European Urology Today: June/July 2023

The EAU’s long-running membership newsletter, European Urology Today has been re-launched as a digital-only publication. From the June/July edition of 2023, the newsletter will be published as an interactive PDF on Uroweb and distributed via e-mail. Its format has been redesigned to a more screen-friendly landscape A4 and features all the existing sections and contributors.

Vol. 35 No. 3 June/July 2023

European Tour 2023 JUA and TUA scholars visit Tübingen and Milan

New but familiar Major EUT redesign for all-digital edition

ESTs1 in Ho Chi Minh City ESU’s endoscopic stone treatment programme debuts in Vietnam




Report: EAU Meets National Societies 2023 Meeting showcases new initiatives, diversity of priorities and commitment to collaboration

By Loek Keizer

skills (E-BLUS) programme as the direction for the ESU’s other courses. Prof. Liatsikos encouraged the national societies to nominate young talent for active roles in the ESU, making sure that faculty is as diverse as the audiences they served. In the break-out sessions, there was a chance to evaluate if the ESU was meeting the needs of the different regions of Europe or individual countries. Currently, work is being done to come up with a syllabus for urology, which aims to compile everything that medical students need to know to pursue a career in urology. Prof. Liatsikos also hailed recently-introduced ESU “Urology Boot Camps” for first year residents, increasing the flow and quality of people choosing careers in urology. This model could be useful all across Europe. The School was joined in its efforts to reach young urologists by the chairman of the YUO, Dr. Juan Luis Vásquez (Copenhagen, DK) who announced a brand new initiative: the EAU Talent Incubator Programme . In his presentation Dr. Vásquez explained that the programme was designed to help foster a new generation of leadership in urology. The medical side of being a urologist can be trained, but skills in leadership, communication

“The EAU can do what national societies cannot do alone,” Prof. Arnulf Stenzl said during his introduction to the 2023 EAU Meets National Societies Meeting in Noordwijk, the Netherlands. Rather than sheer hubris or boastfulness, Prof. Stenzl was highlighting the naturally complementary nature of the relationship between the EAU and Europe’s national urological societies and the benefits of synergy across the European continent. Instead of being in competition, the EAU can offer services and products that would be impossible to achieve for solitary national societies: annually-updated Guidelines, the highest-level scientific events, international training opportunities, data management and the political voice that comes with representing thousands of members. European urologists can benefit from cross-border initiatives and platforms and the EAU can complement each country’s own efforts. As is a well-established custom, the EAU welcomed representatives of Europe’s national urological societies to the Dutch Riviera (with appropriate temperatures) for a wide-ranging

10 June, 2023: Prof. Stenzl welcomes the national representatives to Noordwijk

Training, education and incubation The European School of Urology is one of the most direct ways that the EAU can serve Europe’s urologists, offering training programmes, educational materials and scholarship opportunities. The ESU was represented in Noordwijk by its chairman, Prof. Evangelos Liatsikos (Patras, GR). “Standardisation is the magic word,” said Prof. Liatsikos, pointing to the highly-systematic European training in basic laparoscopic urological

meeting on 10 June, 2023. Representatives from 35 countries took part. In the break-out sessions smaller groups of representatives addressed several topics of shared interest and this was a valuable forum for an exchange of national perspectives. Prof. Stenzl made his debut as Secretary General at the National Societies Meeting, also taking the opportunity to introduce himself to the representatives. Read more about Prof. Stenzl’s first months as Secretary General on page 5.

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New but familiar: Introducing the all-digital EUT A message from the Editor-in-Chief

Report: EAU Meets National Societies 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-3-4 New but familiar: Introducing the all-digital EUT . . . . . . . . . . . . . . . . . . .2 “Collaboration gives us a voice” ..........................5 ESUO: New concepts on complementary treatment for cystitis . . . . . . . . . . . . . . . . . . . . . . .6-7 Clinical challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-9 The benefits of AI in resident education . . . . . . . . . . . . . . . . . . . . . .10 AI applications in laparoscopic optical systems . . . . . . . . . . . . . . . . . . .11 Key articles from international medical journals . . . . . . . . . . . . . . . . . 12-15 EMUC23: A synergy of specialties . . . . . . . . . . . . . . . . . . . . . . .16-17 ESU: Bình Dân Hospital hosts its first ESTs1 . . . . . . . . . . . . . . . . . . . .19 ESIU: How to prevent repeat UTIs . . . . . . . . . . . . . . . . . . . . . . . 21-22 “The Baltic meeting holds immense importance for us” ..............25-26 ESGURS-ESAU23: “The full spectrum of male fertility” . . . . . . . . . . . . . . . .28 ESUP, ESAU and ReproUnion Scholarship 2022 . . . . . . . . . . . . . . . . . . .29 ERUS23: 20th Robotic Section Meeting coming to Florence . . . . . . . . . . . . . 31 European Tour 2023 – Academic Exchange Programme . . . . . . . . . . . . . 33-34 Update from the RESECT Study . . . . . . . . . . . . . . . . . . . . . . . . . 35 Gain your CME credits at home . . . . . . . . . . . . . . . . . . . . . . . . . 36 Update from the IDENTIFY Study .........................37 Experience in highly specialised centre for renal cancer . . . . . . . . . . . . . . .38 PRAISE-U calls for cooperation for prostate cancer screening . . . . . . . . . . . . 40 Japan Tour 2023 - Academic Exchange Programme . . . . . . . . . . . . . . . 41-43 Patient-centred care is key message for EAU Patient Office . . . . . . . . . . . . . 44 A 14-month update on the PRIME Trial . . . . . . . . . . . . . . . . . . . . . .45 “Comparing all technical approaches at our disposal” . . . . . . . . . . . . . . . .46 EAUN section: What accreditation do urology nurses need? . . . . . . . . . . . . . . . . . . . .48 “Spot-on” evidence-based urological nursing care . . . . . . . . . . . . . . . .49-50 EU*ACNE nursing education accreditation system . . . . . . . . . . . . . . . . .51 EAUN: Sexual Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 A crucial prevalence study on female UI conducted in Milan . . . . . . . . . . . . .53

