European Urology Today: April/May 2023

In this edition a comprehensive report of the 38th Annual EAU Congress (EAU23). European Urology Today (EUT) is the official newsletter of the EAU. It is produced five times a year and is distributed worldwide. EUT is our own newsletter, informing our members on announcements, news about the EAU, reports from our meetings and scientific discussion.

Vol. 35 No. 2 - April/May 2023

New Editors-in-Chief European Urology and EU Oncology under new leadership

Launch of PRAISE-U Start of three-year EU-wide project to develop smart early PCa detection

Prizes and awards at EAU23 Congratulations to all winners




EAU23 report: Year-on-year progress Highlights of ground-breaking research and cutting-edge technologies

By Erika De Groot, Stephanie Fitts and Loek Keizer

Phase 3 ZIRCON study Prof. Peter Mulders (NL) presented the latest results in a game changing session on the use of 89Zr-DFO-girentuximab for PET/CT imaging of clear cell renal cell carcinoma (ccRCC). According to Prof. Mulders, the ZIRCON study exceeded sensitivity and specificity targets, which also included small masses (cT1a <4cm), and had a favourable safety and tolerability profile. “These positive results suggest that 89Zr-DFO- girentuximab improves identification of primary ccRCC compared to cross-sectional imaging. It has the potential to improve management by aiding risk stratification and holds promise to improve staging in ccRCC, therapeutic target (radiopharmaceuticals) or to image other solid tumours.” Latest OpeRa results Prof. Marc-Oliver Grimm (DE) delivered an update on the OpeRa study, which compared robotic assisted partial nephrectomy (RAPN) and OPN (open partial nephrectomy) in intermediate/high complexity renal tumours. With RAPN, there was a numerically lower 30-day complication rate (primary endpoint), but with regard to oncologic (R1-rate, TRIFECTA) and functional outcomes (eGFR, ischemia time <25 minutes), there was no difference. There was less intense pain management required with RAPN, less pain reported and a better QoL scored (through POD30). New robotic systems One of the best-attended sessions at EAU23 was without doubt the live surgery session “Technology developments never end”. Running continuously from 10:30 to 19:00hrs, the programme featured more than 30 cases, with extra attention for the newest single-use scopes, and Thulium and Holmium laser enucleation of the prostate. The programme also featured less common cases, for instance two pre-recorded presentations on inflatable penile prostheses. In the afternoon sub-session on robotic surgery, Asst. Prof. Nina Harke (DE) joined Auditorium 1 from Niguarda Hospital in Milan and performed a robotic partial nephrectomy with a highly distinguished panel of moderators: Profs. Alex Mottrie (BE), Henk Van Der Poel (NL) and Alessandro Antonelli (IT). Her demonstration was followed by a Retzius-sparing robotic prostatectomy by Dr. Antonio Galfano (IT), using the new Hugo system, also in Niguarda. The system was installed just three months prior, and the team had performed fewer than 20 cases so far. “We are still exploring the possibilities of the system,” said Dr. Galfano.

The 38th Annual Congress of the European Association of Urology was a momentous occasion in Milan, Italy, earlier this year. An extensive and dynamic scientific programme shed light on ground-breaking research and novel technologies. Attracting over 9,800 delegates from 123 countries, more than 1,700 experts shared their knowledge and latest research findings during 300 sessions that included state-of-the-art lectures, debates, panel discussions and 47 courses (including Hands-on training) organised by the European School of Urology. Over four days, there were eight plenary sessions, a full day of live surgery, multiple game-changing sessions, 28 thematic sessions, 15 Urology Beyond Europe lectures, poster presentations, prestigious awards, Patient Day, YUORDay and industry sessions. During this time, both the 7th International Congress on the History of Urology, and the annual meeting of European Association of Urology Nurses (EAUN23) took place as well. This article provides a short summary of some highlights from EAU23, but for the most complete coverage of the congress, you can read the full news reports on Day 1: GU cancers and supportive care In his state-of-the-art lecture “Optimising supportive care for metastatic GU cancers”, Dr. Florian Scotté (FR) cited the findings of the National Cancer Database retrospective study “Considerations for palliative care in urologic oncology” by Bryn Launer, et al. The study showed supportive care is infrequent for patients with advanced urologic malignancies, and outlined the possible barriers, such as misconception about what palliative care is, limited access to the healthcare system and patients’ acceptance. One of the solutions that Dr. Scotté discussed was derived from the paper “Integration of oncology and palliative care: A Lancet Oncology Commission” by Stein Kaasa, et al. wherein two approaches were combined: tumour-directed approach (focus on treating the disease) and host-directed approach (focus on the patient). He stated that this combination will result in a systematic assessment, improvement in patient-reported outcomes, and active patient involvement in the decisions. As a consequence, there will be better symptom control, improved physical and mental health, and better use of healthcare resources. Kidney transplantation (KT) Dr. Javier Sanchez Macias (ES) presented the lecture “Bladder function and Lower urinary tract symptoms (LUTS) after renal transplant”, whereby he provided information on post-operative lower urinary disorders including absence of bladder, low capacity bladder and neurogenetic bladder. “The implementation of new minimally-invasive technologies for the management of patients with LUTS will in the future oblige their daily use in transplant patients. New studies will be necessary to determine whether Rezūm, Aquablation or transurethral HIFU (high intensity focused ultrasound) techniques will replace endoscopic

Delegates on their way to their next sessions

enucleation and TURP (transurethral resection of the prostate)”, stated Dr. Sanchez Macias.

“We are also doing some fascinating translational work comparing pre- and post- tissues to see what effect LuPSMA has on the tumour microenvironment. This work is ongoing and it may give us an idea of how to better select patients for this type of targeted treatment.” Day 2: Bladder cancer (BCa) sessions Incontinence and sexual dysfunction are of real concern especially in young women after neobladder surgery but it is a frequently overlooked topic. “Roughly 25% of new BCa patients each year are diagnosed in female patients” stated Dr. Manuela Tutolo (IT) in her lecture ‘Treatment of incontinence and sexual dysfunction after cystectomy’. “Our goal as urologists should be to guarantee optimal urological outcomes together with optimal functional outcomes in these patients. The surgeries are difficult with serious complications that have an impact on quality of life (QoL).” “Radical cystectomy with ONB (orthotopic neobladder) is an attractive treatment option, but it has high rates of voiding/sexual dysfunction. We should treat patients conservatively as much as possible.” In Dr. Tutolo’s opinion, it is important to optimise surgery to preserve sexual function, select patients upfront according to their risks of incontinence or other general complications, and properly inform patients to create realistic expectations. She believes there is a clear need for more prospective studies and a real multidisciplinary approach.

