Machine learning enables automated screening for systematic reviews and meta-analysis in urology.

PURPOSE: To investigate and implement semiautomated screening for meta-analyses (MA) in urology under consideration of class imbalance. METHODS: Machine learning algorithms were trained on data from three MA with detailed information of the screening process. Different methods to account for class imbalance (Sampling (up- and downsampling, weighting and cost-sensitive learning), thresholding) were implemented in different machine learning (ML) algorithms (Random Forest, Logistic Regression with Elastic Net Regularization, Support Vector Machines). Models were optimized for sensitivity. Besides metrics such as specificity, receiver operating curves, total missed studies, and work saved over sampling were calculated. RESULTS: During training, models trained after downsampling achieved the best results consistently among all algorithms. Computing time ranged between 251 and 5834 s. However, when evaluated on the final test data set, the weighting approach performed best. In addition, thresholding helped to improve results as compared to the standard of 0.5. However, due to heterogeneity of results no clear recommendation can be made for a universal sample size. Misses of relevant studies were 0 for the optimized models except for one review. CONCLUSION: It will be necessary to design a holistic methodology that implements the presented methods in a practical manner, but also takes into account other algorithms and the most sophisticated methods for text preprocessing. In addition, the different methods of a cost-sensitive learning approach can be the subject of further investigations.

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.

The comprehensive complication index (CCI): proposal of a new reporting standard for complications in major urological surgery.

PURPOSE: The comprehensive complication index (CCI) is a new tool for reporting the cumulative burden of postoperative complications on a continuous scale. This study validates the CCI for urological surgery and its benefits over the Clavien-Dindo-Classification (Clavien). MATERIAL AND METHODS: Data from a prospectively maintained data base of all consecutive patients at a university care-center was analyzed. Complications after radical cystectomy (RC), radical prostatectomy (RP), and partial nephrectomy (PN) were classified using the CCI and Clavien system. Differences in complications between the CCI and the Clavien were assessed and correlation analyses performed. Sample size calculations for hypothetical clinical trials were compared between CCI and Clavien to evaluate whether the CCI would reduce the number of required patients in a clinical trial. RESULTS: 682 patients (172 RC, 297 RP, 213 PN) were analyzed. Overall, 9.4-46.6% of patients had > 1 complication cumulatively assessed with the CCI resulting in an upgrading in the Clavien classification for 2.4-32.4% of patients. Therefore, scores between the systems differed for RC: CCI (mean ± standard deviation) 26.3 ± 20.8 vs. Clavien 20.4 ± 16.7, p < 0.001; PN: CCI 8.4 ± 14.7 vs. Clavien 7.0 ± 11.8, p < 0.001 and RP: CCI 5.8 ± 11.7 vs. Clavien 5.3 ± 10.6, p = 0.102. The CCI was more accurate in predicting LOS after RC than Clavien (p < 0.001). Sample size calculations based in the CCI (for future hypothetical trials) resulted in a reduction of required patients for all procedures (- 25% RC, - 74% PN, - 80% RP). CONCLUSION: The CCI is more accurate to assess surgical complications and reduces required sample sizes that will facilitate the conduction of clinical trials.

Prophylactic abdominal or retroperitoneal drain placement in major uro-oncological surgery: a systematic review and meta-analysis of comparative studies on radical prostatectomy, cystectomy and partial nephrectomy.

PURPOSE: To systematically analyze the impact of prophylactic abdominal or retroperitoneal drain placement or omission in uro-oncologic surgery. METHODS: This systematic review follows the Cochrane recommendations and was conducted in line with the PRISMA and the AMSTAR-II criteria. A comprehensive database search including Medline, Web-of-Science, and CENTRAL was performed based on the PICO criteria. All review steps were done by two independent reviewers. Risk of bias was assessed with the Cochrane tool for randomized trials and the Newcastle-Ottawa Scale. RESULTS: The search identified 3427 studies of which eleven were eligible for qualitative and ten for quantitative analysis reporting on 3664 patients. Six studies addressed radical prostatectomy (RP), four studies partial nephrectomy (PN) and one study radical cystectomy. For RP a reduction in postoperative complications was found without drainage (odds ratio (OR)[95% confidence interval (CI)]: 0.62[0.44;0.87], p = 0.006), while there were no differences for re-intervention (OR[CI]: 0.72[0.39;1.33], p = 0.300), lymphocele OR[CI]: 0.60[0.22;1.60], p = 0.310), hematoma (OR[CI]: 0.68[0.18;2.53], p = 0.570) or urinary retention (OR[CI]: 0.57[0.26;1.29], p = 0.180). For partial nephrectomy no differences were found for overall complications (OR[CI]: 0.99[0.65;1.51], p = 0.960) or re-intervention (OR[CI]: 1.16[0.31;4.38], p = 0.820). For RC, there were no differences for all parameters. The overall-quality of evidence was assessed as low. CONCLUSION: The omission of drains can be recommended for standardized RP and PN cases. However, deviations from the standard can still mandate the placement of a drain and remains surgeon preference. For RC, there is little evidence to recommend the omission of drains and future research should focus on this issue. REVIEW REGISTRATION NUMBER (PROSPERO): CRD42019122885.

Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols.

PURPOSE: Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures. MATERIALS AND METHODS: A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation. RESULTS: The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (n = 12, 46%), metoclopramide (n = 11, 44%), and alvimopan (n = 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay [mean difference (MD) - 3.46 d, 95% confidence interval (CI) - 4.94 to - 1.98, p < 0.01], complications [Odds ratio (OR) = 0.76, 95% CI 0.61-0.94, p = 0.01] and time to defecation (MD - 1.37 d, 95% CI - 2.06 to - 0.69, p < 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52-1.03, p = 0.07). CONCLUSION: Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.

Clinical relevance of gene expression in localized and metastatic prostate cancer exemplified by FABP5.

PURPOSE: Fatty acid-binding protein 5 (FABP5), a transport protein for lipophilic molecules, has been proposed as protein marker in prostate cancer (PCa). The role of FABP5 gene expression is merely unknown. METHODS: In two cohorts of PCa patients who underwent radical prostatectomy (n = 40 and n = 57) and one cohort of patients treated with palliative transurethral resection of the prostate (pTUR-P; n = 50) FABP5 mRNA expression was analyzed with qRT-PCR. Expression was correlated with clinical parameters. BPH tissue samples served as control. To independently validate findings on FABP5 expression, three microarray and sequencing datasets were reanalyzed (MSKCC 2010 n = 216; TCGA 2015 n = 333; mCRPC, Nature Medicine 2016 n = 114). FABP5 expression was correlated with ERG-fusion status, TCGA subtypes, cancer driver mutations and the expression of druggable downstream pathway components. RESULTS: FABP5 was overexpressed in PCa compared to BPH in the cohorts analyzed by qRT-PCR (radical prostatectomy p = 0.003, p = 0.010; pTUR-P p = 0.002). FABP5 expression was independent of T stage, Gleason Score, nodal status and PSA level. FABP5 overexpression was associated with the absence of TMPRSS2:ERG fusion (p < 0.001 in TCGA and MSKCC). Correlation with TCGA subtypes revealed FABP5 overexpression to be associated with SPOP and FOXA1 mutations. FABP5 was positively correlated with potential drug targets located downstream of FABP5 in the PPAR-signaling pathway. CONCLUSION: FABP5 overexpression is frequent in PCa, but seems to be restricted to TMPRESS2:ERG fusion-negative tumors and is associated with SPOP and FOXA1 mutations. FABP5 overexpression appears to be indicative for increased activity in PPAR signaling, which is potentially druggable.

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.

Zonal NephRo Score: external validation for predicting complications after open partial nephrectomy.

PURPOSE: The aim of the study was to externally validate the Zonal NePhRO Score (ZNS) published in 2014 as latest and superior nephrometry score in terms of prediction of perioperative complications and outcome of open partial nephrectomies (OPNs). METHODS: We identified 200 consecutive patients who underwent OPN. Analysis of preoperative CT or MRI scans and retrospective analysis of the patients' clinical records were performed. Tumour complexity was stratified according to the ZNS into three categories: low (4-6), moderate (7-9) and high (10-12) complexity. Predictors for perioperative complications and surgical parameters were identified using univariate and multivariate logistic regression. RESULTS: Tumour complexity was graded in 19.8 % of the cases as low, in 50.3 % as moderate and in 29.9 % as high. In the multivariate analysis, ZNS was significantly associated with a higher complication rate (OR 1.25, 95 % CI 1.04-1.49, p = 0.014), longer ischaemia time (IT) (ß = 1.19, 95 % CI 0.33-2.05, p = 0.007), postoperative drop of estimated glomerular filtration rate (eGFR) (ß = -1.86, 95 % CI -3.71 to -0.01, p = 0.049) and opening of the collecting system (CS) (OR 1.72, 95 % CI 1.40-2.10, p < 0.001). In addition, age and body mass index were identified as independent predictors for complications (OR 1.03, 95 % CI 1.00-1.06, p = 0.043 and OR 1.08, 95 % CI 1.00-1.15, p = 0.031). CONCLUSION: The present study is the first external validation of the ZNS as a predictor of perioperative complications in patients undergoing OPN. A higher ZNS score was associated with a longer IT, a higher rate of opening the CS and drop of eGFR.