projects, directly referring the reader to websites or other resources. In that sense, European Urology Today serves as the glue that holds together all of the EAU’s projects and keeps our members informed. You can also easily share the newsletter with colleagues around the world. As is currently the case, four digital editions of European Urology Today will be prepared and distributed to EAU members throughout the year. A printed edition will still be produced for the Annual Congress. In order to optimise the reading experience for tablets and computers, we have switched to an A4 landscape orientation while largely preserving the familiar layout. In layman’s terms, we have cut each page in half, horizontally. The A4 size also means that each edition can easily be printed if you would like to still have a physical copy in your hospital’s break room.

Prof. Jens Sønksen Editor-in-Chief, European Urology Today EAU Adjunct Secretary General Herlev (DK)


Dear EAU members, dear reader,

This edition of European Urology Today marks a major shift in the EAU newsletter’s history. For the first time since its foundation over thirty years ago, there will not be a printed edition that is posted to members. While we are of course sad to see it go, we also felt the time was ripe for some changes. This change is part of a wider reconsideration of the EAU’s communications strategy. It’s clear that the future is digital. COVID-19 proved that we could change the way we work, and the way we train, and perhaps that gave us the courage to go ahead with this change. An important part of the decision was that it didn’t fit in the EAU’s sustainability ambitions to ship paper copies across the world. Sustainability and environmental concerns are of course not just felt within the EAU but also in our hospitals. Our scientific journal European Urology and its sister publications turned digital several years ago and that transition can serve as proof that a digital publication can be very successful. The new digital format also has its advantages: it will be much easier to tie together all of the EAU’s

We hope you enjoy reading the new screen- friendly EUT .

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addressed as it should be. We need preventive measures, a cure and care.”

Continued from page 1

European Urology Today

and mentoring should be stimulated as well: “our mission at the EAU is to raise the level of urological care, but this includes efficiency and compassion in hospitals and healthcare services.” The programme offers 25 seats for highly- motivated young urologists and will take place in Innsbruck, Austria on 11-13 January 2024. The deadline to apply is 15 September 2023. Mapping out national policies on early detection Despite the European Union’s successes in creating transnational institutions and the harmonisation of many laws, healthcare policy in Europe is still very much a national concern. The differences in national practice and regulation mean that several unique obstacles exist to a successful Europe-wide approach to early detection of prostate cancer as advocated by the EAU Policy Office and its chairman Prof. Hein Van Poppel (Leuven, BE). The National Societies Meeting was a unique opportunity for those leading the recently-launched Praise-U project to get a better picture directly from the national representatives. Prof. Monique Roobol (Rotterdam, NL) and her team of researchers are in the process of learning about the status quo of early detection of Prostate Cancer across the EU, and mapping out the barriers to effective screening. Questions discussed in Noordwijk included whether official statements or positions on PCa screening already exist in countries, how reimbursement of PSA screening is arranged and who the key decisionmakers are. The EAU Policy Office could play a role in helping national societies overcome political barriers they might face in the adoption of early detection. The Policy Office was also represented in Noordwijk by its Vice-Chair, Prof. Philip Van Kerrebroeck (Antwerp, BE), who shared the office’s efforts beyond prostate cancer prevention and specifically when it comes to a Europe-wide approach on (in)continence health. “Continence is a major problem that affects a large part of Europe’s population and it is currently not

Prof. Van Kerrebroeck pointed out that this ties into European health initiatives, such as collaborative programmes on non-communicable diseases (NCDs) and research, as well as European legislation on waste management, green policies and the classification of continence-related products, and that the upcoming European elections were a great time to get continence health on the agenda. Current national approaches to continence are being documented by the Policy Office. All these insights will be published in a manifesto that will be presented at a Summit in the European Parliament in November this year. The EAU has also commissioned a report on the socio-economic costs of continence problems which will be launched at the same Summit. An extensive European campaign will follow to raise awareness for continence health and to align European policies for a more sustainable management of continence care. Building a Europe-wide database Adjunct Secretary General Prof. James N’Dow (Aberdeen, GB) was on hand in Noordwijk to update the national societies on the progress that was being made with the EAU UroEvidenceHub, a recently-launched initiative to collect and process real-world data in order to fill in gaps in current knowledge. EAU Guidelines Office chair Prof. Maria Ribal (Barcelona, ES) gave an update on the IMAGINE project, which documents and strives to analyse adherence to the EAU Guidelines’ recommendations. This has been a collaborative project recruiting data across European centres compiling data on almost 7,000 patients. The project is a good example of the EAU working together with Europe’s national societies, already yielding the first results in a recent paper with a huge list of collaborators. Prof. Ribal announced the launch of IMAGINE Study 2, which aims to describe adherence to Guideline recommendations for antibiotic prophylaxis in cystoscopy, and encouraged the

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) Special Guest Editor Mr. J. Catto, Sheffield (GB) Founding Editor Prof. F. Debruyne, Nijmegen (NL) Editorial Team E. De Groot-Rivera, Arnhem (NL)

Discussions in the meeting’s break-out sessions covered a variety of topical issues and mutual concerns

assembled national societies representatives to join the research network.

