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USANZ 2018: Melbourne

G’day! The 71st  annual USANZ Congress, was held in Melbourne and had the biggest attendance on record for the past 6 years. The Urological Nurse’s congress: ANZUNS ran concurrently, encouraging multi disciplinary learning. An excellent and varied educational programme was masterminded by Declan Murphy, Nathan Lawrentschuk and their organising committee. Melbourne provided a great backdrop and soon felt like home with a rich and busy central business district, cultural and sporting venues, the Yarra river flowing past the conference centre, edgy graffiti and hipster coffee shops, plus too many shops, bars and restaurants to visit.

The programme included a day of masterclasses on a range of subjects, including: urological imaging, advanced robotic surgery with a live case from USC, metastatic prostate cancer and penile prosthetics. These were well attended by trainees and consultants alike. The PCNL session (pictured) with Professor Webb was popular and he generously gave his expertise.  The session was supported by industry and provided an opportunity to use the latest nephroscopes on porcine models and innovative aids to realistically practice different puncture techniques.

Two plenary sessions were held each morning covering the breadth and depth of urology and were well attended. Dr Sotelo is always a highlight; he presented, to an auditorium of collective gasps, a unique selection of ‘nightmare’ cases  His cases gave insight in how intraoperative complications occur and how they can be avoided.  Tips, such as zooming out to reassess in times of anatomical uncertainty during laparoscopy or robotic surgery have great impact when you witness the possible consequences. Tim O’Brien shared his priceless insights on performing IVC thrombectomy highlighting the need for preoperative planning, early control of the renal artery and consideration of pre-embolisation.  His second plenary on retroperitoneal fibrosis provided clarity on the management of this rare condition highlighting the role of PET imaging and, as with complex upper tract surgery, the importance of a dedicated team.

Tony Costello’s captivating presentation covered several myths in robotic prostate surgery, plus the importance of knowing your own outcome figures and a future where robotics will be cost equivalent to laparoscopy. Future technology, progress in cancer genomics and biomarkers were also discussed in various sessions.  One example of new technology was Aquablation of the prostate; Peter Gilling presented the WATER trial results suggesting non-inferiority to TURP.  A welcome addition to the programme was Victoria Cullen (pictured), a psychologist and Intimacy Specialist who provides education, support and strategies for sexual  rehabilitation. She described her typical consultation with men with sexual dysfunction and how to change worries about being ‘normal’ to focusing on what is important to the individual.

Joint plenary sessions with the AUA and EAU were a particular highlight. Prof Chris Chapple confirmed the need for robust, evidence guidelines which support clinical decision making; and in many cases can be used internationally. He suggested collaboration is crucial between us as colleagues and scientists working in the field of urology. Stone prevention and analysis of available evidence was described by Michael Lipkin; unfortunately stone formers are usually under-estimaters of their fluid intake so encouragement is always needed! Amy Krambeck presented evidence for concurrent use of anticoagulants and antiplatelets during BOO surgery and suggested there can be a false sense of security when stopping these medications as it isn’t always safe. She championed HoLEP as her method of BOO surgery and continues medications, although the evidence does show blood transfusion rate may be higher. She also uses a fluid warming device which has less bleeding and therefore improved surgical vision; importantly it is preferred by her theatres nurses! MRI of the prostate was covered  by many different speakers, however Jochen Walz expertly discussed the limitations of MRI in particular relating negative predictive value (pictured). He eloquently explained the properties of cribiform Gleason 4 prostate cancer and how this variant contributed to the incidence of false negatives.

Moderated poster and presentation sessions showcased research and audit projects from the UK, Australia, New Zealand and beyond, mainly led by junior urologists. The best abstracts submitted by USANZ trainees were invited to present for consideration of Villis Marshall and Keith Kirkland prizes. These prestigious prizes were valiantly fought for and reflected high quality research completed by the trainees. Projects included urethral length and continence, no need for lead glasses, obesity and prostate cancer, multi-centre management of ureteric calculi, mental health of surgical trainees and seminal fluid biomarkers in prostate cancer. This enthusiasm for academia will undoubtedly stand urology in good stead for the future; this line up (pictured) is one to watch!

The Trade hall provided a great networking space to be able to meet with friends and colleagues and engage with industry. It also hosted poster presentation sessions, with a one minute allocation for each presenter – which really ensures a succinct summary of the important findings (pictured)! It was nice to meet with Australian trainees and we discussed the highs and lows of training and ideas for fellowships. Issues such as clinical burden and operative time, selection into the specialty, cost of training, burn out and exam fears were discussed and shared universally; however there is such enthusiasm, a passion for urology and inspirational trainers which help balance burdens that trainees face. Furthermore, USANZ ‘SET’ Trainees were invited to meet with the international faculty in a ‘hot seat’ style session which was an enviable opportunity to discuss careers and aspirations.

In addition to the Congress I was fortunate to be invited for a tour and roof-top ‘barbie’ at the Peter Mac Cancer centre; plus a visit to Adelaide with Rick (Catterwell, co-author) seeing his new hospital and tucking into an inaugural Aussie Brunch. Peter Mac and Royal Adelaide Hospital facilities indicated an extraordinary level of investment made by Federal and State providers; the Peter Mac in particular had impressive patient areas, radiotherapy suites and ethos of linking clinical and research. However beyond glossy exteriors Australian public sector clinicians voiced concerns regarding some issues similar to those we face in the NHS.

Despite the distance of travelling to Melbourne and the inevitable jet lag the world does feels an increasingly smaller place and the Urological world even more so. There is a neighbourly relationship between the UK, Australia and New Zealand as evidenced by many familiar faces at USANZ who have worked between these countries; better for the new experiences and teaching afforded to them by completing fellowships overseas. The Gala Dinner was a great chance to unwind, catch up with friends and celebrate successes in the impressive surrounding of Melbourne Town Hall (pictured); the infamous organ played particularly rousing rendition of Phantom of the Opera on arrival.

The enthusiasm to strive for improvement is similar both home and away and therefore collaboration both nationally and internationally is integral for the progress of urology. The opening address by USANZ President included the phrase ‘together we can do so much more’ and this theme of collaboration was apparent throughout the conference. The future is bright with initiatives led by enthusiastic trainee groups BURST and YURO to collect large volume, high quality data from multiple centres, such as MIMIC which was presented by Dr Todd Manning. Social media, telecommunications and innovative technology should be used to further the specialty, especially with research and in cases of rare diseases – such as RPF.  Twitter is a tool that can be harnessed and was certainly used freely with the hashtag #USANZ18. Furthermore, utilisation of educational learning platforms such as BJUI knowledge and evidence based guidelines help to facilitate high quality Urological practice regardless of state or country.

So we’d like to extend a huge thank you to Declan, Nathan and the whole team, and congratulate them for a successful, educational and friendly conference; all connections made will I’m sure last a lifetime and enable us to do more together.

Sophie Rintoul-Hoad and Rick Catterwell

 

#AUA17: Highlights from Boston part 2

The #AUA17 meeting was starting to hot up with the anticipation of the crossfire sessions controversy in urology,  second opinion cases and surgical technique plenary session. The early crossfire session was looking at adult onset hypogonadism. The  debaters  gave convincing arguments on both sides of the discussion but we were left in no doubt that adult-onset hypogonadism is a true medical condition and urologists need to recognise the symptoms and treat when appropriate.

 

There was a lively crossfire debate on the use off transperineal biopsy  vs TRUS biopsy for the detection of prostate cancer. There we some moral arguments in favour of  transperineal biopsy stated. Laurence Klotz presented the AUA MRI targeted biopsy consensus statement.

 

 

 

 

 

The results of the 24 months follow-up of the aquablation study was presented. The mean operative time was 45 mins with a aquablation time of 5 mins!  There was a 34% prostate volume reduction. There were no cases of urinary innocence , ejection or erectile dysfunction. The WATER study was presented comparing aquablation vs TURP.  The study found aqua ablation superior to TURP in terms of safety, Q max and IPSS reduction. We look forward to long term data but the initial results presented look promising

 

 

 

 

In a packed breakfast session we were given an excellent overview of the role of Immune checkpoint inhibitors in bladder cancer. The audience was treated to a state-of-the-art update on the newer drugs on the horizon, their indications, side effects and early clinical trial data. Watch his space for the new check point inhibitors for treatment of metastatic bladder cancer.

