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Cowbells and conundrums – the 3rd Advanced Prostate Cancer Consensus Conference

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by Professor Declan G Murphy

Urologist & Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia

Twitter: @declangmurphy

The 3rd Advanced Prostate Cancer Consensus Conference (APCCC) took place in Basel in late August 2019, and the subsequent manuscript was published in European Urology just recently. We delayed posting this blog until now as the recommendations were under embargo until the manuscript went online. As with the previous two APCCC events (which took place in St Gallen; the so-called “St Gallen meetings”), this “Basel meeting” and its resultant recommendations are certain to provoke discussion due to the contentious nature of the topics which feature. Indeed, much of the raison d’etre of the meeting is to create recommendations from key opinion leaders to help guide decision-making in prostate cancer, particularly in areas where confusion exists, and where traditional guidelines are not clear.

The format is as follows:

  • The meeting takes place every two years and includes two full days of plenary sessions from world leaders, and one half-day of voting to try and achieve consensus on hot topics
  • 72 of the world’s leading experts in prostate cancer are invited to deliver plenary addresses, and more than 750 delegates from 65 different countries
  • Ten areas of controversy are featured in the plenary sessions, and invited experts participate in a live vote on the final day to see if consensus can be reached. More than 120 questions are selected by the panel over the previous few months.
  • The level of consensus was defined as follows: answer options with 75% agreement were considered consensus, and answer options with 90% agreement were considered strong consensus.
  • The results are published in a detailed manuscript (40 pages!) in European Urology

The meeting is convened by Dr Silke Gillessen and Dr Aurelius Omlin who are world-renowned experts in prostate cancer. One of the unique and most enjoyable aspects of the APCCC is the unashamed Swiss-ness which Silke and Aurelius bring to the meeting. The meeting is conducted in a very relaxed manner with excellent interaction between the Faculty which is part of the high value of the meeting. Of course, one would expect a meeting in Switzerland to run efficiently, and Silke and Aurelius wield a goat’s bell for the one minute warning; if you hear the cow bell, then the time is up!

 

As before, the invited panel is a truly global gathering of world experts in prostate cancer:


A truly global gathering of world leaders in prostate cancer

The ten areas of controversy for #APCCC19 are as listed below, followed by a summary of some of the notable areas of consensus, along with some areas of non-consensus.

  1. Locally advanced prostate cancer
  2. Biochemical recurrence of prostate cancer after local therapy
  3. Management of the primary tumour in the metastatic setting
  4. Management of newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), including oligometastatic prostate cancer
  5. Management of nonmetastatic (M0) castration-resistant prostate cancer (CRPC)
  6. Management of metastatic CRPC (mCRPC)
  7. Bone health and bone metastases
  8. Molecular characterisation of tissue and blood
  9. Interpatient heterogeneity
  10. Side effects of hormonal treatments and their management

It was interesting to note the proportion of voting panellists by discipline as listed below, in particular the healthy proportion of urologists in a meeting focussed on advanced prostate cancer:

And also by region as listed below.

Obviously a massive amount of territory gets covered during this meeting, but I have highlighted some of the key recommendations within each of the ten areas of controversy below:

Locally advanced prostate cancer:

This section featured plenary addresses on node-positive prostate cancer from myself and radiation oncologist Dr Mack Roach. There was strong consensus that some sort of loco-regional treatment with surgery or radiation (RT) should be offered to men with node-positive prostate cancer, combined with androgen deprivation therapy (ADT) for men undergoing RT. The impact of PSMA PET/CT in defining N1 disease was considered and was recommended for accurate staging (pending the read out of the proPSMA trial which had not yet been published). Regarding duration of ADT, there was no consensus with answers ranging from six months to three years.

Biochemical recurrence (BCR) of prostate cancer after local therapy:

One of the stand-out themes of this year’s APCCC was the impact of PSMA PET/CT for imaging prostate cancer, and Lu-PSMA theranostics as a treatment for mCRPC. I am pleased to say that much of the focus of this was on data from here in Australia, and there was much favourable comment on how Australia has led in this area. It is fair to say there was a reasonable amount of envy also for how much access we have to PSMA PET/CT compared to many other parts of the world. In one of the opening plenaries, Professor Ian Davis did a terrific job overviewing this, and did introduce some cautionary tones about the management impact of novel imaging.