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

“Our aims are for the incorporation of real-world evidence from the EAU UroEvidenceHub , alongside traditional clinical trials evidence, into the evidence profiles that underpin our recommendations. Ultimately this will further cement the EAU Guidelines’ place as a leader in the field, and we could not have achieved this without the support and collaboration of the National Societies!” countries can yield great and concrete results. For the UroEvidenceHub, we will do the heavy lifting for you, and support you to get ethical approval to use the platform. The EAU is committed to maintaining and managing the database infrastructure, but we rely on your participation and contributions to make the larger project work.” Prof. N’Dow: “IMAGINE has shown us that meaningful collaboration between different Concerns raised and discussed in one break-out session include the labour-intensity of data management and the required computer literacy for patients who might be contributing directly via Patient-reported outcome measures. Potential

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.

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risks of bias by collecting data from only the most motivated centres were also discussed, as were the technical complexities of customising the database with optional “bolt-ons” and issues like anonymisation. Prof. N’Dow thanked discussants and promised that, “in a bespoke way, the EAU will assist participating sites to fix specific problems that they may face at the local country level; however, to achieve this we need your feedback.” Reaching Europe’s patients While Patient Information is now a long-running project for the EAU, it has only recently been reorganised into its own Office, led by Prof. Eamonn Rogers (Galway, IE). In Noordwijk, the suitability and use of patient information materials was discussed with the national societies’ representatives, leading to some interesting points. Discussion revealed that while urology patients may have similar problems and concerns across Europe, it would be dangerous to assume a one-size-fits-all approach to patient information,

particularly when treatment options still differ so much across Europe. Informative videos that might serve as explainers for routine robotic prostatectomies in some countries, could raise unrealistic expectations for patients in countries where such procedures are much more exclusive. The need for trustworthy and accessible patient information was universally accepted, particularly in the fight against unreliable online information. A major challenge for wide adoption is the need for regularly-updated and accurate local translations, an area where the EAU and national societies might have shared concerns and needs. The day-long meeting was ended with concluding remarks from the discussion leaders, back in a group setting. Prof. Stenzl thanked all participants and was proud to have every corner of Europe represented in one room, with urologists strengthening ties and working together to improve the level of care for their patients: “You have given us valuable feedback and we look forward to hearing a lot more from you in the coming months!”

ESUR23 29th Meeting of the EAU Section of Urological Research

19-21 October 2023, Basel, Switzerland

In collaboration with the EAU Section of Uropathology (ESUP)

An application will be made to the EACCME ® for CME accreditation of this event.

Traditional group photo of all of the participants. We hope to see them again next year!

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“Collaboration gives us a voice” A Q&A with the new Secretary General at the 2023 National Societies Meeting

discount will automatically be granted to those practising in the so-called lower income countries. Thankfully our partners, like national societies we have an en-bloc agreement with, have been very understanding.” “Another topic we are continuously evaluating and addressing is diversity within the organisation, whether that’s based on gender, age, race or geography. That means at events and in our boards, we need to be as diverse as our membership already is.” In Noordwijk we also had a meeting of the Scientific Congress Office and preparations are being made for EAU24 in Paris. What sort of expectations do you have? “I’m very positive! The programme we’re putting together is another excellent programme. We received a lot of positive feedback about EAU23, not just in Europe but from abroad, about the quality of discussions and contributions. This shows that we’re on the right track, post-covid.” “We are drawing up an attractive congress for both uro-oncology and non-oncology. We are very much trying to get basic research integrated in the programme in a more understandable way. I personally feel that it will be an increasingly important part of our field, it’s the future. We will maintain the high amount of live surgery, of course in the safest way possible and following all of the protocols.” “Paris historically attracts a lot of people to our congresses, and this will be our fourth visit. Having our congress in France also helps our collaboration with the AFU. We’ve already met with them and they look forward to hosting us in April. Paris is of course a beautiful city, and the Summer Olympics will be held there, so hopefully everything will be in tip-top shape for them, and for us.”

At the 38th Annual EAU Congress in Milan earlier this year, Prof. Arnulf Stenzl succeeded Prof. Chris Chapple and became the EAU’s seventh Secretary General since its formal foundation in 1973. We caught up with him three months later to talk about immediate priorities and larger topics that the EAU and urologists will face in the coming years. We’re in Noordwijk for the EAU Meets National Societies meeting. What can you say about this meeting’s importance for the EAU? “We’re an association that depends on membership and the support and trust of national societies. We have a history of more than five decades. Together, we can achieve things that individual national societies cannot.” “Therefore, we need to really listen to the national societies: where would our presence be more appreciated? What sort of educational courses and masterclasses would be most useful for them? We want to best serve our members and urologists throughout Europe. Geographical Europe is our base, but we are committed to building a diverse and inclusive community with global reach. We act regionally to raise the level of urological care throughout Europe and beyond.”

