COVID-19 Pandemic Impact on Uro-Oncological Disease Outcomes at a German Referral Center.

INTRODUCTION: To assess differences in referral and pathologic outcomes for uro-oncology cases prior to, during, and after the COVID-19 pandemic, comparing clinical and pathological data from cancer surgeries performed at a university medical center between 2018 and 2023. METHODS: We collected data of 212 patients with radical prostatectomy (RP) for prostate cancer, 157 patients with radical cystectomies (RCs) for bladder cancer, 36 patients with radical nephroureterectomies (RNUs) for upper tract urothelial carcinoma, 133 patients with partial nephrectomies (PNs), and 160 patients with radical nephrectomies (RNs) for renal cancer, 93 patients with orchifunicolectomy for testicular cancer, 39 patients with newly diagnosed penile cancer. Data from patients treated between 2018 and February 2020 (before the COVID-19 pandemic) were compared with data from patients treated between March 2020 and March 2022 (during the COVID-19 pandemic) and between April 2022 and February 2023 (after the COVID-19 pandemic). RESULTS: No differences in terms of main pathologic features were observed in patients undergoing RP, RNU, orchifunicolectomy, or circumcision and/or penectomy. Further, a lower pathological tumor stage was diagnosed for RN after the COVID-19 pandemic (p < 0.05). A higher age at diagnosis for penile cancer was observed during the pandemic cohort in comparison to the pre-COVID-19 pandemic cohort (p < 0.05), but this did not translate into a worse pathological stage or lymph node involvement. Another notable change was the shortening of the length of stay (LOS) for orchifunicolectomy over the pandemic (p < 0.05). CONCLUSION: Neither decline in uro-oncologic activity nor pathological features were observed at our institution before, during, and after the COVID-19 pandemic. A significantly lower pathological tumor stage for RN after the COVID-19 pandemic was seen. Penile cancer was diagnosed at a significantly higher age during the COVID-19 pandemic, and a decrease in LOS for orchifunicolectomy was observed.

Financial Distress in Testicular Cancer Survivors and Its Impact on Cancer Survivors' Quality of Life in the German Healthcare System.

INTRODUCTION: Testicular cancer accounts for the largest proportion of solid tumors in young adult men. With an average age of onset under 40 years and a relative 5-year survival of 97%, it is one of the prognostically favorable tumors. Little is known about the relationship between the financial burden and physical and emotional health of testicular cancer survivors. We examined the association between financial problems caused by cancer and the self-reported quality of life in a cohort-based sample of testicular cancer patients. METHODS: A cross-sectional analysis of testicular cancer patients (n = 87, average age 39 years) was performed. Self-reported data were collected on demographics, income, wealth, cost-coping strategies, out-of-pocket costs, supportive medication compliance, quality of life, and perceived social isolation. A multivariable regression model was used to examine the relationship between the degree to which cancer caused financial burdens and the patients' reported quality of life. RESULTS: The survey showed that, in addition to illness-related additional expenses, a disease-related loss of income can lead to severe financial disadvantages and impair quality of life. The study data show that concerns about the economic situation can increase the burden on patients which already results from cancer diagnosis and therapy. In this patient cohort, 32% reported financial stress. CONCLUSION: Financial distress affects testicular cancer survivors in unique ways. To provide support, health professionals should consider survivors' developmental life stage to understand their financial stress, and ultimately, to improve quality of life.

Prospective evaluation of sexual health following radical cystectomy due to bladder cancer.

