Highlights of the European Association of Urology
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By Douglas Chinn, MD
Reprinted from PCRI Insights August, 2006 v 9.3

In April 2006 the European Association of Urology (EAU) held its 21st annual meeting in Paris. This meeting is the largest urological meeting in Europe, and second largest in the world (the American Urologic Association-AUA is number one). There were 11,681 participants, including 9146 delegates. The EAU is based in the Netherlands, and its aim is to promote urology in Europe and worldwide. The EAU does not operate in a vacuum, and there is much interaction with the AUA. However, the EAU operates totally independent of the AUA.

Highlights of the Presentations

The primary topics of the meeting were prostate cancer, female incontinence and overactive bladder, angiogenesis and renal cell carcinoma, and erectile dysfunction. For prostate cancer, minimally invasive new technology for the treatment of prostate cancer was a major focus of the conference. At the introductory the press conference, Professor Pierre Teillac, Medical Director of Saint-Louis Hospital, Paris, France, commented that radical prostatectomy (RP) with an overall 10 year survival rate of 85% is still considered the gold standard by which all other treatments are measured. However, he went on to say, further work is needed to decrease impotency and incontinence. He pointed out that with brachytherapy, the incidence of erectile dysfunction (ED) approaches that of radical after several years, and that the best patients for brachytherapy should be in the low risk group (stage T2a or less, PSA < 10, Gleason Score < 7).

Professor Laurent Boccon-Gibod, Secretary General of the EAU Executive Committee, Professor and Chair, Department of Urology, Centre Hospitalo-Universitaire Bichat, Paris, France, presented an overview of radical prostatectomy at the press conference.
He explained that clinical data from today’s RP procedures continues to demonstrate improved outcome results, and that, over time, side effects can be minimized, but not eliminated. In discussing the risks of incontinence and ED after surgery, he placed them in the proper perspective, saying “We do not improve upon a man’s pretreatment ED or urinary incontinence, we can only make it worse.” He explained that any patient, in making a decision for radical prostatectomy, must understand that at best, surgery will have a neutral effect upon continence and ED. And at worst, it can seriously affect his quality of life. The entire panel at this session agreed that currently, spontaneous erections were maintained by only 50-55% of patients after radical prostatectomy, regardless of the type of procedure.

Professor Teillac discussed the role of PSA and the oft-cited controversy over the value of PSA screening and its potential for over-diagnosis. He gave a very interesting perspective in which he reminded attendees of the difference between knowledge and action. “There is never such a thing as too much knowledge,” he asserted, “and prostate cancer, screening by PSA and diagnosis by biopsy simply provides valuable knowledge. Hence, over-diagnosis is not the issue since over-diagnosis does not cause over-treatment. Treatment, including watchful waiting, is an action. The real issue, therefore, is the possibility of over-treatment caused by the lack of knowledge that PSA screening and other tests can provide. Of course, once there is knowledge, there will be anxiety, but it is determining what action should be taken with this knowledge that is the real controversial topic. Thus, screening is important, and knowledge trumps lack of knowledge any day.”

Professor Guy Vallencien Chief of Urology, Institut Mutualiste Monsouris Paris, France, presented a state-of-the-art lecture on “Functional Outcomes after Radical Prostatectomy and Brachytherapy.” He provided an extensive review of the literature, and explained that much of the confusion of outcome data is due to the non-standardized collection and assessment of the pre- and post-operative information. In this retrospective study literature, not all of the same data was collected or statistically analyzed the same way, he pointed out, nor was this collection discrepancy always defined. Patient assessment surveys for ED and incontinence were also varied or not well defined. This contributes to the varied outcome data results, so that the findings of any such large retrospective study may well be suspect. In fact, he states that the data was like the Tower of Babel, and it is no wonder patients are confused about treatment choices.
Consider just the ranges of the data. For RP, the average continence rate at 12 months was 83%, and the meta analysis at two years for average potency, with or without drugs, with nerve-sparing, is 50%. However, the ranges in this retrospective study are huge: with a range of 67-98.5% for continence and a range of 12.5-95% for potency. There was a similar pattern in brachytherapy reports. The meta analysis at three years concluded that the mean continence was 84% and mean potency was 55%, but again, the ranges were huge: 55-100% for continence and 11-91% for potency.

