[Urethral reconstruction]. / Harnröhrenrekonstruktion.

A urethral stricture is an abnormal narrowing of the urethra due to spongiofibrosis of the urethral mucosa and the underlying corpus spongiosum. The diagnostics include uroflowmetry, sonography and radiology. For penile strictures the success rate of endoscopic treatment is low. Therefore, urethroplasty should always be performed, preferably using oral mucosa. Depending on the complexity, reconstruction must be carried out in one or multiple stages. For short bulbous strictures endoscopic treatment can primarily be carried out. In the case of recurrence urethroplasty should be carried out. The indications for urethral reconstruction are primarily given for long bulbous strictures. Depending on the length and extent of the stricture, a scar resection and end-to-end anastomosis, non-transsecting end-to-end anastomosis or augmentation urethroplasty can be performed. Perineal urethrostomy (the so-called boutonnière procedure) is a treatment option for patients with complex strictures or for patients who want a straightforward solution.

[Development of endoscopic enucleation of the prostate]. / Entwicklung der endoskopischen Enukleation der Prostata.

This article deals with lasers from their initial description to the most advanced applications in the treatment of benign prostate enlargement.

[Thulium or holmium laser or both: where will the journey take us?] / Thulium oder Holmium-Laser oder beides: wo geht die Reise hin?

The Holmium:YAG laser has been the gold standard for laser lithotripsy over the past three decades and, since the late 1990s, also for prostate enucleation. Pulsed thulium fibre lasers (TFL) demonstrated their efficacy in in-vitro experiments and were introduced to the market a few years ago. Initial clinical results for TFL in lithotripsy and enucleation are very promising. In addition to TFL, a pulsed Thulium:YAG solid-state laser has been introduced, but clinical data for this laser are currently limited. This article aims to review the key technological differences between Ho:YAG lasers and pulsed thulium lasers and compare/discuss the initial clinical results for stone lithotripsy and laser enucleation.In-vitro studies have demonstrated the technical superiority of TFL compared with Ho:YAG lasers. However, as TFL is still a new technology, only limited studies are available to date, and optimal settings for lithotripsy have not been established. For enucleation, the differences of TFL compared with a high-power Ho:YAG laser seem to be clinically irrelevant. Initial studies on pulsed Tm:YAG lasers show good results, but there continues to be a lack of comparative studies.Based on the current literature, pulsed thulium lasers have the potential of being an alternative to Ho:YAG lasers. However, further studies are necessary to determine the optimal laser technology for enucleation and lithotripsy of urinary stones, considering all parameters, including efficacy, safety, and cost.

[How good are we really? Incidence of postoperative bleeding requiring intervention and intraoperative electrocoagulation during Thulium laser enucleation of the prostate]. / Wie gut sind wir wirklich? Interventionsbedürftige Nachblutungen und intraoperative Elektrokoagulationen bei der Thulium-Laser-Enukleation der Prostata.

The need for intervention due to postoperative bleeding represents a significant complication in Thulium Laser Enucleation of the Prostate (ThuLEP). This study aimed to retrospectively analyse this complication in the treatment of benign prostatic enlargement. This study focuses on investigating potential causative factors for postoperative bleeding requiring intervention as well as the use of intraoperative electrocoagulation. A total of 503 ThuLEP procedures performed between 08/2021 and 07/2022 were examined. Postoperatively, 4.2% (n=21) of patients experienced bleeding requiring intervention. Study data revealed a significant association between these instances of bleeding and a high prostate volume (p=0.004), high enucleation weight (p=0.004), and intraoperative electrocoagulation (p=0.048). In total, intraoperative electrocoagulation was applied in 41.2% (n=207) of cases. In these cases, statistically significant factors leading to the application of electrocoagulation included intraoperative capsule perforation (p=0.005) and high enucleation weight (p=0.002).

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]. / Minimal Invasive Surgical Techniques (MIST): wie relevant ist der ganze Mist?

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

The influence of socioeconomic status and gender on incidence and survival in bladder cancer: a longitudinal study based on the Hamburg Cancer Registry.