There was consensus that PSMA PET/CT should be used for the assessment of BCR following radiation or surgery. This is a new recommendation compared with the previous meeting, and is in line with the most recent EAU Prostate Cancer Guidelines. What PSA level should we image at? Most discussion centred around a PSA of 0.2ng/mL or greater following surgery.

For patients undergoing salvage RT, there was consensus that this should be accompanied by a short period (4-12 months) of ADT. 83% of panellists voted in favour of offering salvage RT before PSA reaches 0.5ng/mL, with 37% offering RT before PSA reaches 0.2ng/mL. There was consensus that ADT alone should not be used for the majority of patients with rising PSA and no evidence of metastases following prior local therapy.

Management of the primary tumour in the metastatic setting

This was certainly a hot topic. There was much discussion around the role of RT to the primary in men presenting with metastatic prostate cancer (in addition to lifelong ADT), and the most recent data from STAMPEDE led to a strong (98%) consensus for the use of RT in men presenting with low-volume metastatic prostate cancer. Volume was defined based on conventional imaging using classic CHAARTED criteria. The recommended dose was 55Gy over four weeks as per STAMPEDE.

Should we extrapolate from this data and offer surgery as local therapy in the same group of patients? There was 88% consensus that we SHOULD NOT offer surgery, other than within a clinical trial. There was also consensus that patients with N1 disease should be offered RT to the nodes in addition to the primary.

Management of newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), including oligometastatic prostate cancer

This is clearly one of the fastest moving areas in advanced prostate cancer and there was much new data to consider. The panellists reached consensus on 12 areas of mHSPC including:

  • Nomenclature – there was 77% consensus that we should avoid the term “castration”, although there was not consensus on what other term we should use! In describing treatment-naïve men, it is easy as we can use the term mHSPC. However, when treatment resistance emerges, we are still left with mCRPC (87% consensus).
  • I must say there was an outstanding intervention from patient advocate, Mr Millman, after the initial round of voting on this topic, saying how much patients detest the use of the term “castration”. I could not have agreed more. This led to the convenors calling for a repeat vote with subsequent vote in favour of avoiding the use of the term.
  • 95% consensus for obtaining histological evidence of prostate cancer in men suspected of having M1 disease; 96% consensus that ADT could be initiated prior to biopsy.
  • Most striking – 100% of panellists voted for ADT combined with something else (docetaxel or an androgen receptor (AR) pathway inhibitor) in patients with de novo high-volume mHSPC. There was much discussion about which combination should be offered, but there was no consensus. The decision can be individualised based on patient factors and local registration and reimbursement status. In Australia that means docetaxel for most patients while we awai tregistration/reimbursement for agents such as abiraterone, enzalutamide and apalutamide.
  • There was also consensus for combination approaches in men with de novo low-volume mHSPC, with 85% voting in favour of some additional systemic therapy in addition to ADT, and 80% supporting RT to the primary.
  • Similarly, in men with relapsing high-volume or low-volume mHSPC, there was consensus to offer combination systemic approaches, with no consensus on which therapy to offer in addition to ADT.
  • There was consensus (78%) that in men with mHSPC diagnosed with conventional imaging, that no additional imaging (ie PSMA PET/CT) should be utilised. That horse has already bolted in Australia where it is not unusual for men to be diagnosed with M1 disease using PSMA PET/CT in the first instance.

Regarding oligometastatic disease, there was consensus that if metastasis-directed therapy (MDT) is to be considered, that the extent and location of disease should not be defined using conventional imaging (79%), but should be defined using more sensitive imaging such as PSMA PET/CT (75%). There was also strong consensus that a distinction should be made between lymph node-only disease, and M1 disease involving other sites. Systemic therapy should be used in addition to local therapy to all local sites of disease (75%). I must say that I was pretty surprised that consensus was reached on this point, as guidelines still suggest that MDT approaches should still only be offered within clinical trials.