What do you hope to get across at this meeting?

face. And then there’s data: we are in a unique position to provide a European platform for registries and real-world data, to stay on top of scientific developments.” “These examples are of course in addition to what we offer in terms of international scholarship opportunities, educational programmes, patient information, our scientific journals and the EAU Guidelines.” More generally, what are some topics that you are dealing with as the new Secretary General? “One topic we are closely watching is our current portfolio of scientific meetings. Over the past two years we’ve attempted to combine what were once individual Section meetings into larger, combined meetings, leading to new meetings like UROtech and UROonco . We’re very curious to see how this approach will be received, particularly when there’s the risk of competing with our other meetings. When we have fewer but bigger meetings, we have to make sure that the events can be visited conveniently from all over Europe by train or car as well as plane. We really have to do our homework and see how the meetings are received and what the differentiator is.” “A recent issue we faced was the decision to increase our membership fees. Over the last couple of years the EAU has heavily invested in improving and expanding its services and at the last General Assembly we agreed to adjust the membership fees which will give us a sustainable business model and enable the association to continue to fulfil its purpose.” “At the same time, we simplified the membership structure by making the fees for European and non-European the same. Residents enjoy a greatly reduced rate, and medical students and patient advocates will see no increase in fees. To make membership accessible and affordable to all, a

“Of course we want to maintain our ties and discuss all sorts of topics that affect us as urologists in Europe. But we also want to show that we are not a competitor to national societies and we have to convince people that our additional benefit, being a scientific membership association, is worth it.” “There are several things that set us apart from national societies: we can offer the biggest scientific meetings, a platform for top speakers worldwide, for a European and even global audience. The number and quality of speakers, a normal national society could not organise a comparable event. We offer the possibility for young urologists to meet colleagues outside of their country, in an English-speaking platform. They build relationships but are also exposed to ideas that might change their daily practice.” “Because we represent 19,000 medical professionals, our voice means something and we can lobby. Not just in Brussels on EU matters but also at the request of national societies in their own capitals. Particularly on matters like early detection of prostate cancer we can help individual countries overcome political obstacles they might

Prof. Stenzl during one of the break-out sessions at the 2023 National Societes Meeting

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New concepts on complementary treatment for cystitis The effectiveness of natural compounds in ameliorating drug-induced cystitis/IC/OAB-symptoms

Yet, at the moment, none of these fulfilled the criteria for becoming an isolated marker, and combinations of several biomarkers will probably facilitate obtaining the appropriate level of specificity and selectivity to allow their use in clinical practice. [6] So far, we have successfully established animal models of cyclophosphamide- induced cystitis [7] and retinyl-acetate/ corticosterone-induced detrusor overactivity [8, 9]. In the experiments, several biomarkers were used to, analyse bladder urothelium, bladder detrusor muscle, urine, and the central micturition areas. The possible link between OAB and depression was revealed, opening new prospects for further studies on the disease. [8] “Due to the complex etiopathogenesis of these syndromes, studies are aimed at the biomarkers connected with either inflammation or nerve growth...” Traditional herbal drugs for refractory cystitis/OAB Nutraceuticals are defined as foods, plants or herbs that provide possible health benefits, including the prevention and treatment of chronic diseases. [10] Some of them have been reported to relieve IC symptoms and be potent modulators of OAB. The inclusion of herbal drugs into the treatment protocol has been proven to be an ambiguous act [5]. No competitive agents to the existing pharmacological treatment have been found and even promising options lack well- designed studies to confirm their efficacy. [11] Among several herbal compounds most recognised are Gosha-jinki-gan [12], Hachi-mi-jio- gan [13], resiniferatoxin or capsaicin. [14] In general, the herbal drugs are thought to have

poorer efficacy but also less adverse effects in comparison to common drugs [15], and are reported as a complementary treatment rather than a monotherapy. [15, 16] Only a few clinical trials have been published, e.g. Betschart et al. analysed Bryophyllum pinnatum for its safety and effectiveness [17], Xiao et al. studied Weng-li-tong [15], Chen et al. analysed cinnamon patches for OAB symptoms. Schloss used Urox ® (a herbal mixture of Crateva nurvala, Equisetum arvense and Lindera aggregate) for the treatment of nocturnal enuresis [18, 19], and Schoendorfer for OAB symptoms and urinary incontinence. [20] Worth recognising is also the possible role of other natural substances, e.g. L-arginine, or quercetin, that were reported to have potential to reduce some of the IC symptoms. [10] Several authors proposed also probiotics used for irritable bowel syndrome as a treatment option for IC with coexisting IBS due to the “organ cross-talk” theory. [21] In our experiments we reviewed the reversion of the effects of cyclophosphamide or corticosterone/retinyl-acetate by administration of herbal compounds, i.e. Asiatic acid [7], Urox ® [9], or Potentilla chinensis [22], and, most interestingly, cannabinoid ligands e.g. arachidonyl-2’-chloroethylamide (ACEA) [8] and GPR55 agonist, O-1602 [23]. The studies included analyses of conscious cystometry findings, measurements of urothelium thickness and bladder oedema, as well as selected biomarkers. For the first time, we revealed a positive influence of these compounds on major urodynamic findings, including characteristic for both cystometric and voiding phase, i.e. bladder basal pressure, inter-contraction interval, bladder compliance, detrusor overactivity index, non-voiding contraction amplitude, and voided volume. Administration of these agents successfully restored concentrations of several biomarkers both in bladder urothelium (e.g.