Background: There is a lack of data concerning sexual health following open radical cystectomy (RC), especially in elderly patients and women. Aim: To describe sexual health and its impact on general health as well as survival in patients undergoing standard open RC for the treatment of bladder cancer (BC). Due to limited data, subgroup analysis for elderly patients and women was performed. Methods: A prospective noninterventional clinical study was performed evaluating sexual health in RC with any kind of urinary diversion due to BC with a follow-up of 12 months after RC. The study was approved by the local ethics review board (A 2021-0175) and was registered at the German Clinical Trial Register (DRKS00026255). Assessment of sexual health was done with the following validated questionnaires: EORTC QLQ-C30 (for quality of life; European Organisation for Research and Treatment of Cancer), EORTC SH22 (for sexual health), and IIEF-5 (5-item International Index of Erectile Function). Outcomes: The standard measurements of EORTC QLQ-C30, EORTC SH22, and IIEF-5 as well as overall survival. Results: Thirty-two patients participated in the study with a mean age of 71.5 years (SD, 9.7): 25 (78.1%) were male and 7 (21.9%) were female. Overall there is a heterogenic picture for sexual health in the study population, but sexual satisfaction is significantly higher prior to surgery while the importance of a sex life stays high and stable. Interestingly, the general health score is significantly correlated to sexual satisfaction (Pearson's correlation; r = 0.522, P = .002) preoperatively but not following surgery: r = 0.103 (P = .665) after 3 months, r = 0.478 (P = .052) after 6 months, r = 0.276 (P = .302) after 9 months, and r = 0.337 (P = .202) after 12 months. The importance of a sex life is still essential for the patients, especially when recovering from RC; nearly the same can be reported for elderly patients. Unfortunately, the data for women are too limited to report robust results. Clinical Implications: Evaluation, advice, and monitoring of sexual health must be integrated into clinical practice, particularly in women. Strengths and Limitations: At least to our knowledge, this is the first systematic prospective evaluation of sexual health in patients with BC receiving RC. Due to the small sample size, there is a risk of selection bias. Conclusion: Sexual health is important for patients with BC receiving RC, and it is an essential part of quality of life, especially in elderly patients.

Simulation of the effects of molecular urine markers in follow-up of patients with high-risk non-muscle invasive bladder cancer.

A plethora of urine markers for the management of patients with bladder cancer has been developed and studied in the past. However, the clinical impact of urine testing on patient management remains obscure. The goal of this manuscript is to identify scenarios for the potential use of molecular urine markers in the follow-up of patients with high-risk non-muscle-invasive BC (NMIBC) and estimate potential risks and benefits. Information on the course of disease of patients with high-risk NMIBC and performance data of a point-of-care test (UBC rapid™), an MCM-5 directed ELISA (ADXBLADDER™), and 2 additional novel assays targeting alterations of mRNA expression and DNA methylation (Xpert bladder cancer monitor™, Epicheck™) were retrieved from high-quality trials and/or meta-analyses. In addition, the sensitivity of white light cystoscopy (WLC) and the impact of a urine marker result on the performance of WLC were estimated based on fluorescence cystoscopy data and information from the CeFub trial. This information was applied to different scenarios in patient follow-up and sensitivity, estimated number of cystoscopies, and the numbers needed to diagnose were calculated. The sensitivity of guideline-based regular follow-up (SOC) at 1 year was calculated at 96%. For different marker-supported strategies sensitivities ranging from 77% to 97.9% were estimated. Calculations suggest that several strategies are effective for the SOC. While for the SOC 24.6 WLCs were required to diagnose 1 tumor recurrence (NND), this NND dropped below 5 in some marker-supported strategies. Based on the results of this simulation, a marker-supported follow-up of patients with HR NMIBC is safe and offers the option to significantly reduce the number of WLCs. Further research focusing on prospective randomized trials is needed to finally find a way to implement urine markers into clinical decision-making.

Predicting Limited Survival Following Inguinal Lymph Node Dissection in Penile Cancer: Should We Revisit the Goals of Care?

OBJECTIVE: Patients with advanced penile squamous cell cancer have a poor prognosis and can benefit from early palliative care consultation. We built a model to identify those patients most likely to benefit. METHODS: Patients with penile squamous cell cancer undergoing inguinal lymph node dissection were identified from the National Cancer Database (NCDB) and a multi-institutional international dataset (INT). A multivariable Cox proportional hazards model for overall survival (OS) was developed using the NCDB and applied to the INT dataset. Parameters were used to make receiver operating characteristic (ROC) curves. ROC-related criteria were optimized to identify a predictive probability cut point and dichotomize patients from INT into risk groups for limited OS of <6 and <12 months. RESULTS: NCDB had 860 deaths; 105 (5%) at 6 months and 296 (15%) at 12 months. INT had 257 deaths; 56 (8%) at 6 months and 124 (18%) at 12 months. Limited OS was associated with older age, greater T and N stage, and fewer lymph nodes removed. Optimized ROC criteria using the OS <6 months curve best dichotomized INT patients into high-risk group with median OS of 24 months (95% CI 18-34) and low-risk group with median OS of 174 months (95% CI 120-NE). CONCLUSION: We developed a simple model that could be used as a screening tool for early palliative care referral.