The Urological Dyna-CT: ex vivo feasibility study of interventional cross-sectional imaging in the endourological operation room.

BACKGROUND: Imaging of the urinary tract and its surrounding tissue still remains challenging, since standard imaging in the urological operation room consists of fluoroscopy and plain X-rays. The combination of a ceiling-mounted X-ray system and a new urological intervention table now allows cross-sectional imaging and 3D reconstruction to be performed in the endourological operation room (Urological Dyna-CT). MATERIALS AND METHODS: The imaging quality of the Artis Zee Ceiling (Siemens Medical Solutions, Erlangen, Germany) was assessed using slice images of an ex vivo pig kidney model prepared with artificial stones (plaster of Paris). We compared the image quality of three different examination protocols with this model. 3D reconstruction quality was illustrated by means of retrograde filling of one pig`s urinary tract with a diluted contrast medium. RESULTS: Interventional stone detection and localization is possible with a 5 s low-dose Urological Dyna-CT. Detailed imaging of the collecting system by retrograde pyelography is possible with a high image quality. CONCLUSION: The combination of an Artis Zee(®) Ceiling (Siemens Medical Solutions, Erlangen, Germany) with our newly developed urological intervention table we call the Urological Dyna-CT. In addition to such standard procedures as fluoroscopy or plain X-rays, cross-sectional imaging and 3D reconstruction of the urinary tract are possible and provide fast and excellent urological imaging.

New developed urological protocols for the Uro Dyna-CT reduce radiation exposure of endourological patients below the levels of the low dose standard CT scans.

PURPOSE: Cross-sectional imaging by computed tomography (CT) is associated with higher radiation dose compared to plain X-ray. The Uro Dyna-CT provides CT-like images in the endourological operating room. Our aim was to reduce the radiation exposure of endourological patients with the Uro Dyna-CT and optimize the cross-sectional image quality. MATERIALS AND METHODS: For the hard contrast protocol, two artificial stones were placed in a Rando-Alderson phantom's left kidney region. Relevant parameters of the standard abdomen protocol were changed. After each modification, two urologists subjectively evaluated the image quality. We developed two customized protocols (standard, low-dose) for hard contrast imaging. To optimize the examination protocol for soft tissue imaging a standardized cone beam phantom was used. Parameters of the preset high-resolution protocol were changed to develop a protocol with similar objective image quality but lower radiation dose. To evaluate the effective radiation dose we embedded 129 thermoluminescence dosimeters in the kidney and ureter region of the Rando-Alderson phantom and performed each protocol five times (stone, soft tissue) and ten times (low-dose protocol). Mean effective dose values per 3D-examination were calculated. RESULTS: We detected a dose area product (DAP) 776.2 (standard) and 163.5 µGym(2) (low-dose) for the stone protocols with an effective dose of 1.96 and 0.33 mSv, respectively. The soft tissue protocol produced a DAP of 5,070 µGym(2) and an effective dose of 7.76 mSv. CONCLUSION: Our newly developed examination protocols for the Uro Dyna-CT provide CT-like image quality during urological interventions with low radiation dose.

Laser-guided percutaneous kidney access with the Uro Dyna-CT: first experience of three-dimensional puncture planning with an ex vivo model.

