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EAU 2015 Review Days 1 and 2

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IMG_5462The 30th anniversary EAU congress is currently taking place in the beautiful but rainy city of Madrid with over 12,000 delegates attending. The opening Friday proved a monumental day with the start of the congress as well as personally as I gave into the pressure of social media, and joined Twitter. This is being heavily promoted by the EAU this year and with multiple engaging sessions going on at the same time this seemed to be the best way to have my cake and eat it and enjoy highlights from different parts of the meeting.

The second ESO prostate cancer observatory was well attended and led to interesting debates about PSA screening and informed consent due to risks of over-detection and subsequent overtreatment of indolent disease. Indeed Andrew Vickers also highlighted that the results of the much anticipated ProtecT trial should be interpreted with caution given the high number of Gleason 6 patients that have been randomised.

In the evening the opening ceremony took place with an emotional final introduction to the congress by Per Anders Abrahamsson as he steps down and hands over to Chris Chapple as EAU Secretary General (photo courtesy @uroweb).

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The EAU also gave out a number of awards including the Crystal Matula award for promising young urologist which was given to Morgan Roupret.

The scientific programme on Saturday started with the main plenary session on controversies in bladder and kidney cancer. It is difficult to draw conclusions regarding lymphadenectomy in upper tract tumours due to a lack of randomised data but certainly based on retrospective data a benefit is seen both in terms of staging and cancer specific survival. A hot topic lecture on molecular profiling in bladder cancer gave a thrilling insight into how agents will be able to target pathways based on specific mutations and Professor Studer, in his last ever plenary session, led to an interesting debate on robotic vs. open radical cystectomy. This has caused much controversy recently with the Bochner randomised controlled trial and this debate will surely run and run. Maybe most importantly, as Studer concluded “The surgeon makes the difference not the instrument”. This was highlighted on the front cover of the congress news with a more downbeat headline on robotic cystectomy.

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Next came an intriguingly titled talk “What would Charles Darwin make of renal cell carcinoma?” with discussion about the heterogeneity of renal tumours making it difficult to identify specific targeted treatments based on renal biopsy alone.
Multiple section meetings then ensued. From the EAU section of urolithiasis (EULIS) meeting it seems that PCNLs are increasingly being miniaturised with development to mini, ultra-mini and micro procedures. The issues behind “diabesity” and stones were discussed with Professor Reis Santos predicting an epidemic of stones either due to uric acid stone formation from obesity or calcium oxalate formation from malabsorbative bariatric procedures. There was also a recurring theme with poster and podium sessions on “ESWL – is there still a role?” While the argument is made for ESWL there is no doubt that worldwide treatment rates for ESWL are falling.
As the EAU Section of Female and Functional Urology there was an excellent series of talks on mesh and mesh complications. There was a fantastic review of dealing with these complications through a variety of approaches and techniques and whether all these should all be dealt with in high volume centres. Unfortunately, no one knows what high volume means for this. Interestingly the terminology is changing, moving away from ‘erosion’ to ‘exposure’ and ‘perforation’. Removing the mesh only relieves associated pain in 50% of cases and these dedicated centres need to offer multimodality treatments to deal with pain and ongoing continence issues.
In the parallel EAU section meeting of Genito-urinary Reconstructive Surgeons, Professor Mundy gave a personal 30 year series of 169 patients treated with both clam cystoplasty and artificial sphincter. The majority of complications were related to the sphincter. The largest subgroup was patients with Spina Bifida but were the patients with the best outcomes.
David Ralph in the EAU Section of Andrology stated that shunts were ineffective after 48 hours after priapism and that a prosthesis instead should be inserted to prevent corporal fibrosis.
The EAU section of Oncological Urology also heard that 68Ga-S+PSMA-PET improves detection of metastatic lymph nodes in prostate cancer and can be used intra-operatively in radioguided surgery for targeted lymph node dissection.
Overall the organisers have done a fantastic job with a well organised meeting and a great venue despite the disappointing weather. There were sessions that people could not get in to as the rooms were full.

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However, with live TV screens outside those rooms and transmission to an adjacent overflow room this didn’t seem to matter too much. Much to look forward to for the rest of the conference #EAU15.