Lively debates followed between Dr. Oscar Rodriguez Faba (ES) and Dr. Romain Boissier (FR) on the topic of “Urological evaluation of the recipient before kidney transplant should be obligatory”. Dr. Rodriguez stressed that a proper urological evaluation of a KT patient is necessary. “Urological complications comprise the second most common adverse event after KT. Pre- transplant targeted urological evaluation allows for optimisation of the urinary tract accepting the graft.” ''Our goal as urologists should be to guarantee optimal urological outcomes together with optimal functional outcomes in these patients.'' AI and PCa diagnosis Dr. Maarten De Rooij (NL) presented the study design for 'Prostate Imaging: Cancer Artificial intelligence (PI-CAI Challenge)’, which aims to

evaluate the performance of modern AI algorithms at patient-level diagnosis and lesion-level detection of csPCa (clinically

significant PCa). “The preliminary results in the reader study arm show that bpMRI (biparametric) has similar csPCa detections to mpMRI (multiparametric) assessments. We have to look into experience, workflow, image quality and protocol familiarity to evaluate future work. We look forward to the next steps in which we will establish the primary endpoint, comparing AI with radiologists”. Final results of LuTectomy study Dr. Renu Eapen (AU) shared the concluding results for the prospective study of dosimetry, safety and potential benefit of upfront [177Lu] Lu-PSMA-617 radioligand therapy prior to radical prostatectomy in men with high-risk localised PCa. “We have seen that Lu-PSMA, followed by surgery is safe, it is well tolerated, and it is effective. Radiation dose delivery is high and targeted, but variable. We are seeing some encouraging responses from a biochemical, imaging and pathological point of view. Further research is worthwhile to see if this could be an effective treatment strategy in well selected patients.”

Congress days












Read all about EAU23 on page 3

European Urology Today

April/May 2023



Outcomes Study Educational Visualisation Tool

Access the BPH Outcomes Study and associated Educational Visualisation Tool to understand the outcomes in different individual profiles interact and affect treatment response in individual profiles with moderate to severe LUTS/ BPH at the risk of progression. Discover more about how risk factors for disease progression

BPH Outcomes Study:

BPH Tool:

BPH Outcomes Study - Educational Visualisation Tool is intended for educational purposes and not for clinical use. The BPH tool is solely intended to inform healthcare professionals to help visualise and understand the results of the statistical modelling published by Gravas S et al 2022. The BPH Tool has not been validated for and is not intended for clinical use with individual patients. It is not intended to substitute for medical advice or intended to drive or inform to take decisions with diagnosis or therapeutic purposes of any condition for any individual patients. References: 1. Gravas S, et al. EAU Guidelines on the Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO), 2021. Available at: of-non-neurogenic-maleluts/ Accessed March 2023. 2. Avodart Italy SmPC Summary of Product Characteristics (SmPC) effective 22 October 2020. 3. Combodart Italy SmPC Summary of Product Characteristics (SmPC) effective 22 October 2020. Abbreviations: BPH, benign prostatic hyperplasia; LUTS/BPH, lower urinary tract symptoms secondary to benign prostatic hyperplasia. In Italy the registered trade name for dutasteride is Avodart and for dutasteride-tamsulosin is Combodart.

Abbreviated Product Information – Combodart Hard capsules 0,5 mg No prescription SSN Class C* Price € 36,00** *Providing system: medicinal product subject to medical prescription (RR) ** Without prejudice to any reductions and/or modifications imposed authoritatively by the competent Health Authority. Therapeutic Indications Combodart is indicated for the treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction of the risk of acute urinary retention and surgery with moderate to severe symptoms of benign prostatic hyperplasia Posology and method of administration The recommended dose of Combodart is one capsule (0.5 mg/0.4 mg) once a day. When appropriate, Combodart can be used to replace dutasteride and tamsulosin hydrochloride used together in current dual therapy to simplify treatment.

Abbreviated Product Information – Avodart Soft Capsules 0,5 mg Prescription SSN Class A* Price € 11,78** *Providing system: medicinal product subject to medical prescription (RR) ** Without prejudice to any reductions and/or modifications imposed authoritatively by the competent Health Authority. Therapeutic Indications Avodart is indicated for the treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction of the risk of acute urinary retention and surgery with moderate to severe symptoms of benign prostatic hyperplasia Posology and method of administration Avodart can be administrated alone or in combination with the alpha blocker tamsulosin (0,4 mg). Adults (including the elderly): The recommended dose is one capsule (0.5 mg) taken orally per day. The capsules must be swallowed whole and must not be chewed or opened as contact with the contents of the capsule may cause

irritation of the oropharyngeal mucosa. The capsules can be taken with or without food. Although early improvement can be seen, it may take up to 6 months before a response to treatment is achieved. No dose adjustment is required in the elderly. The most commonly observed adverse reactions include impotence, altered (decreased) libido, ejaculation disorder, breast disorder.

When clinically appropriate, a direct switch from dutasteride or tamsulosin hydrochloride monotherapy to Combodart may be considered. The most commonly observed adverse reactions include dizziness, impotence, altered (decreased) libido, ejaculation disorder, breast disorder. Full SmPC of COMBODART (23 November 2017) for EU is available at - Scan the QR code to access the Italian SmPC of Combodart

Full SmPC of AVODART (23 November 2017) for EU is available at - Scan the QR code to access the Italian SmPC of Avodart

For the use of registered medical practitioner or a Hospital or a Laboratory only. Avodart/Duodart is for use in men only. Avodart/Duodart trade marks are owned by or licensed to the GSK group of companies.

Adverse events should be reported. Reporting forms and information can be found at or search for MHRA Yellowcard in the Google Play or Apple App Store. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441.

European Urology Today Submitted to AIFA on 09/03/2023 GlaxoSmithKline S.p.A. Viale dell’Agricoltura, 7 37135 Verona Italy PM-GBL-DUT-ADVT-230002 | Date of preparation: March 2023.


April/May 2023

Day 3: PCa game changer! The British ProtecT trial update was presented by Prof. Freddie Hamdy (GB): “Survival from clinically- localised prostate cancer (PCa) remains very high over a median of 15 years (96-97%), irrespective of treatment allocation. Men with metastases do not necessarily die from PCa and those who do, they have lethality features yet to be identifiable, and are not easily impacted by multimodality treatment approaches.” Prof. Hamdy concluded that current risk- stratification methods are unreliable and that new tools are needed. However, the indications for active monitoring or surveillance can be expanded safely to intermediate-risk disease. Treatment decisions need to balance “trade-offs” between the reduction of metastases, long-term hormones, and local progression with radical treatments against their short-, medium-, and long-term impacts on sexual, urinary, and bowel function. On QoL, Prof. Jenny Donovan (GB) told the plenary session’s audience that based on the newly- published patient-reported outcomes, “Men newly-diagnosed with localised PCa can now carefully assess the trade-offs between the benefits and harms of treatment options: in the short, medium, and long-term and using their own values and priorities to make prudent and well-informed treatment decisions.”