BACKGROUND AND PURPOSE: Safe and successful puncture of the kidney's collecting system is essential for acute therapy of hydronephrosis or as part of percutaneous nephrolithotomy. The procedure is technically challenging and might lead to major complications. We describe the feasibility of a laser guidance system and three-dimensional puncture planning in the endourological operation room. MATERIALS AND METHODS: An Uro Dyna-CT of the biological model was performed with the Artis Zee(®) Ceiling (Siemens Medical Solutions, Erlangen, Germany) to gain multiplanar reconstructions. 10 punctures were performed with the syngo iGuide(®) laser guidance system. Puncture success was depicted with antegrade contrast filling of the collecting system and fluoroscopic control. Puncture time, tract length, and fluoroscopy time was documented. RESULTS: Data acquisition (8 s) and 3D rendering (48 s) was possible in approximately 1 min. Median time for planning the punctures was 7 [5-15] min. Median puncture time was 4.6 [2-10.2] min. Median tract length was 4.96 [4.33-6.5] cm. Median fluoroscopy time was 0.4 [0.2-1] min. 9 of 10 punctures were successful. A second puncture was needed to gain access to the collecting system in one case, and one puncture was broken up. CONCLUSION: The tested laser guidance system was feasible to perform successful percutaneous punctures of the kidney in this ex vivo study. Handling was intuitive and time within acceptable limits. Due to the requirement of multiplanar reconstructions with higher radiation exposure to the patient than with standard fluoroscopy, this technique should be limited to complex cases.

Influence of endourological devices on 3D reconstruction image quality using the Uro Dyna-CT.

PURPOSE: The urological Dyna-CT (Uro Dyna-CT) was established in clinical use for classical imaging as well as for interventional surgery. To evaluate whether irradiation artefacts may occur during interventional surgery, we analysed the impact of different instruments on 3D reconstruction in the Uro Dyna-CT. MATERIALS AND METHODS: Ten different endourological instruments [ureterorenoscope (URS)-fibrescope, percutaneous nephrolithotomy (PCNL) working sheath] and accessory equipments such as ureteral catheter, guide wires and stents (DJ, MJ) were introduced in a porcine renal pelvis either retrograde via the ureter or transparenchymally. Subsequently, digital fluoroscopy, standard X-ray and an Uro Dyna-CT were performed. Three colleagues evaluated the image quality independent from each other. RESULTS: There were basically no limitations regarding image quality in digital fluoroscopy and standard X-ray. In the Uro Dyna-CT, only with the URS fiberscope and the PCNL working sheath, small artefacts and irradiations were detected, whereas ureteric catheter with and without wire, as well as the hydrophilic guide wire, showed no artefacts at all. The remaining material demonstrated minimal artefacts, which did not affect the image quality. CONCLUSIONS: The Uro Dyna-CT can be used for all interventional endourological procedures using the common armamentarium and instruments without significant limitation of image quality. There are only minor limitations according a PCNL working sheath and the rigid URS. These instruments should be removed out of the examination field before performing the computed tomography and be replaced afterwards by using a safety wire.

Optimizing imaging quality in endourology with the Uro Dyna-CT: contrast agent dilution matters.

BACKGROUND AND PURPOSE: The implementation of the Uro Dyna-CT (Siemens Healthcare Solutions, Erlangen, Germany) with interventional 3D- and cross-sectional imaging necessitates the development of new standards for endourologic procedures such as the customized use of diluted contrast agent. Our aim was to find the ideal contrast agent dilution (CAD) for the interventional use of the Uro Dyna-CT in a standardized setting and prove the experimental findings in a clinical case. MATERIALS AND METHODS: Retrograde pyelographies were performed with 10 different CADs of Imeron 300 (Bracco, Konstanz, Germany) in 10 different pig's urinary tracts. Fluoroscopy, X-ray, 3D- and slice-image reconstruction was performed with the Uro Dyna-CT. Image quality was evaluated, blinded and randomized by 5 observers. Small plastic jars were filled with the CADs and 2 artificial stones (Plaster of paris). Images were evaluated by two observers. The ex vivo findings were transferred to a clinical setting in a complex percutaneous lithotomy procedure. Unweighted and weighted kappa coefficients were calculated to indicate the degree of observers' agreement. RESULTS: Twenty percent diluted contrast agent provides the best image quality and stone detection when interventional cross-sectional imaging is considered without limitations in fluoroscopy or X-ray quality. This was proved in a percutaneous lithotomy of an obese patient. CONCLUSIONS: Image quality of the Uro Dyna-CT can be optimized by the use of 20 % diluted contrast agent. This knowledge helps to provide high-quality 3D imaging in the endourological operation room.