Management of nonmetastatic (M0) castration-resistant prostate cancer (CRPC)

What even is M0 CRPC? Once again, PSMA PET/CT dominated the conversation. Although there is a relatively recently accepted definition of high-risk M0 CRPC (castrate levels of testosterone; PSA doubling time of </= 10 months; M0 based on conventional imaging), it is fair to say that there was much interest in the role of PSMA PET/CT in this population of patients. Data about to be published at the time of the meeting reported that 98% of patients in this setting will have identifiable disease on PSMA PET/CT despite being M0/N0 on conventional imaging. There these patients are actually mCRPC, rather than M0 CRPC, albeit based on novel imaging with a lead-time bias. Nonetheless, following various overviews of the recent pivotal data showing improvements in metastasis-free survival (MFS, conventional imaging) in patients with M0 CRPC receiving enzalutamide, apalutamide or darolutamide, the panel voted 86% in favour of using one of these agents in this population of high-risk M0 CRPC. We also voted 86% in favour of NOT extrapolating this data to M0 CROC patients with PSA doubling time of greater than 10 months.

Management of metastatic CRPC (mCRPC)

Another huge area with much data to consider. Although much of this had been considered at the previous APCCC and indeed, there were many areas where consensus was not reached eg which agent to use for first-line mCRPC (docetaxel vs AR pathway inhibitor). Despite general enthusiasm for molecular profiling/precision medicine approaches (and some outstanding talks on these areas), there was 85% consensus that we should not use AR-V7 status when considering mCRPC patients for abiraterone or enzalutamide. There was consensus that a steroid dose of prednisone 5mg bd should be used when starting mCRPC patients on abiraterone, and an 86% consensus that a tapering course of steroids should be used when discontinuing abiraterone or docetaxel.

There was considerable interest in the role of reduced dose abiraterone (250mg with food, instead of 1000mg without food), based on a phase II study, and the panel voted 86% in favour of a reduced dose regimen when there are resource or patient constraints on receiving the full dose.

One of the standout talks of the meeting was delivered by Prof Michael Hofman on the role of Lu-PSMA in progressive mCRPC as he presented data from the phase II trial at Peter Mac published in Lancet Oncology (to date, the only prospective data on Lu-PSMA), and on the TheraP randomised controlled trial from Australia which will read out at ASCO in June this year. For patients with PSMA imaging-positive mCRPC who have exhausted approved treatments and cannot enrol in clinical trials, 43% of panellists voted for Lu-PSMA therapy in the majority of patients, and 46% voted for it in a minority of selected patients. For selecting patients for 177Lu-PSMA therapy, 64% of panellists voted for PSMA PET/CT plus FDG PET/CT with or without standard imaging, 21% voted for PSMA PET/CT plus standard imaging, and 15% voted for PSMA PET/CT alone. Although consensus was not reached on this issue, it was clear that the panel were very influenced by Michael’s excellent presentation on this topic, highlighting observations in the Peter Mac phase II trial that the use of FDG PET/CT in addition to PSMA PET/CT led to enhanced patient selection for Lu-PSMA therapy.

Bone health and bone metastases

There was 77% consensus in favour of routine screening for osteoporosis risk factors (e.g. current/history of smoking, corticosteroids, family history of hip fracture, personal history of fractures, rheumatoid arthritis, 3 alcohol units/day, and BMI), in patients with prostate cancer starting on long-term ADT. There was 86% consensus that mCRPC patients with predominantly bone disease and without visceral metastases, should be considered for radium-223 therapy, although this hardly applies to Australia where radium-223 is difficult to access and not reimbursed (plus Lu-PSMA available).

Molecular characterisation of tissue and blood

The plenaries on this topic were some of the most stimulating of the whole meeting. Truly outstanding talks from the pre-eminent leaders in the world. Among the consensus areas were:

  • 90% support for the assessment of germline BRCA1/2 status in M1 prostate cancer patients at some stage of the disease
  • 94% consensus that mismatch repair status (MSI high) should be assessed at some stage in M1 disease, most likely in mCRPC.
  • 96% consensus that PD-1 inhibition should be considered for MSI high patients at some stage in the disease course
  • Strong consensus (93%) for PARP inhibitor or platinum therapy at some point during the disease course in patients with a deleterious germline BRCA1/2 mutation
  • Genetic counselling and/or germline DNA testing for patients with newly diagnosed metastatic (M1) castration-sensitive/naïve prostate cancer: consensus (84%) for genetic counselling and/or germline DNA testing for the majority of patients with newly diagnosed metastatic prostate cancer.