BACKGROUND: To investigate the influence of socioeconomic status (SES) and gender on the incidence and survival of patients with bladder cancer on a small scale within the city of Hamburg, Germany. METHODS: Patients documented in the Hamburg Cancer Registry aged ≥ 18 years with primary bladder carcinoma (ICD-10: C67, D09.0), diagnosed in the period 2004-2020 (follow-up until 31.12.2021), and residing in Hamburg were included. The patients were divided into three groups (low, intermediate, and high SES) based on the socioeconomic situation at the district level, defined by the proportion of unemployed individuals, social housing, benefit recipients according to law, etc. Relative survival in the years 2004-2020 was calculated using a period approach. RESULTS: Among the 10,659 patients included, age-standardized 5-year relative survival (5YRS) in 2004-2020 correlated with SES. The age-standardized 5YRS differed significantly between patients with high and intermediate SES vs low SES. Women with low SES had the worst 5YRS at 58.2%, while men with high SES presented the best relative 5YRS at 73.5%. This effect remained after stratification by UICC stages. Concerning incidence, there is an indication that women with low SES were more often diagnosed in higher UICC stages III or IV than women with high SES (18.3% versus 12.6%). CONCLUSIONS: The socioeconomic situation at the time of diagnosis, as well as gender, has a substantial impact on the incidence and cancer survival rates in patients with bladder cancer. Further research, including the study of patient care, is needed to better understand and address these inequalities.

[Imaging in nephroureterolithasis]. / Bildgebung bei Nephroureterolithiasis.

In the acute diagnostics of a suspected nephroureterolithiasis, ultrasonography should be the examination modality of choice. In cases of suspected urolithiasis, unclear flank pain with fever or in cases of a solitary kidney, a noncontrast computed tomography (CT) scan should always subsequently be performed. If the sonography findings are inconclusive in pregnant women a magnetic resonance imaging (MRI) examination can be considered. If there are indications for urinary diversion, a retrograde imaging study should be performed as part of the urinary diversion. This or CT imaging is also suitable for preinterventional imaging before shock wave lithotripsy, percutaneous nephrolithotomy or ureteroscopy. Postinterventional imaging is not always necessary and sonography is often sufficient. In a conservative treatment approach an abdominal plain X­ray can be used for follow-up assessment.

[Lichen sclerosus in clinically relevant phimosis: incidence, risk factors, and association with squamous cell carcinoma of the penis]. / Lichen sclerosus bei klinisch relevanter Phimose: Häufigkeit, Risikofaktoren und Assoziation mit Plattenepithelkarzinomen des Penis.

BACKGROUND: Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease. It is frequently diagnosed following circumcision. Diabetes mellitus (DM) is a known risk factor in men. Malignant pathology is more common in patients with LSA. Data on LSA in men are very limited. OBJECTIVE: This study investigated the incidence of LSA in men who had undergone circumcision. Risk factors and likelihood of malignancy were captured. MATERIALS AND METHODS: Data of 215 patients were retrospectively analyzed. As potential risk factors, age, body mass index (BMI), DM, coronary heart disease (CHD) and arterial hypertension were identified. Data were analyzed and displayed graphically as spike histograms. Logistic regression was applied. Age and BMI were transformed using cubic spline function. RESULTS: Mean age of patients was 37 years (±â€¯22 years). Mean BMI was 26.4. In all, 24% of the patients had a BMI > 30. Of the patients, 11% had DM, 5.1% had CHD, and 19% had arterial hypertension. Pathology revealed LSA in 47% of patients. Malignant disease was apparent in 3.3% of patients (2.7% without concomitant LSA, 4% with concomitant LSA). Age (55 vs 20 years, odds ratio [OR]: 3.210 [1.421, 7.251]) was a significant risk factor for LSA. BMI (30 vs 22 kg/m2, OR 1.059 [0.614, 1.828]) and DM (OR: 0.42 [0.148, 1.192]) elevated the risk for LSA. CONCLUSION: We saw high rates of LSA in patients had undergone circumcision. Higher age represents a significant risk factor. In 3.3%, final pathology revealed squamous cell carcinoma of the penis. Therefore, pathologic work-up of circumcision specimen is mandatory.

[Medical expert opinions]. / Medizinische Gutachten.

In the physician-patient encounter the annual risk that this will end in a legal dispute is around 0.08%. Nevertheless, the topic is always very present. In such a situation it is important to act professionally and remain objective. An essential part that contributes to this are expert opinions; however, although these are among the basic tasks of a physician, they are not taught in training and further education. This article aims to make a contribution to this.

[Medical expert opinions]. / Medizinische Gutachten.

In the physician-patient encounter the annual risk that this will end in a legal dispute is around 0.08%. Nevertheless, the topic is always very present. In such a situation it is important to act professionally and remain objective. An essential part that contributes to this are expert opinions; however, although these are among the basic tasks of a physician, they are not taught in training and further education. This article aims to make a contribution to this.

