[Organ-preserving treatment for urothelial carcinoma of the upper urinary tract]. / Organerhaltende Therapien beim Urothelkarzinom des oberen Harntrakts.

Urothelial carcinoma of the upper urinary tract is rare but the incidence is currently increasing in western countries. Radical nephroureterectomy has long been the standard treatment; however, it can lead to chronic kidney failure and also the necessity for dialysis. Therefore, organ-preserving treatment is now recommended for selected patients with low-risk tumors. The choice of treatment depends on the tumor characteristics, comorbidities and individual risk factors. Surgical options for organ preservation include ureterorenoscopy (URS), percutaneous treatment and partial ureteral resection. The URS is the most frequently used method for organ preservation. Photodynamic diagnostics (PDD) and narrow band imaging (NBI) can potentially also be used for tumor detection in the upper urinary tract. Conservative options such as topical treatment with mitomycin C or Bacillus Calmette-Guérin (BCG) and systemic treatment options are also possible.

[Follow-up after urinary diversion]. / Nachsorge nach Harnableitung.

Radical cystectomy is currently the standard of care for muscle-invasive bladder cancer. Different parts of the small and large intestines can be utilized for continent and incontinent urinary diversion. The postoperative follow-up after urinary diversion should consider functional, metabolic and oncological aspects. The functional follow-up of (continent) urinary diversion includes stenosis, emptying disorders or incontinence. The oncological follow-up should focus on the detection of local, urethral and upper tract recurrences as well as distant metastases. As 90% of the tumor recurrences occur during the first 3 years, a close follow-up should be carried out during this period. Metabolic disturbances, such as vitamin B12 and bile acid deficits, acidosis and disorders of calcium metabolism can also occur during long-term follow-up. The metabolic follow-up should consider the metabolic consequences of the parts of the intestines utilized for the urinary diversion.

[Urethral reconstruction]. / Harnröhrenrekonstruktion.

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

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

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

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

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

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

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

Ultrasound imaging of male urethral stricture disease: a narrative review of the available evidence, focusing on selected prospective studies.

PURPOSE: To synthetize the current scientific knowledge on the use of ultrasound of the male urethra for evaluation of urethral stricture disease. This review aims to provide a detailed description of the technical aspects of ultrasonography, and provides some indications on clinical applications of it, based on the evidence available from the selected prospective studies. Advantages and limitations of the technique are also provided. METHODS: A comprehensive literature search was performed using the Medline and Cochrane databases on October 2022. The articles were searched using the keywords "sonourethrography", "urethral ultrasound", "urethral stricture" and "SUG". Only human studies and articles in English were included. Articles were screened by two reviewers (M.F. and K.M.). RESULTS: Our literature search reporting on the role of sonourethrography in evaluating urethral strictures resulted in selection of 17 studies, all prospective, even if of limited quality due to the small patients' number (varied from 28 to 113). Nine studies included patients with urethral stricture located in anterior urethra and eight studies included patients regardless of the stricture location. Final analysis was based on selected prospective studies, whose power was limited by the small patients' groups. CONCLUSION: Sonourethrography is a cost-effective and safe technique allowing for a dynamic and three-dimensional urethra assessment. Yet, because of its limited value in detecting posterior urethral strictures, the standard urethrography should remain the basic 'road-map' prior to surgery. It is an operator-dependent technique, which can provide detailed information on the length, location, and extent of spongiofibrosis without risks of exposure to ionizing radiation.

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

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

[Evaluation and management of urethral strictures-guideline summary 2024 : part 1-anterior urethra]. / Diagnostik und Therapie von Harnröhrenstrikturen ­ Leitlinienübersicht 2024 : Teil 1 ­ anteriore Harnröhre.

In recent years, several international urological societies have published guidelines on the diagnosis, treatment, and follow-up of urethral strictures, but a guideline for the German-speaking region has not been available to date. This summary provides a detailed comparison of the guidelines of the European Association of Urology (EAU), American Urological Association (AUA) and the Société Internationale d'Urologie (SIU) with regard to the treatment of anterior urethral strictures, i.e. from the bulbar urethra to the meatus. In the following work, differences and specific recommendations in the guidelines are highlighted. In particular, the three guidelines largely agree with regard to diagnostic workup and follow-up. However, divergences exist in the management of anterior urethral strictures, particularly with regard to the use of endoscopic therapeutic approaches and the use of urethral stents. In addition, the EAU provides more comprehensive and detailed recommendations on urethroplasty techniques and specific patient follow-up. The EAU guidelines are the most current and were the first to include instructions for urethral strictures in women and individuals with gender incongruence after genital approximation surgery. Reconstructive urology is a rapidly evolving specialty and, thus, the clinical approach has been changing accordingly. Although guideline recommendations have become more inclusive and comprehensive, more high-quality data are needed to further improve the level of evidence.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]. / Harnableitungen mit oder ohne simple Zystektomie in der Salvage-Therapie benigner Erkrankungen des unteren Harntraktes.

