Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement. METHODS: Female bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement. RESULTS: Out of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02). CONCLUSIONS: The type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

Salvage Robotic-assisted Laparoscopic Radical Prostatectomy Following Focal High-Intensity Focused Ultrasound for ISUP 2/3 Cancer.

OBJECTIVE: To report feasibility and outcome of salvage robotic-assisted laparoscopic radical prostatectomy (S-RALP) after focal therapy using high-intensity focused ultrasound (HIFU) treatment compared to primary robotic-assisted laparoscopic radical prostatectomy (pRALP). METHODS: In this bicentric trial patients undergoing S-RALP for detection of WHO2016/ISUP Grade Group 2 or 3 prostate cancer were previously treated in prospective focal HIFU trials. Perioperative data, complications, oncological and functional outcome were analysed. Patients who underwent pRALP were matched in a ratio 2(pRALP):1(S-RALP) according to preoperatively functional, oncological and clinical parameters. RESULTS: A total of 39 patients were included in the study (13S-RALP, 26pRALP). Median operative time in the S-RALP group was 260minutes (pRALP: 257minutes), blood loss was 230ml (pRALP: 300ml). Complications occurred in 46.2% (6/13) of S-RALP patients (pRALP: 26.9%), including four Clavien-Dindo III complications (pRALP: 2/26). In S-RALP adverse histological outcome (≥pT3a, pN+ or R1) was detected in 23.1% (3/13) (pRALP: 26.9%). There was one patient with PSA-persistence (pRALP: 2/26). Regarding functional outcomes there was no difference between the two groups observed (incontinence P=.71, erectile function P=.21). CONCLUSION: S-RALP should be offered to patients with an early relapse after focal HIFU. The early oncological outcome is satisfactory and functional outcome one year postoperatively is similar to pRALP. However, S-RALP is associated with a higher rate of Clavien-Dindo III complications (mainly, placement of a drainage), of which patients should be informed beforehand.

[Intelligent early prostate cancer detection in 2021: more benefit than harm]. / Intelligente Prostatakarzinomfrüherkennung 2021 ­ mehr Nutzen als Schaden.

Prostate-specific antigen (PSA) is used for early detection of prostate cancer which represents the most frequent cancer diagnosed in men in Germany and Europe. Results of the largest screening trials revealed that PSA testing reduces the incidence of locally advanced and metastatic prostate cancer and shows an effect on cancer-specific mortality. However, since early diagnosis also results in overdiagnosis and overtreatment of insignificant cancers with associated morbidities, there is a need for a more individualized and risk-tailored modern strategy. The PSA at baseline is an important part of this strategy although the German Federal Joint Committee declined its financial coverage by health insurances. Available validated instruments should accompany the baseline PSA to optimize detection of clinically significant prostate cancer.

Peritoneal flap for lymphocele prophylaxis following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: study protocol and trial update for the randomized controlled PELYCAN study.

BACKGROUND: Data from interventional studies suggest that a peritoneal flap after pelvic lymph node dissection (LND) during laparoscopic, robotic-assisted radical prostatectomy (RARP) may reduce the rate of symptomatic lymphoceles in transperitoneal approach. However, most of these studies are not conducted in a randomized controlled fashion, thus limiting their scientific value. A recent prospective, randomized, controlled trial (RCT) did not show superiority of a peritoneal flap while further trials are lacking. Therefore, the aim of the presented RCT will be to show that creating a peritoneal flap decreases the rate of symptomatic lymphoceles compared to the current standard procedure without creation of a flap. METHODS/DESIGN: PELYCAN is a parallel-group, patient- and assessor-blinded, phase III, adaptive randomized controlled superiority trial. Men with histologically confirmed prostate cancer who undergo transperitoneal RARP with pelvic LND will be randomly assigned in a 1:1 ratio to two groups-either with creating a peritoneal flap (PELYCAN) or without creating a peritoneal flap (control). Sample size calculation yielded a sample size of 300 with a planned interim analysis after 120 patients, which will be performed by an independent statistician. This provides a possibility for early stopping or sample size recalculation. Patients will be stratified for contributing factors for the development of postoperative lymphoceles. The primary outcome measure will be the rate of symptomatic lymphoceles in both groups within 6 months postoperatively. Patients and assessors will be blinded for the intervention until the end of the follow-up period of 6 months. The surgeon will be informed about the randomization result after performance of vesicourethral anastomosis. Secondary outcome measures include asymptomatic lymphoceles at the time of discharge and within 6 months of follow-up, postoperative complications, mortality, re-admission rate, and quality of life assessed by the EORTC QLQ-C30 questionnaire. DISCUSSION: The PELYCAN study is designed to assess whether the application of a peritoneal flap during RARP reduces the rate of symptomatic lymphoceles, as compared with the standard operation technique. In case of superiority of the intervention, this peritoneal flap may be suggested as a new standard of care. TRIAL REGISTRATION: German Clinical Trials Register DRKS00016794 . Registered on 14 May 2019.