Aside from the lack of a standardized or consistent data, Vallancien also lamented the fact that certain crucial data was almost universally absent.

1. For incontinence, there is very little information about ancillary procedures, including artificial sphincters.

2. There is very little information about urinary symptoms, including urgency and frequency

3. For sexual function, there is no information on ancillary procedures, penile implants, vacuum pump, or penile injection therapy, urethral suppositories or oral agents.

Hence, it is very difficult to rationalize the outcome data from study to study and come up with reliable cumulative results. Quality of life data was also addressed, and the most surprising data came from a paper by Saranchuk, Scardino et al (J. Clin Oncol 23:4146, 2005) in which 647 patients, with an average age of 57 at treatment (RP) and stages T1-T3, were evaluated. The parameters evaluated were:

1. Cancer free (PSA <0.2),

2. Urinary continence

3. Potency

As shown below, the quality of life improves slowly and marginally each year. Vallancien was surprised at the QOL of only 53% at four years. If studies do not indicate the time after treatment in determining a mean QOL, the results will be at best misleading.

Vallancien also reviewed two other papers concerning QOL. The results, which are summarized in Tables 1 and 2, demonstrate that radical prostatectomy has a lower early QOL, but improves with time, whereas QOL decreases over time after brachytherapy. (It should be noted that the measured parameters for the three QOL studies were not defined at the talk.)

With the undeniable value of well designed retrospective studies, I totally agree with Dr. Vallencien’s recommendations that clinical studies of local treatments standardize their data collection and reporting with the following:

1. Include pre-treatment assessment of urinary and sexual function

2. Use validated questionnaires at three years: urinary status, sexual function, PSA, and global health of patients, and standardized statistical data

3. Assess urinary status, including all urinary symptoms and any ancillary procedures

4. assess sexual function using a standardized questionnaire, and also including all sexual functions, plus use and dependence upon medical therapy, and ancillary procedures.

5. Stratify evaluation of two groups of patients, those with PSA < 0.2 and those requiring secondary treatment

From a patient’s perspective, I personally feel that urinary, bowel, and sexual function should be evaluated and reported on patients at 1 month, 3 months, 6 months, 12 months, 5-6 years, and 10 years. I recommend this because each treatment modality can have significant side effects at different time intervals, and they may resolve or get worse with time. For example, early postoperative RP patients often have total urinary incontinence and have to wear diapers constantly for up to 6-12 months, before they regain control, while radiation therapy patients may develop urinary urgency, frequency and incontinence 3-10 years later, and brachytherapy patients may have urinary frequency, urgency and very slow stream for the first year. Patients need to be and should be able to understand what QOL will be like during these time intervals.

Manfred Wirth, Professor and Department Head, Urology, Carl Gustav Carus Medical School, Technical University of Dresden, Dresden, Germany, provided an assessment of robotic surgery. He noted that there has been a rapid increase in its use. In just three years, its use has grown by over 300% to 16,000 procedures in the U.S.
Professor Wirth provided a literature review, and stated that the consensus of the studies was that robotic-assisted radical prostatectomy (RP) has the following advantages over open surgery:

  • Substantially less postoperative pain
  • Shorter recovery period
  • Reduced risk of blood transfusion
  • Less scarring
  • Lower risk of wound infection

This assessment was by no means absolute, however. For example, a study at the Vattikuti Urology Institute in Detroit suggests that robotic-assisted RPs improved cancer control and resulted in a lower incidence of impotence and urinary incontinence whereas another study by Ahlering, at UC Irvine, Irvine, CA found no difference.
In fact, the news conference panel concluded that the skill and experience of the surgeon is still the paramount factor. I believe that the take-home message is that robotic surgery represents the latest technology and is here to stay. There appears to be definite improvement in immediate postoperative morbidity, but there is not as yet adequate direct evidence as to which procedure results in superior long-term outcomes. I tend to agree with the conclusion of the panel that favorable outcomes depend less on the technology utilized and more upon who is performing the procedure.