Challenges in urogenital infections In his presentation, oncologist Prof. Andrea Alimonti (CH) stated that intra-tumoural microbiome plays a role in the development of prostate cancer (PCa). “The microbial species that reside in the urinary tract might be initiators of chronic inflammation in the prostate, ultimately leading to PCa by causing the development of PIA (proliferative inflammatory atrophy). Several species of pro-inflammatory bacteria and/or known uropathogens are enriched in men with PCa. The prostate tumour microbiota is different from the one of normal tissues.” During the state-of-the-art lecture “Pathophysiology and the role of the host in urosepsis”, Dr. Zafer Tandoğdu (GB) stated that sepsis is no longer considered as SIRS (systemic inflammatory response syndrome). “Sepsis is a dysregulated host response with both pro- and anti-inflammatory processes. It is important that we understand timely recognition before the transition to sepsis, and early warning scores can help detect that. We should be mindful that if there is an infection, there can be sepsis,” said Dr. Tandoğdu. Day 4: UroEvidenceHub Prof. James N’Dow (GB) presented details on the EAU’s Data Initiatives, with an overview of current and upcoming efforts by the EAU to host, manage and process real-world clinical data to fill evidence gaps in current urological knowledge. In the setting up of the new UroEvidenceHub, the first pilot of which will deal with PCa, the EAU hopes to use real-world evidence to better individualise patient care. The new “data haven” project will build on established experience and (non-urological) expertise the EAU has with the PIONEER network and OPTIMA partnership. Part of this session also addressed the highly- topical subject of Artificial Intelligence (AI) and how it might transform urology in the coming years. Dr. Michael Bussmann (DE) and Prof. Philippe Lambin (NL) explained the basic principles for successful use of AI and its expected applications within urology. The most likely tasks to be taken over by AI include image analysis, diagnosis, treatment planning, patient monitoring, administrative tasks, research and even aiding in a “hands-on” way on improving surgeons’ accuracy when operating robotically. Urinary stones In his lecture on new laser technologies, Prof. Olivier Traxer (FR) had three important take home messages. He shared the formula Energy x Frequency = Power, or J x Hz = Watts, emphasising

The prevalence of male sexual dysfunction increases with age, with over 50% of men aged 40 to 70 years reporting some degree of ED. Prevalence has also become increasingly common in young men as well, with 14.1% of males aged 18-31 reporting a diagnosis of ED and growing trends show reliance on PDE5i for erectile function in younger men.” Best of EAU23 sessions New to the scientific programme this year was the Special Session “Best of EAU23 Abstracts: An expert discussion” which showcased top-tier research on oncological and non-oncological topics, including three prize winning abstracts. Under the oncology category, the top-prize winning abstract A1163: Proteomic profiling of muscle- invasive bladder cancer treated with neoadjuvant chemotherapy described four pre-NAC and two post-NAC proteomic clusters with distinct biology and survival outcomes, alongside novel prognostic biomarkers.

The second prize was given to A0890: The Stockholm3 prostate cancer screening trial

(STHLM3): An interim analysis of mortality results after 6.5 years of follow-up which concluded that the results cautiously suggest a potential effect on reducing PCa mortality by a single intensive screening intervention using PSA and Stockholm3 in combination to the cost of increasing PCa incidence. Longer-term follow-up is needed and is underway.

EAU23 report: Year-on-year progress. . . . . 1 Overview of prizes and awards. . . . . . 4-7 EAU23 Patient Day shifts the focus to shared decision-making. . . . . . . . . . . . . 8 Clinical challenge . . . . . . . . . . . . 9 Key articles from international medical journals................ 10-11 ESUO: Testis cancer therapy and fertility. . . 13 USANZ Trainee Week 2022 impressions. . . 14 Leading journals welcome new Editors-in-Chief. . . . . . . . . . . . . 15 ESU section: ESU Urology Boot Camp Lisbon 2022. . . . 17 1st Urology Boot Camp Poland. . . . . . . 17 Joining urology’s young, promising urologists atUROBESTT.............. 19 The Greek Patient Office . . . . . . . . . 20 A 12-month update on the PRIME Trial . . . 21 ESGURS: Reconstructive options in penile cancersurgery.. . . . . . . . . . . . 23 ESFFU: Patients with bladder pain syndrome/ interstitial cystitis. . . . . . . . . . . . 24 Multiple successes for urological rare diseasenetwork. . . . . . . . . . . . 25 ESIU: New DEEP-URO study builds on GPIU success. . . . . . . . . . . . . . . 26-27 EAU RF: Introducing the JUPITER project. . 28 Prophylactic radical prostatectomy in BRCA2carriers?. . . . . . . . . . . . 29 PRAISE-U launches encouraging early detectionofPCa. . . . . . . . . . . . 29 YUO section: Updates from ESRU and YUORDay23. . . . 30 Self-injection for penile enlargement. . . . 31 Setting a new course for ESUI: Amanifesto............... 31 What have urologists and the EAU achieved in 50 years?. . . . . . . . . . 33 EAUN section: The best of EAUN23: A recap and key takeaways. . . . . . . . . . . . . . . 36 Educational Framework for Urological Nursing................ 37 The EAUN is listening to you!. . . . . . . 38 Virtual support and the ADT programme. . 39 EAUN23: Travel grant reports . . . . . . . 39 My EAUN fellowship at UV Leuven. . . . . 40 New EAUN Board Member: Marcin Popiński ............. 40

Prof. Andrea Alimonti (CH) gives the state-of-the-art lecture 'Microbiome has a role in the development of genitourinary cancers'

Dr. Manuela Tutolo (IT) presents the non-oncology First prize-winning abstract 'Similar artefact susceptibility for water- and air-filled urodynamic systems' (A0693 ) Abstract A0693: Similar artefact susceptibility for water- and air-filled urodynamic systems: Results from a randomised controlled non-inferiority trial received the top prize of the non-oncology category. The research results demonstrated that AFS are non-inferior to WFS regarding overall quality of urodynamic traces. However, both measurement systems have particular pitfalls that need to be known for problem solving during urodynamic investigation (UDI) and require awareness for accurate interpretation of UDI. The congress concluded with the Special Session “Best of EAU23: Take-home messages”, whereby a panel of experts shared the congress highlights on 10 topics, from liquid biopsy to early detection of PCa, paediatrics, BCa, functional urology, stones, benign prostatic hyperplasia, andrology, and imaging. Access more EAU23 content All webcasts, videos, posters and full-text abstracts are currently accessible via the EAU23 Resource Centre. Delegates have full access. If you did not attend EAU23, you can still register for on-demand access to explore all scientific content shared during the congress. Please note that accreditation is no longer valid. For more details, see

European Urology Today

Editor-in-Chief Prof. J.O.R. Sønksen, Herlev (DK)

Section Editors Prof. T.E. Bjerklund Johansen, Oslo (NO) Dr. B.C. Bujoreanu, Cluj Napoca (RO) Prof. O. Hakenberg, Rostock (DE) Dr. P. Østergren, Copenhagen (DK) Dr. G. Ploussard, Toulouse (FR) Prof. J. Rassweiler, Heilbronn (DE) Prof. O. Reich, Munich (DE) Prof. F. Sanguedolce, Barcelona (ES) Prof. S. Tekgül, Ankara (TR)

the importance of energy and power, over frequency. Secondly, when evaluating the

effectiveness of new laser technology, the real-life application should be leading as laboratory settings cannot always be reproduced bedside. Finally, Prof. Traxer presented a useful rule of thumb for the audience: for kidney stones, work from surface to centre and always use 20-25W or less. For ureteral stones, from centre to surface and using a lower frequency range of 12-15W. Plenary Session: Men’s Health Ass. Prof. Faysal Yafi (US) presented his lecture on “Wearables for erectile quality: Catchy gadget or valuable clinical instrument?”, with a summary of what is currently the market and what is planned for the market in the near future. “Wearable (electronic) devices/gadgets are gaining popularity amongst consumers and investigators for sexual function tracking, erectile dysfunction (ED) and premature ejaculation (PE).