[Urological research in Germany : A retrospective, longitudinal observational study]. / Urologische Forschung in Deutschland : Eine retrospektive, longitudinale Beobachtungsstudie.

BACKGROUND AND OBJECTIVES: The congress of the German Society of Urology reflects urologic research in German-speaking countries. The objective was to identify trends by analyzing the congress' abstracts and following full publications longitudinally. MATERIALS AND METHODS: The abstracts of the 2016 congress were systematically analyzed regarding content, study design, cooperation, following full publications and journals which they were published in. Thereafter, the 2016 congress was compared to the 2002 and 2009 congresses. Statistical analysis included χ2-, Mann-Whitney U-, Cochran-Armitage-, and Kruskal-Wallis test. RESULTS: A total of 1073 abstracts were presented at the 2002, 2009, and 2016 congresses. We found an increase in abstracts regarding prostate disease (24.2%, 29.7%, and 34.0%; p = 0.0043), oncological abstracts (50.6%, 57.9%, and 61.7%; p = 0.003), multicenter studies (18.3, 28.6, and 34.3%; p < 0.0001) and cooperation (55.6%, 62.9%, and 70.5%, p < 0.0001). Experimental (29.0%, 33.2%, and 22.8%; p = 0.009) and prospective studies (62.1%, 42.0%, and 36.0%; p < 0.0001) declined. Abstracts including statistical analysis (18.4%, 14.7%, and 41.2%; p < 0.0001) and the impact factor of following full publications (2.08, 3.42, 4.42; p < 0.0001) rose. In 2016, 11.2% of those full publications were published Open Access. The publication rates of the presented abstracts were 49.1%, 56.3%, and 52.3%, respectively (p = 0.15). CONCLUSIONS: National and international networking of the urological research community has increased. Presentation of prospective studies has declined. The rate of peer-reviewed full publications following the DGU abstracts remains at a stable high level over the three congresses. The publication rate in Open Access journals is low.

Prostate cancer detection among readers with different degree of experience using ultra-high b-value diffusion-weighted Imaging: Is a non-contrast protocol sufficient to detect significant cancer?

AIM: To evaluate the accuracy of a T2-weighted (T2w) - and a parallel transmit zoomed b = 2000 s/mm2 (b2000) - diffusion-weighted imaging sequence among three readers with different degrees of experience for prostate cancer (Pca) detection. METHODS: Ninety-three patients with suspected Pca were enrolled. For b2000 a two-dimensional spatially-selective RF pulse using an echo-planar transmit trajectory was applied, and the field of view (FOV) was reduced to one-third. All three readers (Reader A: 7, B 4 and C <1 years of experience in prostate MRI) independently evaluated b2000 with regard to the presence of suspicious lesions that displayed increased signal. The results were compared to histopathology obtained by real-time MR/ultrasound fusion and systematic biopsy. RESULTS: In 62 patients Pca was confirmed. One significant Pca (Gleason score (GS) 7b) was missed by Reader C. Overall, sensitivity/specificity/positive predictive value/negative predictive value were 90/71/86/79% for Reader A, 87/84/92/76% for Reader B and 85/74/87/72% for Reader C, respectively. Detection rates for significant Pca (GS >7a) were 100/100/94% for Readers A/B/C, respectively. Inter-reader agreement was generally good (Kappa A/B: 0.8; A/C: 0.82; B/C: 0.74). CONCLUSION: B2000 in combination with a T2w could be useful to detect clinically significant Pca. KEY POINTS: • Significant prostate cancer using zoomed ultra-high b-value DWI was detected. • Diagnostic performance among readers with different degrees of experience was good. • mp- MRI of the prostate using a comprehensive non-contrast protocol is clinically feasible.