Haemorrhagic cystitis may take the form of a serious disease, origin of which comes from the effect of various agents on bladder mucosa, including chemotherapeutic drugs. The most common ones are cyclophosphamide and ifosfamide, toxicity of which is connected with urinary tracts and may lead to macroscopic haematuria in 7-53% of cases. [1] The effectiveness of the most recognisable method of treatment (i.e. mesna) remains controversial though. Finally, other alkylating agents like thiotepa or 9-nitrocamptothecin, and certain medications, e.g. penicillins and their derivatives, may be involved in the onset of haemorrhagic cystitis via an immunological mechanism, as well. [2] On the other hand, IC is a specific condition, symptoms of which tend to overlap with other genitourinary disorders like OAB, or endometriosis, making the diagnosis and appropriate treatment a truly challenging task. [3] Antimuscarinic drugs are well-known agents that earned their place in the nowadays management of IC/OAB. However, one should consider their side effects, leading to the phenomenon of the low proportion of patients still on drugs at 1-year observation. [4] Thus, it seems natural that new substances receive growing attention in the trend towards novel concepts of complementary medical treatment aimed at drug-induced cystitis and IC. [5] It is coherent with the finding that 75% of individuals affected take complementary medicines. [5] Biomarkers of IC/OAB Due to the complex etiopathogenesis of these syndromes, studies are aimed at the biomarkers connected with either inflammation or nerve growth, including urothelial differentiation proteins, proteoglycan proteins, urinary nerve growth factors, cytokines, and chemokines. [3,6] The most promising results were related to the diagnostic use of the nerve growth factor (NGF), the brain derived neurotrophic factor (BDNF), C-reactive protein (CRP), prostaglandins, and cytokines. [6]

Dr. Łukasz Zapala Clinic of General, Oncological and Functional Urology Medical University of Warsaw (PL)


Prof. Andrzej Wróbel 2nd Dept. of Gynaecology Medical University of Lublin (PL)


Prof. Piotr Radziszewski

Clinic of General, Oncological and Functional Urology Medical University of Warsaw (PL)


There is a growing need for further discoveries in the treatment modalities of drug-induced cystitis/ interstitial cystitis (IC)/overactive bladder (OAB).

EAU Section for Urologists in Office (ESUO)

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BDNF, NGF) and detrusor muscle (e.g. VAChT). We observed their effects on urothelium thickness and bladder oedema. Thus, these herbal compounds proved to be a potent and effective drugs in the rat model of cyclophosphamide-induced cystitis and retinyl-acetate/corticosterone-induced detrusor overactivity, representing a novel class of uroprotective agents and being candidates for future studies focused on drug-induced cystitis. Back to the origins: is there a place for herbal drugs in contemporary treatment of drug- induced-cystitis/IC/OAB? Definitely. Lifestyle and nutritional modifications have proven their effectiveness in a number of patients. Although, the concepts of the management based on modern drugs play the major role, possibly novel combinations of several therapeutic modalities, including the administration of natural compounds may become helpful in this heterogenous group of patients. Although large-scale randomised, controlled studies should be performed to reveal the actual therapeutic effectiveness of the herbal treatments, these are basic sciences to search for new interesting targets with immunomodulating and neurotrophic properties. References 1. Hurst RE, Greenwood-Van Meerveld B, Wisniewski AB, VanGordon S, Lin H, Kropp BP, et al. Increased bladder permeability in interstitial cystitis/painful bladder syndrome. Transl Androl Urol. 2015;4(5):563-71. 2. Keles I, Bozkurt MF, Cemek M, Karalar M, Hazini A, Alpdagtas S, et al. Prevention of cyclophosphamide-in- duced hemorrhagic cystitis by resveratrol: a compara- tive experimental study with mesna. Int Urol Nephrol. 2014;46(12):2301-10. 3. Rada MP, Ciortea R, Malutan AM, Doumouchtsis SK, Bucuri CE, Clim A, et al. The profile of urinary biomarkers in overactive bladder. Neurourol Urodyn. 2020;39(8):2305-13. 4. Lua LL, Pathak P, Dandolu V. Comparing anticholiner- gic persistence and adherence profiles in overactive

