Best of EAU24: Key learnings, best practices, and fresh perspectives

The scientific programme reflected the multilateral and ever-changing landscape of urology, where the rising role of artificial intelligence (AI) was examined and embraced. The programme comprised the congress’ pièce de resistance, which was the live surgeries, and a myriad of sessions and activities: 8 Plenary Sessions, 5 Game Changing Sessions, 30 Thematic Sessions, 45 European School of Urology (ESU) courses, 7 types of Hands-on Training, 12 section meetings, 6 Patient Day sessions, 6 Special sessions, 63 Abstract Sessions, 16 Video Sessions, and 13 Expert-Guided Poster Tours.

In addition, the first-ever “Fun Run”, a five-kilometre run around Paris, took place on 7 April 2024 to support a project on the positive effects of physical activity on prostate cancer patients. Through the collaborative efforts of the European Association of Urology (EAU), the ESU, the EAU Section Offices, various associations and national societies, EAU24 was an all-encompassing congress. It also generated online buzz with an outstanding 33.3 million impressions on X (a.k.a. Twitter) alone.

This report contains some of the crucial key takeaways of the congress presented during the Special Session "Best of EAU24: Take Home Messages" with links to the full presentations.

On functional urology
Prof. Frank Van Der Aa (BE) began his presentation of functional urology highlights with featured abstracts on overactive bladder and innervation.

The results of the study on women with urinary incontinence were discussed in the abstract “A0781: Interaction between periaqueductal gray (PAG) and Barrington’s nucleus (Bar) during strong desire to void using 7 Tesla functional MRI” which demonstrated significant functional interactions between PAG clusters and Bar. The evaluation of these two areas confirms the importance of the pathophysiological mechanism of lower urinary tract symptoms (LUTS), and this might be the first step in creating new therapeutic targets, especially in patients not responding to medical therapy.

The abstract "A0784: Algorithm based programming of a novel implantable tibial neuromodulation system (iTNM) for urge urinary incontinence” illustrated that this therapy had good outcomes with cure rates of 78.4% at 12 months, compliance of 91.6% at 12 months, and patient satisfaction of 95% at 12 months.

Urogenital reconstruction studies were also highlighted by Prof. Van Der Aa, particularly the high-quality research on perineal urethrostomy, female urethral strictures, and tissue engineering (i.e., considered the future of urethral reconstruction).

Check out the collective take-home messages on functional urology.

On prostate cancer
Prof. Arnauld Villers (FR) presented a summary of the most relevant prostate cancer (PCa), which included the following key takeaways from the Thematic Session “Lancet Commission on prostate cancer”, a first at an EAU congress:

• Diagnosis development and broader integration of PCa diagnosis into men’s health are needed.
• Empower patients by helping them to be well-informed.
• Improvement of the implementation of resource sensitive guidelines for treatment using existing technologies can result to better outcomes.
• Research and evidence-based practice and policy should be further developed.

The Best of EAU24 Session also provided information on the implementations of the EU recommendations (2022) such as incidence and facilities in member states will determine the approach to manpower restrictions; waiting lists; and magnetic resonance imaging (MRI) resources may become dominant factors for early detection programmes.

What’s new in PCa predisposition genes? The session also offered vital information such as men diagnosed with PCa unselected for family history or metastatic disease have 16% pathogenic variants. The recommendation, which the EAU Guidelines also affirmed, was genetic testing at tumour level of a pathogenic variant in a DNA damage response (DDR) gene.

Watch the full PCa presentation here.

More PCa updates
Additional notable developments on large clinical trials on PCa were presented during the Game changing session "Guideline changes in screening and diagnosis for prostate cancer?" such as:

• The first release of the PRIME data investigating biparametric versus multiparametric MRI in the primary diagnosis of PCa
• Data from the PROBASE screening trial which has new information on PSA cut-offs in screening
• The first data releases from the CAP Trial from the UK with results from 15 years and the ProScreen screening trial from Finland with a new risk-adapted strategy.

Furthermore, an update of the ongoing PRAISE-U pilot screening studies was also discussed. These studies investigate the implementation of risk adapted screening strategies in selected regions in Europe.

On paediatric urology
Prof. Anne-Françoise Spinoit (BE) shared the main conclusions from the lectures on paediatric urology. This included the complexity of bladder bowel disfunction (BBD), which requires careful individualised management to prevent recurrent urinary tract infections (UTIs) and renal scarring.

Other highlights included four semi-live videos on the management of challenging situations in hypospadias repair with flaps and grafts, chordee, and cripples; the risks and pitfalls of AI; and foetal interventions, which are still not proven efficient. The treatment for monosymptomatic nocturnal enuresis (MNE) is different in paediatric urology, as it requires active involvement of both patient and parents as opposed to surgical procedures where the paediatric urologist fixes the problem for the patient.

The European Society for Paediatric Urology (ESPU) lecture from Prof. Alice Faure highlighted the evolution in the management of sphincter insufficiently in children. Traditionally, the go-to procedure is complex bladder neck reconstruction but peri-urethral balloons and keeping the virgin urethra as long as possible could be the less invasive solutions.