Interpatient heterogeneity

There were some terrific talks on heterogeneity in prostate cancer, including ethnic and regional diversity, and the assessment and management of older patients. This year’s meeting expanded on this section compared to previously to acknowledge the diversity of prostate cancer around the world, and the fact that much of the data used to make recommendations is based on particular patient cohorts. The panel did reach consensus (76%) for the extrapolation of efficacy data to patients older than the majority of patients enrolled in a trial.

Side effects of hormonal treatments and their management

Professor Mark Frydenberg was one of the invited plenary speakers in this session and did a terrific job overviewing the management of hot flushes. I have not seen this topic discussed better anywhere in the world. There were also terrific talks on strategies to mitigate other side-effects. The panel reached strong consensus (94%) for the use of resistance and aerobic exercise to reduce fatigue in patients receiving systemic therapy for prostate cancer (apart from therapy dose reduction if possible).

Need more detail?

If you are interested in more detail, please download the manuscript from European Urology (open access), or visit Urotoday where the plenary lectures are available, along with exclusive interviews with many of the invited experts.

Finally, the 4th APCCC will take place from 7-9th October 2021. It will take place in the beautiful city of Lugano towards the Italian side of Switzerland. I encourage anyone with a strong interest in prostate cancer to consider attending. It will be a most stimulating and enjoyable few days immersed in the world of prostate cancer, and conducted with wonderful Swiss hospitality once again by the fabulous Silke Gillessen and Aurelius Omlin.

Best Practice Tariffs: could they be the solution to compliance with British Association of Urological Surgeons ureteric stone targets?

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In January 2019, the National Institute for Clinical Excellence (NICE) and British Association of Urological Surgeons (BAUS) published new guidance on the management of Acute Ureteric Stones. This guidance suggests that primary definitive treatment should be the goal for all symptomatic ureteric stones, via either ureteroscopy (URS) or extra-corporeal shock wave lithotripsy (EWSL), and should be undertaken within 48 hours of acute presentation.

This is in stark contrast to current practice in the UK: Getting It Right First Time evidence suggests 20% (2-49%) of acute stones are currently treated in this way with only 8% treated primarily with URS and just 2% with primary ESWL.

It has been shown that primary definitive treatment of acute stones within 48 hours has superior outcomes to secondary definitive treatment after stenting; including a higher chance of achieving a stone free state, lower chance of needing retreatment, reduced exposure to general anaesthetic and associated complications, and avoidance of stent-associated symptoms.

However, due to the nature of current emergency surgery provision in UK NHS Trusts, primary definitive treatment is often impossible. Procedures are performed on pressured CEPOD lists which may not be set up for laser treatment (lacking suitable equipment and trained scrub staff) and are often incredibly time-pressured, necessitating ureteric stenting as a faster and simpler option.

Whilst the upfront investment required to provide sufficient resources and training is expected to be recovered downstream by reducing costs associated with stent use and the need for multiple procedures, NHS Trusts are reluctant to make these upfront investments unless incentivised.

We propose a potential solution in the form of Best Practice Tariffs (BPTs).

Traditionally, NHS Trusts receive their income from Clinical Commissioning Groups (CCGs) on the basis of a ‘Payment by Results’ (PbR) system. Under this system, tariffs are calculated based on the national average cost for clinically similar treatments (grouped together into healthcare resource groups; HRGs) and Trusts can retain additional income by keeping costs below this national average.  However, this can lead to wide variations in the standards of care. Lord Darzi’s 2008 ‘High Quality Care For All – NHS Next Stage Review’ report suggested that a revised payment system be used, where payment depended on compliance with best-known practice; a best-practice tariff (BPT).

BPTs have now been rolled out across more than 50 diseases and procedures including cholecystectomies, strokes/TIA and NSTEMIs and are recognised as an effective tool for changing practice in an acute setting.

One of the earliest examples was in the management of fractured neck of femurs (NOFs). The base tariff was halved and an additional BPT of £1,335 was made available if seven key ‘best practice’ criteria were met. A dramatic improvement in adherence to national guidelines for management of NOF fractures was seen after introduction of this BPT as shown in Figure 1 (Royal College of Physicians; 2014).

