[Digital transformation in urology-opportunity, risk or necessity?] / Digitale Transformation in der Urologie ­ Chance, Risiko oder Notwendigkeit?

Ultimately, new (digital) techniques and artificial intelligence (AI) applications are changing the working environment in urology. This can be an opportunity for further development, but also a change which is not desired. Adjustments to work processes may be necessary. So-called disruptive processes lead to fundamental changes. In the context of the digital transformation, our way of working is changing. Classic hierarchies, working hours, and working environments are dissolving in favor of creative and flexible working models and corporate structures. Clinics and practices in urology must prepare themselves for changing requirements and be able to provide answers.

[Focal therapy of prostate cancer]. / Fokale Therapie des Prostatakarzinoms.

The target of focal therapy (FT) in prostate cancer (PC) is partial treatment of the prostate aiming at preserving surrounding anatomical structures. The intention is to minimize typical side effects of radical treatment options combined with local tumor control. Numerous established and new technologies are used. Results of published studies showed a good safety profile, few side effects and good preservation of functional results. Oncologic long-term data are lacking so far. Photodynamic therapy (PDT) is the only technology that has been studied in a published prospective randomized trial. The FT is challenged by the multifocality of PC; therefore, the quality of prostate biopsy, histopathological assessment as well as imaging are of paramount importance. Multiparametric magnetic resonance imaging (MRI) has gained increasing importance. The FT is experimental and should only be offered within clinical trials.

[MRI/TRUS fusion-guided prostate biopsy : Value in the context of focal therapy]. / MRT/TRUS-fusionierte Biopsiesysteme : Stellenwert bei der fokalen Therapie des Prostatakarzinoms.

BACKGROUND: Several systems for MRI/TRUS fusion-guided biopsy of the prostate are commercially available. Many studies have shown superiority of fusion systems for tumor detection and diagnostic quality compared to random biopsy. The benefit of fusion systems in focal therapy of prostate cancer (PC) is less clear. OBJECTIVES: Critical considerations of fusion systems for planning and monitoring of focal therapy of PC were investigated. MATERIALS AND METHODS: A systematic literature review of available fusion systems for the period 2013-5/2016 was performed. A checklist of technical details, suitability for special anatomic situations and suitability for focal therapy was established by the German working group for focal therapy (Arbeitskreis fokale und Mikrotherapie). RESULTS: Eight fusion systems were considered (Artemis™, BioJet, BiopSee®, iSR´obot™ Mona Lisa, Hitachi HI-RVS, UroNav and Urostation®). Differences were found for biopsy mode (transrectal, perineal, both), fusion mode (elastic or rigid), navigation (image-based, electromagnetic sensor-based or mechanical sensor-based) and space requirements. DISCUSSION: Several consensus groups recommend fusion systems for focal therapy. Useful features are "needle tracking" and compatibility between fusion system and treatment device (available for Artemis™, BiopSee® and Urostation® with Focal One®; BiopSee®, Hitachi HI-RVS with NanoKnife®; BioJet, BiopSee® with cryoablation, brachytherapy). CONCLUSIONS: There are a few studies for treatment planning. However, studies on treatment monitoring after focal therapy are missing.

Why we should not routinely apply irreversible electroporation as an alternative curative treatment modality for localized prostate cancer at this stage.

Irreversible electroporation (IRE), a new tissue ablation procedure available since 2007, could meet the requirements for ideal focal therapy of prostate cancer with its postulated features, especially the absence of a thermal ablation effect. Thus far, there is not enough evidence of its effectiveness or adverse effects to justify its use as a definitive treatment option for localized prostate cancer. Moreover, neither optimal nor individual treatment parameters nor uniform endpoints have been defined thus far. No advantages over established treatment procedures have as yet been demonstrated. Nevertheless, IRE is now being increasingly applied for primary prostate cancer therapy outside clinical trials, not least through active advertising in the lay press. This review reflects the previous relevant literature on IRE of the prostate or prostate cancer and shows why we should not adopt IRE as a routine treatment modality at this stage.

[Focal therapy for small renal masses : Observation, ablation or surgery]. / Fokale Therapie von kleinen Nierentumoren : Beobachtung, Ablation oder Operation.

