be available to the audience with live debates, pre-recorded lectures and video sequences about the following subjects: 5 about prostate cancer, 3 about renal cancer, 2 about bladder cancer and 1 about rare tumours. Moreover, one session will cover the best articles released in onco-urology. This is done with the support of our official journal, European Urology Oncology, and the STEPS session aiming at identifying the rising stars in onco-urology in Europe with the help of Key Opinion Leaders. Prof. Rouprêt says: “We will preserve our lectures in collaboration with the SUO and the research section of the EAU (ESUR). Combined with our close

Join the conversation at #ESOU21 collaboration with the European School of Urology (ESU) and the robotic section (ERUS), we will come up with ‘the best of the best’ in genitourinary cancer, including established leaders, newcomers (from previous STEPS edition) and rising stars from the ESOU network.” “Finally, I would like to emphasise that despite the pandemic, cancer is unfortunately killing more and more people worldwide each year. Our duty as ESOU section is to keep moving forward in the direction of sharing the most recent knowledge about cancer and to be as flexible as we can to adapt to the current situation. I hope to see you online soon!”, Rouprêt concludes.

ESOU21 18th Meeting of the EAU Section of Oncological Urology 29-31 January 2021 www.esou21.org

Virtual meeting

European Urology Today

Urology Week 2020 recap Surprising ED findings, top social media posts & new posters Every year, Urology Week aims to increase public awareness on common urological conditions: what are they, how to prevent them, what symptoms to watch out for, and what treatments are available. This year’s Urology Week, which took place from 21 to 25 September, centred on erectile dysfunction (ED). Although this year's Urology Week only included online activities, the reach and support through social media, the international press, and the support of several national societies was expansive.

21-25 SEPTEMBER Survey says… The European Association of Urology (EAU) commissioned a new survey wherein over 3,000 members of the public from Spain, France, Germany and the UK were asked about their knowledge of and experience with ED. The survey revealed that ED awareness is alarmingly low in men and women aged 20 to 70, and a majority of the respondents do not know what ED entails. One in four has never heard of any of the seven most common treatments for ED. A quarter of the respondents who have ED or have a partner who has/had ED, stated they do not talk about it. Know more about all the findings of this survey via the press release (available in five languages) which is found in www.urologyweek.org/for-press. Based on the information disseminated in the press release, 39 articles from 14 countries were written. This infographic is based on the survey, which Boston Scientific supported through an educational grant.

Ein Tattoo ist kein Tabu... Aber über Erektile Dysfunktion zu sprechen, schon. Lassen Sie uns das Schweigen brechen.

Twitter stats

Facebook reach

Urology Week 2020 tweets have accumulated 122,408 lifetime reach and 3,096 engagements. The most popular tweet has shown the high prevalence but low awareness of ED.

With 20,570 lifetime reach and 703 engagements, Urology Week 2020 also left a mark on Facebook. The top Facebook post announced the eye-opening survey mentioned in this article.

Instagram coverage

LinkedIn posts

Ten Instagram stories and two posts garnered 4,260 lifetime reach and 3,612 engagements. The leading post has shown the prevalence of ED and its definition.

Much like the popular Urology Week 2020 post on Instagram, the top LinkedIn post was also about ED definition and the surprising number of low ED awareness. Urology Week 2020 posts on LinkedIn has accumulated 7,075 lifetime reach.

Haz que vuelva arriba!

Don’t let anything stop you. Erectile dysfunction (ED) can affect many aspects of your life. Talk to your urologist about ED and ask about the best treatment for you.