[Initial presentation of the Pentafecta score as a quality instrument for outcome evaluation of primary surgical treatment in patients with penile cancer]. / Erstvorstellung des Pentafecta-Scores als Qualitätsinstrument der Outcome-Bewertung einer chirurgischen Primärtherapie an Patienten mit Peniskarzinom.

BACKGROUND: Recently, the Tetrafecta score has been published as the first instrument for assessing the quality of primary surgical treatment for penile cancer (PECa). An external scientific discussion about the defining criteria is still pending and forms the study objective. MATERIAL AND METHODS: An international working group consisting of 12 urologists and an oncologist with clinical and academic-scientific expertise in penile cancer was established. In a modified four-stage Delphi process, a total of 13 criteria for PECa patients in clinical AJCC stages 1-4 (T1-3N0-3, but M0) were defined, incorporating the Tetrafecta criteria. Each expert had to select five of these criteria in a secret ballot to generate an individual Pentafecta score. Subsequently, the experts' ratings were aggregated and a final Pentafecta score was formed. RESULTS: None of the original Tetrafecta criteria were included in the final Pentafecta score, which consisted of the following criteria: 1) organ preservation, if possible (≤T2), but always with negative surgical margins, 2) bilateral inguinal lymph node dissection (ILND) from ≥pT1G2N0, 3) perioperative chemotherapy if indicated by guidelines, 4) ILND, if indicated, within a maximum of three months after primary tumour resection, and 5) the treating clinic should perform at least 15 primary surgical treatments in PECa patients. Only in seven out of the 13 experts (54%), a strong correlation was found between individual Pentafecta scores and the final Pentafecta score (rsp >0.60). CONCLUSION: Based on a moderated voting process among international PECa experts, a Pentafecta score was developed as a quality assurance instrument for primary surgical treatment, which now needs to be validated using patient-relevant and patient-reported endpoints.

ERBB2 Amplification as a Predictive and Prognostic Biomarker in Upper Tract Urothelial Carcinoma.

Upper tract urothelial carcinomas (UTUCs) occur in about 5-10% of all urothelial carcinomas and are frequently discovered in high-stage disease. We aimed to evaluate human epidermal growth factor receptor 2 (ERBB2) protein expression immunohistochemically and ERBB2 amplification in UTUCs by fluorescence in situ hybridization, applying a tissue microarray technique. ERBB2 overexpression and ERBB2 amplification were defined according to the recommendations of the American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) for breast cancer and gastric carcinoma (GC), revealing scores of 2+ and 3+ in 10.2% and 41.8% of UTUCs, respectively. The performance parameters showed obviously higher sensitivity of ERBB2 immunoscoring according to the ASCO/CAP criteria for GC. ERBB2 amplification was detected in 10.5% of UTUCs. ERBB2 overexpression was more likely to be found in high-grade tumors and was associated with tumor progression. Univariable Cox regression analysis revealed a significantly lower progression-free survival (PFS) in cases with ERBB2 immunoscores of 2+ or 3+ according to the ASCO/CAP guidelines for GC. UTUCs with ERBB2 amplification showed a significantly shorter PFS in the multivariable Cox regression analysis. Irrespective of their ERBB2 status, patients with UTUC treated with platin showed a significantly lower PFS than UTUC patients who had not received any platin-based therapy. In addition, UTUC patients with a normal ERBB2 gene status who had not received platin-based therapy showed significantly longer overall survival. The results suggest that ERBB2 is a biomarker for progression in UTUCs and may define a distinct subgroup of UTUCs. As previously shown, ERBB2 amplification is infrequent. However, the small number of patients diagnosed with ERBB2-amplified UTUC might benefit from ERBB2-targeted cancer therapy. In clinical-pathological routine diagnostics, the determination of ERBB2 amplification is an established method in some defined entities and also successful in small samples. Still, the simultaneous use of ERBB2 immunohistochemistry and ERBB2 in situ hybridization would be important in order to record the low rate of amplified UTUC cases as completely as possible.

The Goal of Achieving High-Quality Surgical First-Line Therapy in Patients with Penile Cancer Is Important; However, Some Collective Efforts Are Still Required in Order to Reach It. Comment on Brassetti et al. Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement. Curr. Oncol. 2023, 30, 1882-1892.

