EUROPEAN UROLOGICAL SCHOLARSHIP PROGRAMME (EUSP) [3-month visit: 2 November February 2016]

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1 EUROPEAN UROLOGICAL SCHOLARSHIP PROGRAMME (EUSP) [3-month visit: 2 November February 2016] Department of Urology of the Siloah St. Trudpert Klinikum Pforzheim, Germany Dr. Amelia Pietropaolo MD Resident in Urology Dept. of Urology, University of Perugia, Santa Maria della Misericordia Hospital Perugia, Italy

2 The city The urology department that I chose for my scholarship program is settled in a quite big city called Pforzheim, which is part of the Baden-Württemberg state in the southwest of Germany. Pforzheim, a town of nearly 120,000 inhabitants, is known for its jewellery and watch-making industries. It is situated between the cities of Stuttgart and Karlsruhe at the junction of the three rivers Enz, Nagold and Würm. During World War II, Pforzheim was bombed a number of times. The largest raid, and one of the most devastating area bombardments was carried out by the Royal Air Force on the evening of 23 February Nearly a third of the town's population was killed during the air raid. About 83% of the town's buildings were destroyed. In the 20 years after the war, Pforzheim was gradually rebuilt, giving the town a quite modern look. Incredibly beautiful natural landscapes and very important cities distinguish the region. Pforzheim is located at the northern rim of the eastern part of the Black Forest (Schwarzwald).

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5 I attended the Pforzheim clinic for a period of about three months, from the 2 nd of November to the 12 th of February. The stay included comfortable accommodation in a residence near the hospital.

6 The department The head of t h e department is Prof. Med Sven Lahme, member of Eulis, assistant medical director of the Department of Urology, and a professor at the University of Tübingen. The staff is composed of four consultants, two specialists and eight residents. Prof. Dr. med. Sven Lahme Dr. med. Volker Zimmermanns Theodosios Antonopoulos Dr. med. Philipp Ober Dr. med. Carsten Lange

7 The fourth floor has two stations with a total of 65 beds, four of which are for intermediate care for the first days of recovery after major surgery operations like cystectomy or radical prostatectomy. The fifth floor has the secretary s, professors, meeting, lithotripsy, and diagnostic Rx rooms, and three ambulatories provided of ultrasound. On the same floor, there are the endourologic operating rooms: TUR, Endo-omnia, Uro-endo and cystoscopy rooms.

8 The first floor has the robotic room with the latest model of t h e da Vinci Xi System and the open surgery room. I had the opportunity to attend each of these services which improved my knowledge a lot thanks to a full, daily operating plan.

9 Outpatient Therapies - Renal and ureteral stones - Incontinence, bed wetting - Bladder Dysfunction - Erectile Dysfunction - Unfulfilled Fertility - Vasectomy (sterilization) - Circumcision - Cystoscopy (bladder) - Prostate biopsy (tissue samples) - Aging Male - Venoport - Implantation to chemotherapy - Sperm-cells Extraction (TESE) - Treatment of varicoceles Inpatient Therapies Andrology - Man's infertility - Erectile dysfunction - Operative treatment of Peyronie's disease (IPP) - Micro surgery (microsurgical repair of obstructive azoospemie) Bladder - Bladder cancer resection (TUR B) - Da Vinci computer-assisted radical prostatcetomy - Open cystectomy - Urinary diversion (neobladder and ileal conduit) - Systemic and local chemotherapy - Laser treatment of urethral strictures - Open urethral reconstruction for Hypospadia orstricture (with oral mucosa or foreskin) Ureter - Laparoscopic nephroureterectomy - Ureteral reimplantation after injury - Ureteral stricture - Rigid and flexible endoscopy of the entire urinary tract - Ureteropelvic junction obstruction - URS+RIRS Testis - Surgical removal of the testicles (Orchiectomy) - Testicular biopsy - Epididymectomy - Enucleation of the testicles - Hydrocele (hydrocele testis) - Excision of spermatocele - Torsion - Chemotherapy for testicular tumours Continence - Female and male urinary incontinence - Bladder prolapse and bladder lift - Stress incontinence - Artificial Devices for continence (i.e. Male sling, artificial sphincter) Kidney - Laparoscopic radical nephrectomy and adrenalectomy - Nephron-sparing laparoscopic or robotic-assisted (Da Vinci ) kidney tumour surgery - Laparoscopic nephrectomy

