EAU Congress Stockholm, Sweden - 1999

The crowds are getting thinned out as the days advance. The fine weather of the past few days is for many delegates a good reason to visit the city and its surroundings. Since the days that Stockholm was considered the poorest and filthiest capital of Europe back in the 17th century, much has changed for the better. The city is now spacious and much of the old center of town has been torn down in the sixties to make room for a modern city with commercial complexes and offices. The side effects of this policy are the complete absence of old buildings and the large and sometimes windy spaces. It sometimes even seems that the city is too large for the number of inhabitants. An advantage is the extended subway and railway system, that takes you almst anywhere you want to go. And it is clean to the point that you can even swim in the many waters that surround it.

Some 1800 abstracts were submitted to the XIVth EAU congress, while about 700 were actually accepted for presentation. While some presentations must have slipped though the mazes of detection, most subjects are informative whilst skillfully presented. A problem does exist in the use of the English language by some presenters. Although most non-native English speakers only have a beautiful accent, some are just impossible to understand. This is a pity, since a lot of the work they have done is well worth being mentioned and discussed. This is especially problematic when two such 'problem cases' try to set up a discussion between them. While some moderators try their best to ignore those problems or just accept them because they themselves have the same problem, others try to help by putting the speakers at ease, rephrasing questions for them and allow more time if needed. One of those was Hargreave from Edinburgh, Great Britain, who really succeeded to bring speakers and audience closer together through his excellent moderation of a poster session on Male Infertility.

The oral session on 'Bladder Substitution and Urinary Diversion' started off with a possible difference in Quality of Life after cystectomy between Italian and Swedish men. Månsson from Sweden (#419) showed that postoperative adaptability after cystectomy and bladder substitution was largely independant of cultural and religious factors. Using bladder replacement in females and reconnecting it to the spared urethra may lead to postvoiding residual urine (100-400 cc) when the neobladder expands, which may be cured by administering alpha blockers, according to Jarolím from the Czech Republic (#421). A nice study by Kleinschmidt from Germany (#422) on 363 patients who received an ilium neobladder in 1986-97 showed quite some early and late complications, although most were treatable and/or acceptable, while the functional results were good. Therefore, the teatment remains first choice after cystectomy.

The poster session on 'Prostate Cancer - Early Detection' brought us up to date on new developments in marker technology and statistical ways to figure out their worth. Human glandular kallikrein (HK2) was shown to be an improvement when used in combination with Total and free PSA in the Total PSA range of 4-10 ng/ml, the 'grey zone' in prostate cancer detection. Becker from Sweden (#428) explained the statistics well, but emphasized that the advantage as shown in the ROC curves is significantly better when compared with Total vs. free PSA, although not much. The same proved true for the other posters on this subject. The problem remains that few urologists are prepared to miss even one case of prostate cancer, while statisticians keep telling us that with a cut-off in F/T ratio of so-and-so you only miss a few percent of cases.

In an oral session on 'How to Monitor Superficial Bladder Cancer', Kurth from the Netherlands expressed his concern over the fact that large differences in recurrent bladder tumours after TURT can be found between different centers. This may be caused by an inter-examiner difference in the use of cystoscopy, i.e. some urologists tend to overlook bladder tumours at the time of TURT. So the 'golden standard' of cystoscopy in the detection of bladder tumours has lost some of its shine.
Witjes from the Netherlands, who seems a busy man and could only find ample time to attend the meeting, told us more about cytology. The sensibility is only 30-45 percent, while cytology is dependent on interpretation by the pathologist. Proper and prompt handling of the specimen is important, while washouts are better than urine, during intravesical therapy, it is useless. The Quanticyt method, in which a computer adds to the pathologists view, using DNA content and nuclear shape measurements, is an improvement. Although tumour associated antigens like Immunocyt and NMP22 do add up to a better diagnosis, all markers suffer the sam fate: once senitivity goes up, specificity goes down, and vice versa. A combination of cytology, cystoscopy and markers will probably have to do the trick.
Bassi from Italy talked about the BTA Stat and Trak tests, which proved to be able to predict recurrences and were less influenced by intravesical therapies. Böhle from Germany showed that NMP22, one of the nuclear matrix proteins, had a negative predictive value of 88 percent although sensitivity was measured to be quite different in different studies. Finally, Djavan from Austria discussed the monitoring of the upper urinary tract, emphasizing that only 10-15 percent of patients have an asymptomatic tumour there. These show up on IVU as a filling defect in 50-70 percent. CT scanning has no place here for lack of sufficient sensitivity and specificity. He recommends once yearly markers, Ultrasound and IVU in high risk patients and markers and Ultrasound in low risk patients.
The panelists agreed that the new tests are still too experimental to be used in general practice, although Djavan saw a place for them in low risk patients. Cystoscopy, although less of a gold standard, still should be routinely used for tumour detection, but the frequency may perhaps be adjusted according to risk and marker outcome.

The oral session on 'BPH: TURP, TUIP and Lasers' brought about nice presentation by Gilling from New Zealand on a tissue morcellator to be used in conjuction with Holmium Laser Enucleation of the Prostate (HOLEP). Getting rid of the tissue after Holmium laser therapy of the prostate was a problem, but now seems to have been solved. Resections up to 152 grams were possible with a hospital time of around 24 hours and catheter time of 20 hours. After one year follow-up retreatment percentage was only 2.4. The retrieved tissue could well be used for pathologic examination.

The session on 'Penile Disorders, Cancer and Peyronie's Disease' primarily dealt with Peyronie's. Schultheiss from Germany showed the results in 61 patients using the Essed plication technique. There was a 30 percent recurrence, while many patients had pain at the area where the non-absorbable sutures were placed. However, he used Prolene sutures instead of the softer Mersilene, while he sticked to the original Essed procedure and not the modifications like the suture technique introduced by Tom Lue and a longitudinal incision instead of circumcision. Extracorporal shockwaves were also used against Peyronie's. The evolving cavities would in the end cause an anti-inflammatory reaction responsible for the effect. Colombo from Italy showed about 25 percent satisfactory improvement in curvature, as did Sautter from Switzerland. In all, it seems worth a try in less advanced forms of Peyronie's.

One of the nice things during the congress was the opportunity to attend special hands-on training sessions, like ureterorenoscopy and the use of the SANS afferent nerve stimulation device to treat pelvic floor dysfunction. Instead of sacral root stimulation, Stoller from the USA introduced a simpler method by stimulating the sacral region through the posterior tibial nerve. Although randomized placebo-controlled trials are not yet done, many patients suffering from urge(-incontinence), frequency or pelvic pain benefit from the therapy. Although solid scientific data are failing, many urologists are attracted to this treatment, mainly because it is simple for the doctor and cheap, safe and undemanding for the patient. Every afternoon the method is demonstrated using available urologists as guinea pigs. FDA approval is underway.

Many of the dutch urologists (about 110 of them are in Stockholm, i.e. one third of the urologic population in the Netherlands) attended the 'Dutch Evening', comprising a fine dinner with lots of fish - more food than the previous evening - accompanied by the Flow Masters, a nine strong dixieland band, who have been practising hard to add a special athmosphere to the evening.

More tomorrow.

07 April 1999 08 April 1999 09 April 1999 10 April 1999 11 April 1999