5. Chughtai B, Kavaler E, Lee R, Te A, Kaplan SA, Lowe F. Use of herbal supplements for overactive bladder. Rev Urol. 2013;15(3):93-6. 6. Wrobel AF, Kluz T, Surkont G, Wlazlak E, Skorupski P, Filipczak A, et al. Novel biomarkers of overactive bladder syndrome. Ginekol Pol. 2017;88(10):568-73. 7. Wrobel A, Zapala L, Kluz T, Rogowski A, Misiek M, Juszczak K, et al. The Potential of Asiatic Acid in the Reversion of Cyclophosphamide-Induced Hemorrha- gic Cystitis in Rats. Int J Mol Sci. 2021;22(11). 8. Zapala L, Niemczyk G, Zapala P, Wdowiak A, Bojar I, Kluz T, et al. The Cannabinoid Ligand Arachi- donyl-2’-Chloroethylamide (ACEA) Ameliorates Depressive and Overactive Bladder Symptoms in a Corticosterone-Induced Female Wistar Rat Model. Int J Mol Sci. 2023;24(4). 9. Zapala L, Juszczak K, Adamczyk P, Adamowicz J, Slusarczyk A, Kluz T, et al. New Kid on the Block: The Efficacy of Phytomedicine Extracts Urox((R)) in Reducing Overactive Bladder Symptoms in Rats. Front Mol Biosci. 2022;9:896624. 10. Pang R, Ali A. The Chinese approach to comple- mentary and alternative medicine treatment for interstitial cystitis/bladder pain syndrome. Transl Androl Urol. 2015;4(6):653-61. 11. Zhou J, Jiang C, Wang P, He S, Qi Z, Shao S, et al. Effects and safety of herbal medicines on patients with overactive bladder: A protocol for a systema- tic view and meta-analysis. Medicine (Baltimore). 2019;98(37):e17005. 12. Kajiwara M, Mutaguchi K. Clinical efficacy and tolerability of gosha-jinki-gan, Japanese traditional herbal medicine, in females with overactive bladder. Hinyokika Kiyo. 2008;54(2):95-9. 13. Ito Y, Seki M, Nishioka Y, Kimura M, Yasuda A, Kirimoto T, et al. Pharmacological effects of Hachi- mi-jio-gan extract (Harncare) on the contractile response and on pharmacologically relevant receptors in the rat bladder. Yakugaku Zasshi. 2009;129(8):957-64. 14. Heng YJ, Saunders CI, Kunde DA, Geraghty DP. TRPV1, NK1 receptor and substance P immunore- activity and gene expression in the rat lumbosacral spinal cord and urinary bladder after systemic, low dose vanilloid administration. Regul Pept. 2011;167(2-3):250-8. 15. Xiao DD, Lv JW, Xie X, Jin XW, Lu MJ, Shao Y. The combination of herbal medicine Weng-li-tong with Tolterodine may be better than Tolterodine alone

in the treatment of overactive bladder in women: a randomized placebo-controlled prospective trial. BMC Urol. 2016;16(1):49. 16. Chen LL, Shen YC, Ke CC, Imtiyaz Z, Chen HI, Chang CH, et al. Efficacy of cinnamon patch treatment for alleviating symptoms of overactive bladder: A double-blind, randomized, placebo-con- trolled trial. Phytomedicine. 2021;80:153380. 17. Betschart C, von Mandach U, Seifert B, Scheiner D, Perucchini D, Fink D, et al. Randomized, dou- ble-blind placebo-controlled trial with Bryophyllum pinnatum versus placebo for the treatment of overactive bladder in postmenopausal women. Phytomedicine. 2013;20(3-4):351-8. 18. Schloss J, Ryan K, Reid R, Steel A. A randomised, double-blind, placebo-controlled clinical trial assessing the efficacy of bedtime buddy(R) for the treatment of nocturnal enuresis in children. BMC Pediatr. 2019;19(1):421. 19. Schloss J, Ryan K, Steel A. A randomised, double-blind, placebo-controlled clinical trial found that a novel herbal formula Urox(R) (Bedtime Buddy(R)) assisted children for the

treatment of nocturnal enuresis. Phytomedicine. 2021;93:153783. 20. Schoendorfer N, Sharp N, Seipel T, Schauss AG, Ahuja KDK. Urox containing concentrated ex- tracts of Crataeva nurvala stem bark, Equisetum arvense stem and Lindera aggregata root, in the treatment of symptoms of overactive bladder and urinary incontinence: a phase 2, randomised, double-blind placebo controlled trial. BMC Com- plement Altern Med. 2018;18(1):42. 21. Gordon B, Shorter B, Sarcona A, Moldwin RM. Nutritional considerations for patients with in- terstitial cystitis/bladder pain syndrome. J Acad Nutr Diet. 2015;115(9):1372-9. 22. Juszczak K, Adamowicz J, Zapala L, Kluz T, Adamczyk P, Wdowiak A, et al. Potentilla chinen- sis aqueous extract attenuates cyclophosphami- de-induced hemorrhagic cystitis in rat model. Sci Rep. 2022;12(1):13076. 23. Wrobel A, Zapala L, Zapala P, Piecha T, Radzis- zewski P. The effect of O-1602, a GPR55 agonist, on the cyclophosphamide-induced rat hemorrha- gic cystitis. Eur J Pharmacol. 2020;882:173321.

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bladder patients based on gender, obesity, and major anticholinergic agents. Neurourol Urodyn. 2017;36(8):2123-31.

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European Urology Today June/July 2023


Clinical challenge

An example of the most frequent aetiology of urethral strictures nowadays: iatrogenic strictures

Prof. Oliver Hakenberg Section editor Rostock (DE)

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

Comments by Prof. Luis Martínez-Piñeiro Madrid (ES)

with approximately 85-90% good long-term results [2]. The graft can be placed dorsally, dorsolaterally, or ventrally with similar results. The latter technique would not be adequate in case of strong spongiofibrosis and lack of spongy tissue. Most probably the very tight distal aspect of the stricture will require an augmented anastomotic reconstruction or a double graft (dorsal-Asopa + ventral). In case that the stricture appears shorter during surgery and with strong fibrosis, pseudodiverticula or epithelialized false passages, a resection and end to end anastomosis could be another alternative. References: 1. A drug-coated balloon treatment for urethral stricture disease: Three-year results from the ROBUST I Study. Virasoro R et al . Urology 2022;14:177–183 ; One-year results for the ROBUST III Randomised controlled trial evaluating the Optilume drug-coated balloon for anterior urethral strictures. Elliot S et al. J Urol April 2022;207(4):866-875 . 2. U rethral Strictures EAU Guidelines 2022. Lumen N et al .