Comparison of endoscopic versus CT assessment of stone-free status after percutaneous nephrolithotomy (PCNL).

This study is aimed to determine whether postoperative low dose computed tomography (LDCT) imaging is necessary after percutaneous nephrolithotomy (PCNL), or the surgeon's intraoperative assessment of residual fragments (RF) is sufficient and avoidance of postoperative imaging with reduction of radiation exposure can be achieved. Data of all 610 patients who underwent PCNL in prone position in our institution from February 2009 to September 2020 was collected. Parameters such as age, gender, BMI, ASA-Classification, stone related parameters and the surgeon's assessment of stone-free status were analyzed. The LDCT performed postoperatively was compared to the intraoperative assessment of the surgeon regarding RF. The mean age of patients was 52.82 years; the mean BMI was 28.18 kg/m2. In 418 cases, the surgeon made a clear statement about the presence of RF and postoperative LDCT was carried out. The discrepancy between the two methods (surgeon´s assessment vs. LDCT) was significant at p < 0.0001. The sensitivity, specificity, positive and negative predictive value of the surgeon when assessing RF were 24.05%, 99.45%, 98.28% and 50%. Stone free rate (SFR) after primary PCNL was 45.57%. The overall SFR at discharge was 96.23%. Although the surgeon´s assessment of RF was reliable, postoperative LDCT imaging should still be performed if endoscopic stone clearance is suspected due to the high false negative rate and the low negative predictive value. The optimal timing of postoperative imaging following PCNL remains unclear.

[Certified continuing education curriculum of the German Society for Urology (WECU)]. / Zertifiziertes Weiterbildungscurriculum der Deutschen Gesellschaft für Urologie (WECU).

The education curriculum in urology is aimed at better integration of inpatient and outpatient medicine and high-quality specialist training in order to recruit well-trained young people for urology in the future. For this purpose, in a modular system, rotations of 6-12 months in outpatient offices as well as optionally in other disciplines or in other clinics with different priorities are planned. The training period includes 5 modular seminars and a webinar series including examinations, in which the entire learning content required in the specialty training regulations is presented in interactive lectures. Clinics and outpatient offices certified to participate in the curriculum undergo regular evaluation, which leads to continuous improvement of training centers.

[Analysis of the impact of increasing feminization in the healthcare system on urology]. / Analyse des Einflusses der zunehmenden Feminisierung im Gesundheitswesen auf die Urologie.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate gender aspects and trends in urological clinics, research and private practice. The focus was on the objectification of gender-specific changes in the field of urology at the current time and in the future. MATERIAL AND METHODS: A digital survey among urological physicians in Germany was conducted with the SurveyMonkey© portal, which was sent to all registered members via the email distribution lists of the German Society of Urology (DGU) and the Professional Association of German Urologists (BvDU). Baseline data were collected in the outpatient and inpatient sectors, as were gender-specific data related to job distribution, goals, satisfaction, and reasons for career decisions. RESULTS: The analysis of 398 responses revealed that urological colleagues in private practice were less likely to be female (23.6%) and significantly older (mean age 53 years) than in the inpatient sector (female proportion 47.2%, mean age 43 years). More men (49.4%) than women (29.9%) were in private practice and this was indicated as a career aspiration by more men than women (28.1% vs. 22.8%). The reasons for setting up a practice were more often family-related for women than for men (main reasons good opportunity or career aspiration). Women were more likely to work part-time (27.0% vs. 11.5%) and more likely to aspire to a career as a senior physician (29.1% of women, 9.4% of men). Correspondingly, the desire for a postdoctoral position or professorship was more common among women than among men (20.5% vs. 15%). Significantly more female urologists perceived inequality in career advancement opportunities (59.7% vs. 17.5%, p < 0.001) and 73.3% (vs. 18.5% of men, p < 0.001) perceived their gender as a cause of disadvantage. This resulted in significantly lower satisfaction of women with their professional status (p = 0.008) as well as a lower feeling of being valued (p < 0.001). CONCLUSION: In order to prepare our specialty field for the future, it is essential to give even greater consideration to gender aspects. The path taken to offer the next generation of urologists a modern specialty in which all physicians, regardless of their gender, enjoy working, are valued and where equal opportunities prevail, should definitely be pursued and intensified in order to position urology well for the future.