 

 

Burnout was a main theme across many of the sessions at the AUA. The poster by Nash et al. looked at results from the AUA census. They found that 41% of urologist surveyed  between the ages of 29-65 experienced burnout. Other risk factors included working in a multi speciality practise. Paediatric  urologists and urologist older than 65 were least likely to suffer from burnout. Very important issues have been highlighted at this meeting and gives food for thought for us all.

 

 

 

 

 

 

The eagerly awaited results of the randomised open verses robotic cystectomy (RAZOR) trial was announced at the AUA. the findings of the study showed that robotic cystectomy is not inferior to open cystectomy with respect to 2 year progression free and overall survival. As expected blood loss, length  to stay favoured the robotic cystectomy group but complication rates, overall surgical margins and lymph node yield were similar.

 

 

Bladder cancer diagnosis cost effectiveness was highlighted in a plenary session. Cost-effectiveness of ultrasound vs CT with cystoscopy was presented. The study found that the use of CT rather than ultrasound increased costs by $65 million / 1 cancer detected. This study highlights the need to risk stratify the use of CT in investigation of patients with non visible heamaturia.

 

 

One of the major announcements was the much anticipated phase 3 trial results looking at immediate post-TURBT instillation of gemcitabine vs saline in patients with newly diagnosed or occasionally recurring low grade non-muscle invasive bladder cancer,  SWOG S0337. The study shows reduced recurrence by 34% with little toxicity. There was a lot of excitement regarding gemcitabine as it 5-10 times cheaper than the widely used mytomycin C.

 

 

 

 

 

baus-bjui-usanz17The BAUS-BJUI-USANZ joint session was a fantastic overview from some of the top UK, US and Australian urologists. The highlights of the session included the talks on personalised medicine. The president of the British Association of Urological Surgeons Mr Kieran O’Flynn gave an insightful talk on training and inspiring the next generation of urologists. This was followed up by the Australian perceptive on urological training for the future. Khurshid Guru, Director of Robotic Surgery at Roswell Park Cancer Institute, gave an overview of cognitive training in surger . Finally the Coffey-Krane Award – the BJUI Journal prize for trainees based in The Americas – was awarded to Drs. Ranjith Ramasamy and Jason Kovac on their paper titled ‘Hypogonadal symptoms in young men are associated with a serum total testosterone threshold of 400 ng/dL’.

ckprize17Dr Ramasamy receives the 2017 Coffey-Krane prize from Prof Dasgupta

The Christchurch Medal was awarded to  Dr. Catherine deVries for her work on developing urological training programs in Asia, Africa, and Latin America. Congratulations to all the award winners and the BJUI team on an  exceptional programme.

 

 

 

In a busy trauma symposium the management of grade 4 renal injuries was presented. A multi centre study  looking at  safety in early mobilisation after renal trauma examined the benefits. The study concluded that the advantages for early mobilisation included increase in return of bowel function, reduced length of hospital stay, but acknowledged the increased risk of early mobilisation in higher grade traumas. One study looking specifically at outcomes in grade 4 renal injuries found 14% of the patients were unstable on  presentation, 52% required a blood transfusion with 24 hours and 74% of those with grade 4 renal injury had associated injuries.

 

 

 

 

 

The medical expulsive therapy (MET) debate rumbled on in 2017 at the AUA. Results of the late breaking abstract the Study of Tamsuolsin for Urolithiasis in the Emergency department (STONE) was presented.  The end point was stone passage at 28 days, with CT used to confirm stone passage. The study found no difference for stone passage rates for stones less than 9 mm compared to placebo.

 

 

 

At the ROCK session UK urologist Matthew Bultitude (@MattBultitude) gave an excellent case against  MET has he debated with John Hollingsworth. It is safe to say now ‘MET IS DEAD’

 

 

 

The NBA playoff final were on the Monday evening with the Boston Celtics beating the  Washington Wizards 115-105 in Game 7 of the Eastern Conference semi-finals. Many of the conference attendee took time out to watch the game live and support their adopted team the Boston Celtics.

 

 

 

 

 

It has been another excellent AUA in Boston. It was good to catch up with old friends and urologists from across the globe to debate and update on the latest management in urology. It was another record breaking year for the #AUA17 on twitter. It surpassed the stats for #AUA16 with over 52 million impressions, 20,530 tweets 3,591 participants. See you all in San Fransisco  for AUA 2018.

 

 

 

By Jonathan Makanjuola (@jonmakurology) and Nicholas Raison (@NicholasRaison)

 

 

#AUA17: Highlights from Boston part 1

It was a cold and wet Boston that welcomed the thousands of delegates from around the world for the start of #AUA17. Being home to such pre-eminent centres of learning and academia as Harvard, MIT and Fenway Park, we looked forward to a productive and enjoyable meeting. Set on the South Boston Waterfront, the Boston Convention and Exhibition Centre offered an elegant home to us for the next 5 days and provided all the necessary tools for scientific discussion: numerous coffee shops and speedy wi-fi.

Friday morning started off with a fascinating plenary session hosted by Prof Prokar Dasgupta (@prokarurol) on surgical techniques in radical prostatectomy. Three great “as live” demonstrations of open perineal, laparoscopic and robotic single site prostatectomy thrilled the packed room and once again demonstrated that it really isn’t the technique but the surgeon that really counts.

Following on in the plenary hall, the Tumour Boards offered informative panel discussions on all the major tumours. Of note the multidisciplinary discussion on prostate cancer highlighted some important key messages. Use of risk calculators was emphasised as well as the importance of reducing our reliance on PSA and the number of biopsies. Dr Stacey Loeb (@staceyloeb) gave some helpful reasons for the greater incorporation of the prostate cancer biomarkers into the clinical decision making process. But Dr Kibel made the excellent point that especially with all these new tests, the key is that we and, more importantly, the patients believe the results.

Similarly, the bladder cancer panel offered a number of points for discussion. Interestingly Dr Ashish Kamat(@UroDocAsh) highlighted the discrepancies between the EAU and AUA in risk stratification of high grade tumours which prompted extensive discussion in the twitter-sphere.

The potential for the new urinary markers to aid prostate cancer risk stratification featured prominently throughout the conference. The clear message was for their greater integration with other diagnostic tests such as MRI.

But worrying evidence that urologists in the States are already having to fight with insurance companies for an mpMRI, how easy this will be remains to be seen.

 

The morning in the plenary hall was nicely rounded off by the presentation of the latest AUA guidelines for managing RCC. In particular, the emphasis on biopsy and active surveillance of the small renal mass was strongly promoted.

 

Friday ended with a great evening session on robotic surgery organised by Mount Sinai Hospital. A panel of experts discussed and critiqued a trio of robotic procedures performed by Dr Tewari (Prostatectomy), Dr Badani (Kidney) and Dr Wiklund (Bladder). Despite the lengthy queues for the free snacks, Mount Sinai Hospital put on a great evening with some truly incredible 4K 3d video courtesy of Sony.

 

And for those urologists that have managed to resist the alluring charms of the Da Vinci Robot, an AUA trip to Fenway park offered the chance to enjoy something some top-level baseball as well as the classic Boston snack of the Fenway Frank (Hotdog). Even if the precise rules of baseball remained somewhat of an enigma, the great atmosphere inside the ground, not to mention the Jumbotron proposal, meant a fantastic evening was had by all.

 

Saturday morning kicked off with another strong programme. Dr Robert Sweet’s Journal of Urology lecture gave us some pause for thought. Entitled “Staying Relevant in the Modern Age”, Dr Sweet set out a very persuasive case why it is up to us as urologists to take charge of training and accreditation. Especially since device manufacturers wash their hands of any responsibility, before adopting any new technology it is vital that we recognise the learning curve and ensure the correct systems are in place.

 

The journal of urology top papers of 2016 provided a handy summary of the new hot topics and points of interests. In particular recognition of the worryingly aggressive but also MRI-invisible cribiform subtype of prostate cancer caught the audience’s’ attention.