10 - Immunotherapy, chemotherapy - Robot-assisted pyeloplasty - Extracorporeal shock wave lithotripsy (ESWL) - Minimally invasive Percutaneous nephrolitholapaxy (MINI PCNL) Prostate - Laparoscopic and robot-assisted (Da Vinci ) radical prostatectomy - Medical treatment for benign prostatic hyperplasia - TURP (transurethral resection of prostate) Other - Chemotherapy, immune system and treatment of all urologic tumours - Outpatient chemotherapy, oncological follow-up and Pain Management The daily practice On my first day, I ve been immediately welcomed by the staff during the morning meeting which takes place at 7:30 am. It lasts for about 45 minutes. The staff talks about the planned and emergency operations of the day, and about the patients admitted in the clinic watching the relative CT and ICV radiologic images or laboratory examinations. It's also a good way to stay all together and to exchange clinical opinions before starting the always-full program of the day. Immediately after the morning meeting, the professor and a part of the staff make the morning round visit, checking all emergency room and operated patients.

11 The remaining staff are split among different operating rooms, four of which are always active at the same time. I spent the main part of the day attending the operating plan that was very full, so I could attend to the endoscopic theatre or just changing floor I could join the interesting world of open and robotic surgery as well. When I arrived, Prof. Lahme asked me what my favourite field of interest was, so I started to attend the endourologic room every day. The fifth floor was only dedicated to endoscopic procedures and included four different rooms and an area for relaxing. The first room was dedicated to transurethral resections (TUR) procedures. Every day at least five TURP or TURB procedures were performed. I already had a moderate experience in these procedures before, but I found their method very interesting particularly because of the special technique of suction they use during the monopolar TUR which allows a continue in-out irrigation from the bladder. The twin endourologic rooms : Endo-omnia and Uro-endo are two-paired operating rooms dedicated to endourology. For this reason, they are provided with UROSKOP Access: a high-performance table for endourology and urodiagnostics that includes an intensifier based x-ray system, movable with a remote control. It allows the user to look at the x-ray and the endoscopic intraoperative images at the same time, enabling the physicians to control everything with his foot without the need for a technician. In this room, we can also find all the most modern equipments for endourology as rigid and flexible ureteroscopy including the new digital Richard Wolf flexible ureteroscopy (COBRA), guidewires, ureteral access sheats, Holmium laser, catheters and others accessories. In these two rooms, I could attend a lot of operations. The daily plan was composed of three to four rigid or flexible URS (ureteroscopy and endoscopic lithotripsy) or RIRS (retrograde intrarenal surgery) and very often, one or two mini PCNL (Minimally invasive Percutaneous nephrolithotomy). During the operations all consultants gave me the translated information about the clinical cases and then the trips and tricks of flexible and rigid URS. The very big amount of patients affected by steno disease in this department allowed me to learn a lot about this pathology and specifically, about the way of solving it thanks to a great tool of endoscopic management.

12 In the same rooms, I also attended very interesting procedures of anterograde ureteroscopies and stenting with percutaneous access using the Amplatz sheath and the ureteral access sheath used to reach the distal part of the ureter in cases of stenosis or suspicious of malignancies. Considering the elevated number of patients admitted with an ureteral stone and renal colic, it is necessary to guarantee an adequate system to manage the emergencies. For this reason, in this room, the physicians also make procedures as retrograde pyelography and double J stenting in general anaesthesia of patients that will subsequently be operated.

13 In the last room, they routinely perform video urodynamic examinations, nephrostomy tubes access, prostate biopsies with stranrectal approach and under general anesthesia, then diagnostic flexible cistoscopies. This part is very important in order to join the moment of the diagnosis with the moment of therapy. The first floor was dedicated to major surgery. This is a big floor where all the other fields of surgery take place. One urologic room was daily dedicated to the robotic surgery. For about three years now, this room has the latest da Vinci Xi robot. Two procedures per day are performed with the da Vinci system. This is a form of intuitive surgery that allows to operate the patient without the necessity to stay at the table. The operation must be performed by the first operator who controls the mechanical arms movements with a remote-controlled console and from an assistant that helps the operator at the side of the patient. The Xi model also has some advantages than the previous model because it is smaller, trocar placements are easier thanks to target lasers. It has smaller, thinner robot arms that offer a greater range of motion and they move with a push of the hand. The operation is usually performed by the same senior consultant and sometimes by a junior. Radical prostatectomy, partial nephrectomy, pyeloplasty and nephroureterectomy are usually performed with a great majority of radical prostatectomies.