Rebecca Tregunna, Speciality Trainee, Burton Hospitals NHS Foundation Trust, West Midlands Deanery. @RebeccaTregunna

Matthew Bultitude, Consultant Urologist, Guy’s and St. Thomas’ Foundation Trust; Web Editor BJU International. @MattBultitude

 

Guideline of Guidelines Poll Results

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The recently published ‘guideline of guidelines’ attempts to bring together conflicting guidance from different authorities. But overall how often do you refer to AUA, EAU or other national urological guidelines in clinical practice?

At least weekly – 23%

At least once a month – 27%

Every 2-3 months – 15%

Less than 3 monthly – 23%

Never – 12 %

 

5 Questions with Per-Anders Abrahamsson and Gopal Badlani

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Secretary Generals to the big Spring Meetings, European Association of Urology and the American Urological Association

Every Spring, thousands of urologists gather in big cities with mega-venues to attend one or both of the annual congresses of the EAU and the AUA. These are big events with respect to release of the latest scientific trials, instructional courses, plenary sessions, and of course multiple ways to see and interact with advances in industry partners. But who orchestrates these massive events occurring over multiple days? Of course it requires a full team of expert staff members, and in both groups, they employ an outstanding Urologist to a multi-year contract to serve as secretary and be a principle organizer of the annual meeting. We asked each secretary general to share their perspectives with 5 questions.

Gopal Badlani–Secretary to the AUA 2011-2015. The New Orleans AUA will be Prof. Badlani’s last as AUA and will certainly be an exciting meeting and fitting celebration to an excellent term of service and creative updates to the annual meeting.

1) What excites you about your meeting format and location?

PAA:  Stockholm of course is a major draw, but we don’t know if it will be Spring or Winter at the time. Forty percent of our draw is from beyond Europe—Latin America, China, and India. We know that Stockholm is an exotic city worth the trip, but hopefully they find the meeting and the quality of education worth the trip. Stockholm is recognized as one of the best venues, and our office staff knows venues across Europe. The problem here is that the Swedish economy is booming and its one of the most expensive cities in the world. We were able to downsize the hotel prices, but its very expensive. In addition, Pharma support for attendees has dropped from 80% to 60%. The weather has been rather decent.

GB:  We changed our format this year to incorporate Friday as the first official day of the AUA Annual Meeting, showcasing a full day of research programs and a highly successful Crossfires: Controversies in Urology program. It certainly generated “buzz” and continued discussions surrounding such controversies throughout the meeting.

 

2) What about high impact studies being presented?

PAA:  One coming up is the PREVAIL study with Enzalutamide “Pre-chemo”. We also have our own Swedish national cancer registry and there are some data coming out favoring early treatment of prostate cancer. This is one of the oldest in the world. Peter Wiklund will present this. Another that will be updated Tuesday is the European randomized screening trial. The principal investigator after Fritz Schroeder is Jonas Hugosson from Gothenberg. He got permission from Lancet to update the Swedish arm of that trial. You will find differences between centers and there will be an update with longer follow-up.

GB:  Our plenary sessions highlighted late-breaking news, new AUA clinical guidelines and the latest advances in urologic medicine. It was in this forum, we heard from Dr. Anthony Fauci on ending the HIV/AIDS pandemic and its lifecycle from scientific advances to public health implementation.

It was also where attendees heard from Dr. Ajay Nangia about the adverse effects of common medications on male fertility to outstanding sessions on benign disease, the challenges in managing spinal cord injury patients with neurogenic bladder as well as mesh use for urinary incontinence (Drs. Flynn and Rovner).

Our International Prostate Forum more than tripled anticipated attendance. Dr. Andrew Schally, a recipient of the Nobel Prize in Medicine, as well as a number of experts from around the world, provided global perspectives on prostate cancer.

Eight debates on today’s hottest topics in urology were showcased through our standing-room only Crossfire-Controversies in Urology event. Our Town Hall transported attendees into the future of simulated surgical training and imaging. This session included presentations from experts and pioneers in 3D and molecular imaging as well as surgical simulation.      