[First-line treatment of metastatic renal cell carcinoma]. / Erstlinientherapie beim metastasierten Nierenzellkarzinom.

In recent years the first-line treatment of metastatic renal cell carcinoma was revolutionized by the introduction of checkpoint inhibitors (CPI). Within a few years several combined modality treatments with CPI and tyrosine kinase inhibitors (TKI) have proven to be effective and safe in the application. According to the guidelines, up to five different combined modality treatments can now be considered, depending on the risk profile. Based on the current data situation, a direct distinction between the treatments cannot be made as no comparative studies are available. Therefore, the decision for a particular treatment is often guided by individual factors. In particular, a clear processing of the patient with the respective risk factors and tumor identity is essential. Hence, it is all the more important to discuss complex cases in an interdisciplinary tumor board.

First Clinical Experience of a Novel Pulsed Solid-State Thulium:YAG Laser during Percutaneous Nephrolithotomy.

INTRODUCTION: Laser lithotripsy during Mini-PCNL is one treatment option in urinary stone disease. In recent years, a new era in stone treatment has been initiated with the introduction of new pulsed thulium lasers. The aim of this study was to investigate the safety and efficacy of laser lithotripsy with a new pulsed solid-state thulium:YAG laser during mini-PCNL. MATERIALS AND METHODS: All patients, regardless of stone size, who were treated with a Mini-PCNL using the new pulsed thulium laser were prospectively enrolled. Operation times, stone size, laser time, and laser settings were noted. The stone-free rate was assessed postoperatively with sonography and either X-ray or computed tomography as a clinical standard. The complications were analyzed using the Clavien-Dindo classification. RESULTS: A total of 50 patients with a mean age of 52 years were included. 31 (62 %) patients were male. The average stone size was 242.3 (±233.1) mm2 with an average density of 833 (±325) Hounsfield units. The mean operating time was 30.56 (±28.65) min, and the laser-on-time was 07:07 (± 07:08) min. The most commonly used settings were 0.4 J and 115 Hz (46 W). The mean total energy for stone ablation was 14,166 (±17,131) kJ. The total stone-free rate was 84 %, with an overall complication rate of 32% according to Clavien-Dindo (grade 1: n = 9, grade 2: n = 6, 3b: n = 1). In the group of patients with singular stones (n = 25), the stone-free rate was 88%. SUMMARY: The new pulsed solid-state Thulium:YAG laser allows a safe and effective lithotripsy during Mini-PCNL. The stone-free rates were high regardless of stone size with a comparable low rate of complications.

[Medical expert opinions]. / Medizinische Gutachten.

In the physician-patient encounter the annual risk that this will end in a legal dispute is around 0.08%. Nevertheless, the topic is always very present. In such a situation it is important to act professionally and remain objective. An essential part that contributes to this are expert opinions; however, although these are among the basic tasks of a physician, they are not taught in training and further education. This article aims to make a contribution to this.

Influence of Prostate Cancer on Thulium Vapoenucleation of the Prostate-A Multicentre Analysis.

Purpose: Prostate cancer (PCa) and benign prostatic hyperplasia (BPH) are common in elderly men. Data on the laser-based surgery known as thulium vapoenucleation of the prostate (ThuVEP) in PCa patients are rare. Our objective was to analyse the feasibility, safety and functional outcome of ThuVEP in patients with lower urinary tract symptoms (LUTS) and PCa. Methods: Multicentre study, including 1256 men who underwent ThuVEP for LUTS. Maximum urinary flow rate (Qmax) and post-void residual volume (PVR) were measured perioperatively. The International Prostate Symptome Score (IPSS) was measured perioperatively and at follow-up (FU). Perioperative complications were captured. Reoperation rate was captured at FU. Results: Of 994 men with complete data, 286 (28.8%) patients had PCa. The most common Gleason score was 3 + 3 in 142 patients (49.7%). Most common was low-risk PCa (141 pts; 49.3%). PCa patients were older, had smaller prostates and had higher prostate-specific antigen (PSA) values (all p < 0.001). Comparing non-PCa and PCa patients, no differences occurred perioperatively. IPSS, quality of life and PVR decreased (all p < 0.001) and Qmax improved (p < 0.001) in both groups. Reoperation rates did not differ. The results of low- vs. intermediate-/high-risk PCa patients were comparable. Conclusion: ThuVEP is a safe and long-lasting treatment option for patients with LUTS with or without PCa. No differences occurred when comparing low- to intermediate-/high-risk PCa patients.