Special Guest Editor Mr. J. Catto, Sheffield (GB)

Founding Editor Prof. F. Debruyne, Nijmegen (NL)

Editorial Team E. De Groot-Rivera, Arnhem (NL)

S. Fitts, Arnhem (NL) L. Keizer, Arnhem (NL) H. Lurvink, Arnhem (NL) EUT Editorial Office PO Box 30016 6803 AA Arnhem The Netherlands T +31 (0)26 389 0680

Disclaimer No part of European Urology Today (EUT) may be reproduced without written permission from the Communication Office of the European Association of Urology (EAU). The comments of the reviewers are their own and not necessarily endorsed by the EAU or the Editorial Board. The EAU does not accept liability for the consequences of inaccurate statements or data. Despite of utmost care the EAU and their Communication Office cannot accept responsibility for errors or omissions.

Day 2: A full day of live surgery!

European Urology Today

April/May 2023


Overview of prizes and awards

EAU Willy Gregoir Medal 2023

EAU Frans Debruyne Lifetime Achievement Award 2023

L. Martínez-Piñeiro, Madrid, Spain - Handed out by C. Chapple

J. Catto, Sheffield, United Kingdom - From left to right: C. Chapple, F. Debruyne, J. Catto

Opening Ceremony Friday, 10 March

EAU Crystal Matula Award 2023

EAU Hans Marberger Award 2023

J. Gómez Rivas, Madrid, Spain Supported by LABORIE - From left to right: C. Chapple, J. Gómez Rivas, M. Fürstenberg (LABORIE)

R. Campi, Florence, Italy Supported by KARL STORZ SE & CO.KG - From left to right: C. Chapple, R. Campi, P. Cantu (KARL STORZ SE & CO.KG)

New EAU Honorary Members 2023

A. Chiu, Taipei, Taiwan - Handed out by C. Chapple

C. Evans, Sacramento, United States of America - Handed out by C. Chapple

H. Haas, Heppenheim, Germany - Handed out by C. Chapple

A. Rodríguez, Winston Salem, United States of America - Handed out by C. Chapple

M. Roobol, Rotterdam, The Netherlands - Handed out by C. Chapple

A. De La Taille, Créteil, France - Handed out by C. Chapple

EAU Innovators in Urology Award 2023

EAU Ernest Desnos Prize 2023

R. Vela Navarrete, Madrid, Spain - From left to right: C. Chapple, R. Vela Navarrete, P. Van Kerrebroeck

P. Wiklund, Stockholm, Sweden - Handed out by C. Chapple

EAU Prostate Cancer Research Award 2023 E. Ventimiglia, Milan, Italy Supported by the FRITZ H. SCHRÖDER FOUNDATION - From left to right: C. Chapple, E. Ventimiglia, M. Roobol (FRITZ H. SCHRODER FOUNDATION)

EAU Patient Advocacy Medal of Excellence 2023 R. Giles, Duivendrecht, The Netherlands - From left to right: C. Chapple, R. Giles, E. Rogers

CAU Lecturer Recognition Award 2023

SUO Lecturer Recognition Award 2023

P. Spiess, Tampa, United States of America - Handed out by C. Mir

J. Sanchez Macias, Barcelona, Spain - Handed out by A. Breda

Plenary Sessions

SIU Lecturer recognition Award 2023 A. Ackerman, Los Angeles, United States of America - Handed out by S. Silay

AUA Lecturer recognition Award 2023 J. Denstedt, London, Canada - From left to right: S. Ferretti, J. Denstedt, T. Knoll

38th Annual EAU Congress

European Urology Today


April/May 2023

at the 38th Annual EAU Congress

Top-3 Best Patient Poster Award 2023 – 1 st place prize

Top-3 Best Patient Poster Award 2023 – 2 nd place prize

A. Filicevas, Brussels, Belgium

R. Giles, Duivendrecht, The Netherlands - Handed out by M. Jewett

Patient Day Friday, 10 March

Top-3 Best Patient Poster Award 2023 – 3 rd place prize A. Lawler, London, United Kingdom

Best paper published in 2023 by YAU

Best abstract published in 2023 by YAU

G. Gandaglia, Milan, Italy

T. Piramide, Turin, Italy - Handed out by J. Gómez Rivas

YAU Meeting Friday, 10 March

Best reviewer published in 2023 by YAU

R. Bertolo, Rome, Italy

ESTU René Küss Prize 2023 V. Gomez Dos Santos, Madrid, Spain - From left to right: E. Lledo Garcia, V. Gomez Dos Santos, M. Musquera Felip

ESUO Helmut Haas Award 2023

H. Heers, Marburg, Germany - Handed out by H. Haas

Section Awards Saturday, 11 March

Prize for the Best Paper published on Fundamental Research in the Urological Literature L. Au , E. Hatipoglu, M. Robert De Massy, K. Litchfield, G. Beattie, A. Rowan, D. Schnidrig, R. Thompson, F. Byrne, S. Horswell, N. Fotiadis, S. Hazell, D. Nicol, S. Shepherd, A. Fendler, R. Mason, L. Del Rosario, K. Edmonds, K. Lingard, S. Sarker, M. Mangwende, E. Carlyle, J. Attig, K. Joshi, I. Uddin, P. Becker, M. Werner Sunderland, A. Akarca, I. Puccio, W. Yang, T. Lund, K. Dhillon, M. Vasquez, E. Ghorani, H. Xu, C. Spencer, J. López, A. Green, U. Mahadeva, E. Borg, M. Mitchison, D. Moore, I. Proctor, M. Falzon, L. Pickering, A. Furness, J. Reading, R. Salgado, T. Marafioti, M. Jamal-Hanjani, on behalf of the PEACE Consortium, G. Kassiotis, B. Chain,J. Larkin, C. Swanton, S. Quezada, S. Turajlic (London, Sutton, United Kingdom; Bizkaia, Spain; Melbourne, Australia; Antwerp, Belgium) For the paper: “Determinants of anti-PD-1 response and resistance in clear cell renal cell carcinoma” Cancer Cell 39 (2021); - Handed out by C. Chapple