 

3) What are key metrics of the meeting?

PAA:  We have 120 countries represented. Registration is about 700 off from Milan last year, but are pleased overall given the expense noted, and sponsorship from Pharma continues to decrease.

GB:  Our meeting continues to attract over 15,000 attendees from over 120 countries. More than 2,200 abstracts were presented and more than 2,500 speakers. 

 

4) What are key trends important to Urologists attending your meeting? Why do they attend?

PAA: There is a need for meetings like this for people to meet and to start up multi-institutional trials, even trans-Atlantic. We hope to facilitate translational research. For example, we facilitated the first ever World Chinese meeting—Taiwan, Hong Kong, and Mainland—all together, and very difficult to organize from a political viewpoint. We were very pleased with this and left politics aside. 

GB:  There are a number of major concerns affecting American urologists, including issues affecting fair and appropriate payment (e.g., the sustainable growth rate, or SGR, the formula which is used to set Medicare payments for U.S. physicians), certain provisions under the Affordable Care Act (such as the 90-day grace period for recipients of advanced payments in the large group health insurance market places) and the impact that unfunded mandates such as prior authorizations, required accreditations, etc., have on our practices. All of these issues are compounded by the fact that our U.S. physician workforce is shrinking and, unless significant steps are taken to fundamentally reform graduate medical education, the country will have an insufficient supply of physicians to adequately meet patients’ needs in a timely manner. This shortage is of specific note to urology, since we have the second-oldest surgical subspecialty workforce, and limits on funding for urology residency programs make it extremely difficult to get more medical students into urology residencies.

 

5) What are your impressions of the venue and city?

PAA:  Honestly I was not involved in that decision-making. We have 70 people working full time in our office in Holland. We had our own congress consultants working, looking at new venues. We have mainly concentrated our annual congress to limited venues—Madrid, Barcelona, Paris, Vienna, Milan, London in the future, and in Germany Munich and Berlin. Scandinavia so far its only been Stockholm as we can take care of 15,000 people here and we have a good congress venue. In the future it will be Copenhagen as they have a new congress venue that is closer to Europe. So we are going to rotate between these venues. We have not been able to find a venue in Eastern Europe that accommodates that many people.

GB: We enjoyed being in sunny, warm Orlando in May. Orlando has a good mix of hotels to offer to our attendees – from an impressive full service Ritz Carlton to a few lower cost options such as the Days Inn and Marriott Courtyard. Overall, I think the Orlando Convention Center worked well for us. Looking forward, the excitement is in the air surrounding next year’s location, New Orleans May 15-20, 2015. Program planning begins this summer! 

 

So there you have it. While most of us run around these meetings trying to figure out which session suits our interest, or where we have to moderate/speak next, the secretaries have a very different perspective. They worry about meeting formats, costs, weather, who will show up, what will they think. I was also impressed that while most of us tend to network on the fly by just walking around the venue and bumping into colleagues, the secretaries have very tight schedules run by their staff. I appreciate the time both gave to us. Note that the answers may flow differently as Per-Anders did a sit down interview with an iPhone recorder running, while Gopal gave me typed answers after the meeting. 

Thank you to both secretaries on strong annual congresses.

John W. Davis, MD, FACS
Associate Editor, BJUI

 

Urologists up in arms? ….Diclofenac no longer indicated in high risk groups

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This blog is an update form the originally published comment article in BJU International, 110: 607–608.
DOI: 10.1111/j.1464-410X.2012.11330.x

On the 23rd June 2013 the MHRA (The Medicines and Healthcare products Regulatory Agency) issued a press release stating that ‘patients with serious underlying heart conditions, such as heart failure, heart disease, circulatory problems or a previous heart attack or stroke should no longer use diclofenac’. The MHRA is responsible for regulating all medicines and medical devices in the United Kingdom (UK) by ensuring they work and are acceptably safe.

 

 

The new guidelines in the UK state:

  • Diclofenac is now contraindicated in patients with established:
    – ischaemic heart disease
    – peripheral arterial disease
    – cerebrovascular disease
    – congestive heart failure (New York Heart Association [NYHA] classification II–IV)

Patients with these conditions should be switched to an alternative treatment at their next routine appointment

  • Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g., hypertension, hyperlipidaemia, diabetes mellitus, smoking).