La salud sexual es una parte importante en tu vida. No lo escondas! #UROLOGYWEEK

#UROLOGYWEEK

New campaign posters To start relevant discussions, share experiences, and break taboos, Urology Week 2020 created and featured new campaign posters to help spread the word. Due to popular demand to have the posters in various languages, the posters in English were translated in 9 languages. View the posters via www.urologyweek.org/healthcare-providers/awareness-campaign

#UROLOGYWEEK

urologyweek.org Supported by Boston Scientific

urologyweek.org

urologyweek.org Supported by Boston Scientific

For more information about Urology Week, please visit www.urologyweek.org 28

European Urology Today

EuropeanOctober/December Urology Today 20201

YAU - Urothelial Cancer group New chairman takes over in challenging times Dr. Marco Moschini YAU Urothelial Cancer Group Luzerner Kantonsspital Dept of Urology Lucerne (CH) marco.moschini87@ gmail.com It has been a great honour to take the lead of the YAU Urothelial Cancer Group this month after the incredible work Evanguelos Xylinas did. Under his supervision the group reached many successes, with

fruitful collaborations, research projects and real friendships between the team members. Many of the members he selected became leaders in the field of urothelial cancer. Inspiring answer Before I took the lead, I had the opportunity to ask Evanguelos for some suggestions regarding the role I should play. I also asked him about the meaning of the YAU itself. I found his answer inspiring and would like to share with you all. He said that the point of such a group is more than `just` publishing articles; it is about making young, motivated and talented urologists grow and improve. YAU is a unique platform which gives its members the opportunity to meet other physicians with the same interest and

passion, so they can work together to improve. New young members Many more members left the group after reaching the age limit (40 years) as did Evanguelos. I would like to thank them for their outstanding contributions to the YAU over the past years. Simultaneously, it gives new young members the possibility to apply and to enter into the group. I think diversity should be one of the main values of the group. We welcome physicians from different parts of the world, and even nonurologists, but also young oncologists, pathologists, radiologists or radiotherapists are very welcome to the team. Having different points of view is fundamental to finding the answers to many relevant questions, but is also essential to finding new important questions.

Online meeting Two weeks ago, we had our first ZOOM meeting and all the 10 members managed to stay connected for a 3-hour discussion, which I believe demonstrates what passion and dedication mean. Unfortunately, the COVID situation prevents us from organising real life meetings, but even with this modality we were able to discuss and start exciting new projects for the future of the group. Finally, I would like to ask: what is the YAU urothelial group mission? It is finding future urothelial cancer leaders and defining the main research challenge in the field they will try to solve. If you think you can contribute and you are younger than 40 years of age, I would like to invite you to apply!

Third edition of HUCAD: The last course before COVID-19 Human cadaveric advanced laparoscopic 3D postgraduate course held in Lisbon (PT) Just before the start of COVID-19 epidemic in Europe, the 3rd edition of the human cadaveric advanced laparoscopic 3D urology postgraduate course (HUCAD) took place from 19-21 February 2020 in Lisbon (PT). The course was organised in the NOVA Medical School in the beautiful city of Lisbon by an international faculty of experts in laparoscopic urology, lead by Dr. Nuno Domingues (PT). Special embalming technique The course lasted three days. Eighteen participants from different countries in Europe, Asia, Central and South America attended the course under supervision of more than 20 experts in laparoscopic urology. NOVA Medical School organised the course in association with the department of anatomy that prepared cadavers for hands-on training. The school is renowned for their special embalming technique that allows for longer preservation of cadavers. These cadavers simulate reality very accurately and are excellent tools for surgical lab training. Before attending the course we received materials (written,

Dr. Milena Taskovska Dept. of Urology University Medical Centre Ljubljana (SI)

milenataskovska@ gmail.com videos) to prepare for the course. The course was very intensive: 10 hours per day. It consisted of three parts: kidney (days 1 and 2) and prostate (day 3). Postgraduate training diploma Every day started with an introduction to the daily programme, theoretical lectures on surgical techniques with tips and tricks, warming up on the pelvitrainer and practical hands-on training on cadavers. We worked in groups of 3 at 6 stations.

Every station had its own mentor and cadaver to practise with. During the course, we had ample opportunity to perform laparoscopic pyeloplasty, laparoscopic partial nephrectomy, laparoscopic nephrectomy, laparoscopic prostatectomy and lymphadenectomy. Every participant had the opportunity to perform different phases of procedures based on previous experience. The course was concluded with a test and an assignment to write a paper on a topic regarding laparoscopy in urology. Every participant who fulfilled all requirements received a postgraduate training diploma.

“It was a great opportunity to learn tips and trick on laparoscopic urology from experts and practice on cadavers - an almost perfect simulation of a real situation.”