 

The AUA further supported the importance of education and training with an extensive presentation programme. The benefits of crowdsourcing where endorsed by a number of presentations led by a plenary presentation by Dr Khurshid Ghani (@peepeeDoctor). Crowdsourced reviews of videos of robotic prostatectomies performed by expert surgeons were again shown to be effective, this time correlating closely with patient outcomes.

 

Similarly, Dr Tom Lendvay (@LendvayT) presented even more surprising data that when compared to expert reviewers, the Mechanical Turks (as the crowdsource workers on Amazon are known) gave more reliable and consistent evaluations! Given the growing calls for ongoing technical assessment of surgeons together with the time and financial expense of recruiting expert surgeon appraisers, the somewhat unpalatable option of crowdsourced assessment of surgeons continues to grow.

 

The highly popular crossfire debates returned with Dr Gerhard Fuchs (@GerhardFuchs9) leading a lively debate on dusting vs basketing. Dr Olivier Traxer and Dr Khurshid Ghani (@peepeedoctor) made a strong case for dusting in front of a packed crowed. But the “basketeers” championed by Dr Sara Best (@BestSaraMD) and Dr Jodi Antonelli defended well. Backed up by a strong SoMe debate, the final opinion was that as with everything the key is selecting the right technique for the right patient although the definition of dust was still hotly contested.

 

SoMe was of course a critical component of the conference, with some lively debates really helping to create the feeling of a very inclusive and connected conference despite the thousands of delegates. SoMe also featured strongly in the presentations with interesting studies showing both a relationship between social media presence on online ratings and surgical volume.

 

The highlight of the Saturday evening was the highly popular annual BJUI Social Media Awards. The city bar of the Westin Waterfront quickly filled and Prof Prokar Dasgupta kicked off the evening with a boisterous but nevertheless very warm welcome. A/Prof Declan Murphy, compère for the night, presented the many awards for the organisations and individuals that had done most to promote SoMe in urology. Best urology journal for social media was awarded to the Journal of Urology – recognising the significant steps they have made recently in this field. Other winners included Dr Stacey Loeb for best social media paper, the EAU for the best app and Christopher Wallis for the most read blog.

 

By Jonathan Makanjuola (@jonmakurology) and Nicholas Raison (@NicholasRaison)

 

 

EAU 2017 Congress Days 3&4

London calling! On Sunday morning London called one hour earlier than I had planned – damn daylight saving time! Last nights’ celebrations with urology friends from around the world at the ESRU (European Society of Residents in Urology) dinner party made me pay. Yet this was going to be a great meeting day.

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Sunday morning sessions served as a wake-up call after a short night due to daylight saving time.

Dr. Rajesh Nair has already reported on a great kick-off and continuation of the EAU17 congress in his blog on congress days 1 & 2.

The Sunday programme started with a plenary session in eURO auditorium on redefining and optimising contemporary bladder cancer care. The EAU chose a great concept for the plenary session by presenting an easily digestible mix of different lectures: Experts in the field used case discussions to illustrate real-life clinical scenarios and everyday issues for urologist. Speakers delivered their best arguments in the debates on pros and cons on urgent clinical questions. Finally, State-of-the-art lectures summarized the most important aspects in the field.

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EAU17 Delegates joining the congress action.

Sunday’s State-of-the art lectures on bladder cancer were held by James Catto and Walter Artibani. Catto reported on “Enhanced Recovery After Surgery (ERAS) for bladder cancer: Non-surgical options to improve outcomes of cystectomy”. Catto systematically covered 22 ERAS items on preoperative, intraoperative and postoperative measures. Appliance of ERAS for radical cystectomy yielded better outcomes for length-of-stay as well as readmission and transfusion rates when compared to traditional recovery concepts.

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State-of-the-art lecture: Three principles of the Enhanced Recovery after Surgery (ERAS) Philosophy.

The second State-of-the-art lecture by Walter Artibani gave perspectives on “What determines Quality-of-Life after urinary diversion and how do we measure it?” Artibani pointed out that we have to do a better job in defining and researching health-related quality of life in order to compare outcomes of urinary diversions. Multidisciplinarity is a must and there is room and need for enhanced long-term personalized information and support programs.

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Quality of Life after urinary diversion – Walter Artibani’s twist of Albert Einstein’s wisdom.

Besides scientific meetings, the Annual Meeting of course is the place for board meetings of the EAU bodies. The EAU Section Office Members took the opportunity to step out of the congress and enjoy London’s incredibly good weather.

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EAU Section Office Members enjoying London’s sun for a group photo.

At high noon it was time for me to join the Advanced Course on Social Media – take it to the next level! An expert panel of Social media users in urology gave insights on the wide variety of Social media use in our field. Twitter queen Stacy Loeb (@LoebStacy) gave examples on the use of social media for scientific research and for dissemination of content. Matthew Cooperberg (@dr_coops) showed in his talk “reputation management” why and how urologists should take care of their digital self. Finally, Inge van Oort (@onco_uroloog) presented do’s and don’ts of Twitter use emphasizing the importance of Social Media guidelines.

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Great conclusion of the advanced Social Media Course by @LoebStacy.

Yet, ESU Courses weren’t limited to lectures and discussions. HOT – Hands on Training was offered to delegates with 1-on-1-supervision. I was amazed by the variety of simulators and technical equipment for course participants. But why would they use red irrigation fluid? – Making the TURP simulation a more realistic experience? 😉

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Simulation and tutoring during European School of Urology Hands-on-training courses.

On Monday morning the EAU launched a new initiative: the Young Urologist Office provided a new course format: the EAU Leadership Course. Ambitious urologists from all over the world gathered to expand on their leadership skills: What are my leadership styles? Can I flex my style? Am I effective? These were only some of the aspects covered by a team of specialized leadership coaches.

 

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One key skill for leadership: great rhetorical skills!

Another thing I liked about the EAU congress was the professional media coverage – EAU TV offered short interviews covering highlights from abstract sessions, plenary sessions and insights from the EAU bodies. It was EAU TV that attracted my attention to Amanda Chung’s study “Is your career hurting you? – The ergonomic consequences of surgery in 701 urologists worldwide”.  Against common presumption, Chung et al. didn’t find a dose-response relationship between volume of surgeries performed and back pain. A protective effect against back pain was found for exercise, instead increasing weight and BMI were associated with higher pain – thanks for these insights! I definitely aim for a lifestyle change after hearing these findings!

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EAU TV enriches the conference experience.

There were a lot of things to learn during the congress. During the congress first-ever e-Poster Abstract Session on New technologies: Urology and multimedia, I learned from session chair and BJUI’s editor-in-chief Prokar Dasgupta that the highest cited paper on Altmetrics in 2015 was on a new antibiotic that kills pathogens without detectable resistance. Maybe this is why the EAU heavily announced it’s thematic session on infections in urology: “Killer bacteria and viruses in urology”. One must-read I got from this session was an update on the management of sepsis and septic shock.

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Highlights from the EAU Infectious diseases session “Killer bacteria and viruses in urology”.

As usual the EAU congress featured lots of live and semi-live surgeries. For some of them the Copenhagen Room wasn’t quite enough to accommodate all delegates interested.

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Live and semi live surgery as usual attracting lots of EAU delegates.

The EAU congress truly offered a cocktail of everything: the latest science presented in plenary & poster sessions, education, updates on guideline knowledge and of course lots of networking in form of meeting, greeting and tweeting.

Finally, my EAU17 journey ended on Monday night after lots of congress input, short nights and a great time meeting urology friends from around the world. Thanks a lot to all organisers and contributors for your hard work and great performance! See you in Copenhagen!

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Hendrik Borgmann, Urologist, University Hospital Mainz

@HendrikBorgmann

 

EAU 2017 Congress Days 1&2

 
rajesh-nair≠WeAreNotAfraid. Perhaps the standout memory of EAU – London 2017. The 32nd Annual EAU Congress in London was marked with a message of defiance from colleagues and delegates from London, Great Britain, Europe and Worldwide. These were messages of solidarity, which rang through in person and on social media after an attack at Westminster.  It was quite simple. London, Europe and the World will continue regardless of these tragic events and our urological fraternity beautifully demonstrated this as days following, a record-breaking attendance of 12000 delegates from over 123 countries descended to the Excel Centre in London, UK.