Now for urologists in the UK this has wider implications. What else are we to use for acute renal colic, chronic pelvic pain, prostatitis, urethritis and any other type of..-itis?

We are treating an ever aging population and the use of non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, will increase. NSAIDs have been the cornerstone of pain relief in patients with first presentation of renal and ureteric lithiasis. The British Association of Urological Surgeons (BAUS) and the European Association of Urology (EAU) guidelines for the acute management of renal and ureteric lithiasis state the first line analgesia is an NSAID e.g. diclofenac [1][2]. There have been a number of clinical trials which have clearly shown that NSAIDs provide effective relief in patients who have acute stone colic [3][4][5].

Controversies of NSAID use

Rofecoxib (trade name Vioxx ®), was approved by the Food and Drug Administration (FDA) in May 1999. The drug was heavily promoted by the global pharmaceutical and chemical company Merck as safer than older generation NSAIDs. The increased risk of stroke was highlighted in a large study, the Vioxx gastrointestinal outcomes research (VIGOR) study, published in the New England Journal of Medicine in 2000. Merck voluntarily took rofecoxib off of the market on 30 September 2004 after research showed that it almost doubled the risk of myocardial infarction and stroke when taken for 18 months or longer. In 2007 Merck paid $4.85bn to settle about 26 000 lawsuits in the United States relating to the drug in state and federal courts.

What are the alternatives suggested?

Naproxen and low-dose ibuprofen are considered to have the most favourable thrombotic cardiovascular safety profiles of all non-selective NSAIDs. There is limited evidence for the use of naproxen and low-dose ibuprofen in the management of acute renal colic. We do not know if the efficacy is equivalent to diclofenac. There are a lot of unanswered questions since the press release, but the key questions remain: Is this guidance applicable to us as urologists? And will this change my practice?

This topic is an important area for urologists to be aware of as NSAIDs are prescribed daily in urological practise to a wide range of patients. There is some caution that has to be exercised when reviewing the published data. In a recently published meta-analysis by the Coxib and traditional NSAID Trialists’ (CNT) Collaboration group their data provides further evidence that the vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs.

The majority of trials evaluating the cardiovascular risk of NSAIDs have looked at a group of patients with predominately arthritis or Alzheimer’s disease; not a typical urological cohort of patients. None of the studies in the meta-analysis looked at the short term use of NSAIDs, in particular diclofenac. Some may argue that absolute rates of events were low and clinically irrelevant as the event rates in the included trials are considerably lower than in routine clinical settings.

The options for the treatment of acute urological pain have not changed in the past 15 years. COX-2 selective inhibitors and diclofenac are associated with an increased risk of thrombotic events. Naproxen is associated with a lower thrombotic risk and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction. The lowest effective dose of NSAIDs should be prescribed for the shortest period of time to control the symptoms and the need for long term treatment should be reviewed periodically. As we treat an ever aging population with increasing medical co-morbidities the widespread use of NSAIDs has to be evaluated and urologists need to keep up to date with current prescribing guidelines and long term cardiovascular risk factors. 

 

Jonathan Makanjuola is a Urology Trainee, Innovator and techie based at King’s College Hospital, London, United Kingdom. @jonmakUrology

References

  1. EAU guidelines on urolithasis. European Association of Urology; 2011. https://www.uroweb.org/gls/pdf/18_Urolithiasis.pdf. Accessed 12 December 2011.
  2. Guidelines for acute management of first presentation of renal/ ureteric lithiasis (excluding pregnancy). British Association of Urological Surgeons; 2008. https://www.baus.org.uk/AboutBAUS/publications/stones-guidelines. Accessed 12 December 2011.
  3. Phillips E, Kieley S, Johnson EB, et al. Emergency room management of ureteral calculi: current practices. J Endourol 2009; 23: 1021–1024.
  4. Micali S, Grande M, Sighinolfi MC, et al. Medical therapy of urolithiasis. J Endourol 2006; 20: 841–847.
  5. Engeler DS, Schmid S, Schmid HP. The ideal analgesic treatment for acute renal colic–theory and practice. Scand J Urol Nephrol 2008; 42: 137–142.