Almost perfect simulation The course was excellently organised! It was a great opportunity to learn tips and tricks on laparoscopic urology from experts and practice in cadavers - an almost perfect simulation of a real situation. It was also a great opportunity to meet urologists and urology residents from different countries/continents and share experiences. Finally, I would like to thank the organising committee, mentors, nurses and technical staff who made sure the course was running smoothly and provided a very pleasant environment to learn new surgical skills. I am looking forward to the 4th edition of HUCAD. Obrigado! More information on twitter at: https://twitter.com/ militasko and https://twitter.com/UrologyHucad

ERUS-DRUS20: Meeting attracts new global audience Live surgery meeting well-placed to go virtual after years of experience The EAU’s premier robotic urology event took place on November 6-7. Not in Düsseldorf as originally intended (and long hoped for), but as a two-day virtual event. The EAU Robotic Urology Section has years, if not decades, of experience with live transmissions of surgery from all across the world so it was well prepared for holding a virtual meeting. Close to 1200 participants registered to take part, turning the drawback of an online-only event into an advantage of reaching a much larger audience than usual. ERUS Chairman Prof. Mottrie (Aalst, BE) welcomed viewers on Friday morning, kicking off two days with six live surgery sessions, covering 18 procedures. This year, ERUS co-organised the meeting with the German Society of Robotic Urology (DRUS), as a joint ERUS-DRUS20 meeting. Prof. Mottrie’s meeting co-organiser Prof. J.H. Witt (Gronau, DE) was one of the first surgeons to start his procedure at ERUS20, performing a full anatomical RARP with headsetbased team communication. Prof. Witt: “It was radical prostatectomy with complete anatomical preservation of the surrounding structures and it went quite well. We had some very interesting discussion on technique with moderators Profs. Rocco and Dasgupta, who also passed on questions from the audience.” “It was pretty straightforward case. It demonstrated the headset team communication approach in the OR. Everyone is connected which makes communication process during surgery much easier.” Next to deploying the latest in communication technology, Witt also demonstrated the preparation of the prostate for intraoperatively frozen section and evaluation through confocal microscopy. Other highlights of Friday include updates on robotic guidelines, a demonstration of a (nearly) sutureless technique for RAPN, and RARP after TURP (with October/December 2020

VIRTUAL 6-7 November 2020

confocal microscope). The sessions were a seamless mix of pre-recorded “as live” cases and live broadcasts from all across the world. International participation Saturday morning started with three plenary sessions organised jointly with the Asian Robotic Urology Society (ARUS), the Chinese Urological Association (CUA) and the Chinese Anti-Cancer Association Genitourinary Oncology Committee (CACA-GU). Taking advantage of the different time zones, the audience saw some procedures carried about robotically for indications that are more rare in Europe. Prof. Mottrie: “Last year some of us went to the ARUS meeting and we were happy that they returned the favour by taking part in our meeting. We’re working closely together with our colleagues in Asia, they have fantastic robotic surgeons. We’re not only working together scientifically, but also when it comes to challenge but Prof. Mottrie and I worked closely together to make it possible with the help from the robotic education and training programmes.” scientific committee and the congress organisers.” During the session, Prof. Mottrie pointed out that the audience was seeing procedures that are much more Prof. Mottrie was pleased that an advanced virtual rare for European surgeons and are generally not congress platform meant that while the meeting was performed robotically. “Radical nephrectomy with shortened to two days, a lot of the sessions could still very large tumours and cavathrombusare more rare in go ahead. ERUS-DRUS20 featured four virtual rooms, Europe, probably due to more routine checks. In Asia, letting viewers choose which sessions they wanted to see. “Thanks to the platform, they can also always robotic techniques have been developed for these indications,” Mottrie explained. watch back what they initially missed.” Going virtual Prof. Witt was understandably disappointed to not host the ERUS-DRUS20 meeting in Düsseldorf as initially conceived. “The ongoing pandemic situation forced us to postpone the Düsseldorf meeting to next year. For quite a while we were still hoping to have a regular meeting but about two months before it became clear that it would not be possible to host large groups of surgeons from all over Europe. Reimagining the scientific programme was a