We read with great interest the manuscript by Brassetti et al. recently published in your journal and hope it will encourage discussion and debate around the optimization of the surgical management of patients with penile cancer (PECa) [...].

[Procedure Guideline for Prostate Cancer Imaging with PSMA-ligand PET/CT]. / DGN-Handlungsempfehlung (S1-Leitlinie) ­ PSMA-Liganden-PET/CT in der Diagnostik des Prostatakarzinoms ­ Stand: 01/2022 ­ AWMF-Registernummer: 031-055.

PSMA-PET/CT for imaging prostate cancer (PC) has spread worldwide since its clinical introduction in 2011. The majority of experiences have been collected for PSMA-PET-imaging of recurrent PC. Data for primary staging of high-risk PC are highly promising. Meanwhile, a plethora of PSMA-ligands are available for clinical use (e. g. 68Ga-PSMA-11, 68Ga-PSMA-I&T, 68Ga-PSMA-617, 18F-DCFBC, 18F-DCFPyL, 18F-PSMA-1007, 18F-rhPSMA-7 and 18F-JK-PSMA-7). However, an official approval is available only for 68Ga-PSMA-11 (approved by the US FDA in 2020) and 18F-DCFPyL (approved by the US FDA in 2021).Recommendations for acquisition times vary from 1-2 h p. i. It has been shown that for the majority of tumour lesions, the contrast in PSMA-PET/CT increases with time. Therefore, additional late imaging can help to clarify unclear findings. PSMA-PET/CT should be performed prior to commencing an androgen deprivation therapy (ADT) since (long term) ADT reduces the visibility of PC lesions. Following injection of PSMA-ligands, hydration and forced diuresis are recommended for PSMA-ligands with primarily excretion via the kidneys in order to increase the visibility of tumour lesions adjacent to the urinary bladder.PSMA-ligands are physiologically taken up in multiple normal organs. For some 18F-labelled PSMA-ligands, presence of unspecific focal bone uptake has been reported. When using these tracers, focal bone uptake without CT-correlate should be interpreted with great caution. Besides prostate cancer, practically all solid tumors express PSMA in their neovasculature thereby taking up PSMA-ligands, although usually at a lower extent compared to PC. Also multiple benign lesions and inflammatory processes (e. g. lymph nodes) take up PSMA-ligands, also usually at lower extent compared to PC.

Thirty-Year-Old Male Patient with Non-Seminoma and Coincidental Rectal Cancer.

We present the case of a 31-year-old male patient with non-seminoma (90% embryonal carcinoma, 10% teratoma) pT1b L1 V0 Pn0 R0 cN2 cM0, Clinical Stage IIb and "good prognosis group" according to IGCCCG of the left testis. According to EAU guidelines, he received three cycles of BEP. After the second cycle, he developed recurrent, clinically not significant rectal bleeding, which we associated with deep thrombocytopenia. Following chemotherapy, there was one lymph node in the CT scan left, with a diameter of 0.9 cm at the inferior mesenteric arteria and the rectal bleeding did not stop; so coloscopy and staging revealed rectal cancer (adenocarcinoma) with peritoneal carcinosis. The patient was scheduled for radio-chemotherapy. Next-generation sequencing of the adenocarcinoma showed two mutations in KRAS and TP53 genes. To our knowledge, this is the first case of non-seminoma and coincidental rectal cancer. Furthermore, this case underlines the significance of molecular biological studies for the development of individualized targeted therapies, especially in younger patients and in chemo- and/or platin-resistance.

Concomitant vs Staged Therapeutic Inguinal Lymphadenectomy in Clinically Node Positive Penile Squamous Cell Carcinoma: Does It Make a Difference?