[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.

[Urological care in practices and clinics during the corona virus pandemic in Germany]. / Versorgungssituation urologischer Patienten in Praxen und Kliniken während der Coronaviruspandemie in Deutschland.

The coronavirus pandemic has had an immediate and far-reaching effect on the care of urological patients. The pandemic monitor of the German Society for Urology was able to record the restrictions on patient care in urological practices and clinics by means of regular surveys of the members. A total of 689 responses at four survey time points were included. In April there was a reduction in urological inpatients to 44% and the number of patients in practices dropped to 50%. Available operating theater capacities for urological patients were 45% in April, normalized to 90% in June and fell again to 50% in December. Elective operations could not be performed at all or only to a very limited extent in most hospitals in April and December. While urgent operations could be treated to 100% in more than 75% of the clinics in April, in December more than half of the clinics stated that they could not treat all patients with urgent indications. To some extent (8-19%) practices and clinics had to resort to a pandemic-related supraregional referral of patients. The reduction of outpatients in urological practices in April normalized to 95% in June and remained stable during the second wave of the pandemic. The increase in urological emergencies in practices observed at the beginning of the pandemic did not show up in November and December. The coronavirus pandemic has led to a significant reduction in the care of urological patients, which in particular in the second wave also affects urgent operations.

Impact of perioperative blood transfusions on oncologic outcomes after radical cystectomy: A systematic review and meta-analysis of comparative studies.

This study aimed at systematically analyzing and evaluating the impact of perioperative blood transfusions (PBT) on oncologic outcomes of patients undergoing radical cystectomy for bladder cancer. This systematic review follows the recommendations of the Cochrane Handbook for Systematic Reviews and Interventions and was conducted in line with the PRISMA statement and the AMSTAR II criteria. A comprehensive database search was performed based on the PICO criteria. Two independent reviewers performed all screening steps and quality assessment. Risk of bias and certainty in evidence were assessed with the Newcastle Ottawa Scale for non-randomized trials and the GRADE approach. Of 1123 identified studies 20 were eligible for qualitative analysis and 15 for quantitative analysis reporting on 21,915 patients. Receiving a PBT was associated with an increased risk of all-cause mortality (hazard ratio (HR) [95% confidence interval (CI)]: 1.29 [1.18, 1.40]; p < 0.001), cancer-specific mortality (HR [CI]: 1.27 [1.15; 1.41]; p < 0.001) and disease recurrence (HR [CI]: 1.22 [1.12; 1.34]; p < 0.001). Subgroup analysis of transfusion timing revealed a significantly increased risk of mortality with intraoperative or combined intra- and postoperative transfusions compared to postoperative transfusion only for all three outcomes (p < 0.001). Leukocyte-depletion was associated with increased all-cause mortality, but not cancer-specific mortality. The administration of PBT negatively impacts oncological outcomes after radical cystectomy. Therefore, careful treatment indication and strict adherence to transfusion guidelines is encouraged in order to avoid adverse effects during the perioperative course.

[Empowerment for our patients : Innovation in everyday urology]. / Empowerment für unsere Patienten : Gelebte Innovation im urologischen Alltag.

Patient empowerment includes measures that promote their autonomy and self-determination in the physician-patient relationship. In addition to successful medical treatment, goals include long-term treatment satisfaction and the best possible quality of life for the patients and their social environment. Various initiatives and projects from German urology are already used to empower our patients. Entscheidungshilfe Prostatakrebs (decision aid for prostate cancer) and the German language decision aid for advanced bladder cancer and for the choice of urinary diversion are implemented under the umbrella of the PatientenAkademie (patient academy) of German Urologists. With more than 12,000 users, Entscheidungshilfe Prostatakrebs is very well established in urological care in Germany. The randomized evaluation study with planned 1200 participants is close to the successful completion of recruitment. Another project from the German urology sector is the project "antiCoagulation Help App for SurgERy" (CHASER). The aim is to develop a smartphone-based decision aid for the perioperative management of patients undergoing antithrombotic therapy. Online support groups can also contribute to empowerment and have been analyzed systematically for prostate cancer patients. A large randomized study on this topic is currently in preparation. Continuing advances in digitalization can thus provide us with useful support in order to provide individual information to our patients. The German Urological Association and its PatientenAkademie have been committed to this for many years.