BACKGROUND: The rising incidence of renal cell carcinoma, its more frequent early detection (stage T1a) and the increasing prevalence of chronic renal failure with higher morbidity and shorter life expectancy underscore the need for multimodal focal nephron-sparing therapy. DISCUSSION: During the past decade, the gold standard shifted from radical to partial nephrectomy. Depending on the surgeon's experience, the patient's constitution and the tumor's location, the intervention can be performed laparoscopically with the corresponding advantages of lower invasiveness. A treatment alternative can be advantageous for selected patients with high morbidity and/or an increased risk of complications associated with anesthesia or surgery. Corresponding risk stratification necessitates previous confirmation of the small renal mass (cT1a) by histological examination of biopsy samples. Active surveillance represents a controlled delay in the initiation of treatment. RESULTS: Percutaneous radiofrequency ablation (RFA) and laparoscopic cryoablation are currently the most common treatment alternatives, although there are limitations particularly for renal tumors located centrally near the hilum. More recent ablation procedures such as high intensity focused ultrasound (HIFU), irreversible electroporation, microwave ablation, percutaneous stereotactic ablative radiotherapy and high-dose brachytherapy have high potential in some cases but are currently regarded as experimental for the treatment of renal cell carcinoma.

[Irreversible electroporation. Current value for focal treatment of prostate cancer]. / Irreversible Elektroporation. Aktueller Stellenwert in der fokalen Therapie des Prostatakarzinoms.

BACKGROUND: Irreversible electroporation (IRE), a new tissue ablation procedure available since 2007, could meet the requirements for ideal focal therapy (FT) with its postulated features, especially the absence of a thermal ablative effect. Thus far, there is no adequate tumor-entity-specific proof of its effectiveness, and its clinical application has hitherto been confined to very small patient cohorts. This also holds true for prostate cancer (PCA). Nevertheless, it is now being increasingly applied outside clinical trials-to a certain extent due to active advertising in the lay press. AIM OF THE STUDY: In this study, current discrepancies between the clinical application and study situation and the approval and market implementation of the procedure are described. The media portrayal of IRE is discussed from different perspectives, particularly with reference to the FT of PCA. This is followed by a final clinical assessment of IRE using the NanoKnife® system. DISCUSSION: Strict requirements govern new drug approvals. According to the German Drug Act (AMG), evidence of additional benefit over existing therapy must be provided through comparative clinical trials. For medicotechnical treatment procedures, on the other hand, such trial-based proof is not required according to the Medical Devices Act (MPG). The use of IRE even outside clinical trials has been actively promoted since the NanoKnife® system was put on the market. This has led to an increase in the number of uncontrolled IRE treatments of PCA in the last 2 years. The patients have to cover the high treatment costs themselves in these cases. If articles in the lay press advertise the procedure with promising but unverified contents, false hopes are raised in those concerned. This is disastrous if it delays the use of truly effective treatment options. CONCLUSION: IRE basically still has high potential for the treatment of malignancies; however, whether it can really be used for FT remains unclear due to the lack of data. This also holds true for the treatment of PCA. Only carefully conducted scientific research studies can clarify the unresolved issues regarding IRE of PCA. The urgently needed development of universally valid treatment standards for IRE is unnecessarily hampered by the flow commercially driven patients.

[Cryoablation of prostate cancer]. / Kryoablation des Prostatakarzinoms.

BACKGROUND: Due to continuous technical developments for more than 60 years followed by better clinical results with minimal side effects, cryoablation of the prostate for localized prostate cancer has evolved as a true alternative therapeutic option for selected patients. THEMATA: The current form of cryoablation has almost nothing in common with those established in the 1960s and 1970s, which were further developed in the 1980s and 1990s. Nowadays it is a minimally invasively and highly effective treatment for high-risk carcinomas and failure of other therapeutic modalities. CONCLUSION: Thus, cryoablation of the prostate is indicated if there are absolute or relative contraindications for radical surgery. In salvage cases for localized prostate cancer, cryoablation is the therapy of choice. Cryoablation is also an option for focal therapy. Standardization of the procedure, definition of freeze-thaw cycles, and structured training programs have led to this status.

[Cancer control in focus insights and future perspectives for the focal treatment of prostate cancer]. / Krebskontrolle im Fokus - Einblicke und Ausblicke rund um die fokale Therapie des Prostatakrebses.

