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Plenary session sheds light on microbiome and strategies for urosepsis

What is the link between microbiome and the development of genitourinary (GU) cancers? How does one manage urosepsis effectively? Experts explored the answers to these questions and provided key takeaways during today’s Plenary Session “Challenges in urogenital infections”. Chairs Prof. Mesrur Selçuk Silay (TR) and Prof. Florian Wagenlehner (DE) spearheaded the session.

In his state-of-the-art lecture “Microbiome has a role in the development of genitourinary cancers”, oncologist Prof. Andrea Alimonti (CH) stated that intra-tumoural microbiome plays a role in the development of prostate cancer (PCa). Prof. Alimonti stated, “The microbial species that reside in the urinary tract might be initiators of chronic inflammation in the prostate, ultimately leading to PCa by causing the development of PIA (proliferative inflammatory atrophy). Several species of pro-inflammatory bacteria and/or known uropathogens are enriched in men with PCa. The prostate tumour microbiota is different from the one of normal tissues.”

According to Prof. Alimonti, microbiome has a role in the development of bladder cancer (BCa) as well. Several studies published in the last 50 years have shown the association between bladder schistosomiasis and BCa. He added that many microbes of the GU tract are also potentially involved in GU tumours. However, there is opposing evidence: the usage of BCG (Bacillus Calmette-Guérin) to prevent the recurrence of NMIBC (non-muscle-invasive bladder cancer), and urinary microbiome strains attenuate mucosal inflammation (e.g. Lactobacillus casei can activate immunosurveillance to block inflammation and consequently, impede the development of BCa).

He also cited the paper by N. Pernigoni, et al. (Science journal, 2021) which showed that bacteria located in the gut can also give rise to PCa, particularly the lethal castration-resistant prostate cancer (CRPC). The paper also demonstrated that antibiotic therapy can delay the onset of CRPC.

Prof. Alimonti said, “In PDX (patient-derived xenograft) mice, depletion of intestinal microbiota affected tumour growth. Antibiotic therapy is also effective in enzalutamide-treated mice. In mice treated with pharmacological castration, there is an expansion in the gut of a specific bacteria. This bacteria can produce androgen starting from the precursor. Therefore, in a patient treated with enzalutamide, we see an expansion of bacteria such as the ruminococcus species which can affect the DHA (docosahexaenoic acid) in testosterone, rendering the enzalutamide treatment inefficacious.”

A focus on urosepsis

During the state-of-the-art lecture “Pathophysiology and the role of the host in urosepsis”, Dr. Zafer Tandoğdu (GB) stated that sepsis is no longer considered as SIRS (systemic inflammatory response syndrome). “Sepsis is a dysregulated host response with both pro- and anti-inflammatory processes. It is important that we understand timely recognition before the transition to sepsis, and early warning scores can help detect that. We should be mindful that if there is an infection, there can be sepsis,” said Dr. Tandoğdu.

Recipient of the Société Internationale d’Urologie (SIU) Recognition Award, Dr. A. Lenore Ackerman (US) presented her SIU lecture “A nightmare for urologists: How to manage urosepsis?”.

In her presentation, Dr. Ackerman emphasised that management of urologic predisposing risk factors includes relieving the obstruction, removal of indwelling devices if possible, and if not, replacement. She stated that the role of the urologist involves resolving underlying issues as much as possible and identifying urosepsis cases with an obstructive or structural cause (e.g. obstructive urolithiasis, urinary retention resulting from BPH [benign prostatic hyperplasia], neurogenic bladder, structurally abnormal bladder, solitary kidney, or urethral obstruction/stricture). “Our first job as urologists is to decompress, drain or remove those causes in the least invasive way,” said Dr. Ackerman.

During her presentation, Dr. Ackerman also provided the SIRS criteria for when sepsis is suspected. She advised, “Although there is a remote risk of progression to urosepsis for a patient presenting in the outpatient scenario, if your patient meets at least two of these criteria, the best practice is to get that patient into the hospital.”  The SIRS criteria are as follows:

  • Temperature of > 38°C or < 36°C
  • Heart rate is > 90bpm
  • Respiratory rate is > 20 or PACO2 < 32mm Hg
  • White blood cell count is > 12,000/ml, < 4,000/ml, or the presence of > 10% immature neutrophils
  • Altered Glasgow coma scale
  • Blood glucose > 7.7 mmol/l in non-diabetic patients

Dr. Ackerman underscored that urinalysis, urine, and blood cultures must be prioritised early in the patient presentation. “Make sure that culture data are obtained before initiating antibiotics. This is your one shot. If you miss that chance of what you’re treating, it’s difficult to determine later.”

(Re)view the presentations and check out the full Plenary Session via EAU on Demand on the Virtual Platform. For more information on the prevalence of urosepsis, overmedication, and antimicrobial resistance, watch the lively discussion among Prof. Wagenlehner, Prof. Tandoğdu and Dr. Ackerman on EAUTV!