Of particular relevance here was the BPT criteria that required a ‘time to surgery within 36 hours from arrival in A&E to the start of anaesthesia’. The overall median time reduced from 44 hours pre-BPT to 23 hours post-BPT (p<0.005) and the proportion of patients being operated on within 36 hours of admission increased from 36% pre-BPT to 84% post-BPT (p<0.005).

BPTs have the most potential utility for high volume procedures with large variations in national practice and where there is a strong evidence base regarding what constitutes best practice. Renal stones are high volume, affecting 12.5% of the population and resulting in 18,000 URS  procedures a year. There is significant national variation in management and there is strong evidence on best practice.

Therefore, if we truly believe that the BAUS and NICE guidelines are in the best interests of patients, BPTs should be considered as a tool to prompt a rapid paradigm shift and make the gold standard, of primary definitive treatment within 48 hours, the new norm.

Further details available here.

by Sam Folkard, Richard Menzies-Wilson, Charlotte Burford, Paula Pal and James Green

Twitter: @FolkardSam

February 2020 – about the cover

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One of the authors of February’s Article of the Month (Understanding volume–outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme) is from Wakefield in Yorkshire, UK.

The cover image shows the moat and ruins of Sandal Castle, which is located in Sandal Magna on the outskirts of Wakefield. The castle was originally built of timber by the 2nd Earl of Surrey, William Warenne, early in the 12th century. In the 13th century, the timber motte-and-bailey castle was rebuilt in stone by a later member of the Warenne family. The castle was maintained until the late 14oos, with the Battle of Wakefield taking place nearby, and a brief resurgence whilst in Royalist hands during the English civil war, but eventually the stone was taken for use in local buildings leaving the ruin you can see today.

There is a good view of the cathedral town of Wakefield, situated on the River Calder, from the hill at Sandal Castle.

 

 

 

 

Making real change where it is needed! The HSIB investigation into a case of testicular torsion

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This week saw the first Health Service Investigation Branch (HSIB) investigation into a urological condition. The HSIB is the health services version of the Air Investigation Branch, which investigate air crashes, and the case that it was investigating was one of testicular loss from torsion.

The investigation followed the best principles of human factors theory and causal analysis. It was not looking to assign blame but instead to constructively implement better process and systems that do not relay solely on one individual, as humans are notoriously fallible. The outcome of any investigation is to make it easier for medical teams and administrators to perform well and to mitigate the risk of errors, in an inherently complex area such as medicine.

Only a small number of HSIB investigations have taken place so far so we are fortunate that a Urology case was chosen. The report concentrated on the community aspects of the testicular pain pathway, and the investigating team had fruitful meetings with NHS 111 that led to changes in the questions and prompts that were asked of callers with testicular pain who dialled in. The Royal College of GPs, as a result of the investigation, has convened a group to review the communication standards between practices running telephone services and emergency departments; and NICE has agreed to improve the on-line guidance on testicular torsion and scrotal pain to make it more accessible to clinicians, patients and their carers.

The fact that this came about after an investigation of a single case shows the power of this investigative process and the rigour with which it was carried out.

I would encourage others who may want to be involved with this type of work. I was lucky enough to be approached by the HSIB to be the subject matter expert (SME) on this case as I have a known interest in both Quality Improvement (QI) and Torsion. Anyone approached to help with investigations of this type should be reassured of the professionalism under which a case is undertaken: no individuals or organisations are named; no fingers are pointed but instead the HSIB are able to open a lot of doors and instigate change by negotiating agreements from departments and institutions that most clinicians involved in QI could only dream of getting.

Maybe we need a few more investigations of this type in Urology; retained stents spring immediately to mind as a strong candidate as the HSIB is also experienced in talking to industry. Wouldn’t retained stents be so much easier to avoid if each stent had an individualised barcode that could be scanned and tracked? The companies making stents could perhaps be encouraged to be more involved in making sure that they were easier to track across the whole of the UK (or the world) so patients wouldn’t have so many problems with stents in the future.  Every component of a jet is tracked in a similar way so why shouldn’t we look for the same standard in Urology Healthcare!

by Tony Tien & James Green

Twitter: @greenxmedical

 

James S. A. Green is a Urological Surgeon, Network Lead for Urology at Barts Health NHS Trust, Quality Improvement Director at Whipps Cross University Hospital and visiting Professor in Health Services Research at Kings College, London. His interest in medical education and improvement started when developing medical support for the British Army and he has published extensively on team-working and improving clinical care. He was SME for the HSIB investigation into a case of delayed testicular torsion.