Prize for the Best Paper published on Clinical Research in the Urological Literature

G. Basile, M. Bandini, E. Gibb, J. Ross, D. Raggi, L. Marandino, T. Costa De Padua, E. Crupi, R. Colombo, M. Colecchia, R. Lucianò, L. Nocera, M. Moschini, A. Briganti, F. Montorsi, A. Necchi (Milan, Italy; Vancouver, Canada; Massachusetts, New York, United States of America) For the paper: “Neoadjuvant Pembrolizumab and Radical Cystectomy in Patients with Muscle-Invasive Urothelial Bladder Cancer: 3-Year Median Follow-Up Update of PURE-01 Trial” Clin Cancer Res (2022); - Handed out by C. Chapple

Award Gallery Saturday, 11 March

First Prize for the Best Abstract (Oncology)

A. Contreras-Sanz, M. Reike, G. Negri, Z. Htoo, S. Spencer Miko, K. Nielsen, M. Roberts, J. Scurll, K. Ikeda, G. Wang, R. Seiler, G. Morin, P. Black (Vancouver, Canada) For the abstract: “Proteomic profiling of muscle invasive bladder

Second Prize for the Best Abstract (Oncology)

C. Micoli, A. Crippa, A. Discacciati, H. Vigneswaran, T. Palsdottir, M. Clements, M. Aly, J. Adolfsson, W. Fredrik, P. Wiklund, T. James, J. Lindberg, H. Grönberg, L. Egevad, T. Nordström, M. Eklund (Solna, Sweden) For the abstract: “The Stockholm3 prostate cancer screening trial (STHLM3): An interim analysis of mortality results after 6.5 years of follow-up” - Handed out by A. Stenzl

cancer treated with neoadjuvant chemotherapy” - Accepted by M. Reike, handed out by A. Stenzl

First Prize for the Best Abstract (Non-Oncology)

M. Kasten, O. Gross, M. Wettstein, C. Anderson, V. Birkhäuser, J. Borer, M. Koschorke, S. Mccallin, U. Mehnert, H. Sadri, L. Stächele, T. Kessler, L. Leitner (Zürich, Switzerland) For the abstract: “Similar artefact susceptibility for water- and air- filled urodynamic systems: Results from a randomized controlled non-inferiority trial” Supported by the IBSA - From left to right: A. Stenzl, M. Kasten, G. Villa (IBSA)

Best Scientific Paper Award 2023 published in European Urology

S. Siva, M. Bressel, S. Wood, M. Shaw, S. Loi, S. Sandhu, B. Tran, A. Azad, J. Lewin, K. Cuff, H. Liu, D. Moon, J. Goad, L-M. Wong, M. LimJoon, J. Mooi, S. Chander, D. Murphy, N. Lawrentschuk, D. Pryor (Melbourne, Brisbane, Australia) For the paper: “Stereotactic Radiotherapy and Short-course Pembrolizumab for Oligometastatic Renal Cell Carcinoma— The RAPPORT Trial” European Urology; Volume 81, Issue 4, P364-372, April 1, 2022 Supported by ELSEVIER - From left to right: J. Catto, D. Murphy on behalf of S. Siva, B. Chen (ELSEVIER)

38th Annual EAU Congress

European Urology Today

April/May 2023


Overview of prizes and awards

Best Paper Award 2023 published on Fundamental Research in European Urology

Best Paper Award 2023 published on Clinical Research in European Urology L. Harper, T. Blanc, M. Peycelon, J. Michel, M. Leclair, S. Garnier, V. Flaum, A. Arnaud, T. Merrot, E. Dobremez, A. Faure, L. Fourcade, M. Poli-Merol, Y. Chaussy, O. Dunand, F. Collin, L. Huiart, C. Ferdynus, F. Sauvat (Saint Denis De La Réunion, Bordeaux, Paris, Nantes, Montpellier, Rennes, Marseille,

K. Welén, E. Rosendal, M. Gisslén, A. Lenman, E. Freyhult, O. Fonseca-Rodríguez, D. Bremell, J. Stranne, Å. Balkhed, K. Niward, J. Repo, D. Robinsson, A. Henningsson, J. Styrke, M. Angelin, E. Lindquist, A. Allard, M. Becker, S. Rudolfsson,R. Buckland, C. Carlsson, A. Bjartell, A. Nilsson, C. Ahlm, A-M. Connolly, A. Överby, A. Josefsson (Gothenburg, Umea, Uppsala, Lingkoping, Jonkoping, Malmo, Sweden) For the paper: “ A Phase 2 Trial of the Effect of Antiandrogen Therapy on COVID-19 Outcome: No Evidence of Benefit, Supported by Epidemiology and In Vitro Data ” European Urology; Volume 79, Issue 1, Pages 16-19 Supported by ELSEVIER - From left to right: J. Catto, K. Welen, A. Josefsson. B. Chen (ELSEVIER)

Limoges, Reims, Besançon, Saint-Pierre, France) For the paper: “ Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial ” European Urology; Volume 81, Issue 1, P64-72 Supported by ELSEVIER - From left to right: J. Catto, T. Loubersac on behalf of L. Harper, B. Chen (ELSEVIER)

First Prize Best Paper Award 2023 published on Robotic Surgery in European Urology

Second Prize Best Paper Award 2023 published on Robotic Surgery in European Urology

G. Marra, M. Agnello, A. Giordano, F. Soria, M. Oderda, C. Dariane, M. Timsit, J. Branchereau, O. Hedli, B. Mesnard, D. Tilki, J. Olsburgh, M. Kulkarni, V. Kasivisvanathan, A. Breda, L. Biancone, P. Gontero (Turin, Italy; Paris, Nantes, France; Hamburg, Germany; Istanbul Turkey; London, United Kingdom, Barcelona Spain) For the paper: “ Robotic Radical Prostatectomy for Prostate Cancer in Renal Transplant Recipients: Results from a Multicenter Series ” European Urology, Volume 82, issue 6, Pages 639-645 Supported by the VATTIKUTI FOUNDATION - From left to right: J. Catto, G. Marra, M. Bhandari (VATTIKUTI FOUNDATION)

H. De Barros , M. Van Oosterom, M. Donswijk, J. Hendrikx, A. Vis, T. Maurer, F. Van Leeuwen, H. Van Der Poel, P. Van Leeuwen (Amsterdam, Leiden, The Netherlands; Hamburg, Germany) For the paper: “ Robotic-assisted prostate-specific Membrane Antigen-radioguided Salvage Surgery in Recurrent Prostate Cancer Using a DROP – IN Gamma Probe: The First Prospective Feasibility Study ” European Urology, Volume 82, Issue 1, Pages 97-105, July 1, 2022 Supported by the VATTIKUTI FOUNDATION - From left to right: J. Catto, A-C. Berrens on behalf of H. De Barros, Dr. M. Bhandari (VATTIKUTI FOUNDATION)