 

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 EAU-2017 had surpassed many a milestone. A record breaking 5000 abstracts were submitted for poster and video presentations from over 81 countries. 1200 presentations were displayed across 300 poster and video sessions. This year showcased an expansion of the number of plenary sessions from 4 to 7 allowing for a greater choice for all delegates. The quality, breadth and expertise behind the EBUS educational courses must be commended. Finally, as always, live surgery, which has year on year, proved to be popular was broadcast from Guy’s Hospital, London. They showcased the crème de la crème of surgical talent from live procedures with over 30 surgeons involved in operating, moderating, acting as patient advocates and in organisation. I, as I am sure all delegates extend our gratitude to the patients involved during the live surgical broadcast.

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 The camaraderie was clear to see. One could not take more than ten steps without running into a colleague or friend. It was a perfect opportunity to catch up, network and build relationships. Perhaps it was Prof. Sir Bruce Keogh (NHS England’s Medical Director and Commissioner of the Commission for Health Improvement (CHI)) who described it best in his opening address: ‘meetings like this are vitally important since it is at these occasions that knowledge and professional links are developed, and at these events ideas take seed and take hold: the important ideas that will later lead to significant work and progress in medicine.”

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In addition, the opening ceremony showcased some the serious talent in urology. Awards for Prof. Paul Abrams, Prof. Per-Anders Abrahamsson, Prof. Christian Gratzke, Dr. Riccardo Autorino and Mr. Richard Turner-Warwick demonstrated their commitment, hard work and dedication to the specialty.

Day 1 began with multiple subspecialty meetings and meetings between affiliated sections. These themed discussions were stimulating and really addressed the trials and tribulations as well as successes in the delivery of urology worldwide. Day 1 also showcased a fantastic session organised by the prostate cancer prevention group. They examined the role of active surveillance in low risk prostate cancer with specific reference to data from ProtecT, ESRPC and the PLCO trials. Prof. Hamdy gave a comprehensive overview of the ProtecT study and reminded the audience that the risk of death from prostate cancer remains low (1% over ten years), and that surgery and radiotherapy although reduce cancer progression can result in bothersome side effects.  The increasing role of urine based biomarkers; microRNA, imaging and genetic testing were all discussed when redefining the cohort of patients suitable for active surveillance.

The night ended with drinks at the Healtap, a bar outside Guy’s hospital, London. This was a throwback to the past for many. Old friends and colleagues, past fellows and current urologists all gathered to reminisce about past UK experiences. Following this, a late night serious session of serious recording and video production ensued with Declan Murphy and Alastair Lamb. For those open surgical protagonists who wonder ‘what have the robots ever done for us?’ I encourage you to watch:

The opening plenary session of Day 2: ‘Sleepless nights: Would you do the same again?’ chaired by Mr. Tim O’Brien critically re-evaluates some of the management decisions for kidney cancer from a medico-legal perspective. This session was fascinating and almost akin to a TV drama. A medico-legal lawyer (Mr. Leigh) vociferously cross-examining key members of faculty and an audience watching them sweat over what would have been initially perceived an acceptable clinical decision. A key message: allow your patients to take on decisions and not shoulder the entire burden yourself and the phrase; ‘your skills are for your patient, your notes are for yourselves’ continues to resonate.

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Another EAU annual conference goes by with yet more casualties from a verbal punch up. The second session showcased a debate on robotic salvage prostatectomy between Declan Murphy and Axel Heidenreich. Perhaps the blood spilt from this joust reminded the audience that despite the rising bank of evidence favouring salvage prostatectomy, there will always remains debate when a salvage procedure is associated with increased morbidity and risk for the patient.

The ‘twitosphere’ was heavily active. The beauty of this as always is that if you were to miss sessions, lectures or abstracts, the ability to follow them on twitter in real time adds another dimension to conference attendance.

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The most re-tweeted slide was presented by Dr. Ashish Kamat, a simple yes incredibly powerful slide demonstrating the equivalence in disease specific survival between high grade T1 urothelial carcinoma of the bladder and advanced prostate cancer reminded us all of the need to be vigilant and aggressive with high grade non muscle invasive disease of the bladder.

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Day 2 brought out some of the best in abstracts, EBUS courses and updates in clinical trials.  The latest developments in urological research include: the PROstate MRI Imaging Study (PROMIS) trial results reviewed by Hashim Ahmed and futher evidence and discussion from the Prostate Testing for Cancer and Treatment (ProtecT) trial by Freddie Hamdy. Prof. Jim Catto gave an eloquent talk examining the role of the enhanced recovery programme in radical cystectomy.

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What a fantastic start to the meeting! As you shall see, the remainder of the meeting did not disappoint. Dr. Hendrick Borgmann will reveal all in the update of day 3 and 4.

 

Mr. Rajesh Nair

Fellow in Robotics and Uro-Oncology

The Royal Melbourne Hospital & Peter MacCallum Hospital, Melbourne, Australia

Twitter: @nairajesh

 

Capitalising On Our Strengths: The 70th USANZ ASM

Canberra, our nation’s capital and the host city for the 2017 USANZ ASM, is a gem in its own right, but one which was created to satiate two feuding states locked in a bitter rivalry. In 1908, Canberra embodied the very meaning of compromise and collaboration, a technique which has garnered much success for our Country over the ensuing 100 odd years. Arguably the first official Australian collaborative effort, this way of thinking has become an almost uniquely Australian attribute and a strength imbued in our national pride.

USANZ 2017 was held in CanberraCanberra from up high, a breathtaking backdrop for a fantastic USANZ ASM.

Given this year’s mantra of: “Capitalising on our strengths” It is perhaps fitting then, that the 70th anniversary of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting (ASM) including the Australia and New Zealand Urological Nurses Society (ANZUNS) 22nd ASM, should be held in such a location. In addition to providing some wonderful tourist opportunities for guests including the War Memorial, the National Gallery and Parliament House.

Convenors A/Prof Nathan Lawrentschuk and Kath Schubach went to great efforts to successfully welcome both national and international guests and Scientific Program Directors A/Prof Shomik Sengupta and Carla D’Amico ensured a star-studded academic program addressing contemporary updates in Urological evidence based practice, which were aptly discussed both inside and outside the confines of the National Convention Centre.

1-2Senior YURO members standing outside Parliament House (from left to right): Dr. Daniel Christidis, Dr. Tatenda Nzenza, Dr. Todd Manning, Dr. Shannon McGrath

 

The representation by International faculty was exceptional, with countless urological household names from world leading centres across the globe both involved in the academic program and socially. Urological goliaths including Prof. Christopher Chapple, Prof. Prokar Dasgupta and Prof. Laurence Klotz weighed in on various topical issues providing an intercontinental perspective that complimented the equally impressive national line-up of speakers.

As with previous years, use of social media was rife, with those not able to attend kept in the loop via #Usanz17 and a steady stream from the ever focused twitterati. The ASM provided more than 5 million impressions and over 2800 individual tweets from more than 400 participants. The usual suspects were eminent as always, along with a few newcomers who provided impact in their own right. The official USANZ 2017 App also kept participants up to date via timely notifications and was user friendly.

Guests were spoilt for choice in the convention centre during well timed breaks, which was perpetually abuzz with attendees networking. In the background the ‘Talking Urology’ team headed by Mr Joseph Ischia and A/Prof Nathan Lawrentschuk provided a steady stream of captivating interviews with guests, regarding a myriad of urological topics. Simultaneously, numerous academics gave brief summaries of research posters during allocated presentation sessions. Exhibitors provided a captivating backdrop for these activities including many hands-on simulators and challenges for those keen to test their dextrous mettle. All the while guests relished a variety of delectable culinary options.

1-3Guests networking at the Gala Dinner, whilst being entertained by opera classics in the Great Hall foyer of Parliament House

 

The meeting’s common themes were strong and pertinent to contemporary urology. They centred around collaborative research efforts such as the ANZUP trials group and the Young Urology Researchers Organisation (YURO), technology especially PSMA PET and social media and social justice including women in urology and operating with respect. Discussions were directed by chairpersons during purposefully allocated Q&A times at the conclusion of each session, a new and well received addition to this years meeting. This was generously embraced by both senior and junior academics and led to intriguing symposiums and at times heated debate.