Faced with the dilemma of choosing between the extremes of standard whole gland therapy and active surveillance, those affected by prostate cancer have recently been on the lookout for less invasive alternatives. Particularly the question of whether it would be possible in low risk cancer to treat only the tumour itself while sparing the organ has long been considered. This article discusses the pros and cons of focal treatment and elucidates the latest innovative technologies. High overtreatment rates in low-risk patients submitted to standard therapy and considerable technological advances in diagnosis (particularly multiparametric MRI) and therapy are regarded by the authors as key arguments for abandoning complete tumour eradication with its side effects in favour of sufficient local cancer control by focal treatment with better preserved quality of life in suitable cases.

[Focal prostate cancer therapy: capabilities, limitations and prospects]. / Fokale Therapie des Prostatakarzinoms: Möglichkeiten, Limitierungen und Ausblick.

INTRODUCTION: Patients with low-risk prostate cancer (PCa) face the difficult decision between a potential overtreatment by one of the standard therapies and active surveillance (AS) with the potential insecurity regarding cancer control. A focal therapy (FT) implies a treatment of the tumor within the prostate only. METHODS: This review evaluates the current literature and expert opinion of different therapies suited for FT as well as concepts for prostate imaging, biopsy and histopathological evaluation. RESULTS: Currently there is a lack of multicenter, randomized, prospective data on the effectiveness of FT. Nonetheless, the published data indicate a sufficient tumor control with a favorable side effect profile. There are still flaws in the diagnostics with regard to tumor detection and histological evaluation. Multicenter studies are currently recruiting worldwide which will provide new data with a higher level of evidence. CONCLUSION: At present, the effectiveness of FT should not be compared directly to standard radical therapies and FT should only be performed within studies. In cases of cancer progression after FT a salvage treatment should still be possible.

[Active surveillance for renal cell carcinoma]. / Aktive Überwachung beim Nierenzellkarzinom.

The incidence of renal cell carcinoma (RCC) and especially that of small RCCs is increasing. However, not all tumours are malignant and not all malignant tumours are RCCs. Although partial nephrectomy is the therapeutic standard of care, an increasing number of patients is being treated with cryoablation, radiofrequency ablation, or active surveillance. The latter options require a pretherapeutic tumour biopsy. Approximately 85% of all biopsies can distinguish benign from malignant tumours. In the case of a RCC, histological subtype and grading are correctly diagnosed in 85% and 65%, respectively. However, tumour growth and metastasis in patients undergoing active surveillance cannot be predicted. A later tumour growth is the main trigger to change to active therapy. In this paper the results of tumour biopsy and active surveillance of patients with a renal mass are presented.

Green light laser (KTP, 80 W) for the treatment of benign prostatic hyperplasia.

AIM: An attractive alternative for the management of benign prostate hyperplasia (BPH) is the use of 80 W potassium titanyl phosphate (KTP). We evaluated the efficacy and safety of this procedure in patients with bladder outlet obstruction (BOO). METHODS: A total of 171 patients with obstructive BPH underwent the 80 W potassium-titanyl-phosphate laser procedures. Preoperatively the international prostate symptom score (IPSS), the maximal urinary flow rate (Qmax), prostate volume and the post-void residual urine volume (PVR) were determined. Perioperative complications and postoperative blood loss, hospitalization, catheterization time, Qmax and PVR were also assessed. RESULTS: From the 171 patients, who underwent KTP laser procedure, 143 have been evaluated. The mean preoperative prostate volume was 43.9+/-17.1 (15-76). Eighty-nine patients (62.2%) were on chronic oral anticoagulant therapy (Coumarin or Aspirin 100). The mean applied energy was 170+/-65 kJ (100-275). There was no significant blood loss or fluid absorption during the KTP procedure. The mean Qmax values preoperatively and postoperatively were 3.4+/-4.3 and 16.3+/-7.3, respectively. PVR decreased from 74+/-47.7 mL preoperatively, to 16.6+/-21.5 mL postoperatively. Catheteriza-tion time was 1.4+/-0.8 days (0-5). CONCLUSION: KTP laser for the prostate represents a safe and effective treatment for patients with BPH. The procedure has a low rate of postoperative complications. It can be used for high risk patients especially for them who are receiving oral anticoagulation therapy.

Cryoablation of the prostate: technical recommendations.

The European Association of Urology guidelines on prostate cancer state that cryotherapy is a true therapeutic alternative for patients with clinically localized prostate cancer. The aim of this paper is to establish a uniform practice for performing prostate cryoablation. A collaboration has been set up among five European centres with experience in almost 1000 prostate cancer patients on the use of cryotherapy. The present recommendations were developed through sharing of experience and thorough discussions within the group. This first paper from the group establishes the technical recommendations for use of prostate cryotherapy.