“It’s our first meeting with Edu4health, the developers of the congress platform. On the first day we had some minor technical difficulties but these were rapidly resolved. It’s a learning process for everyone involved. The quality of the live video streams were just about the best available.” Collaborative meeting ERUS-DRUS20 marks a joint, collaborative meeting between ERUS and its German equivalent. The

Clockwise from top left: Profs. Rassweiler, Wiklund, Stolzenburg and Rocco bid the virtual audience adieu at the end of the first day of ERUS20

scientific programme was composed with input from DRUS, and was expected to attract a lot of German delegates. With the change to a virtual meeting, and the postponement of the Düsseldorf meeting, this collaborative aspect was also postponed somewhat. Prof. Witt: “In retrospective it’s difficult to say which topics were proposed by the German or the European colleagues, but the programme was developed with everyone’s involvement. Next year will also be an ERUS-DRUS meeting, so in fact it’s two years of combined meetings.” Prof. Mottrie hailed the collaboration, pushing for even closer integration with DRUS. “Over the coming months we hope to achieve a very strong and more centralized collaboration. I think this will lead to quicker and more effective decision-making, if we speak with one voice. We see the ‘ERUS’ model works in Asia, in North America and it is my hope that ERUS and DRUS together can become one pan-European initiative.” European Urology Today

EAU Best Papers published in Urological Literature Awards

Apply now!

To be awarded at the 36th Annual EAU Congress in Milan, 9-12 July 2021 The two EAU Prizes for Best Paper published in Urological Literature are tools through which the EAU encourages young and promising urological scientists to continue their work and to communicate their achievements to the European urological community. Two awards of € 5,000 each will be made available for the two Best Papers published in Urological Literature on Clinical and Fundamental Research. These papers have to be published or accepted for publication between 1 July 2019 and 30 September 2020. The awards will be handed out at the 36th Annual EAU Congress in Milan, 9-12 July 2021. Rules and Eligibility • Eligible to apply for the EAU Best Paper published in Urological Literature are urologists, urologists-intraining or urology-related scientists. All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • The paper must be written in English (or translated into English).

• The subject of the paper must be urological or urology related. • The deadline for submission is 1 February 2021. How to apply • Please send your paper by e-mail to m.smink@uroweb.org, indicating clearly the category in the subject line: “EAU Best Paper on Clinical Research” or “EAU Best Paper on Fundamental Research”. • Include a copy of your curriculum vitae. • Supply a list of all authors who have significantly contributed (if relevant). • Mention any financial support by companies, government or health organisations. • A publisher’s letter of acceptance has to be submitted along with your paper. A review committee consisting of members of the EAU Scientific Congress Office will review all submitted papers and select the winner of the two EAU awards for Best Paper published in Urological Literature.

EAU Hans Marberger Award 2021 For the best European paper published on Minimally Invasive Surgery in Urology The EAU Hans Marberger Award will be handed out for the best European paper published on Minimally Invasive Surgery in Urology. The award, annually given since 2004, is named after Prof. Hans Marberger to honour his pioneering achievements and contributions to endourology and the development of urologic minimally invasive surgical procedures. The award will be handed over at the 36th Annual EAU Congress in Milan, 9-12 July 2021 during the Opening Ceremony. Rules and Eligibility • All urologists and scientists are invited to send in papers. • The topic of the paper should deal with Minimally Invasive Surgery in Urology. • The paper must have been published or accepted for publication in a European Journal between 1 July 2019 and 30 September 2020.

Apply now!

• All papers must be submitted in English. • All applicants have to be a member of the EAU. • The submitting author must be either the first or the corresponding senior last author. • Each author is allowed to submit no more than one paper. • Deadline for submission is 1 February 2021. A review committee, consisting of members of the EAU Scientific Congress Office, will select the winning paper. How to apply Please send your paper to the EAU Central Office at m.smink@uroweb.org and mention “EAU Hans Marberger Award 2021” in the subject line of your e-mail.