PURPOSE: Inguinal lymph node dissection within 3 months of primary tumor resection in penile cancer has been associated with longer recurrence-free and cancer-specific survival. However, the optimal timing and effect of lymphadenectomy performed concurrently at the time of primary lesion management on oncologic outcomes in clinically lymph node positive penile squamous cell carcinoma remains unknown. MATERIALS AND METHODS: An international, multicenter cohort of 966 penile cancer cases was queried for penile squamous cell carcinoma management after the year 2000, clinically lymph node positive status, and performance of penile surgery and inguinal lymph node dissection. Cohorts were stratified as concomitant if inguinal lymph node dissection and penile surgery occurred on the same date or staged when inguinal lymph node dissection was performed after penile resection. Rates and patterns of penile squamous cell carcinoma recurrence were reported. Distant recurrence-free, cancer-specific, and overall survival were estimated using Kaplan-Meier analyses and groups compared with log-rank testing. RESULTS: Of 253 contemporary men with clinically lymph node positive penile squamous cell carcinoma, 96 (38%) underwent concomitant inguinal lymph node dissection and 157 (62%) had inguinal lymph node dissection performed in a staged manner. Penile cancer was most likely to recur distantly (19%) followed by in the groin (14%) or pelvis (5%). There were no differences in distant recurrence-free, cancer-specific, or overall survival between management strategies. Multivariable analysis adjusting for stage, treatment center, and perioperative chemoradiation also demonstrated no recurrence-free, cancer-specific, or overall survival benefit between management strategies. CONCLUSIONS: Inguinal lymph node dissection performed concurrently with excision of the penile tumor for clinically node positive penile squamous cell carcinoma is not associated with differences in recurrence-free, cancer-specific, or overall survival compared to staged lymph node dissection.

Prediction of Treatment Response and Survival with Chemotherapy for Metastatic Penile Cancer by the Modified Glasgow Prognostic Score.

PURPOSE: There is increasing evidence that a persistent systemic inflammatory response predicts lower survival in patients with malignant disease. The modified Glasgow Prognostic Score (mGPS) is defined by a combination of elevated C-reactive protein (CRP) (>10 mg/L) and hypoalbuminemia (<35 g/L). It is considered as an independent prognostic marker in several organ malignancies. The aim of this study was to investigate the value of mGPS in metastatic penile carcinoma in predicting treatment response and survival. METHODS: One hundred and fifty-six patients with penile carcinoma treated with chemotherapy were included in this retrospective study. The mGPS before chemotherapy was classified into 3 groups (mGPS 0 [CRP <10, any albumin], mGPS 1 [CRP >10 mg/L, albumin >35 g/L], and mGPS 2 [CRP >10 mg/L, albumin <35 g/L]). Overall survival and disease-free survival were calculated by Kaplan-Meier analysis and chemotherapy toxicity by CTC criteria. Univariate Cox proportional hazards models were calculated to estimate the effect of each predictor on OS and DFS. RESULTS: Survival was significantly different in the 3 mGPS classes, with mGPS 0 patients showing the best treatment response and survival. Univariate analysis showed that mGPS (p < 0.0001), tumor stage (p = 0.004), and venous and lymphatic invasion (p = 0.011) were factors independently associated with prognosis. The response to chemotherapy differed significantly between mGPS groups (mGPS 0, 36/51 [71%]; mGPS 1, 24/70 [34%]; mGPS 2, 9/35 [26%], p = 0.03 and p = 0.37, respectively). mGPS was significantly associated with chemotherapy-associated toxicity, with treatment adaptation (p < 0.01) and toxicity-related deaths (p = 0.028). CONCLUSIONS: Systemic inflammatory response and nutritional status as expressed by the mGPS are independent predictors of treatment response, chemotherapy-associated toxicity, and survival in metastatic penile carcinoma. In addition to other known pathological markers of tumor aggressiveness, the mGPS can be used as a clinical predictor of prognosis.

Discriminative capacity of guideline recommendations in the assessment of patients with asymptomatic microhematuria.

