EUROPEAN UROLOGICAL SCHOLARSHIP PROGRAMME (EUSP) [3-month visit: 2 November 2015 – 12 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 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 1945. 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). I attended the Pforzheim clinic for a period of about three months, from the 2nd of November to the 12th of February. The stay included comfortable accommodation in a residence near the hospital. 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 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. ® The first floor has the robotic room with the latest model of the 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. 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 - 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. 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. 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. 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