The EAU Hans Marberger Award is supported by a grant of €5,000 from KARL STORZ SE & CO.KG

European Urology Today

October/December 2020

Former EAUN Chair elected AAN Fellow 20 years of serving the public and the nursing profession by advancing health policy, practice, and science Susanne Vahr, RN, MEd, PhD Chair EAUN Copenhagen (DK)

s.vahr@eaun.org

pandemic the festive event in the United States, during the AAN conference had to be cancelled this year, unfortunately. Bente has been working in the EAUN since 2007. During these 13 years, she has contributed to the development of urology nursing in many different roles: as chair of EAUN, member of the Scientific Congress Office, developing guidelines, and recently as chair of the Special Interest Group on Bladder cancer. Bente also takes part in developing patient information with the EAU.

Co-author: Nora Love-Retinger (US) Bente's ability to network and create essential collaborations globally is remarkable. Bente met Nora The EAUN wants to congratulate Bente Thoft Jensen, RN, MPH, PhD, Department of Urology, Aarhus Love in 2008 at a Society of Urologic Nurses and Associates (SUNA) meeting in Philadelphia, where Bente University Hospital, Denmark, on her election as a Fellow in the American Academy of Nursing (AAN). represented the European society as President of the EAUN. Our colleague Nora states: "I was impressed with The virtual induction of Bente Thoft as a Fellow into the her work with Bladder Cancer patients; I could only American Academy of Nursing took place on 31 October imagine what it would be like to work in partnership last, and was live streamed. Due to the COVID-19 with such a force. Who would have thought our paths would cross again one year later in Stockholm at the 10th International EAUN Meeting. There, we talked about European Association of Urology Nurses our patients' similarities, despite the difference in

geography, politics, socioeconomics, and healthcare policy. Connecting again that year in Chicago at the SUNA meeting, we collaborated on a comparison study of cystectomy patients and their nutrition assessment as it affects the length of stay. This study indicated that our patients were comparable, leading to replicating Bente’s prehabilitation study at Memorial Sloan Kettering (MSK). Bente accepted a 7-month Surgical Fellowship at MSK, where we conducted the study culminating in a presentation at the American Urological Association and a publication in Urologic Nursing." In addition to conducting research while at MSK, Bente also mentored the urology nurses to become more involved and elevate their practice. This mentoring included supporting nurses with research, presenting at international conferences, publishing, and completing advanced degrees. The urology nurses now better understand their patients and how a nurse can influence outcomes through data analysis and evidence-based practice. Collaborations continue here in the United States with colleagues at Mt. Sinai Hospital, including Dr. Nihal Mohamed, leading to additional work in the bladder

Bente Thoft Jensen, Aarhus (DK)

patient's unmet needs and quality of life, always advancing nursing practice to the highest quality of care. Presently, Bente is co-chairing a multinational group working on a systematic review of pre- and post-habilitation. Once again, driving urology nurse initiatives on a global scale to improve patient care. In being elected as a Fellow in the American Academy of Nursing (FAAN), Bente truly exemplifies this prestigious institute's tenets, enhancing the quality of healthcare and nursing. Through her unwavering commitment to quality care, Bente has strengthened nursing and health delivery systems nationally and internationally.

Bile acid loss syndrome A phenomenon associated with specific urological operations

veronika.geng@ msstiftung.de

Bile fluid is produced in the liver (approx. 900 ml /24 h) and stored in the gallbladder. Together with the pancreatic secretions, the bile is released into the duodenum and reabsorbed and reused in the enterohepatic circulation. Bile is necessary for good digestion and contains bile acid, cholesterol, phospholipids and bilirubin, fatty acids and proteins. During food intake, bile acid is released into the small intestine, where it helps to break down the nutrients, especially fats. This enables the body to absorb the fats. Bile acids act as a "solvent" for cholesterol and supports the absorption of the fat-soluble vitamins A, D, E and K. The bile acid is reabsorbed into the bloodstream at the lower end of the small intestine (terminal ileum) and returned to the bile acid circulation. In addition, the bile fluid reduces the acidity of the food from the stomach.