 

USANZ 2017 Friday Highlights

The first official day of proceedings provided a smorgasbord of morning and afternoon workshops ranging from technical skills courses to the medico-legal implications of E-Health and technology. This was followed by an allocated networking session for Urology trainees with International faculty.

Officially opening the conference in the Royal Theatre of the convention centre, A/Prof Lawrentschuk introduced this year’s Harry Harris orator; Elizabeth Cosson, AM CSC.  Her speech entitled “leading with grit and grace” eloquently detailed her journey in the armed forces and highlighted the difficulties of the unmistakably imbalanced workplace for women in the military. Her talk clearly underlined her role in not only forging a highly successful career for herself but also for those women following in her footsteps. Her inspiring dialogue was synchronous with contemporary issues surrounding Urological practice, especially concerning equality for women but more resolutely, appropriate equity both in training and established practice.

With the tone well established for an exceptional meeting, guests enjoyed a variety of canapés and drinks in the exhibition hall, unwinding with social discussion.

1-4YURO President, Dr Todd Manning talks to young researchers with help from Prof. Henry Woo and A/Prof. Lawrentschuk during the YURO annual meeting

 

Saturday Highlights

Plenary sessions aplenty began the second day of proceedings with International academic giants including Prof. Klotz, Prof. Chapple, Prof. Traxer and Prof Nitti mixed in with National heavy hitters such as Prof Frank Gardiner, Mr Daniel Moon and outgoing USANZ president Prof. Mark Frydenberg.

Afternoon sessions included subspecialty discussions and some stellar Podium Poster presentations, with an especially impressive mix of senior and junior researchers regarding countless and diverse urological topics.

 

Sunday Highlights

Heralding the beginning of another exceptional day, the ‘Women in Urology’ breakfast symposium chaired by Dr Anita Clark along side distinguished panellists including Dr Caroline Dowling and Dr Eva Fong was a conference stand out for many.

Following this, more plenary sessions filled the remainder of the pre-lunch program, leading into the highly anticipated Keith Kirkland and Villis Marshall presentations by Urology SET trainees. The presentations did not disappoint. As in previous years, research of unyielding professional and academic quality was offered by the group of future urologists, who as is tradition weathered the gauntlet of probing and tough questions from the floor. All presentations were captivating in their own right.  2017 Villis Marshall winner Dr Marlon Perera presented ground-breaking research regarding the reno-protective role of zinc in contrast nephropathy. Dr Amila Siriwardana was deservedly awarded the Keith Kirkland

award for his multicentre retrospective review on Robot assisted salvage node dissection to treat recurrences detected by PSMA PET.

Following these presentations, the YURO annual meeting once again heralded a complement of enthusiastic, innovative and clever minds from all Australian states, eager to pursue research opportunities through collaborative means. Joined this year by Prof. Henry Woo, the group was fortunate to receive his valuable insight and feedback regarding past success and future direction. The group solidified upcoming positions of leadership and highlighted new directions in educational, research and mentorship avenues for younger members.

The Gala Dinner is a stand out affair during each ASM and this year was no exception. Guests were provided with the unique opportunity to see Australia’s Parliament House from the inside. The night began with surprise operatic renditions of many well known classics in the spacious foyer of the Great Hall and culminated with a climactic performance of Nesson Dorma. Guests then enjoyed a delectable 3 course meal in identical fashion to a rare collection of political royalty including; Barack Obama, Prince William and the Duke and Duchess of Cambridge.

1-5Twitter metrics tabulated from the conference via the #Usanz17 (courtesy of Symplur LLC)

 

Monday Highlights

The final day of proceedings saw once again provided an array of interesting and thought provoking topics.  The clear highlight of the morning was the metaphorical prize fight between Mr Joseph Ischia and Dr Shankar Siva debating the roles of surgery and radiotherapy in Oligometastatic disease. Although these two went toe to toe over many rounds, the inevitable conclusion was understandably a draw. Although on PowerPoint slide pictures alone, Dr Siva’s extensive use of Star Wars based analogies won my vote.

Insight and introduction to the 71st USANZ ASM was then delivered and as a Melbournian my bias was admittedly hard to hide. Attendees received a taste of the excitement to come, with what is assured to be another blockbuster cast of national and international urologists led boldly by Convenor Mr Daniel Moon and Scientific Program Director Prof. Declan Murphy. I for one, eagerly anticipate the return of the ASM to out Nation’s culinary and cultural capitol and I’m sure guests in 2018 will be captivated by the world most liveable city!

It can be said with certainty that this years USANZ 70th ASM presented a scientific program as strong as ever within a fascinating and historical backdrop and complimented by a lively social atmosphere. This consensus of a highly successful meeting, I’m sure was shared by all.

I look forward to seeing you all next year and hope you are eagerly anticipating the ‘flat whites’.

 

Dr. Todd G Manning, Department of Surgery, Austin Health, Melbourne, and Young Urology Researchers Organisation (YURO), Australia. Twitter: @DocToddManning

 

Should we abandon live surgery: reflections after Semi-Live 2017

Prokar_v2Ever since 2002, I have performed live surgery almost every year where it is transmitted to an audience eager to learn. This year I was invited by Markus Hohenfellner to the unique conference, Semi Live 2017 in Heidelberg. To say that it was an eye opener is perhaps stating the obvious. One look at the program will show you that the worlds most respected Urological surgeons had been invited to participate, but with a difference. There was no live surgery. Instead videos of operations – open, laparoscopic and robotic were shared with the attendees “warts and all” as a learning experience. These were not videos designed to show the best parts of an operation. There were plenty of difficult moments, do’s and don’ts and troubleshooting, but all this was achieved without causing harm or potential harm to a single patient.

My highlights were laparoscopic sacrocolpopexy (Gaston), robotic IVC thrombectomy up to the right atrium (Zhang) and reconstructive surgery for the buried penis (Santucci). The event takes place every 2 years and the videos are all available on the meeting app which can be downloaded here and is an outstanding educational resource.

We were treated to a heritage session which included the superstars Walsh, Hautmann, Clayman, Mundy, Schroder and Ghoneim. This was followed by our host Markus Hohenfellner comparing and contrasting the art of Cystectomy and reconstruction by Ghoneim, Stenzl and Studer.

 

Open surgery is certainly not dead yet. The session ended with Seven Pillars of Wisdom from Egypt which turned out to be a big hit on Twitter.

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The editor’s choice session, a new innovation for 2017, allowed me to showcase the Best of BJUI Step by Step, a section that has now replaced Surgery Illustrated with fully indexed and citable HD videos and short papers.

Has live surgery had its day?

Many on Twitter seemed to agree that in 20 years time we might look back and say that it was not the right thing to do.

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Surgeons do not operate “live” every day. Most doctors in a survey, would not subject themselves or their families to be patients during live surgery. Talk about hypocrisy!! Why should it be any different for our patients? Live surgery is NOT a blood sport practised in Roman times….

The counterpoint is that patients often have the services of the best surgeons during live surgery, recorded, edited videos are not quite the same and that the whole affair has become safer thanks to patient advocates and strict guidelines from some organisations like the EAU. Others have banned the practice for good reason. While the debate continues, I for one came away feeling that Semi-Live was as educational, less stressful and much safer for our patients.

 

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

 

RSM Urology Winter Meeting 2017, Northstar, California

rsm-2017-blogThis year’s Annual RSM Urology Section Winter Meeting, hosted by Roger Kirby and Matt Bultitude, was held in Lake Tahoe, California.

A pre-conference trip to sunny Los Angeles provided a warm-up to the meeting for a group of delegates who flew out early to visit Professor Indy Gill at the Keck School of Medicine.  We were treated to a diverse range of live open, endourological and robotic surgery; highlights included a salvage RARP with extended lymph node dissection and a robotic simple prostatectomy which was presented as an alternative option for units with a robot but no/limited HoLEP expertise.