Mr Tony Tien MRCS is a clinical fellow in Urology at Whipps Cross Hospital and a champion for Quality Improvement.

 

EAU19 Barcelona – Highlights from days 3-5 of the 34th Annual EAU Congress

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The early Sunday morning start did not deter delegates from attending one of the three packed plenary sessions of the day. They covered a broad range of rapidly changing areas in urology from imaging in prostate cancer, an update on renal cell carcinoma (RCC) and the breaking news session discussing the potentially game changing results from the recent ARAMIS study and new research into fast bi-parametric MRI.  The role of imaging in prostate cancer is swiftly evolving, with the plenary discussion focusing on recent changes in the diagnostic pathway of localised prostate cancer, particularly with the use of MRI. Next door in the RCC plenary, the speakers debated ‘knife, needle or nothing?’ for the small renal mass in the young patient followed by an update on the very recent and potentially guideline-changing advances in systemic therapy for RCC.

The mid-morning thematic sessions covered the full spectrum of urology from semi-live surgery, the newest advances in immunotherapy, imaging and even how to run a urology office in Europe.

The 7th BJUI social media awards on Sunday night were again the social highlight of the EAU. A view of the Museu Nacional d’Art de Catalunya provided a stunning backdrop to the packed event, with the stars of #UroSoMe recognised for their outstanding work. The night kicked off with the award for the most read blog going to social media champion Professor Declan Murphy.

The awards highlighted the far reaching and valuable impact of social media, recognising a number of important achievements in the field such as Nature Reviews Urology for ‘Both sides of the scalpel: the patient and surgeon view’ with a special guest video appearance from Stephen Fry.

However, for me the most special part of the night was seeing my friend Daniel Christidis remembered and honoured with the most ‘social’ trainee award. Dan was a leader in the real and #UroSoMe world (and had personally set up my Twitter account, and those of many of the other young attendees that night) and I know would have been proud to be remembered for one of the things he did so well.

After the BJUI social media awards, it was time for a little black-tie glamour with the EAU19 Friendship Dinner at the historical Casa Llotja de Mar. The night started with a welcome from Professor Christopher Chapple underlining the importance of international partnerships in urology, followed by a fantastic night of good food, wine and enjoying the beautiful Catalan Gothic architecture.

The Monday morning plenary sessions delivered another jam-packed morning of a mix of cutting-edge science, quality of life issues in cancer survivorship and prostate cancer. The breaking news session discussed the primary results from SAUL, confirming tolerability and safety of atezolizumab in real-world mUC patients, and the results of ARCHES, which investigated the efficacy of androgen deprivation therapy with enzalutamide or placebo in metastatic hormone-sensitive prostate cancer. The controversies in prostate cancer were again debated in an interactive and diverse way between ‘jury members’ including a geriatrician, psychologist, radiation oncologist and urologist.

The last day of the thematic sessions of the congress again provided a smorgasbord of topics in urology. Later in the day, the expert-guided poster tours gave delegates a chance to navigate the huge number of posters from guidelines to local treatment of prostate cancer.

The closing plenary on Tuesday morning to a full auditorium gave a sweeping overview of the top contributions to EAU19 leaving us with a free half day to explore our generous host city and take in the stunning architecture, food and sunshine!

 

Bustling Barcelona provided the perfect backdrop to a well organised, action packed conference which featured world leading urologists and scientists from around the world presenting practice changing new data. Cannot wait for EAU 2020 in Amsterdam! #EAU20 #Amsterdam #UroSoMe

by Jiasian Teh, Urology Registrar, PhD Candidate, Peter MacCallum Cancer Centre

@JiasianTeh

EAU19 Barcelona – Highlights Days 1 and 2

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The European Association of Urology Congress brings together delegates from across the globe to showcase cutting-edge urological research, and the 34th EAU Congress in Barcelona was no different. With a record high number of 5,500 abstracts submitted, over 1,600 presentations were due to be presented over five days. Adding to that a dizzying selection of 79 courses and hands-on workshops, this year’s EAU Congress was set to be one of the biggest to date.