Resident’s Corner Awards - Awards for the two Best Scientific Papers published in European Urology by residents

K. Meghani, L. Cooley, B. Choy, M. Kocherginsky, S. Swaminathan, S. Munir, R. Svatek, T. Kuzel, J. Meeks (Chicago, San Antonio, United States of America) For the paper: “ First-in-human Intravesical Delivery of Pembrolizumab Identifies Immune Activation in Bladder Cancer Unresponsive to Bacillus Calmette-Guérin ” European Urology, Volume 82, Issue 6, P602-610, December 1, 2022 - no picture available

K. Beyer, L. Moris, M. Lardas, M. Omar, J. Healey, S. Tripathee, G. Gandaglia, L. Venderbos, E. Vradi, T. Van Den Broeck, P-P. Willemse, T. Antunes-Lopes, L. Pacheco-Figueiredo, S. Monagas, F. Esperto, S. Flaherty, Z. Devecseri, T. Lam, P. Williamson, R. Heer, E. Smith, A. Asiimwe, J. Huber, M. Roobol, J. Zong, M. Mason, P. Cornford, N. Mottet, S. MacLennan, J. N’Dow, A. Briganti,

S. MacLennan, M. Van Hemelrijck, on behalf of the PIONEER Consortium (London, Aberdeen, Liverpool, Newcastle-upon-Tyne, Cardiff, United Kingdom; Leuven, Belgium; Athens, Greece; Milan, Rome, Italy; Rotterdam, Utrecht, Arnhem, The Netherlands; Berlin, Dresden, Germany; Porto, Braga, Portugal; Leon, Spain; Paris, St. Etienne, France; Massachusetts, New Jersey, United States of America) For the paper: “ Updating and Integrating Core Outcome Sets for Localised, Locally Advanced, Metastatic, and Nonmetastatic Castration-resistant Prostate Cancer: An Update from the PIONEER Consortium ” European Urology, Volume 81, Issue 5, P503-514, May 1, 2022 - From left to right: J. Catto, K. Beyer, L. Moris

Award Gallery Saturday, 11 March

First Prize EAU Guidelines Cup 2023

Second Prize EAU Guidelines Cup 2023

Third Prize EAU Guidelines Cup 2023

D. Mucharski, Krakow, Poland - From left to right: J. Vasquez, D. Mucharski, D. Carrión Monsalve

L. Albers, Rotterdam, The Netherlands - From left to right: J. Vasquez, L. Albers, D. Carrión Monsalve

L. Tzelves, Athens, Greece - From left to right: J. Vasquez, L. Tzelves, D. Carrión Monsalve

First Prize for the Best Abstract by a resident

YUORDay23 Saturday, 11 March

A. Ng, F. Giganti, A. Asif, V. Chan, M. Rossiter, A. Nathan, P. Khetrapal, L. Dickinson, S. Punwani, C. Brew-Graves, A. Freeman, M. Emberton, C. Moore, C. Allen, V. Kasivisvanathan, Q. Prime (London, United Kingdom)

Audience Prize EAU Guidelines Cup 2023 G. Margue, Bordeaux, France - Handed out by J. Vasquez

EUSP Best Scholar Award 2023

For the abstract: “ Global variation in the quality of multiparametric magnetic resonance imaging of the prostate from the PRIMEtrial (the glimpse study) ” - From left to right: E. Checcucci, A. Ng, D. Carrión Monsalve, J. Vasquez

Y. Abu Ghanem, Ramat Gan, Israel - Handed out by A. Merseburger

Second Prize for the Best Abstract by a resident

Third Prize for the Best Abstract by a resident

N. Rahav, M. Udah, S. Cohen, B. Chertin, O. Shenfeld (Jerusalem, Israel)

F. Möller, M. Månsson, J. Wallström, M. Hellström, J. Hugusson, R. Arnsrud Godtman (Skövde, Gothenburg, Sweden) For the abstract: “ Prostate cancers detected in the PSA interval 1.8-3 ng/mL - results from the Göteborg 2 prostate cancer screening trial ” - From left to right: E. Checcucci, F. Möller, D. Carrión Monsalve, J. Vasquez

For the abstract: ” Proximal urethrostomy (PU) versus urethroplasty (U) for complex urethral strictures (CUS) ” - From left to right: J. Vasquez, N. Rahav, E. Checcucci, D. Carrión Monsalve

38th Annual EAU Congress

European Urology Today


April/May 2023

at the 38th Annual EAU Congress

Exhibition Saturday, 11 March

Best Booth Award 2023

Ipsen Pharma - From left to right: H. Clinton, C. Chapple, P. Cabri

First Video Prize

Video Session Sunday, 12 March

S. Cho, J. Kim, B. Cheon, J. Han, D-S. Kwon, J. Lee (Seoul, South Korea) For the video: “ V40: Multi-center, prospective, single arm, pivotal study to evaluate the efficacy and safety of robotic-assisted surgery easyuretero-100 in patients in need

of retrograde intrarenal surgery ” - Handed out by F. Van Der Aa

Second Video Prize C. Yee, P. Lam, Y. Hong, P. Lai, Y. Tam, T. Ng, S. Yuen, M. Tam, C. Chan, K. Lo, J. Teoh, P. Chiu, C. Ng (Hong Kong, China) For the video: “ V83: Robotic augmentation cystoplasty: 1-year

Third Video Prize A. Ta, J. Olphert, W. Tan, M. Alkhamees, G. Shaw, A. Sridhar, J. Kelly (London, United Kingdom) For the video: “ V16: Technique and outcomes from prostate capsule-sparing during robotic male cystectomy ” - Accepted by J. Olphert; handed out by F. Van Der Aa

outcome of the anterior and posterior approaches ” - Accepted by C-F. Ng; handed out by F. Van Der Aa

International Friendship Dinner Sunday, 13 March

The European Urology Platinum Awards 2023

T. Morgan, Ann Arbor, United States of America

A. Vickers, New York, United States of America

M. Albersen, Leuven, Belgium - Handed out by J. Catto

J-N. Cornu, Rouen, France - Handed out by J. Catto

A. Mottrie, Aalst, Belgium - Handed out by J. Catto

G. Novara, Padova, Italy - Handed out by J. Catto

First Prize for the Best Practice development-oriented Poster Presentation

Second Prize for the Best Practice development-oriented Poster Presentation

C. Oliveira, S. Ross, C. Gkika, C. Molokwu (Bradford, United Kingdom)

R. Dalton, R. McConkey, T. Kelly, G. Rooney, M. Healy, L. Murphy, M. O'Loughlin, M. Dowling (Galway, Roscommon, Limerick, Ireland) For the poster: " Establishing a journal and research club to support urology nursing research culture " Supported by HOLLISTER - From left to right: Paula Allchorne, R. Zonderland (HOLLISTER), T. Kelly, who received the prize on behalf of R. Dalton