Bile acid that is not reabsorbed ends up in the colon where it does not belong. There it prevents the reabsorption of water from the colon and stimulates peristalsis. As a result, liquid stool is excreted, is partially uncontrollable and can thus also lead to incontinence. This phenomenon is often described in connection with irritable bowel syndrome. However, a group of urological patients can also be affected: patients who have received a bladder augmentation or a neobladder and for whose reconstruction the terminal ileum was used. Symptoms • Diarrhoea (Chologene diarrhoea) • Fatty stools • Cramp-like pain, which is often relieved by abstinence from food. • Low levels of fat-soluble vitamins A, D, E and K can be associated with the loss of bile acid. • Since the bile acid is not reabsorbed, there is a deficiency of bile acid in the gallbladder. This can lead to gallstones.

4C-glycocholate breath test After oral administration of 14C-glycocholate, there is increased exhalation of radioactive carbon dioxide. This is caused by the increased bacterial metabolism of bile acids in the large intestine (colon). The procedure is rarely used. Detection of bile acid in stool using enzymatic, chromatographic or mass spectrometric methods is only carried out within the framework of scientific studies. Therapy If possible, search for and treat the cause of the loss of bile acid (e.g. Crohn's disease).

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Susanne Vahr (DK) Paula Allchorne (UK) Jason Alcorn (UK) Jerome Marley (GB) Tiago Santos (PT) Corinne Tillier (NL) Jeannette Verkerk (NL) Giulia Villa (IT) Franziska Geese (CH) Ingrid Klinge Iversen (NO)

www.eaun.uroweb.org The symptoms of diarrhoea after neobladder or bladder augmentation can be positively influenced with exchange resin (cholestyramine). The correct dosage for treating the symptoms while preventing constipation, should be determined empirically. In the case of bile acid loss syndrome after using the terminal ileum for a urological operation the diarrhoea stops immediately after taking the first dose of cholestyramine.

Under normal physiological conditions, calcium is bound to oxalic acid in the intestine and thereby excreted. In fatty stools, calcium is bound to fat and thus increasingly absorbed in the small and large intestine. This can lead to oxalate stones in the area of the draining urinary tract. Causes Causes of the bile acid loss syndrome are diseases of the ileum (Crohn's disease) but also surgical interventions using parts of the terminal ileum, e.g. bladder augmentation or neobladder. Diagnostics Optical: Detection of fatty stool From certain causative factors, the bile acid loss syndrome can be deduced. I.e. if terminal ileum fails in its function due to illness or surgery, one can assume that the bile acid loss syndrome occurs.

Enterohepatic circulation of bile acids By Frank Boumphrey, CC BY-SA 3.0, https://commons.wikimedia.org/w/index. php?curid=7006980

October/December 2020

SeHCAT test (SelenoHomoCholic Acid Taurine test) Nuclear medical test for the diagnosis of bile acid loss syndrome. Radioactively marked bile acid (selenohomocholic acid taurine, Se-HCAT) is administered orally and then measured with a whole-body counter. The measured values can then be used to calculate bile acid excretion. The test is not a routine procedure.

Often an acid binding agent - e.g. cholestyramine - is administered on a trial basis. If the diarrhoea and other symptoms are thereby eliminated, it can be assumed that the cause of the diarrhoea is bile acid loss.

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Veronika Geng, RN Manfred-Sauer-Stiftung Lobbach (DE)

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European Urology Today

Working together to improve healthcare through EAUN Upcoming Norwegian board member introduces herself to the membership Ingrid Klinge Iversen, RN EAUN Board Member Elect Kristiansund Sykehus Dept. of Urology and General Surgery Kristiansund (NO) icki@online.no Dear EAUN members, My motivation to apply to become a member of the board started while working on the latest prostate EAUN Guidelines, and has grown after attending the EAUN conference in 2019. I am professionally

engaged and love constantly gaining new knowledge - I think that is one of my strengths. I have also been professionally involved as a member of a national group for improving catheterisation equipment in Norway. I find it inspiring to teach and have taught on the Norwegian National Nursing Day and on a course for Urotherapists discussing Patient cases, both children and adults. I am an engaged Urotherapist and I teach urological topics in our hospital, such as catheterisation and other subjects. I have a collaboration with nurses in the municipality and teach them about catheterisation and about leakage problems in children. To tell you a little bit about my professional background, I would like to mention that I qualified as a State Registered Nurse in 1992 (Oslo, Norway)