Long-term evaluation of outcomes and costs of urolithiasis re-interventions after ureteroscopy, extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy based on German health insurance claims data.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years. METHODS: This retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008-2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models. RESULTS: 54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients. CONCLUSION: This study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.

[Image-guided biopsy of the prostate gland]. / Bildgesteuerte Biopsie der Prostata.

The recommendations on carrying out a multiparametric magnetic resonance imaging (mpMRI) for the primary diagnostics and during active surveillance of prostate cancer, include as a consequence an image-guided sampling from conspicuous areas. In doing so, the information on the localization provided by mpMRI is used for a targeted biopsy of the area suspected of being a tumor. The targeted sampling is mainly performed under sonographic control and after fusion of MRI and ultrasound but can also be (mostly in special cases) carried out directly in the MRI scanner. In an ultrasound-guided biopsy, it is vital to coregister the MR images with the ultrasound images (segmentation of the contour of the prostate and registration of suspect findings). This coregistration can either be carried out cognitively (transfer by the person performing the biopsy alone) or software based. Each method shows specific advantages and disadvantages in the prioritization between diagnostic accuracy and resource expenditure.

Does a 55-year-old Male with Lower Urinary Tract Symptoms and a 50-ml Gland Have To Decide Between Ejaculation and Voiding Function?

Treatment of lower urinary tract symptoms secondary to benign prostatic obstruction may affect ejaculatory function. However, preservation of ejaculation via minimally invasive surgical therapies might impair the long-term durability of voiding improvement.

Outcomes and costs of ureteroscopy, extracorporeal shockwave lithotripsy, and percutaneous nephrolithotomy for the treatment of urolithiasis: an analysis based on health insurance claims data in Germany.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term health and economic outcomes based on claims data are rare. Our aim was to analyze URS, SWL, and PCNL regarding complications within 30 days, re-intervention, healthcare costs, and sick leave days within 12 months, and to investigate inpatient and outpatient SWL treatment as the latter was introduced in Germany in 2011. METHODS: This retrospective cohort study based on German health insurance claims data included 164,203 urolithiasis cases in 2008-2016. We investigated the number of complications within 30 days, as well as time to re-intervention, number of sick leave days and hospital and ambulatory health care costs within a 12-month follow-up period. We applied negative binomial, Cox proportional hazard, gamma and two-part models and adjusted for patient variables. RESULTS: Compared to URS cases, SWL and PCNL had fewer 30-day complications, time to re-intervention within 12 months was decreased for SWL and PCNL, SWL and PCNL were correlated with a higher number of sick leave days, and SWL and particularly PCNL were associated with higher costs. SWL outpatients had fewer complications, re-interventions and lower costs than inpatients. This study was limited by the available information in claims data. CONCLUSION: URS cases showed benefits in terms of fewer re-interventions, fewer sick leave days, and lower healthcare costs. Only regarding complications, SWL was superior. This emphasizes URS as the most frequent treatment choice. Furthermore, SWL outpatients showed less costs, fewer complications, and re-interventions than inpatients.

Simulation-based prostate enucleation training: Initial experience using 3D-printed organ phantoms.

INTRODUCTION: Anatomical endoscopic enucleation of the prostate (AEEP) is an effective treatment for benign prostatic hyperplasia (BPH); however, there is controversy regarding the difficulty of learning such a technique. Simulation-based training can mimic real-life surgeries and help surgeons develop skills they can transfer to the operating room, thereby improving patient safety. This study aimed to evaluate the validity of a novel organ phantom for use in AEEP simulation training. METHODS: Participants performed AEEP on organ phantom simulators during a Masterclass using one of three energy modalities: holmium:YAG laser, thulium fiber laser, or bipolar energy. The organ phantom is composed of hydrogels and uses 3D molds to recreate prostatic tissue. Participants completed a questionnaire assessing content validity, face validity, feasibility, and acceptability of using the prostate organ phantom. RESULTS: The novice group consisted of 13 urologists. The median number of AEEP previously performed was 0 (interquartile range [IQR] 0-2). Two experts in AEEP (surgeons having performed over 100 AEEP interventions) also participated. All participants agreed or strongly agreed that there is a role for simulators in AEEP training. Participants positively rated the overall operative experience (7.3/10). Morcellation (4.7/10) and hemostasis (3.1/10) were deemed the least realistic steps. All participants considered it feasible to incorporate this organ phantom into training programs and 92.9% agreed that it teaches skills transferrable to the operating room. CONCLUSIONS: This study has established content and face validity for AEEP with three different energy sources for an organ phantom. Participants considered its use both feasible and appropriate for AEEP training purposes.