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On arrival to Northstar, Dr Stacy Loeb (NYU) officially opened the meeting by reviewing the social media urology highlights from 2016. Next up was Professor Joseph Smith (Nashville) who gave us a fascinating insight into the last 100 years of urology as seen through the Journal of Urology. Much like today, prostate cancer and BPH were areas of significant interest although, in contrast, early papers focused heavily on venereal disease, TB and the development of cystoscopy. Perhaps most interesting was a slightly hair-raising description of the management of IVC bleeding from 1927; the operating surgeon was advised to clamp as much tissue as possible, close and then return to theatre a week later in the hopes the bleeding had ceased!

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With the promise of beautifully groomed pistes and stunning views of Lake Tahoe, it was hardly surprising that the meeting was attended by a record number of trainees. One of the highlights of the trainee session was the hilarious balloon debate which saw participants trying to convince the audience of how best to manage BPH in the newly inaugurated President Trump. Although strong arguments were put forward for finasteride, sildenafil, Urolift, PVP and HoLEP, TURP ultimately won the debate. A disclaimer: this was a fictional scenario and, to the best of my knowledge, Donald Trump does not have BPH.

The meeting also provided updates on prostate, renal and bladder cancer. A standout highlight was Professor Nick James’ presentation on STAMPEDE which summarized the trial’s key results and gave us a taste of the upcoming data we can expect to see in the next few years.

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We were fortunate to be joined by prominent American faculty including Dr Trinity Bivalacqua (Johns Hopkins) and Dr Matt Cooperberg (UCSF) who provided state-of-the-art lectures on potential therapeutic targets and biomarkers in bladder and prostate cancer which promise to usher in a new era of personalized therapy.

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A personal highlight was Tuesday’s session on learning from complications. It was great to hear some very senior and experienced surgeons speaking candidly about their worst complications. As a trainee, it served as a reminder that complications are inevitable in surgery and that it is not their absence which distinguishes a good surgeon but rather the ability to manage them well.

There was also plenty for those interested in benign disease, including topical discussions on how to best provide care to an increasingly ageing population with multiple co-morbidities. This was followed by some lively point-counterpoint sessions on robot-assisted versus open renal transplantation (Ravi Barod and Tim O’Brien), Urolift vs TURP (Tom McNicholas and Matt Bultitude) and HOLEP vs prostate artery embolization for BPH (Ben Challacombe and Rick Popert). Professor Culley Carson (University of North Carolina) concluded the session with a state-of-the art lecture on testosterone replacement.

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In addition to the excellent academic programme, delegates enjoyed fantastic skiing with perfect weather and unparalleled views of the Sierra Nevada Mountains. For the more adventurous skiiers, there was also a trip to Squaw Valley, the home of the 1960 Winter Olympics. Another highlight was a Western-themed dinner on the shores of Lake Tahoe which culminated in almost all delegates trying their hand at line dancing to varying degrees of success! I have no doubt that next year’s meeting in Corvara, Italy will be equally successful and would especially encourage trainees to attend what promises to be another excellent week of skiing and urological education.

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Miss Niyati Lobo
ST3 Urology Trainee, Brighton and Sussex University Hospitals NHS Trust

@niyatilobo

 

5th International Neuro-Urology Meeting (INUM)

The Annual Congress of the International Neuro-Urology Society (INUS), organized by the Swiss Continence Foundation (SCF)

Neurogenic urinary tract, sexual and bowel dysfunction is highly prevalent and affects the lives of millions of people worldwide. It has a major impact on quality of life and, besides the debilitating manifestations for patients, it also imposes a substantial economic burden on every healthcare system.

It was a great honour and pleasure to organize the 5th International Neuro-Urology Meeting (INUM), which took place from 25-28 January 2017, in Zürich, Switzerland. We are proud to announce that the International Neuro-Urology Meeting, organized under the umbrella of the Swiss Continence Foundation (www.swisscontinencefoundation.ch), has become the official annual congress of the International Neuro-Urology Society (INUS, www.neuro-uro.org), a charitable, non-profit organization aiming to promote all areas of Neuro-Urology at a global level and whose inauguration was inspired during the last INUMs.

The world’s leading experts in Neuro-Urology provided an overview on the latest advances in research and clinical practice of this rapidly developing and exciting discipline. This unique meeting combined state-of-the-art lectures, lively panel discussions, and hands-on workshops with emphasis placed on interactive components. There were many opportunities to exchange thoughts, experiences and ideas and also to make new friendship.

The Swiss Continence Foundation Award: To promote the next generation of outstanding young researchers and clinicians who represent the future of Neuro-Urology, the prestigious Swiss Continence Foundation Award of 10’000 Swiss francs was awarded to the best contribution from a young Neuro-Urology talent: Marc Schneider from Zürich, Switzerland, convinced the international jury with the presentation of his PhD project “Anti-Nogo-A antibodies as a potential causal treatment for neurogenic lower urinary tract dysfunction after spinal cord injury”. He demonstrated in an animal model that intrathecally applied antibodies against the central nervous system protein Nogo-A which inhibits nerve fibre growth had beneficial effects on lower urinary tract dysfunction in rats with incomplete spinal cord injury by re-establishing a physiological micturition and preventing detrusor sphincter dyssynergia. This effect presumably occurs due to neuronal re-wiring of descending micturition circuits facilitated by the anti-Nogo-A antibodies. Anti-Nogo-A immunotherapy enters currently clinical trials in humans and could become a unique causal treatment option for lower urinary tract dysfunction in patients with incomplete spinal cord injury.

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One of many other highlights was the joint presentation of the EAU Secretary General Christopher R. Chapple and the BJUI Editor-in-Chief Prokar Dasgupta on the challenging topic “What should the neuro-urologist learn from the onco-urologist and vice-versa?”

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Finally, we are delighted to announce the 6th International Neuro-Urology Meeting to be held in Zürich, 25 to 28 January 2018. Save the date! For details please visit: www.swisscontinencefoundation.ch. We are looking forward to seeing you in Zürich!

Thomas M. Kessler, SCF Chairman and INUS Vice-President

Ulrich Mehnert, SCF Vice-Chairman and INUS Treasurer

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Société Internationale d’Urologie : Buenos Aires 2016


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Hola como estas? The 36th SIU congress was held in Buenos Aires, Argentina 20-24th October. Their motto: ‘we bring urologists together’ was certainly fulfilled as reflected by the warm atmosphere and international mix of speakers and attendees. The scientific programme included plenary sessions, debates, hands on instructional courses, trainee Q&A sessions and symposiums.

The location and facilities at the Hilton were first class. A large exhibition hall allowed for interaction with industry. The use of the pool bar hosted by the SIU innovators group was a particular highlight.

The conference app was easy to use and the conference hashtag #SIU16 and a #selfie challenge were promoted.  The selfie prize of a trip to SIU Portugal was won by Argentine resident Dr. Jose Nolazco with over 300 likes!

siu1Thursday

The conference kicked off with varied and interesting sessions on a range of urology, which included sub-section meetings such as societies of the Middle East, Africa, Asia, and Argentina; plus the 2nd SIU nurses educational symposium. The most popular meeting (in numbers attending and discussions after) was the World Urological Oncology Federation Symposium (WUOF). A delegate from South Africa told me that he appreciated the summary of new research and highlighting the areas of change, especially in a field when advances can occur quickly, for example PMSA-PET which may be able to give more information on metastatic prostate cancer than MRI. Arnaud Villiers vs Robert Reiter debated the issue of focused vs radical therapy to an intermediate, solitary lesion in the prostate. Reiter argued NOT for focal therapy on the basis of the imperfections of the MRI.

The MRI-TRUS fusion course, hosted by SIU Innovators division and with MIMS from industry present, championed MRI as a primary diagnostic test to investigate prostate cancer. Boris Hadaslick quoted (PROMIS trial) that TRUS biopsy without MRI had a 50% chance of finding cancer: ‘like flipping a coin’. He emphasised that targeted plus systematic biopsy sampling was best practice and highlighted the fusion software systems can improve cancer diagnosis. However cognitive fusion can be as good.