and started my career at Kristiansund Hospital on the northwest coast of Norway. I now work with urological topics - as a urotherapist - in an outpatient clinic of the same hospital. I also have two qualifications for further education: Specialist Nurse in Rehabilitation (Ålesund, 60 study points) and Urotherapy (Bergen, 60 study points). As a urotherapist, my main responsibilities include patient observation through various urological tests, urodynamics tests, and to take medical histories and guide patients to better cope with their illnesses. I monitor paediatric and adult patients with various bladder dysfunctions, assist urologists performing prostate biopsy and do the follow-up for patients who have undergone radical prostatectomy for prostate cancer.

For the last 12 years, I have been involved in conducting a 2-day course for patients who have or have had prostate cancer twice a year. By joining the EAUN Board I hope I can use my qualities and engagement to work together with other people in Europe for better healthcare in Norway and other European countries. Together we can achieve much more! I’m looking forward to seeing you all at the next International EAUN Meeting in Milan. With kind regards, Ingrid Charlotte Klinge Iversen European Association of Urology Nurses

EAUN Fellowship Report Learning experience at Berne University Hospital (Inselspital), Switzerland, 6-19 July 2020 Eleni Zouzoula, RN, MSc General Hospital of Santorini Santorini (GR) Eleni Zou elenitsazou@ gmail.com My name is Eleni Zouzoula and I am a registered nurse from Greece. In 2014 I completed my nursing studies. In 2019 I earned my master degree in Health Science Informatics and now I’m studying for my second master degree in Health Services Management. I have been working at the General Hospital of Santorini since 2016, mostly at the emergency department. Santorini is a small and popular island in the South Aegean of Greece. It is considered to be the lost Atlantis. Santorini is well-known for its beautiful sunset, the volcano and sea view from the caldera, attracting more than 1 million tourists per year, especially during summer. The General Hospital of Santorini is one of the three general hospitals in Cyclades. It is located in Karterados, a village of Santorini, and is open 24 hours a day. It is equipped with 37 beds and has 154 employees. The health services are divided into two sections, the surgical and the clinical section. The urological cases fall within the surgical field, as there is no autonomous urological department. However, there is a urological office at the outpatient clinic, as well as facilities for urological patients to get examined at the emergency department, operated in the operation theatre and hospitalised at the main clinic. Every year the hospital admits approximately 450 urological patients. The hospital employs 1 urologist and the main fields of action are: UTI, stone treatment of the urinary tract, urinary retention and neurogenic bladder. Main operations taking place are: TURP and testicular torsion. The nursing team consists of 1 nurse director, 2 head nurses, 17 registered nurses and 8 assistant nurses. Each member of the team is responsible for many care tasks and aims to provide high quality nursing care with respect for the patients’ needs. Fellowship programme As a young nurse and restless spirit who supports lifelong learning and education, I didn’t have to think twice when I received the e-mail about the fellowship programme, I just applied! It was a great opportunity to visit a differently organised European hospital for two weeks and to enrich my knowledge on nursing practice. In my home hospital, unfortunately, I have not yet had a chance to see that many urological cases. The reasons that convinced me to apply for Berne University Hospital were the wide range of modules offered, most of them were unknown to me, and the opportunity to observe the clinical processes European Association of Urology Nurses