After missing my flight here, I also missed the lines:

and swiftly registered to join a sea of red and yellow bags, coloured appropriately for the Spanish setting. With a big day ahead, the Catalonian capital had turned up the weather and the Fira Gran Via was humming with excitement.

The scientific program was already off to a flying start with a number of Urology beyond Europe sessions. These showcased the links between EAU and international urological societies, including USANZ, SIU and the CAU to name a few, and offered a chance to discuss regional differences in practice patterns and cutting-edge work from all corners of the globe.

Laser focus during a hands-on flexible ureteroscopy workshop

The evening approached rapidly, leaving no time for a siesta, as delegates made their way to the official opening ceremony. Prof Christopher Chapple welcomed delegates from around the world to make the most of what EAU19 had in store over the next four days. Presentation of EAU awards ensued, including the Crystal Matula and award for Best Prostate Cancer Research.

The end of formal proceedings had us seeing red, literally, as the Red area set alight with song and dance over a fiery backdrop in a vibrant performance from the opera Carmen.

This was soon to be eclipsed by two aerial silk acrobats accompanying an emphatic rendition of Freddie Mercury’s 1992 Olympic classic, Barcelona.

As the ceremony came to a close, it was time to network with colleagues and enjoy some Catalonian cuisine.

Court was in session early on Saturday morning, as a plenary on nightmares in stone disease chaired by Tim O’Brien and Thomas Knoll kicked off Day 2. With a medico-legal theme, Palle Osther spoke about the forgotten stent and sung the importance of leaving no stone unturned.

He was followed by horror stories of bowel injury during PCNL.

The mood was very different across the hall, however, as delegates geared up for a live surgery session courtesy of the Section of Uro-Technology, including a number from Barcelona’s own Fundació Puigvert Hospital.

Presenting and learning from live surgery is always a privilege, and all were grateful to those patients who generously agreed to participate.

With no shortage of residents at this year’s congress,

the European Society of Residents in Urology and Young Urology Office ran the extremely useful YUORDay19, covering ‘need to know’ information for residents, with topics ranging from the recent PRECISION and POUT trials to career advice and surgical tips and tricks.

EAU Guidelines also proved hugely popular once again, with delegates lining up to collect their copy of the brand new edition.

No meeting would be complete without a plethora of debates, and EAU19 was no different. The Controversies in Guidelines sessions covered a range of contentious topics in areas such as MRI-guided prostate biopsy, TURBT and adjuvant chemotherapy in UTUC. It was often standing room only, forcing a one-in one-out policy with some lines wrapping around the presentation rooms.

Pitting subspecialty heavyweights against each other, these sessions brought out a fighting spirit in all, even threatening to turn colleagues into enemies.

Fortunately, all ended well as another riveting day came to a close.

Barcelona has been the perfect setting to reunite with old friends and meet new ones at EAU19. Days 1 and 2 were a brilliant start to my first EAU congress, leaving me excited to see what the next three days have to offer.

by Arveen Kalapara, Research Fellow, Department of Urology, University of Minnesota

@ArveenKalapara

 

March 2019 – About the cover

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The Article of the Month for March (Mortality after radical prostatectomy in a matched contemporary cohort in Sweden compared to the Scandinavian Prostate Cancer Group 4 (SPCG-4) study) is from work carried out at Uppsala University in Sweden.

Uppsala University was founded in the 15th century in Sweden’s fourth biggest city, Uppsala. It was the first university in the nordic region and today has over 40 000 students.

March’s cover picture shows Uppsala Cathedral, which was built in 1270. It is open daily and offers tours in English.

 

#UroPoet – restoring our humanity with creative writing and poetry

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The global urology community on Twitter

— Todd M. Morgan, MD (@wandering_gu) February 9, 2019


Over the past several years, many urologists have gravitated to Twitter. Through Twitter we have shared information and experience, created relationships, and built community. Twitter has brought us together in many ways never thought possible before. Some great examples include #UroSoMe, #prostateJC, #CUAJC, and the grandfather of them all, #urojc.