For the poster: “ Prediction of missed clinically significant prostate cancer after adoption of new prostate specific antigen (in mcg/L) referral guidelines ” Supported by HOLLISTER - From left to right: R. Zonderland (HOLLISTER), A. Semedo, who received the prize on behalf of C. Oliveira, P. Allchorne

International EAUN Meeting Monday, 13 March

First Prize for the Best Science-oriented Poster Presentation

Prize for the Best EAUN Nursing Research Project Presentation

C. Cassells, C. Semple, S. Bingham (Dundonald, Jordanstown, Antrim, United Kingdom)

G. Villa, S. Trapani, S. Gnecchi, A. Poliani, D.F. Manara (Milan, Rome, Italy) For the research project: “ Female urge urinary incontinence in an Italian tertiary referral university and research hospital: A prevalence study ” - Handed out by P. Allchorne

For the poster: " Maximising sexual wellbeing | cancer care e-Learning resource: Healthcare professionals’ views on acceptability, utility and recommendations for implementation “ - From left to right: P. Allchorne, C. Cassells, J. Verkerk-Geelhoed

38th Annual EAU Congress

European Urology Today

April/May 2023


EAU23 Patient Day shifts the focus to shared decision-making Poster Sessions and roundtables on survivorship, cystitis and patient-physician communication

By Kevin McBride

outcomes like a patient’s emotional state and understanding of their medical situation. It was agreed by all that this fundamental issue needs to be tackled early on in specialists’ medical journeys, potentially starting with training in medical school, and that the subject needs more research and specific, clear guidelines targeting patient education and communication. Surviving urological cancer and chronic disability from urological disease Survivorship was the focus of the day’s second roundtable, as the panel discussed the needs of patients suffering from chronic urological illness and addresses strategies that empower them to manage their disability in partnership with healthcare professionals. Dr. Christian Schulz-Quach discussed the mental health consequences of survivorship and why urological patients are particularly vulnerable. “Now turn to your neighbour and discuss your genitals” Dr. Schulz-Quach directed the audience to demonstrate the sociological element to protecting our genitals. Urological patients are particularly hesitant to actively engage, so physicians need to open the dialogue and understand the mental health issues their patients may be experiencing and additionally must give communication tools to help handle shame. “In today’s world it seems irresponsible and patient- unfriendly to keep changing the name of a disease. Time for global consensus on the name and definition, and a truly patient-centric approach.” Further compounding breakdowns in communication are the taboos around discussing sexual dysfunction or conditions in gender nonconforming persons. Erik Briers emphasised the need to adequately inform patients about the risks to sexual health when treating male cancers. “Libido loss is not a side effect, but a consequence of ADT.” Lydia Makaroff from the World Bladder Cancer Patient Coalition (WBCPC) discussed how these problems are amplified in gender nonconforming

This year patients took the spotlight at EAU23, with representation across the scientific programme, three roundtables, and the first EAU Patient Advocacy Medal of Excellence. Roundtable discussion: Patient-physician communication Dr. Rachel Giles from the International Kidney Cancer Coalition (IKCC), winner of the EAU Patient Advocacy Medal of Excellence, built on her momentum by opening the day’s first roundtable discussion “Patient-Physician Communication” by underlining how patient engagement interventions save lives. There is a large body of RCT-based evidence that patient engagement interventions improve qualitative outcomes, including quality of life, anxiety, depression, compliance and fatigue. Data suggests a survival benefit for engaged patients, and early data is very promising, but the interdisciplinary consensus at the first roundtable of EAU23’s Patient Day agreed that the subject demands greater attention and additional research is required. It is crucial for both medical experts and patients to recognise that contemporary patient advocacy must take a comprehensive and holistic approach, encompassing not only direct support for patients, but also guidance for research initiatives and influence over the healthcare and regulatory policies that affect patients' lives. To help understand where patient-physician communication breaks down, social psychologist Tamás Bereczky pointed to the hierarchical nature of healthcare and how that facilitates barriers to functional patient-physician communication. The healthcare system often places doctors on the top of a hierarchy, while patients are often “reduced to a number or a line on an Excel sheet.” This creates a system of epistemic injustice, as the patient’s experience can be invalidated on the basis of their hierarchical status. The roundtable concluded with some best practices should include tackling paternalistic and hierarchical approaches, educating both physicians and patients, limiting jargon and using empathy. Patient experts recommended shifting from only considering “hard” outcomes, like time limits and financial constraints, to including soft

Patient lounge in the EAU23 Exhibition

patients, particularly when their condition does not align with their gender.

The Patient Office further had representation across one plenary session: Controversies on EAU Guidelines II: Testicular and bladder cancer and stones, by Rob Cornes from ORCHID and two thematic sessions: Locally advanced BCa: Misconception of informed consent, by Lydia Makaroff from the WBCPC and EAU Guideline session: Non-neurogenic female LUTS, by Monica De Heide from BekkenBodum4All. The Patient Lounge served as a homebase for patient advocates to network, and recharge for more sessions. Patient Day at EAU23 was a resounding success and the Patient Office is already hard at work ensuring more is to come. Urological patients’ presentations 2022 Global Patient Survey: Reported experience of diagnosis, management, and burden of renal cell carcinomas in >2,200 patients from 39 countries • R achel Giles • Best Patient Poster Presentation: First Prize A comprehensive summary of patient and caregiver experiences with bladder cancer: Results of a survey from 49 countries • A lex Filicevas •  Best Patient Poster Presentation: Second Prize How can we improve patient-clinician communication in men diagnosed with prostate cancer? • Ailbhe Lawlor • Best Patient Poster Presentation: Third Prize Commitment to collaboration in continence care • Lynne Van Poelgeest-Pomfret Importance of shared decision making in prostate cancer to ensure that patients and clinicians recognize and address patients’ treatment goals • Ernst-Günther Carl Collection of patient reported outcomes in daily clinical practice – experiences from a prostate cancer network • Lionne Venderbos

Roundtable discussion: What is cystitis? Ms. Jane Meijlink from the International Painful Bladder Foundation (IPBF) opened the discussion with a monologue on the convoluted, and often contradictory web of taxonomy and nomenclature of cystitis. The history of misunderstandings around cystitis led to an intricate and misleading vocabulary around cystitis, confusing for even experienced physicians, let alone patients. Interstitial Cystitis has a wide array of debilitating symptoms that can be easily misdiagnosed due to their lack of uniformity as Anna De Santis from the European Reference Network (ERN), eUROGEN, discussed. Between the dizzying array of terminology and symptoms, patient engagement and physician awareness are crucial to improving patient outcomes. Patient representation across the congress The Patient Office participated in multiple sessions throughout the congress. The Patient Office hosted a sold out Clinical Leadership Development Workshop: Educating clinicians on the value and benefits of patient empowerment and engagement.