The biggest personal surprise of the meeting came from Peter Scardino, Chairman of the Department of Urology, Memorial Sloan Kettering Cancer Center, NY. He actually discussed and promoted focal therapy as a therapeutic treatment in highly selective patients, as an alternative to watchful waiting with delayed intervention (a topic I previously presented in the PAACT Cancer Communications Newsletter, Volume 18, No. 5 December 2002). Dr. Scardino strongly stated his view that traditional treatments may be “overkill” in cancer with very low malignant potential. In support of this view, he described in detail such factors as the risk of perioperative complications, long-term issues with ED and incontinence for radical surgery, and ED, bowel, and urinary side effects associated with radiotherapy. Dr. Scardino also clearly explained the risks of focal therapy, but surprised almost everyone by stating that he now felt that there were suitable indications for focal therapy, and that long-term careful surveillance is required. He supported the role of 12-16 selected core biopsies and Endorectal MRI in evaluating potential candidates for focal therapy. Even more intriguing, he singled out the use of an experimental technology, “Vascular-targeted Photodynamic Therapy”, as the primary therapy, seemingly indicating that he believes it to be superior to focal cryosurgery. In the process, he ignored the role of high intensity focused ultrasound, despite the body of early HIFU data currently available. (I was particularly bemused by this oversight since I have been utilizing Endorectal MRI and focal cryosurgery since 1993.)
Regardless of the technology, I believe this topic represents a radical shift in the thought process of treating very low-risk forms of prostate cancer, especially from an eminent proponent of radical prostatectomy. Furthermore, it is encouraging to see new technology being embraced as an alternative to traditional therapies that entail risks that “can only make things worse,” and a progressive thought process developing to improve patient lives. 

My Personal Assessment
By Doug Chinn, MD

As a veteran attendee of the annual AUA conferences, I found the EAU Congress to be refreshingly different. Of course, the EAU meeting was much smaller, but the plenary sessions were in full attendance. The basic difference seemed to be two different philosophies. At the EAU Congress, I sensed more openness and introspective discussion of the options for prostate cancer. For the most part, the speakers would discuss their areas of expertise, but none really claimed superiority. It was more of just stating the pros and cons and presenting new outcome data, (individual or multiple articles) and inviting the listeners to form their own opinions. Rarely did any speakers promote a single individual and his results, so that the presenters gave an impression of more openness, and there was less inclination for the presenters to feel pressured to be “the best.”

There was a real willingness to provide a forum for discussion of new, novel and experimental treatments. This was in direct contrast to many AUA-type presentations that caution: “it may not work, there are many complications and it’s experimental (so not worth discussing)”. Rather, experts at the EAU Congress were allowed to present data that was then discussed, and taken for what they were: glimpses into what may be valuable research and treatment in the future. At the EAU Congress, I did not perceive the academic “not invented here” syndrome that implies that if no specific academic center(s) were involved, the presentation was unlikely to have scientific merit. I heard only one plenary EAU speaker display such an attitude, even with discussing the newer treatment modalities of cryosurgery and HIFU.

The meeting itself is more compact, with fewer sessions, but even so there was less conflict of subject schedules, at least for me, who was concentrating on minimally invasive procedures for prostate cancer. At the AUA conference in Atlanta, the topics were spread over several days, but even so the schedules of presentations dealing with similar areas of interest were often in conflict, and attendees had to choose between them as they could not hear both.

It is ironic that while cryosurgery is an accepted procedure by the EAU, and HIFU is not, the number of HIFU presentations and posters exceeded those of cryosurgery by at least 10:1. It was refreshing to note, that although the EAU has not formally accepted HIFU, there was an expressed awareness that in the future, HIFU may be the best choice for focal and salvage therapy. Finally, at least for this year, many of my colleagues, distributors, and friends who attended both the EAU and AUA conferences felt that this year, there was more energy and excitement at the EAU, and there were more innovative topics discussed.