BACKGROUND & OBJECTIVE: Asymptomatic microhematuria (aMh) remains a diagnostic challenge in urological practice: while aMh is a risk factor of urothelial carcinoma (UC), prevalence of aMh is high. Guidelines were developed to permit risk stratification and reduce diagnostic workload. This study investigates the efficacy of several recommendations. MATERIAL & METHODS: Sixty hundred eight patients with newly diagnosed aMh without previous UC from an academic referral center (A; n = 320) and a private outpatient clinic (B; n = 288) were included. All patients underwent clinical workup including medical history, urine cytology, upper tract imaging and cystoscopy. Eleven former and current guidelines were applied to each patient individually; every patient was classified as either low risk (no further workup recommended) or high risk. Furthermore, a recently developed nomogram for hematuria assessment was included. RESULTS: The cohort comprised 142 females and 466 males (mean age 62 [range 18-92] years). Sixty-one patients (10.0%) were diagnosed with UC. Excluding the Swedish and recent NICE guideline generally advising against urologic workup, application of 9 other recommendations would have diagnosed all UCs and saved 1.6% to 16.1% of patients from workup. For the 2020 US guideline, solely applied to cohort B, 10.6% of patients were classified as low risk. The use of the nomogram would have saved 17.1% to 25% of patients from workup. CONCLUSIONS: Practical relevance of current guidelines is limited as they do not sufficiently identify patients not requiring clinical work up. Thus, guideline adherence may trigger overdiagnosis and even overtreatment. New ways of risk stratification are needed to improve aMh assessment.

Prospective Evaluation of Health-Related Quality of Life in Patients with Metastatic Urothelial Carcinoma Undergoing Immunotherapy with Pembrolizumab: Symptom Burden Can Predict Survival.

INTRODUCTION: Despite the fact that guidelines recommend monitoring of quality of life during all phases of treatment in urothelial carcinoma, prospective data about health-related quality of life (HRQoL) in metastatic urothelial carcinoma undergoing immunotherapy are sparse. Consequently, we performed a prospective clinical pilot study about HRQoL using the Functional Assessment of Cancer Therapy - Immune Checkpoint Modulator (FACT-ICM) questionnaire. MATERIALS AND METHODS: Formally, this study is a prospective uni-centric noninterventional observation from January 2021 to December 2021. RESULTS: Fourteen patients with a mean age of 73.9 years (SD 8.8) participated in the study. The physical well-being subscale of FACT-G is most impaired during therapy with mean scores of 7.5, 6.2, and 4.0 followed by the emotional well-being. The FACT-G total score is stable during therapy with mean scores of 51.1, 50.4, and 48.0 and it is not significantly decreasing during therapy (p = 0.317). Furthermore, the symptom burden of these patients is low and not significantly changing over time (p = 0.500), but survival decreases significantly if symptom burden is high (FACT-ICM score over 40; p < 0.001). CONCLUSION: Physical and emotional needs have a strong impact on HRQoL and should be dealt with during treatment. If symptom burden is high, survival decreases. This needs further evaluation.

German S3 Evidence-Based Guidelines on Focal Therapy in Localized Prostate Cancer: The First Evidence-Based Guidelines on Focal Therapy.

BACKGROUND: Focal therapy (FT) is an option to treat localized prostate cancer (PCa) and preserve healthy prostate tissue in order to reduce known side effects from primary whole-gland treatment. The available FT modalities are manifold. Until now, national and international PCa guidelines have been cautious to propose recommendations regarding FT treatment since data from prospective controlled trials are lacking for most FT modalities. Moreover, none of the international guidelines provides a separate section on FT. In this purpose, we provide a synopsis of the consensus-based German S3 guidelines for a possible international use. SUMMARY: The recently published update of the German S3 guidelines, an evidence- and consensus-based guideline, provides a section on FT with recommendations for diagnostic work-up, indications, modalities, and follow-up. This section consists of 12 statements and recommendations for FT in the treatment of localized PCa. KEY MESSAGE: The German S3 guidelines on PCa are the first to incorporate recommendations for FT based on evidence and expert consensus including indication criteria for FT, pretreatment, and follow-up diagnostic pathways as well as an extended overview of FT techniques and the current supportive evidence.

Reduction of Perioperative Antibiotic Prophylaxis in Open Radical Cystectomy with Ileal Conduit Is Feasible: Results of a Prospective Clinical Trial.