Precision of MRI/ultrasound-fusion biopsy in prostate cancer diagnosis: an ex vivo comparison of alternative biopsy techniques on prostate phantoms.

PURPOSE: Comparing the accuracy of MRI/ultrasound-guided target-biopsy by transrectal biopsy (TRB) with elastic versus rigid image fusion versus transperineal biopsy (TPB) with rigid image fusion in a standardized setting. METHODS: Target-biopsy of six differently sized and located lesions was performed on customized CIRS 070L prostate phantoms. Lesions were only MRI-visible. After prior MRI for lesion location, one targeted biopsy per lesion was obtained by TRB with elastic image fusion with Artemis™ (Eigen, USA), TRB with rigid image fusion with real-time virtual sonography (Hitachi, Japan) and TPB with rigid image fusion with a brachytherapy approach (Elekta, Sweden), each on a phantom of 50, 100 and 150 ml prostate volume. The needle trajectories were marked by contrast agent and detected in a postinterventional MRI. RESULTS: Overall target detection rate was 79.6% with a slight superiority for the TPB (83.3 vs. 77.8 vs. 77.8%). TRB with elastic image fusion showed the highest overall precision [median distance to lesion center 2.37 mm (0.14-4.18 mm)], independent of prostate volume. Anterior lesions were significantly more precisely hit than transitional and basal lesions (p = 0.034; p = 0.015) with comparable accuracy for TRB with elastic image fusion and TPB. In general, TRB with rigid image fusion was inferior [median 3.15 mm (0.37-10.62 mm)], particularly in small lesions. CONCLUSION: All biopsy techniques allow detection of clinically significant tumors with a median error of 2-3 mm. Elastic image fusion appears to be the most precise technique, independent of prostate volume, target size or location.

Immunity to Rhodococcus equi: antigen-specific recall responses in the lungs of adult horses.

Rhodococcal pneumonia is an important disease of young horses that is not seen in immunocompetent adults. Since all foals are normally exposed to Rhodococcus equi in their environment, we hypothesized that most develop protective immune responses. Furthermore, these antigen-specific responses were hypothesized to operate throughout adult life to prevent rhodococcal pneumonia. A better understanding of the mechanisms of immune clearance in adult horses would help define the requirements for an effective vaccine in foals. Adult horses were challenged with virulent R. equi by intrabronchial inoculation into the right lung, and pulmonary immune responses were followed for 2 weeks by bronchoalveolar lavage. Local responses in the inoculated right lung were compared to the uninfected left lung and peripheral blood. Challenged horses rapidly cleared R. equi infection without significant clinical signs. Clearance of bacteria was associated with increased mononuclear cells in bronchoalveolar lavage fluid (primarily lymphocytes) and inversion of the normal macrophage:lymphocyte ratio. There was no significant increase in neutrophils at 7 days post-challenge. Flow cytometric analysis of bronchoalveolar lavage fluid demonstrated that clearance correlated with significant increases in pulmonary T-lymphocytes, both CD4+ and CD8+. Prior to challenge, most adult horses demonstrated low proliferative responses when pulmonary lymphocytes were stimulated with soluble R. equi ex vivo. However, clearance was associated with marked increases in lymphoproliferative responses to soluble R. equi antigen and recombinant VapA, a virulence associated protein of R. equi and candidate immunogen. These results are compatible with previous work in mice which showed that both CD4+ and CD8+ T-cells play a role in immune clearance of R. equi. Recognition of VapA in association with clearance lends further support to its testing as an immunogen. Importantly, the cellular responses to R. equi challenge were relatively compartmentalized. Responses were more marked and the sensitivity to antigen dose was increased at the site of challenge. The blood, including peripheral blood mononuclear cells, was an insensitive indicator of local pulmonary responses.