Dr. Christian Gratzke, was one of the four challengers at the European Urology Forum in Davos earlier this month. While all the participants did an excellent job in the challenge, Gratzke made an outstanding case for the urology topics he chose to elaborate on, which landed him with the winner's title. In this article he describes his experience at the event.
The European Urology Forum in Davos is a unique meeting in many ways. The programme contains excellent state-of-the-art lectures, hot topics presented by keynote speakers from Europe and the US, and the “Challenge the experts” sessions. There, five young academic urologists present three topics of their choice to the audience, followed by extensive discussions by an expert panel – the "challenge".
The presenter is judged based on different criteria (topic, presentation, discussion etc). This session is without doubt attractive for the audience, since the discussions usually give in-depth insight to the topic. This year, the selection of topics covered a broad spectrum ranging from oncological surgery, functional urology, systemic medical treatment, and imaging to epidemiology. The topics I presented were “Cannabinoids – From Bench to Bedside”, “Novel Minimally-Invasive Treatment for Male LUTS” and “Aggressive Surgery in Advanced Prostate Cancer”.
Research on Cannabinoids
I started doing research on Cannabinoids in 2007/2008 during a research fellowship at Wake Forest University, North Carolina, with Professor Karl-Erik Andersson, followed by a research fellowship with Professor Petter Hedlund at Lund University, Sweden. The rationale to study the endocannabinoid system is based on observations that patients with multiple sclerosis who suffer from OAB symptoms improve after the administration of cannabis extracts. Our research group has studied the endocannabinoid system over the last 7 years with the aim to understand their mechanism of action in the lower urinary tract.
Briefly, two different pharmacological approaches have been identified, the exogenous application of cannabinoid agonists, and inhibition of the main enzyme degrading endogenous cannabinoids. Using preclinical in-vitro and in-vivo techniques (particularly cystometry in conscious rats), various drugs were identified which improved lower urinary tract symptoms in rat models. Currently we aim to translate these findings to humans by performing a pilot study in patients with OAB.
Minimally-invasive approaches to improve male LUTS
My second talk was directed to novel minimally-invasive approaches to improve lower urinary tract symptoms in male patients. Our department is involved in various clinical studies of male LUTS. Studies on intraprostatic Botox injections for the treatment of male LUTS have produced contradictory results; while studies with low level of evidence have shown significant improvements after Botox injections, recent RCTs had resulted in disappointing results showing no superiority over placebo (albeit with considerable placebo effect). Currently, studies with a slightly different mode of actions are being tested in clinical studies, among them NX 1207 and PRX302. Phase II studies had shown promising effects with significant improvements over placebo. The results of the ongoing studies are awaited next year.
The second part of the talk was about the Urolift (“Prostatic Urethral Lift”) system. This is a completely novel approach where the prostatic urethral lift mechanically opens the prostatic urethra with implants that are placed transurethrally under cystoscopic visualization, thereby separating the encroaching prostatic lobes. Recent RCTs have shown significant improvements of LUTS; currently, a European phase III trial is performed which evaluates the effects of Urolit vs TURP. Results are awaited next year. In summary, novel minimally-invasive procedures could be beneficial for selected patients, particularly young patients who would like to preserve sexual function (antegrade ejaculation).
Aggressive surgery in advanced prostate cancer, a controversy
In my last presentation I covered a highly controversial topic which is currently under debate. In analogy to other oncological entities such as ovarian cancer, breast cancer and even renal cell cancer, studies have shown significant survival benefits in patients with advanced disease when removing the primary tumour. In prostate cancer, however, only few series have shown beneficial effects. Both in patients with node positive disease as well as in those with bone metastases, removal of the prostate led to improvements in overall survival.
However, these data are usually based on retrospective series; prospective studies are still lacking. Therefore, a collaboration of different European centres will take a two-step approach. First, we will analyze morbidity and feasibility of radical prostatectomy in M1 prostate cancer patients who were treated accordingly over the last years. More importantly, an RCT will be initiated to study overall survival in oligometastatic patients (max 3 bone metastases) in addition to ADT with or without radical prostatectomy led by Prof. Markus Graefen (Hamburg). Results are awaited after 60 months follow-up, enrolling appr. 500 patients. I expected a controversial discussion on this topic, which did take place. The common notion was that an RCT is needed using strict inclusion and exclusion criteria.
To summarize my experience from the Davos meeting, I was very happy to be selected to participate among a group of excellent challengers who all gave high quality presentations. All of us enjoyed being invited to the meeting and became friends over these days. I feel that this format is highly attractive for the audience and also challenging for the young presenters, given the selection of experts in the jury. It has to be noted, of course, that the setting of the meeting, in between the “Parsenn” and the “Jakobshorn” included some great skiing in the middle of the Alps – then, without strict distinction between jurors and challengers.