Impressions from Patient Day

Patient Advocacy Medal of Excellence – R. Giles

European Urology Today


April/May 2023

Clinical challenge Prof. Oliver Hakenberg

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

Surgery with or without neoadjuvant treatment

Section editor Rostock (DE)

Comments by Prof. Axel Heidenreich Köln (DE)

such as blockage or infiltration of the right renal vein, blockage of the liver veins (Budd Chiari syndrome), repetitive haematuria, to name a few. However, surgery in this situation is complicated, extensive and needs the presence of a multidisciplinary team involved in a 2-cavitary approach with cavotomy and cardiopulmonary bypass surgery. A mere transperitoneal of thoraco-abdominal approach (which is our preference in first line surgery), will not be able to completely resect the thrombus. The peri- operative mortality is in the range of 2-5% and 90 day mortality is in the range of about 15%. Due to the high risk of systemic relapse, adjuvant


Reflecting the medical data given and the 2 CT images presented, we have to consider the following issues with regard to the most appropriate second-line management • the tumour thrombus was removed completely during the first surgery so recurrence could be due an infiltration of the wall of the inferior vena cava resulting in subsequent re-growth • just interpreting the abdominal CT image, the left renal vein seems to be in place with a local recurrence, which is quite unique since the vein needs to be resected including the left caval orifice of the renal vein at time of thrombus surgery • postoperative pulmonary embolism could have been due to tumour thrombus material or due to a classical apposition thrombus • postoperative recovery was prolonged for reasons we do not know (blood loss, comorbidities, SIRS, etc.), but which have to be integrated in the decision-making process with regard to the next step of treatment • postoperative adjuvant immune-oncological therapy with pembrolizumab was not delivered The next step of treatment could be first line immune-oncological therapy, redo surgery or a combination of neoadjuvant immuno-oncological therapy followed by surgery. What I need to know prior to the next step of therapy • pre-existing comorbidities and physical fitness of the patient. • presence, localisation and extent of the potential infiltration of the wall of the inferior vena cava. The thrombus looks like a floating thrombus in the right atrium, but I cannot identify the true extent of the intracaval thrombus. Therefore, MRI scan and an transoesophageal echocardiography should be performed since this information will dictate the primary treatment approach. Infiltration of the IVC above the diaphragm would be a severe contraindication for a surgical approach. • presence of or absence of metastatic systemic disease Treatment options Surgery is an option if the patient is in good general health and if the thrombus is only partially infiltrating the IVC wall below the diaphragm. In this scenario, the IVC can be replaced by a venous prosthesis (Figure 1). Our own data on redo surgery of intracaval relapses of tumour thrombi are good with long-term cure in all patients. Surgery will effectively prevent future complications to local growth

Case study No. 75

Case study No. 74 This 70-year-old man underwent left radical nephrectomy with cavotomy and extraction of a long intracaval tumour thrombus extending into the atrium in April 2022. The operation was performed together with cardiac surgeons and went well. The histology was clear cell renal carcinoma and some parts of the tumour thrombus had been adherent to the vena cava. Post-operative recovery was prolonged and complicated by a pulmonary embolism. Now the patient presents with a follow-up CAT scan showing extensive recurrence of the intracaval tumour thrombus, again extending into the right atrium.

A 28-year-old man complained of dysuria 3 weeks after a ureteroscopy with fragmentation of a ureteric stone. A urethrogram showed a bulbar stricture and direct vision internal urethrotomy was performed. Due to an intraoperative false passage, the indwelling urethral catheter was left in situ for one week. Three months later, the patient still has a weak urinary stream. The current urethrogram is attached.

immuno-oncological treatment with pembrolizumab should be initiated postoperatively.

Neoadjuvant systemic therapy with the combination of ipilimumab/nivolumab or PD-L1 inhibitors plus multityrosine kinase inhibitors might be another option. However, response rates are low and the tumour thrombus shrinkage is reported in the range of about 10%, which usually does not result in significant reduction of the difficulties of surgery. Treatment-associated side effects have to be considered as the fact that any progression will result in the impossibility to completely resect the thrombus with the negative consequences reported above. If a partial response would be achieved after four cycles of treatment, surgery can be performed with a lesser rate of complications. Stereotactic ablative radiation therapy might represent an individual and still experimental approach. However, the current series describe a response rate of 58% with a palliation of symptoms in all patients. Treatment associated side effects are low and only grade 1-2 side effects have been described. The median overall survival is 34 months which is not poorer as compared to surgery alone. Depending on the extent and size of the residual tumour thrombus, second line surgery can still be performed after radiation therapy. In my view, redo surgery represents the treatment modality with the highest chance for cure, but also with the highest probability of severe, life-threating complications.

Discussion point: What management is possible and advisable?

Fig. 1 Retrograde

Fig. 1

Fig. 2

Fig. 2 Antegrade

Case provided by Prof. Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail:

Discussion point: • What treatment is advisable?

Case provided by Dr. Amin Bouker Coral Médical, Tunis, Tunisia E-mail:

Fig. 1: Replacement of the subdiaphragmatic IVC and part of the left renal vein for relapsing intracaval thrombus

A surgical approach with assistance of both the liver transplantation and cardiothoracic teams

Case study No. 74 continued

The patient underwent surgery together with the cardiothoracic team. With cardiopulmonary bypass, the intracaval thrombus was removed; however, the intraatrial part of the thrombus was adherent to the wall of the atrium and had to be dissected after opening the atrium. Thus, the resection had to be considered incomplete at least on the microscopic level (R1). Histology again showed renal cell carcinoma, partially necrotic. The patient recovered well from surgery and was discharged after 8 days. Adjuvant immunotherapy was recommended.

Comment by Prof. Kilian Walsh Galway (IE)

of both the liver transplantation and cardiothoracic teams.

you are unable to get a clamp above the level of the thrombus, then the patient can be put on cardiopulmonary bypass so that the cardiothoracic team can open the atrium and milk the thrombus back into the IVC. This gives the liver transplant team more time for resection and anastomosis, and they will not have to work against the clock. I know this is possible as we performed such a case when I was a Consultant Urologist at King's College Hospital in London and the case went well. Sadly, my present institution in University Hospital Galway does not have liver transplantation, so I would have to refer to a suitable centre, but I believe surgery is the best option for this patient.

The liver transplant team usually have donor IVC from a previous retrieval, but if they do not, they can utilise a PTFE graft. After mobilisation of the liver they can resect the IVC and replace it with donor IVC tissue or a PTFE graft. When the IVC is clamped the tongue of tissue in the atrium can fall back into the IVC with a reduction of flow and a vascular clamp can be applied above the level of the thrombus. This will give a 30 to 40 minute window to resect and replace the IVC with graft and if necessary anastomose the left renal vein back into the graft. However, if

The original surgery was performed with the assistance of cardiothoracic surgery and I assume the patient was put on cardiopulmonary bypass for the procedure. As you stated, technically the procedure went well and the patient has recovered from his pulmonary embolism. The present CAT scan shows caval recurrence, the options include a biotherapy regimen with a combination of oncological agents, but I would favour a surgical approach and utilise the assistance

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