[Cryoablation of localized prostate cancer. Current state]. / Kryoablation des lokalisierten Prostatakarzinoms. Aktueller Stand.

Due to continuous technical developments for more than half a century followed by better clinical results with minimal side effects, cryoablation of the prostate for localized prostate cancer has evolved as a true alternative therapeutic option in selected cases. The current version of cryoablation has almost nothing in common with those versions established in the 1960s and 1970s and further developed in the 1980s and 1990s. The present version is minimally invasive and has a high efficacy for treatment of high risk carcinomas and failure of other therapeutic modalities. Cryoablation of the prostate is indicated if there are absolute or relative contraindications for radical surgery. In salvage cases cryoablation is the therapy of choice for localized prostate cancer. Standardization of the procedure, definition of freeze-thaw cycles and structured training programs have led to this status.

[Cryoablation of prostate cancer]. / Die Kryoablation des Prostatakarzinoms.

Because of continuous technical development for more than half a century, followed by better clinical results with minimal side effects, cryoablation of the prostate for localized prostate cancer has evolved as a true alternative therapeutic option in selected cases. Today's form of cryotherapy has almost nothing in common with those versions established in the 1970s and further developed in the 1990s. Nowadays it shows minimal invasiveness and high efficacy for treatment of high-risk carcinomas and failures of other therapeutic modalities. Cryoablation of the prostate is indicated if there are absolute or relative contraindications for radical surgery. In localized prostate cancer, cryoablation is the therapy of choice for salvage cases; standardisation of the procedure, definition of freeze-thaw cycles, and structured training programs have led to this status.

[History of ureteropelvic junction obstruction repair (pyeloplasty). From Trendelenburg (1886) to the present]. / Die Geschichte der operativen Behandlung der Harnleiterabgangsstenose (Pyeloplastik). Von Trendelenburg (1886) bis zur Gegenwart.

The first reconstructive procedure for ureteropelvic junction (UPJ) obstruction was performed by Trendelenburg in 1886. The important milestones in the reconstruction of UPJ are discussed and all available historical papers and reports since 1886 are reviewed. Kuster published the first successful dismembered pyeloplasty 5 years later, but his technique was prone to strictures. In 1892, the application of the Heineke-Mickulicz principle by Fenger resulted in bulking and kinking with obstruction. Plication of the renal pelvis, first introduced by Israel in 1896, was modified by Kelly in 1906. After the principle of the Finney pyloroplasty, von Lichtenberg designed his pyeloplasty in 1921, best suited to cases of high implantation of the ureter. Foley modified flap techniques, first introduced by Schwyzer in 1923 after the application of the Durante pyloroplasty principle, successfully to Y-V pyeloplasty in 1937. Culp and de-Weerd introduced the spiral flap in 1951. Scardino and Prince reported about the vertical flap in 1953. Patel published the extra-long spiral flap technique in 1982. In order to decrease the likelihood of stricture, Nesbit, in 1949, modified Kuster's procedure by utilizing an elliptic anastomosis. In the same year, Anderson and Hynes, published their technique. With the advent of endourology, several minimally invasive procedures were applied: antegrade or retrograde endopyelotomy, balloon dilation, and laparoscopic pyeloplasty. The concept of full-thickness incision of the narrow segment followed by prolonged stenting was first described in 1903 by Albarran and was popularized by Davis in 1943. Several basic principles must be applied in order to ensure successful repair: the resultant anastomosis should be widely patent, performed in a watertight fashion without tension. Endopyelotomy represents an alternative to open surgery.

[Prediction of calculus clearance after extracorporeal shock wave lithotripsy of calculi in the inferior kidney calices. Application of the artificial neural network]. / Prädiktion der Steinfreiheit nach extrakorporaler Stosswellenlithotripsie bei unteren Nierenkelchsteinen. Einsatz eines artifiziellen neuronalen Netzwerks.