See Prof. Spinoit’s full presentation on the paediatric urology highlights.

On bladder cancer and upper tract TCC
Prof. Joost Boormans (NL) shared his clinical perspective on various bladder cancer and upper tract transitional cell carcinoma (TCC) topics, including AI-guided detection of cancer cells with urine cytology, urine assays to de-escalate non-muscle-invasive bladder cancer (NMIBC) follow-up, novel intravesical therapies in Bacillus Calmette Guerin (BCG) unresponsive NMIBC, adjuvant immunotherapy and ctDNA-guidance after radical cystectomy in MIBC, antibody drug conjugates and immunotherapy as new standard of care first-line therapy in metastatic urothelial carcinoma, and upper tract urothelial carcinoma (UTUC).

For UTUC, Prof. Boormans stressed five points:

• UTUC differs from urothelial carcinoma of the bladder (UCB), anatomically, clinically and molecularly
• UTUC and matched intravesical recurrence (IVR) are clonally related
• Peri-operative intravesical instillation with chemotherapy reduces risk of IVR
• Diagnostic ureteroscopy (URS) increases risk of IVR after radical nephroureterectomy
• Molecular urine assays for UTUC diagnosis and follow-up hold promise
  

View the presentation on bladder cancer and upper tract TCC here.

On kidney cancer
Dr. Maria Carmen Mir Maresma (ES) presented the kidney cancer highlights. Of note, she shared points from the discussions related to adjuvant use of immunotherapy (IO) for high-risk RCC: “KEYNOTE-564 is the only phase 3 study to show improved overall survival with any adjuvant therapy in RCC”. According to Dr. Mir Maresma, this generated a lot of debate because of the differences in population, stratification, no biomarkers to classify the patients, and minimal data on the nomograms of how to predict the risk of recurrence. This debate continued when the use of subsequent therapies was presented.

She highlighted several kidney cancer abstracts, including the 14-year follow-up results of the DISSRM registry: Active surveillance versus primary intervention for clinical T1a kidney tumours. The take-home messages were that overall survival is better with primary intervention, however this is mostly driven by age-related/ comorbidity factors. To highlight that patients with delayed intervention did not show worst cancer specific survival. Personalised active surveillance for small renal masses as per growth rate and size should be taken into consideration, as well as, improved patient counselling.

Dr. Mir Maresma also shared key points from the abstract “A0474: Artificial intelligence links pre-operative multi-phase computerised tomography (CT) images to pathologic features, survival outcomes and biological behaviours of renal masses using real-world data.” According to the results, deep learning models can non-invasively predict the likelihood of malignant and aggressive pathology of a renal mass based on preoperative multi-phase CT images, and in the future, improved algorithms will be useful for renal tumour identification.

Watch Dr. Mir Maresma’s kidney cancer summary.

On BPH/LUTS
Prof. Jean Nicolas Cornu (FR) provided a digest of updates on male LUTS and benign prostatic hyperplasia (BPH) which included the male LUTS’ link to overactive/ underactive bladder syndromes; inflammation/colonisation in urinary tract; shared innervation with other pelvic organs; rate of urine production; psychology; frailty, and undiagnosed neurology.

On the combination of silodosin and tadalafil, a study by Saha, et al. showed there is a statistically significant reduction in the International Prostate Symptom Score (IPSS) in the test arm in contrast to the comparator. This demonstrated the superiority of the test product at week 12.

Prof. Cornu cited the abstract by Asmundo, et al., "A0700: “Water Vapor Thermal Therapy vs. TURP for the treatment of benign prostatic obstruction: A Multicenter Propensity-Score Matched Pair ‘tetrafecta’ Analysis (URAN Collaborative Group)”, which concluded that transurethral resection of the prostate (TURP) demonstrated was more frequently associated with Tetrafecta outcomes compared to Rezūm after a one-year follow-up. However, Rezūm offers a better chance to maintain antegrade ejaculation. These results should be taken into account during the counselling of patients before surgery.

For the complete summary of BPH and male LUTS take-home messages, click here.

On imaging
Dr. Jochen Walz (FR) presented and cited abstracts such as by Neuville P. et al, “A0226: Acute imaging practices after paediatric renal trauma: The multi-institutional paediatric acute renal trauma study (Mi-PARTS) experience”, which concluded that non-contrast computerised tomography (NCCT) was insufficient to grade the trauma and manage cases, and contrast-enhanced CT (CECT) with late phase is the most informative exam, with follow up in low-grade trauma rarely necessary.

In a four-year review analysing unwarranted imaging requests for undescended testis “A0113: Descent: Departmental evaluation of scrotal imaging considering European and national testicle guidelines” Bernstein D.E. et al, found that effective measures (e.g., rejecting unnecessary imaging requests), ensured guideline adherence, cost effectiveness and improved patient care.

A study by Jeong, S. et al, resulted in radiomics feature-based multi-class classification showing good performance in simultaneous predictions for urolithiasis composition.