Speakers enthusiastic about advances in urology described high costs that had to be justified to their healthcare system like PSMA-PET and immunotherapy for bladder cancer. Yet these costs would be impossible for other delegates to take back to their home countries. Indeed the most innovative speakers presented their cost-saving techniques in the ‘SANTU’ session; the opening remarks of ‘how can you drive a Ferrari if you don’t have paved roads?’ was particularly levelling. One speaker, Mohammed Lezrek, stood out as being particularly creative, which he says is as a result of necessity, he showed videos using rubber from syringes or saline bag ports to fix the bungs on his endoscopes in Morocco (https://m.youtube.com/user/lezrekmohamed). These are issues I wouldn’t even think to know how to fix, being fortunate enough to work in the NHS. Other speakers in the same session described using generic, mass produced Ureteric stents that were a fraction of the price, another described treating a condition common to him in Indonesia of penile dermatosclerosis caused by penile injections of oil obtained as easily as ‘getting a haircut’ with the low cost surgical technique of scrotal flap. There was also a symposium on Urology in the Developing World, which included the best-titled talk: ‘the hunt for the perfect penis’ given by Ms Rampersad. She is the only surgeon performing hypospadias repair in Trinidad and Tobago, at an incidence of 2.7 per 1000 live births and recommended that specialist surgery be performed by those who are keen and performing larger volumes.

The Endourology Society Symposium was a popular session with standing room only. There were lessons on the possibilities, but also the limitations of flexible ureteroscopy, including an impromptu debate on use of access sheath and a case of stone clearance in a patient with HSK. A Canadian audience member spoke of his difficulty in justifying the use of flexi URS to managers in view of longer operation time compared to PCNL due to OR pressure. Michael Grasso captivated the audience with his experience in using flexible URS for diagnosis and treating upper tract TCC. In his series this meant less nephrectomies, no dialysis and better palliation. He even does LA flexi URS in selected patients! An important message on the dangers of IntraRenal pressure was presented by Palle Osther, which can occur even at an irrigation height of 40cm. He highlighted that whilst papers are championing the use of Flexi URS in more complex cases this means more time in the renal pelvis with the added risk of complications. He quoted Hippocrates ‘do no harm’. Grasso and Olivier Traxer explained their methods of stringent use of irrigation via piston controlled syringe and limiting operation time to an hour.

siu2My personal highlight was the presentation of videos by Mr René Sotelo on ‘getting out of sticky situations’ (SIU innovators symposium). An expert panel described similar mistakes to the ones shown on the videos and added what they would do if faced with the problem, leading to a fruitful and rich discussion. He showed tachycardia inducing, faint provoking videos of bleeding from upper and lower tract minimally invasive surgery. Advice such as stay calm, phone a friend, increase the pneumo, ‘suture fast’ was useful and practical. One case showed a rectal perforation at cystectomy where the attending/junior had been asked to place a swab (on stick) into the vagina, but it became apparent once the swab was on show and the vagina was intact that the swab had been misplaced into the rectum, thus highlighting the need to know your anatomy! An amazing image of a Ureteric stent that had been accidentally placed in the atrium was shown; but we were told the next step should not be to call an endourologist!

siu3In the opening ceremony we were welcomed by Argentine tango dancers, the Minister of Health: a qualified doctor with degree in public health, and some Argentine hospitality of wine and typical foods. Friendly and collegiate atmosphere is what the Secretary of the SIU promised us, and friendly banter was present during the day. The first Brexit joke came when Mr Chris Parker started to explain to one presenter of the World Oncology federation why the UK was not included in the observation of deterioration of prostate cancer outcomes during the 2008 world recession, to which the presenter replied that it was only European countries in the paper. There was a mix of cheers and boos from the audience. However UK prostate cancer research, such as the PROMIS trial and the Emberton team studies were frequently quoted, as well as other British papers, with high esteem as corner stones of cancer research and advancing patient care.

 

Day 2 Friday

There was an early start for many who attended one of four optional instructional courses: each covered a different theme. I attended ‘management of priapism’ in view of its direct relevance to potential situations I may find myself in as an on call registrar. UCLH Consultants Asif Muneer and Guilio Garaffa hosted and gave clear information on acute management and surgical shunt techniques, plus imaging for more difficult cases, such as CT to exclude intra-abdominal cause of refractory priapism. The take home message was to consider early implantation of penile prosthesis if priapism lasts >72 hours. This was shown clearly on operative videos of prosthesis surgery at 3 weeks compared to 6 m; where the latter had penile fibrosis increasing surgical difficulty.

The first plenary session covered new advances in testicular cancer and another debate of focal therapy in intermediate prostate cancer. Scott Eggener presented a polished and compelling argument on why focal therapy could be the future, but Markus Graefen described his reluctance to accept it based on the research, limitations in MRI, and need for follow that is similar to active surveillance; but perhaps patient choice will drive us to make a conclusion. Fernando Secin described the low uptake of Active Surveillance within Argentina. This may be due to costs (both AS costs and costs lost by not operating) and lack of protocols; however, those clinicians who had undergone oncological training and worked in Academic centres were more likely to recommend AS.

Description of how Ebola affected our African colleagues and sadly mortality due to HSW highlights the breadth of education and world issues covered by the SIU congress. Winner of the SIU Astellas European Foundation Award, Dr John M Barry, described how five transplantation principles can be applied to urology. This included using life expectancy calculations, not age, in making decisions (he used his own Charlson comorbidity score to illustrate the point that it can be improperly used); he suggested using a quality of life grid and that practice guidelines, from numerous organisations use different grading systems thus he calls for unified, world scientific language.

I was invited to attend a ‘quick fire session for trainees’ where I met five experts and discussed career questions such as fellowships, choosing urology specialties and engaging with academia, which includes networking that we can practice during the conference. The experts were super friendly and one attendee was thrilled to meet Olivier Traxor who is his endourological hero.

Other sessions included the first session on ‘Professionalism in urology’ and included information on using Twitter and working with industry without compromising or influencing patient care by always practising evidence-based medicine. However, many researchers have ties to industry. Several tweets were shared during this session, for example:


Another session popular with trainees was ‘how to write a paper’ hosted by the World Journal of Urology.

Dan Wood from UCLH, UK chaired the session for congenital reconstruction, which included how to set up a service by Miss Claire Taylor; she emphasised the need to define the service you want to provide, decide which paediatric hospital you want to work with and having an excellent MDT and clinical specialist nurse, of which she is fortunate to have Winnie Nugent who works to bridge the gap between child and adult services.

The ‘Surgical Demo, session on Laparoscopy was well attended and the audience watched excellent videos from Karim Touijer on lap prostatectomy and Gonzalo Vitagliano on lap nephrectomy. The videos were clear and narration highlighted the relevant steps and anatomy. They emphasised the need to gain a mentor to reduce the learning curve and not attempt to set up a lap service solo. There was also an ‘encyclopaedic’ style Surgical Masters session of all types of prostate surgery for BPH that included surgical videos and tips/tricks.

 

Saturday

Many attended the sessions with a sore head on Saturday morning following the SIU Night party held at La Rural, a National Historic Landmark located in the Palermo district of Buenos Aires. It was inaugurated in the late 1800s in order to support and promote agricultural issues in Argentina. We were treated to typical foods: empanadas, freshly barbequed meats and sausages, breads and of course home grown wine. Entertainment was provided by Argentinian tango dancers and Argentine Gaucho dancers whose finale ended with Bolleadoras a dance that made hearts pound from the open male shirts, fast rhythm and the whirling ropes. Additionally, there was a photo booth for traditional Argentine dress, football snooker and a mechanical bull; luckily the only injury was an Australian trainee’s trousers.

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The morning’s plenary session ‘Shifting sands – new technologies in stone disease’ covered a range of topics including retrograde intrarenal surgery by Mr Traxer. Mr Jorge Guitierrez highlighted the dangers of sepsis in stone disease; one key message included stopping stone surgery (including PCNL) when there was purulent urine. The panel agreed that 1-2cm stones fall in a grey area in the guidelines as to which treatment is the best. The majority of the panel favoured flexible ureteroscopy; but admitted that a patient’s ability to afford PCNL vs flexi URS and the surgeon’s skills and availability of equipment was what often governed practice rather than choice. Mariano Gonzalez described stone disease affecting pregnant women and the challenges of treating; interestingly he suggested that a low dose CT in the 2nd and 3rd trimester can be considered safe. Pradeep Rao informed us of the changing PCNL sizes and how the smaller ‘seeing needle scope’ at 4.8F enabled him to remove the stone in an infant less than one years old. Norberto Bernardo shared his experience with managing stones in complex patients, such as a case with severe scoliosis and another in a HSK. Mr Traxor made a plea that stents be used for the shortest time to reduce patient morbidity, i.e. as soon as they have been placed make a plan for ureteroscopy to enable stone treatment and removal.