European Urology Today

and approaches. I had the intention to learn as much as possible and apply this to my everyday clinical care practice. Host Institution Berne University Hospital, Inselspital, has excellent facilities, is very organised and uses up to date equipment. The medical and nursing staff is well educated and ready to deal with every medical case they have to face. The Swiss healthcare system is regulated by the Swiss Federal Law on Health Insurance and there are no free state-provided health services. Private health insurance is compulsory for everyone residing in Switzerland. The Department of Urology is located in the Anna Seiler-House of the Inselspital. The clinic was founded in 1941 by Professor Wildbolz and today it consists of 45 beds and is the largest stone-treatment centre in Switzerland. In the outpatient clinic, comprehensive and modern treatment is given to about 10,000 urological patients per year. About 2,000 patients receive inpatient treatment, including the day care clinic, plus 500 day care patients per year. Multiple specialised treatments are offered, such as minimal invasive prostate treatment and extensive reconstructive surgery for all urological disorders. The programme was as follows: Tuesday 7 July • Welcome & introduction to the Department of Urology Wednesday 8 July • Visiting the operation theatre: cystectomy and ileal conduit • Attending the educational meeting Thursday 9 July • Accompanying the nurse for patients with neobladder and ileal conduit • Pelvic floor training Friday 10 July • Operation theatre: URS Stone treatment Monday 13 July • Urostoma Care • Palliative Care Tuesday 14 July • Operation Theatre: TURP Wednesday 15 July • ICU • Attending the educational meeting Thursday 16 July • Bladder dysfunction, intermittent selfcatheterisation Friday 17 July • Accompanying the nurse at the ward

The ward The ward consists of two floors with single, double and triple rooms. The nurses of the ward were friendly and full of smiles. They explained to me what they did and how they organised patient care. They are responsible for three or four patients and they take care of all their individual needs. Patients stay at the hospital alone, so nurses are the persons that take care of patients and patients can rely on them for everything. In Greece is not the same. There is a shortage of nurses in every hospital, which means that they do not have the time to provide all the necessary care. For this reason, the patients’ relatives contribute to their care. Outpatient clinic In the outpatient clinic, nurses specialise in various fields. I accompanied Daniela, a nurse specialised in self-catheterisation. That day, she taught a male patient how to self-catheterise. This procedure took 1 hour and a half. They tried it three times with different types of catheters, until the patient felt comfortable trying it at home and figure out which one is easier for him to use. She explained each step of the catheterisation to the patient in detail and also answered his questions and concerns. Palliative care At the palliative care centre, I had the pleasure of meeting Mrs. Monica Fliedner, a nurse specialised in palliative care. She showed me around in the centre and in the meantime we had a conversation on what palliative care means and can offer and about the SENS structure for palliative assessment and planning. Palliative care is more than just painkillers. Monica explained to me that nowadays, with the coronavirus in the foreground, palliative care can play a very important role, and take away some of the workload from other nurses, as palliative care nurses will talk to the patients and their relatives about end-of-life decisions and offer them alternatives.

The city Berne is the capital of Switzerland and the most beautiful city I’ve ever been to so far. Berne is built on the banks of the river Aare and there are water fountains almost everywhere; you never miss the pleasant water element. This city is peaceful, green, clean and well-organised. There are pathways close to the river banks where you can have a walk, bike or jog, as well as have a picnic or swim in the river. The city offers places with outstanding views, like Gurten and Rosengarten. The Swiss are friendly and always willing to provide directions in English if anyone asks, even if 4 other languages are spoken: German, French, Italian and Romansh. Take home messages After having two wonderful weeks in Berne, I returned to Greece full of new knowledge, new friends and good memories. I observed the differences in the way nurses work in Greece and in Switzerland and returned home hoping that nursing care and health services in Greece will get better soon. Acknowledgements First of all, I would like to thank Mrs. Rita Willener for her hospitality and the dinner she organised at her home to welcome me and the special programme she created based on my needs.

Operation theatre The second day of the fellowship programme included a visit to the operation theatre. It was the day that impressed me the most. I had the chance to see a cystectomy and how a stoma with external drainage was being created. After the operation, Kathi Ochner, an expert urology nurse, explained to me how the patients are trained in order to take care of their stoma and get used to the change in their body image, the advantages and side effects of it and what the patient should take care of in the first three months post-operatively.

A beautiful view on the river Aare in Berne, Switzerland

I would also like to thank the EAUN for giving me the opportunity to visit another European country and a well organised Urology Department.

Prof. E. Wildbolz, founder of Inselspital’s urology clinic

And finally, I would like to thank everyone I met at the Inselspital and especially Ana Patricia Da Silva, Kathi Ochsner, Natalie Tschan, Margret Palermo, Barbara Roth, Doris Kisslig, Monica Fliedner and also Angelos Tasios, the Greek doctor who helped me by offering simultaneous translation. October/December 2020