According to Dr. Walz, the most important prostate cancer study presentation was the PRIME study (NCT04571840) where Prof. Veeru Kasivisvanathan (GB) shared results indicating that biparametric MRI (bpMRI) was non-inferior to multiparametric for csPCa diagnosis with no increase in number of men with a biopsy indication based on bpMRI. Discussant Dr. Giorgio Gandaglia (IT) rebutted the results with the main flaw that 95% of the MRI scans in the PRIME trial had a PI-QUAL equal to or above 4. He inquired if it is possible to achieve this in the community setting.

Watch Dr. Walz’s full presentation to learn more about the other studies featured, such as PRECISE v2, DEPROMP-Study: PSMA-PET/CT prior to prostate biopsy, and the TARGET classification.

On stones
Prof. Thomas Knoll (DE) provided expert insights and developments on stones. He cited the multi-centre study "PUrE RCT1: Clinical and cost-effectiveness of flexible ureteroscopy (fURS) and extracorporeal shock wave lithotripsy (ESWL) for lower pole stones ≤ 10 mm”, which showed that there was no difference in the mean health status; but higher complete stone clearance with FURS compared to ESWL. However, the latter is more cost effective.

What is the link between fURS skills and video gaming? The study “P359: Video gaming and surgical proficiency: Investigating the impact of video gaming experience to fURS among post graduate medical interns” surmised that video gaming experience can enhance proficiency in performing fURS tasks. The study concluded, “This insight could be valuable for developing innovative training modules in medical education, integrating elements from gaming to expedite skill acquisition in techniques such as fURS.”

The stones presentation also covered the pharmacological modulation of intrarenal pressure using a novel isoprenaline eluting guidewire called IsoWire. The latter elutes the beta-agonist isoprenaline to cause relaxation of the ureteric smooth muscle. IsoWire decreased intrarenal pressure by 29%. Furthermore, endoluminal isoprenaline administration may increase safety of retrograde intrarenal surgery (RIRS).

View all the conclusions of the presentation on stones here.

On andrology
Dr. Maarten Albersen (BE), recently-appointed Chair of the EAU Scientific Congress Office, spearheaded the presentation on andrology. He offered highlights on the topic, specifically derived from seven notable abstracts and posters. He discussed a German randomised controlled trial (RCT) where the authors studied the usage of an app to treat erectile dysfunction (ED) versus standard lifestyle advice in 241 patients as a means to improve the adoption of lifestyle changes and exercise. The use of the app resulted in a meaningful improvement of erectile function scores with a larger effect size than those observed in earlies studies on lifestyle change in this disease. However, the single-blind design of the study may warrant caution in overinterpreting these results.

Regenerative medicine is a hot topic in andrology and platelet-rich plasma is being used throughout the world without hard data supporting its effects in the treatment of ED. Authors from Spain presented the “PRePED study: A randomised, double-blind controlled trial to evaluate the efficacy of intracavernosal infusion of platelet rich plasma (PRP) against control platelet poor plasma (PPP) in the treatment of vasculogenic erectile dysfunction” and explained that the trial was stopped early due to concerning safety signals (e.g. plaque formation) which warrant further caution in the application of such strategies outside of controlled trial settings.

The abstract “A1106: Cardiac structure and function in men with erectile dysfunction” stated that a majority of patients with ED demonstrated impairment of cardiac structure and function as assessed by measures of diastolic dysfunction and myocardial deformation. These detectable signs of impairment might improve risk stratification in this susceptible patient group, and may trigger further investigation in patients identified to be at risk for cardiac disease.

Watch all the take-home messages on andrology here.

On testis/penile cancer
Dr. Albersen continued with the final presentation of EAU24 key takeaways, which centred on testis and penile cancer. He presented the findings of a large series on long-term surveillance of clinical stage I pure teratoma of the testis by Dr. Rob Hamilton’s group. The latter showed the cumulative incidence of pure teratoma was 12.2% vs 29/6% in CS1 non seminoma, and cancer-specific survival was 100% at six years for the teratoma patients. They concluded that active surveillance is a viable strategy for these patients and adjuvant therapy would have resulted in overdiagnosis in 87% of patients.

Regarding penile cancer, the novel data which explored the penile tumour micro-environment at unprecedented resolution by various groups from Belgium, China, Germany, and Sweden were presented at EAU24. The abstracts collectively identified new clues for treatment personalisation based on tumour characteristics and showed clues for the use of immune-checkpoint inhibition and antibody-drug conjugates in this rare disease, while treatment resistance seemed to be rooted in immune-exclusion and epithelial-mesenchymal transition.

The abstract “A0338: Quality of life after penile cancer surgery: Comparison between amputative and penile-sparing surgery” concluded that health-related quality of life (HRQoL) improved with surgery. In terms of sexual function, patients reported that it was poor at baseline and the improvements observed with both types of surgery were minor yet significant for organ-sparing approaches. However, over the course of the disease and post-surgery, it seems that penile cancer patients have a profoundly reduced sexual satisfaction compared to healthy controls.

For more notable key messages on testis and penile cancer updates, click here.

We look forward to welcoming you next year at the 40th Annual EAU Congress (EAU25), which will take place in Madrid, Spain from 21 to 24 March 2025. Mark your calendars!