The use of mesh for vaginal prolapse was debated by Nissrine Nakia (pro) and Paulo Palma (con). Palma highlighted the anatomy of the pelvic floor and the importance of identifying the level of deformity, which should then be used to select the right patients and select the correct procedure. The counter argument from Nakia started with a campaign slogan P.R.O.M.E.S.H in keeping with the ongoing US presidential debate. She stated that whilst the FDA did raise concerns regarding re-operation rates, there are now more modern meshes and are subjected to rigorous testing, plus experience has been gained regarding placement of mesh, post-mesh cystoscopy and use of oestrogen cream, which have all improved patient outcomes.


The European and Asian societies both presented in the plenary sessions. The EUA lecture, given by Arnulf Stenzl, described ongoing changes on how to improve TURBT, which included better training for juniors, including simulation, better visualisation (photo dynamic diagnosis) and the use of ‘bloc’ dissection with hybridknife to enable whole tumour removal in once piece, which can aid histological analysis.

Mr Foo from Singapore presented the UAA lecture on the subject of ‘holistic approach’ to care of BPH. Additionally that perhaps the Intro vesicular prostatic protrusion (IPP) tells us more about the likelihood of obstruction and when surgery would make the most difference.

Three parallel plenary sessions provided learning in the fields of spinal cord injury, paediatric urology and urological histology. The histology speakers had a tough job describing their field to us surgeons! The plenary session ‘SIU-ICD joint consultation on urological management of Spinal cord injury patients’ was well attended and covered the anatomy, surgical and non -surgical options, urodynamics and bladder emptying options. Speakers emphasised the need for Long-term follow-up, including upper tract imaging, blood tests (U&Es) and QOL questionnaires of which there are several. Each presenter clearly stated their recommendation and the level of evidence to support it. Tweets from this session included a commitment to reduce urine culture and treatment of UTI on asymptotic patients.


‘Ageing and urology’ session complemented the holistic theme as an expert panel discussed optimisation of elderly patients and the difficult decision making process of offering surgery in patients with frailty, high risk GA and delirium and co-morbidities. One panellist said it was about making a judgement that if the patient will appreciate the change and it will add to their QOL then age is not a barrier to operating; however, teamwork with anaesthetists and geriatrics is key to optimisation.

Each day a ‘Surgical Demo’ session’ ran, Saturday’s was on stones which was, like many stone sessions, full; Perhaps highlighting the enthusiasm towards Endourology. Pictured is Mr Guitierrez describing correct ureteroscopic hand manoeuvres and his ‘painting’ technique to dust stones. Additionally Mr Lojanapiwat from Thailand presented his operative experience in subcostal access for upper pole stones.

Throughout the afternoon were moderated poster sessions; from reducing laparoscopic camera fogging to comparison of traditional vs western medicine. These accepted abstracts were presented by urologists who were at varying stages of their careers. Presentations reflected high standards of research and a culmination of hard work. After watching some of the poster presentations I joined the urethral reconstruction ‘surgical tips’ session, which drew the biggest audience. The presentations offered high-quality operative pictures and complimentary radiology pictures showing the complexity of some of these strictures. Daniela Andrich from UCLH presented their experience of post-traumatic strictures and emphasised that the mechanism of injury correlates to the stricture pattern. Furthermore that partial ureteric injuries are probably under reported as they heal with the catheter in situ, sited by the trauma/orthopaedic team.

 

Sunday

The sun shone brightly on the last day of the conference and whilst many In the city were enjoying their Sunday lie in or preparing for church, conference delegates made their way to the last four early morning instructional courses. I attended ‘surviving prostate cancer’ chaired by Prof Mundy, which covered the aftermath of treatment for prostate cancer: fistulae, strictures, incontinence. Interestingly as our colleagues in General Surgery change techniques it provides new challenges relating to recto-vesical fistulae. It was recommended that MRIs should include sagittal views to best define the fistula anatomy. Prof Mundy described the difficulty that radiotherapy creates by scarring the tissues, which makes these patients more at risk of post-operative complications. This means it’s imperative to properly assess people prior to radiotherapy, including a cystoscopy to assess the bladder (and if applicable the post-prostatectomy anastomosis). Then consent the patient thoroughly prior to radiotherapy so that they’re aware of the more difficult surgery they face, should it be required.

The plenary session started with four speakers describing the emerging role of immunotherapy and specifically in cancers of the prostate, bladder and kidney. The research presented gave optimism of improving treatments for these cancers and that trials are ongoing and concluding. Fred Saad described how access to tissue can try to develop precision medicine; mutations specific to that tumour and patient could be assessed and tested in the laboratory so that treatment can be targeted and avoid treatments that don’t work.

A fierce debate regarding the role of varicocele surgery in the era of assisted reproduction ended in favour of offering surgery. Robert Brannigan presenting the ‘yes’ argument argued that varicocelectomy needs to be synergistic to assisted contraception, especially if time is of the essence in relation to maternal age. He gave evidence that varicocelectomy improves sperm quality for assisted conception and sees changes 3 months post-surgery. Alex Pastusak said he’d rather be ‘successful than lucky’ and was in favour of assisted contraception as the evidence for varicocelectomy, even the meta-analysis papers, has limitations so casts doubt on validity of available studies.

Rene Sotelo presented his endoscopic techniques for fistula repair, which included lap or robotic surgery within the bladder to remove the tract, create a plane between the bladder and surrounding tissues, place omentum or fascia between and then close the defect. We quickly moved from advanced techniques to trying to establish the basic technique with the next speaker. Alain Houlgate described his experience of establishing an endourological teaching programme between France and Senegal, which cumulates in a diploma.

Abstract prize winner Henry Woo presented his work on the International journal club #urojc where each month newly published articles are sent out to twitter followers and discussion generated. Unsurprisingly he was congratulated via twitter:


The last plenaries of the conference prior to further poster sessions included uroradiology, systemic cancer therapies and surgical demo on robotic cystectomy. The radiology session highlighted the advances in PSMA PET for prostate cancer recurrence but that TRUS still had a role.


siu13River Plate Urological Meeting: representatives from the RSM – Urological section, UK, met with representatives from the Hospital Británicos in Rosario and Buenos Aires, Argentina and Montevideo, Uruguay. This is the first time these groups have met with the aim of collaboration and training. The day included presentations from the hospitals’ urology trainees, in English, on a range of topics and were marked as per the RSM marking criteria. The winning presentation was on ‘laparoscopic nephrectomy for living kidney donors’ and 2nd place for a presentation on ‘history of circumcision’. We had a tour of the hospital and were then welcomed into the British Embassy, to meet the Ambassador who is supportive of the relationships that are forming as a result of this meeting.

 

Concluding remarks

Overall the SIU was well organised, navigable and the incredible range of urology was well represented by experts in their field. The conference delegates were friendly, approachable and our host Buenos Aires warm and welcoming. Friendships and collaborations will undoubtedly continue beyond this congress.

The SIU Night was a particular highlight, showcasing the Argentine spirit in one evening for those who weren’t staying long in the country. The programme used varied formats and operative videos shown were generally of good quality. The presentations were of good calibre and the research presented both new and established. Reference was often made to EAU and AUA guidelines and international papers from a range of journals, in particular BJUI, Eur Urol and J Urol. The meeting of minds is certainly healthy to urological progress and exchanging ideas is key to innovation and improvement within our specialty across the world. There is so much we can learn from each other.

Adios SIU 2016! and ‘Até logo’ SIU 2017 Portugal!

 

Sophie Rintoul-Hoad is a urology trainee in the South Thames Deanery, currently working at King’s College hospital. She attended the SIU 2016 conference in Buenos Aires and then saw some of Argentina’s highlights, including a few days at El Venado Estancia playing polo and learning how to be a gaucho!

 

 

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