Retrograde and voiding cystourethrographies show a stricture of the proximal bulbar urethra of approximately 3 cm. The stricture starts distally to the external urethral sphincter and has a very tight portion at its distal aspect. Spongiofibrosis and small pseudodiverticula can be seen at this proximal aspect, most probably related to the false passage reported during previous urethrotomy. Internal urethrotomy is not an option because the stricture is too long, and the patient was already treated with internal urethrotomy with bad results. The treatment that offers the best results is urethroplasty. Dilatation using the Optilume balloon is another alternative, although the length of the stricture is almost out of the manufacturer’s recommendation (< 3 cm). The results reported by the ROBUST studies [1] are less effective than the standard urethroplasty and taking into account the young age of the patient, I would offer the treatment with best long-term results.


Case study No. 75 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.

Bulbar urethral augmentation with buccal mucosa graft or internal preputial mucosa is a technique

Fig. 1 Retrograde

Fig. 2 Antegrade

Case study No. 75 continued Iatrogenic strictures usually have superficial lesions, but due to the number of failed procedures in this gentleman, spongiofibrosis may be present. It has to be assessed intraoperatively since the distal part of the stricture is very tight and doesn’t allow endoscopic assessment. Palpation after perineal incision shows thick and soft spongiosum (Fig. 1) and a ventral urethral approach is performed. The dorsal aspect of the stricture is 13 mm long. It is excised superficially (Fig. 2) leaving a dorsal gap (Fig. 3). Mucosal anastomosis is performed (Fig. 4) which avoids dorsal grafting. Proximal to this suture, the lumen is now

Discussion point: • What treatment is advisable? Case provided by Dr. Amin Bouker Coral Médical, Tunis, Tunisia E-mail:

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European Urology Today June/July 2023


Continued from page 8

Case study No. 76 This 62-year-old lady has been suffering from multiple sclerosis for many years from which she has a spastic tetraplegia and is confined to a wheelchair. She also has been suffering from neurogenic bladder and neurogenic bowel disorders. For many years the bladder was treated by indwelling catheters and has a small capacity. The bowel disorder led to many episodes of ileus and numerous surgical procedures including an extensive large bowel resection with a terminal colostomy of the ascending colon in the left abdomen. In addition there have been several laparotomies for adhesions. A baclofen pump has been inserted in the right abdominal wall. After years of indwelling catheter treatment she now has developed muscle invasive bladder cancer (squamous cell differentiation).

very wide (Fig. 4 ). A buccal mucosa graft is harvested (Fig. 5), defatted (Fig. 6) and allows ventral closure of the urethra (Fig. 7). Spongial suture over the graft (Fig. 8) will get it vascularized. A urethral catheter is placed and removed 3 weeks later, after the urethrogram demonstrates a normal urethral lumen with no fistulation.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 1

Discussion point: • Which management and treatment is advisable?

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

Fig. 7

Fig. 8

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European Urology Today June/July 2023


The benefits of AI in resident education How it boosts and helps standardise training programmes

University and Sheikh Khalifa Medical City in the United Arab Emirates. This is a first project of its kind supported by the ESUT across different geographical regions. Such collaboration and support from international organisations can accelerate progress in this field.

increasingly important role in urologic technology training and other areas of medical education.

programmes. AI algorithms can analyse large amounts of data, identify patterns and trends whilst performing a procedure, and provide personalised constructive feedback to residents and fellows. This can help trainees develop their skills more quickly and effectively by evaluating their performance. AI could enhance the modular training concept as well by evaluating specific steps in a procedure where trainees need more focus and extra guidance. Secondly, AI technology can objectively evaluate residents’ skills and knowledge. Traditional methods of evaluating residents’ performance are often subjective and can be influenced by various biases. On the other hand, AI algorithms can provide an objective and standardised evaluation of residents’ performance, which can help identify areas where additional training is needed. Thirdly, AI technology can provide virtual simulations to help residents practise various procedures and develop their skills in a safe and controlled environment. This can reduce the risk of complications and errors during surgical procedures, which is especially important for complex urologic procedures. Finally, using AI in urologic technology training can also help standardise training across different institutions. This can ensure that all urology residents receive high-quality training regardless of where they train. Notably, there have been some promising developments in the use of AI for urolithiasis management, such as predictive models for stone recurrence and image recognition technology for stone identification. Additionally, AI has shown the potential to enhance medical education through personalised learning and adaptive assessments. As AI technology advances, it will likely play an

Prof. Kamran Ahmed Sheikh Khalifa Medical City & Khaifa University, Abu Dhabi (AE) King’s College London (GB)

The EAU Section of Uro-Technology (ESUT) and King’s College London have been collaborating with the input from relevant teams from Khalifa


Become an EAU member today!