 

 

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You are Not Connected to the Internet: Seeking Stable WiFi at the Modern Conference

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Urologists the world over have at last settled back into their rhythms after congregating en masse in San Diego, California for the American Urological Association Annual Meeting. While I hadn’t expected to escape balmy Ontario for crisp breezes in Southern California, the setting was an excellent one.

This year’s AUA meeting had all the hallmarks of years past – heaving throngs of AUA-branded-faux-leather-bagged urologists speed-walking between sessions in the enormous SD Convention Centre, bleary-eyed sufferers burning away their respective fogs with espresso in the cavernous Exhibit Hall, and plenary sessions packed to the gills to hear the latest and greatest. One pernicious tradition was unfortunately manifest again, however, in the form of unreliable wireless internet access in the conference hall and ancillary venues.

Modern conferences and conference centres (where (ironically) the latest technologies and scientific advances are presented) seem to have barricaded themselves from the digital world the modern conference-goer inhabits. This may at first seem inconsequential, as the sequestration and forced attention might keep the focus on the presented data. In truth, an entire communication meta-layer, that of the conversations, opinions and dissemination created by social media activity, are needlessly compromised.

As has been stated repeatedly in social media circles, this year’s annual meeting was a bonanza of twitter activity at the #aua13 hashtag, with over 4000 tweets sent from 468 users during the meeting proper. The recent European Association of Urology meeting in Milan was similarly well subscribed, with almost 1800 tweets from 251 users.

It seems universal at urology (and doubtless other disciplines’) meetings that some of the earliest twitter activity centers around the pain of spotty or absent wifi. To wit:

 – from #uro12 (AUA Atlanta):

 

 – from #eau13 (EAU Milan):

 

 – from #aua13 (AUA San Diego):

These are but a few of the dozens of agonized tweets based on weak, spotty or absent wifi, and for each there is doubtless a dozen, fifty, a hundred more people in the same building steaming with the same frustrations. International delegates, loathe to “roam” outside their home data plans, are perhaps the most handicapped. One imagines the conference centre tech team testing their seemingly robust signal in an empty room, devoid of the hundreds or thousands of devices queuing for bandwidth space once the meeting is in full swing. And let’s not forgive the conference-adjacent hotels that host dozens of ancillary meetings, such as the well-attended Society of Urologic Oncology meeting, each year in advance of the AUA proper. Typically there is a total absence of available wifi in these conference halls. In 2013, the mind boggles at this omission (on the part of organizers as well as the hotels).

Certainly the modern conference centre and the modern meeting must see beyond their own walls, and address the modern realities of communication. The reach of social media, and indeed the basic need of busy attendees to connect with their practices, lives and colleagues make this all the more imperative. Relative to all the other logistic feats that underpin a conference, building in extra bandwidth (with redundancy to avoid catastrophe) should be a simple infrastructure and expenditure issue, well within the means of the centre to predict and to deploy.

 A brief set of expectations for the modern conference centre’s wireless internet:

  1. Conference wifi must be available to all who wish to access it, when and where they wish to do so. Hotels are not exempt if they host parts of the meeting. Wifi is no longer a perk or a luxury.
  2. Login should be simple and able to be performed in the native settings of the users’ devices, rather than the agonizing experience of web- or browser-based login.
  3. Requiring repeated logins when re-entering rooms or buildings is excruciating and anathema to the speed of communication and discussion that define social media. One formal login per device per meeting.
  4. The ubiquity of mobile devices may require a building retrofit or construction of stations to facilitate the ability of delegates to charge these devices.

Until these conditions are met, associations, conferences and conference centres will be forced by their own inertia to stifle the full potential of the meetings they host. Here’s hoping that the volume of our discontent is heard by organizers, and suitable guarantees are established and met as conditions of hosting our meetings.

Mike Leveridge is an Assistant Professor in the Departments of Urology and Oncology at Queen’s University, Kingston, ON, Canada. @_theurologist_

 

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