The purpose of this retrospective study was to define prognostic factors which determine the stone clearance (SC) for lower caliceal stones after extracorporeal shock wave lithotripsy (ESWL) and to compare the prediction accuracy of artificial neural network analysis (ANNA) and standard computational methods. Since January 1995, 321 renal units in 310 patients with single or multiple inferior caliceal calculi of all sizes and compositions have been treated with ESWL (Lithotriptor: Piezolith 2500, Wolf company). The classification accuracy of ANNA in the test set was 94%, with a sensitivity of 95%, a specificity of 92%, and a receiver operating characteristic curve area of 0.966, results significantly better than those yielded by a logistic regression analysis (classification accuracy 77%, sensitivity 75%, specificity 81%, and ROC curve area 0.779). Patients with lower renal caliceal stones appear to have the best chance of successful ESWL when their body mass index (BMI) and urinary transport (UT) are normal, the infundibular width (IW) is 5 mm or more, and the infundibular ureteropelvic angle (IUPA) is 45 degrees or more. Stone size and composition, as factors of SC, are not statistically significant. After determining the angle, width, and UT in patients with optimal age and body mass suitable for ESWL, SC can be achieved irrespective of stone size and composition.

Birth of two infants with normal karyotype after intracytoplasmic injection of sperm obtained by testicular extraction from two men with nonmosaic Klinefelter's syndrome.

OBJECTIVE: To report two births of a healthy male and a healthy female baby after use of testicular spermatozoa from two patients with nonmosaic Klinefelter's syndrome. DESIGN: Case report. SETTING: General academic hospital with IVF center and university institute of human genetics. PATIENT(S): Two couples with primary infertility in which the men had secretory azoospermia and nonmosaic 47,XXY karyotype. Both women had a normal karyotype and no gynecologic abnormalities. INTERVENTION(S): ICSI was performed using testicular spermatozoa after ovarian stimulation and transvaginal ultrasonography-guided oocyte pick-up. MAIN OUTCOME MEASURE(S): Normal fertilization, embryo cleavage, clinical pregnancy outcome, and peripheral blood karyotype of the newborn. RESULT(S): In each case, 13 metaphase II oocytes were injected, of which 7 fertilized normally. Three good-quality embryos (4-cell stage) were transferred into the uterine cavity. Both women conceived, and normal pregnancies followed. Genetic analysis of the neonates revealed normal 46,XX and 46,XY karyotypes. CONCLUSION(S): These case reports reaffirm that patients with nonmosaic Klinefelter's syndrome produce normal spermatozoa with fertilization potential. Although it is premature to make conclusions about the rate of transmission of this aneuploidy because of the low number of the published cases, this report substantiates the idea that rates of transmission of this gonosomal aneuploidy are low.

Alpha-fetoprotein-producing renal cell carcinoma.

Alpha-fetoprotein (AFP) is recognized as a tumor marker of yolk sac tumors, liver cancer and some other cancers of the digestive organs. Renal cell carcinoma (RCC) producing AFP is a rare entity. A case of AFP-producing RCC with solitary bone metastasis, but without liver involvement, is reported. The stain specific to AFP proved the presence of AFP in the cytoplasms of more cells of the renal tumors. Additionally, the other published cases are reviewed. These cases indicate that mesoderm-originating malignant tumors such as RCCs can produce AFP in some situations. So, AFP is probably more universal than believed, although it is generally a popular and useful tumor marker for hepatocellular carcinomas and yolk sac tumors.

Antegrade percutaneous endoluminal treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion.

OBJECTIVE: We report our experience on antegrade percutaneous incision of ureterointestinal anastomosis strictures after urinary diversion. MATERIALS AND METHODS: Since 1994, we have evaluated retrospectively 18 patients with 22 ureterointestinal anastomosis strictures (UAS), who were treated with cold-knife incision. After placement of an 8-french nephrostomy tube, a 0.035-inch guide wire bypassed the stricture under guidance of a centrally opened (5-french) ureter catheter. A wire-mounted cold-knife was pulled through the strictured area retrogradely under fluoroscopic control. Routinely, following the incision, an 8-french external stent was left in place for 6-8 weeks. RESULTS: After stent removal as a primary procedure, the ureteroenteric area has remained patent in 14 of 19 (74%) UAS. In 3 cases undergoing a secondary or repeated procedure, treatment failed. The average follow-up was 23.5 (range 12-39) months. Failures were associated with radiogenic injury of the ureter in 5 UAS and unexplained in 2. No complication was observed. CONCLUSION: Percutaneous endourological management of UAS with the cold-knife incision, when used as a primary treatment, is a safe and effective alternative to open surgical repair and should be considered as an initial approach.