INTRODUCTION: The aim of this study is to perform a prospective clinical trial in antibiotic prophylaxis, infectious complication, and colonization of ileal conduit (IC) following radical cystectomy (RC) since urinary tract infections (UTIs) and surgical site infections (SSIs) contribute significantly to the morbidity associated with RC and IC. Moreover, an optimal regimen of antibiotic prophylaxis has not been established, yet. MATERIAL AND METHODS: After a positive vote of ethical review committee and the registration at the German Clinical Trials Register (DKRS 00020406), we started a prospective clinical unicentric not interventional study. The urine samples were collected by sterile catheterization of the IC. All patients received an antibiotic prophylaxis with 3 × 500 mg metronidazole and 3 × 1.5 g cefuroxime intravenously for 3 days starting on the day before RC. Ureteral stents got removed on days 9 and 10 after surgery without prior antibiotic administration. The student t test and the χ2 test or the Fisher exact test were used. For risk factor assessment, the univariate Cox regression method was applied. RESULTS: Nineteen male (63.3%) and 11 female patients (36.7%) with a median age of 70.5 years were included. Three patients developed complicated UTI (10%) on day 12 after RC with E. faecium and needed antibiotic treatment with meropenem (Clavien-Dindo II). Two patients (6.7%) developed SSI with E. faecium and needed surgery (Clavien-Dindo IIIb). Palliative RC (p < 0.0001), prior radiation therapy (p < 0.0001), and timeframe >3 months from diagnosis to RC (p = 0.036) are significantly associated with the development of complicated UTI. Interestingly, the IC got colonized with Staph. haemolyticus at day 12 after RC (n = 12; 40.0%). We must assume that our data have some limitations like a unicentric study population. CONCLUSION: Further evaluation of reduction to single-shot antibiotic prophylaxis in nonpalliative RC with IC could be feasible.

Predictors of Delayed Graft Function in Renal Transplantation.

PURPOSE: This study aimed to analyze our data on delayed graft function (DGF) and to identify associated factors. METHODS: This is a retrospective case-control study of all patients transplanted in our center over a period of 11 years (January 1, 2003, to December 31, 2014) comparing patients with immediate graft function (n = 332) to those with DGF (n = 165). DGF was defined as the need for hemodialysis within the first 7 days after transplantation. Donor and recipient characteristics as well as procedural factors were compared by univariate and multivariate logistic regression analyses. RESULTS: Overall, 33% of patients had DGF. The rate of DGF declined from 2003 to 2011. In cases with DGF, donors and recipients were significantly older (p = 0.004 and p = 0.005, respectively), had longer cold ischemia times (p = 0.039), more revision surgeries (p < 0.001), and more HLA mismatches (p = 0.001), especially in the DR locus (p = 0.002). Neither donor nor recipient gender, waiting time, nor CMV status had any influence. In multivariable analysis, significant risk factors were ischemia time and mismatches at the HLA-DR loci. CONCLUSIONS: DGF is a common complication in renal transplantation which occurred in 33% of our cases. Important factors identified were donor and recipient age, ischemia time, HLA mismatching, and revision surgery.

Risk factors and survival outcomes for upstaging after inguinal lymph node dissection for cN1 penile squamous cell carcinoma.

OBJECTIVES: To identify incidence and risk factors for upstaging from cN1 to pN2/N3 at inguinal lymphadenectomy (ILND) for penile cancer (pSCC). Our secondary objective is to assess survival outcomes and associations for cN1 patients undergoing ILND. SUBJECTS/PATIENTS AND METHODS: Patients with pT≥1cN1cM0 pSCC who underwent bilateral ILND and had complete data were identified in a multi-institutional international cohort from 8 referral centers in 7 countries diagnosed from 1980 to 2017. Upstaging was defined as pN2/N3 at ILND. Multivariable logistic regression analysis was used to determine associations with upstaging, and Cox multivariable logistic regression analysis to determine associations with overall survival (OS). RESULTS: Of 144 patients were included in the final study population. 84 patients (58%) were upstaged from cN1 to pN2/N3, and 25 (17%) were down staged to pN0. Upstaging was associated with pT3/T4 (OR 4.1, 95%CI 1.5-11.7, P < 0.01) and pTX (OR 7.1, 95CI 1.6-51.1, P = 0.02). Age, smoking status, HPV status, and LVI were not associated with upstaging. Age (HR 1.03/y, 95%CI 1.01-1.06, P < 0.01) and upstaging (HR 2.8, 95%CI 1.3-5.9, P < 0.01) were associated with worse OS. Upstaged patients had a 5-year OS of 49%, compared with 86% for patients who were not upstaged. CONCLUSION: The majority of cN1 pSCC patients harbor a higher-risk disease state than their clinical staging suggests, especially those with higher pT stages. More intensive pre-operative workup may be warranted for these patients to identify upstaging prior to ILND and potentially qualify them for neoadjuvant chemotherapy or clinical trials.