Dr. Atinc Tozsin Trakya University

School of Medicine Urology Department, Edirne (TR)


Artificial intelligence (AI) in medical education and training has become increasingly popular in recent years. One field that has seen significant benefits from using AI technology is urologic technology training for residents. Urology is a complex field that requires extensive training and expertise. Traditionally, this training has been done through a combination of didactic lectures, clinical rotations, and surgical observation. However, using AI in urologic technology training can provide several advantages over traditional training methods.

Apply online today and be part of the largest urological community.

Firstly, AI technology can enhance the effectiveness and efficiency of training

EAU Section of Uro-Technology (ESUT)

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European Urology Today June/July 2023


AI applications in laparoscopic optical systems Artificial intelligence enables surgeons to navigate complex anatomies with greater precision

Stryker employs AI algorithms in their optical systems to offer features like automated image processing, instrument tracking, and augmented reality guidance for laparoscopic procedures. Intuitive Surgical (da Vinci) utilise AI algorithms in its optical systems. These algorithms assist in advanced imaging, instrument tracking, and tissue recognition during robotic-assisted laparoscopic procedures. The Asensus Surgical System employs AI algorithms and machine vision technology to augment surgical procedures in object recognition, tissue identification, and tracking instruments and their movements. The adoption of AI algorithms in laparoscopic optical systems is a rapidly evolving field, and in the near future more companies will integrate AI algorithms in their laparoscopic optical systems. By leveraging AI algorithms to interpret real-time images, urologic surgeons will benefit from advanced guidance and improve the accuracy and effectiveness of their procedures. Noteworthily, AI algorithms as decision-support tools can provide valuable assistance, but do not replace the expertise and experience of urologists. Urologists remain in control of the procedures and use AI algorithms as aids to enhance their surgical skills. In summary, the integration of AI in urologic minimally invasive surgery optical systems holds immense promise, enabling surgeons to navigate complex anatomies with greater precision. AI and image guidance work together to enhance surgical precision, improve decision-making, and optimise patient outcomes.

Surgical workflow optimisation AI algorithms can analyse laparoscopic videos and recognise patterns in surgical workflows, such as instrument usage and movement patterns. This data can be also used to provide feedback to surgeons, optimise their technique, and potentially improve efficiency and patient outcomes. Leading manufacturers of endoscopy and laparoscopy equipment such as KARL STORZ, Olympus, Stryker, Medtronic, Intuitive Surgical, and Asensus Surgical employ AI algorithms in their products. “The adoption of AI algorithms in laparoscopic optical systems is a rapidly evolving field, and in the near future more companies will integrate AI algorithms in their laparoscopic optical systems.” KARL STORZ incorporates AI algorithms in optical systems to provide features such as automated image analysis, real-time tissue differentiation, and augmented reality visualisation during laparoscopic procedures. Olympus has utilised AI algorithms in endoscopes and laparoscopic optical systems to offer features such as automated image recognition, lesion detection, and enhanced image quality for laparoscopic visualisation. Medtronic integrated AI algorithms in laparoscopic optical systems to provide real-time image analysis, tissue characterisation, and advanced visualisation capabilities.

of these critical structures during laparoscopic operations. AI algorithms can also recognise surgical phases of laparoscopic operation videos spanning a range of complexities. These algorithms can suggest the optimal instrument or camera angle, provide warnings about potential complications, or assist in precise tissue manipulation and aid the surgeon in navigating complex anatomies and reducing the risk of accidental damage and complications. Machine learning (ML) algorithms can improve surgical outcomes also by augmenting the display with information such as tumour localisation during the operation. AI algorithms have been applied in characterising different types of tissue based on visual cues and can provide real-time feedback to surgeons by analysing the optical properties of tissue and helping them differentiate abnormal tissue and tumours. Image enhancement AI algorithms can enhance laparoscopic images by reducing noise, improving contrast, and optimising the overall quality of the visual data. This can lead to clearer and more informative images, aiding urologists in their decision-making process during the surgery. The last studies showed that augmented reality (AR) technology combined with AI algorithms can overlay important virtual information in real time onto laparoscopic images. This can provide surgeons with additional guidance, such as highlighting the location of critical structures or displaying preoperative imaging data on the laparoscopic view, improving surgical precision. AI implementations Tissue characterisation

Prof. Ali Gözen Dept. of Urology Medius Kliniken Ostfildern-Ruit (DE)

The intersection of urologic minimally invasive surgery and artificial intelligence (AI) has paved the way for a new era of surgical precision, efficiency, and in the end, improved patient outcomes. Current endoscopy optics rely on digital technology with high-resolution imaging sensors and bright LED backlight displays. In urologic laparoscopy, AI algorithms can be employed in conjunction with modern optical systems to enhance various aspects of the procedure. Several optical companies employ AI algorithms in laparoscopy to enhance their products and provide advanced imaging and analysis capabilities. The optical systems employing AI can assist surgeons with different image analyses before, during and after the surgery. One critical aspect of urologic minimally invasive surgery is the precise identification and preservation of important structures such as neurovascular bundles during radical prostatectomy. AI algorithms can analyse laparoscopic images in real-time and identify anatomical structures, such as nerves, blood vessels, and tumours. This will assist urologic surgeons in the accurate and efficient identification

EAU Section of Uro-Technology (ESUT)

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European Urology Today June/July 2023


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