Behind the screens

Behind our screens, however, many of us face significant challenges, both professional and personal. Urologists around the world find themselves spending more and more time typing on their keyboards and less and less time in face-to-face conversation with patients.

Growing rates of burnout in urology are being reported in the United States. There is also a burgeoning trend toward consolidation, mergers, and loss of autonomy in healthcare. When you add in the current global political and cultural turmoil, even Twitter starts to lose its luster and become divisive.

 

The power of creative writing and poetry

Recently, at the invitation of my friend Pam Ressler, I had the opportunity to participate in a January haiku challenge. To be honest, I was really busy in January, and initially, wasn’t all that excited about it.

However, I quickly began to realize that the discipline of writing a daily haiku made me feel better. Over the course of that month, I developed a new sense of gratitude. By spending just a few minutes, here and there, thinking about the next poem I might write, the recurrent annoyances of each day became fewer and smaller.

Humankind has a rich history of storytelling with prose. Poems about ‘pee’ were written long before urology, as exemplified in Dr. Johan Mattelaer’s wonderful book, “For this Relief, Much Thanks!”

Restoring our humanity

In the spirit of friendship, I invite you to join me in celebrating life, and our noble profession of urology, with the power of creative writing and poetry on Twitter at #UroPoet. My hope is that everyone will feel welcome to use this hashtag, responsibly, and to share the things they love most about our profession, our patients, our families, and life itself through the use of creative writing and poetry.

— Dr. Brian Stork (@StorkBrian) February 3, 2019

In the short time the hashtag has been active, topics ranging from research to prolapse have been posted in the form of limericks, essays, song lyrics, poems and haiku. I hope you will take a moment to at least follow along and consider making a regular or one-time post of your own – adding the hashtag #UroPoet.

I’ll be posting regularly from a second Twitter account @UroPoet where I will also be retweeting #UroPoet tweets. If the spirit moves you, you can also follow me @StorkBrian.

February 2019 – About the cover

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February’s Article of the Month (Implementation of mpMRI technology for evaluation of patients with suspicion for PCa in the clinical practice setting) is from work carried out at Northwell Health in New York, and various other institutions in the USA.

Northwell Health was founded in 1997 and is a not-for-profit healthcare network that includes around 20 hospitals, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research, a Center for Emergency Medical Services and a range of outpatient services.

February’s cover shows Gapstow Bridge in Central Park, Manhattan: this stone version was constructed in 1896 replacing the earlier wooden version. It provides a welcome contrast to the modern skyscrapers which form part of the Manhattan skyline beautifully viewed to the South of the bridge. The bridge has been famously used in many films and TV shows, including Home Alone 2 and Dr Who.

 

Resident’s podcast: Retzius‐sparing robot‐assisted radical prostatectomy

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Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it’s time for critical appraisal

Thomas Stonier*, Nick Simson*, John Davis† and Ben Challacombe‡

 

*Department of Urology, Princess Alexandra Hospital, Harlow, ‡Urology Centre, Guy ’s Hospital, London, UK and †Department of Urology, MD Anderson Cancer Center, Houston, TX, USA

 

Read the full article

Abstract

Since robot‐assisted radical prostatectomy (RARP) started to be regularly performed in 2001, the procedure has typically followed the original retropubic approach, with incremental technical improvements in an attempt to improve outcomes. These include the running Van‐Velthoven anastomosis, posterior reconstruction or ‘Rocco stitch’, and cold ligation of the Santorini plexus/dorsal vein to maximise urethral length. In 2010, Bocciardi’s team in Milan proposed a novel posterior or ‘Retzius‐sparing’ RARP (RS‐RARP), mirroring the classic open perineal approach. This allows avoidance of supporting structures, such as the puboprostatic ligaments, endopelvic fascia, and Santorini plexus, preserving the normal anatomy as much as possible and limiting damage that may contribute to improved postoperative continence and erectile function. There has been much heralding of the excellent functional outcomes in both the medical and the lay press, but as yet no focus or real mention of any potential downsides of this new technique.

Read more Articles of the week

 

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