14 The most frequent operations were radical prostatectomies and partial nephrectomies, both performed by Dr. Zimmermans. He was tutored by Patel. That is why he is an expert in Patel s technique of radical prostatectomy by transperitoneal approach and is now one of the most known in the region who performs this type of surgery. Thanks to the technology of the da Vinci system during difficult partial nephrectomy, it is useful to use Firefly Fluorescence Imaging System that allows real-time visualization and assessment of vessels and tissue perfusion, and the intraoperative ultrasound probe enables detection of kidney tumours that are more difficult to detect. In the opposite side of the corridor, you can find the open surgery urologic room, dedicated to big and small operations, which happens almost every day. I had the opportunity to assist in a very wide range of procedures in that room. I was also part of: - Radical Cystectomy with neobladder or ilea conduit - Vasovasostomy, a microsurgical operation that allows to reconnect the vas deferens in patients with obstructive infertility or to reverse the effect of vasectomy

15 - Penile Prosthesis and artificial sphincters implantation and removal. - Surgical correction of penile deviation in patients with Peyronie's disease: a particular technique described by Prof. Lahme in 2002 that includes a novel surgical technique by which tunical defects after partial excision of plaques are covered by a ready-to-use collagen fleece coated with tissue sealant (TachoComb) in a few hours totally integrated in the native tissue. This technique is really effective and solves the problem in the most of the cases without leading a penis shortening as often happens with tunical plication. - Hypospadias repair of a patient with congenital defect, already underwent to more than four operations, performed by a big expert from Stuttgart (Dr. Seybold). The first stage of the operations consisted in removing two parts of the oral mucosa that partially filled the original defect. The second stage is after two months when it is finally allowed to create a new urethral lumen.

16 - Male urinary incontinence treatment with new devices (Phorbas), performed by a great expert of Munich. - A lot of lower surgery operations like Hydrocele, spermatocele, varicocele corrections. At midday, the staff spends their lunch break to refresh from work and to spend time together. This is an interesting habit, as oppose to the Italian tendency to avoid lunch breaks due to lack of time. The day was always very full and in the afternoon, the operating time was allowed only until 4 pm. After the operating theatre, I attended Prof. Lahme s outpatient visits. Every afternoon, he visited almost 20 patients affected by all fields of urological pathologies. I had opportunities to see a lot of difficult and rare cases, and to learn how important is to join the diagnosis with the patient counselling for the selection of the best therapeutic approach. Scholarship activities The Pforzheim clinic for urology is actively involved in teaching. For this reason, Prof. Lahme organises congresses, conferences and workshops multiple times a year to attract urologists from all over Europe.

17 During my stay, I had the opportunity to attend the courses to be involved in the scientific activity of the clinic and to write with them the abstract Comparison of Conventional PCNL and mini PCNL in the Treatment of Upper Urinary Tract Stones. An abstract on the same topic has been presented at the last EAU meeting, together with a lot of works about several different subjects. During the meeting, I had the chance to meet some of my colleagues again.

18 Take-home message and purpose Prof. Lahme is well-known especially in the endourologic and andrologic fields. I really appreciate the technique that the Pfrozheim clinic uses to treat renal stones: the mini PCNL. This is the first time I ve learned this technique, which I ve learned from Prof. Lahme. In Italy, it is not used as often as the traditional PCNL. The latter involves the use of bigger instruments which is often related to complications and adverse events. In 2001, Prof. Lahme, with the help of the Richard Wolf company, conceptualised and created a miniaturised nephroscope based on the idea of the paediatric one but with adapted dimensions to be used in adults. The mini nephroscope (12ch VS 24ch of the biggest one) is able to reach the same results with the same operating times but of course, with less postoperative complications and to afford humongous stone burden (average 4 cm²). Miniature Nephroscope 15 / 18 Fr. by Lahme

19 During my scholarship, I had the possibility to discover and learn the principles of this innovative technique and its advantages. With the help of Prof. Lahme, I started to make a comparison between the results, postoperative complications and stone free-rate between the mini PCL and traditional PCNL. The work will be presented in the urologic congress, Südwestdeutsche Gesellschaft für Urologie, in June. It will also be extended and presented as the final thesis of my residency in Italy. Conclusion My experience as an EAU scholar in Pfrozheim was very exciting. It gave me clinical and surgical knowledge on several fields of urology. The experience also imparted strong examples of different work organisation. Acknowledgement I want say thank you to the staff of the Dept. of Urology of Siloah St. Trudpert Klinikum for their unconditional hospitality. I would strongly recommend Pforzheim to all urology residents and young specialists as a place to learn and improve themselves. And at the same time, the opportunity to meet great specialists but mostly, great souls.