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

[Randomised comparison of different exit strategies in hydrocele resection]. / Randomisierter Vergleich unterschiedlicher Exit-Strategien bei der Hydrozelenresektion.

INTRODUCTION: Adult hydrocele is a benign enlargement of the scrotum seen in approximately 60/100,000 men >18 years of age. Surgical resection of the hydrocele has been established as the gold standard for the treatment of symptomatic hydroceles. Postoperative complications are common with this surgery. Due to the lack of guidelines for the therapy of hydrocele, treatment is based primarily on clinical experience. The aim of the study was to conduct a randomised study on the influence of drains on complications in hydrocele resection according to von Bergmann. MATERIAL AND METHODS: A total of 60 patients were prospectively randomised into three groups. The groups each received an Easy-Flow drainage, a Cuti-Med Sorbact drainage, or no drainage. Haematoma and swelling, postoperative bleeding, infection, epididymal injury and revision surgery were clinically diagnosed as complications. RESULTS: A complication was observed in 31.6% (n=19/60) of all patients. The complication rate was 50% (n=10) for the easy-flow drainage, 30% (n=6) for the Cuti-Med-Sorbact and 15% (n=3) for the group without drainage. Overall, a haematoma with swelling was observed most frequently, in 20% (n=12) of the cases. Revision surgery was required in 5% (n=3) of cases. Epididymal injuries were found histologically in 10% (n=6). Comparing the collective with the Easy-Flow drainage with the collective without drainage, the occurrence of complications was observed significantly more frequently in the drainage group (p<0.018). A statistically significant correlation regarding complications between the group of Cuti-Med-Sorbact and no drainage could not be shown (p<0.25). CONCLUSIONS: Hydrocele resection is a complicated procedure. Based on the data presented here, the insertion of a drain is associated with an increased risk of postoperative complications. If the decision to insert a wound drainage is made intraoperatively, the Cuti-Med-Sorbact drainage appears to be associated with fewer complications.

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

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

Reaching Consensus for Comprehensive Outcome Measurement After Urethral Stricture Surgery: Development of Study Protocol for Stricture-Fecta Criteria.

Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a "success" after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the "stricture-fecta criteria". The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.

Special surgical aspects of radical cystectomy in spinal cord injury patients with bladder cancer.

PURPOSE: Radical cystectomy in people with spinal cord injury (SCI) provides numerous additional difficulties, compared to able-bodied people. Therefore, it is important to obtain information from an experienced team about optimally managing these patients. METHODS: Surgical procedures, based on the experience of 12 radical cystectomies in SCI patients with bladder cancer between January 1st, 2001, and December 31st, 2020, were recorded and the operative and perioperative clinical data were evaluated. Surgery was performed in a high-volume center by the surgeon most experienced in radical cystectomies, assisted by the neuro-urologist, involved in the care of the patient from the spinal cord center. Furthermore, a checklist based on the experience of the surgeon and the assisting neuro-urologist was developed. RESULTS: SCI patients mostly suffered from an advanced disease and were always operated by the same team. The hospital stays ranged from 23 to 134 days (median 42 days). Four of the patients suffered from a postoperative paralytic ileus. Otherwise, both the operation time and the intraoperative blood loss as well as intraoperative and postoperative complications were basically comparable with those in able-bodied patients. The special features of radical cystectomy in SCI bladder cancer patients are described. Furthermore, a checklist addressing preoperative red flags, intra-operative challenges and post-operative challenges is presented. CONCLUSION: Radical cystectomy in SCI patients should be performed in a high-volume department by the most experienced surgical team. The inclusion of the urologist caring for the patient from the spinal cord injury center is highly recommended.

Contemporary Outcomes after Transurethral Procedures for Bladder Neck Contracture Following Endoscopic Treatment of Benign Prostatic Hyperplasia.

OBJECTIVES: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. MATERIAL AND METHODS: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. RESULTS: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3-14) months and differed significantly in those with (6.5 months; IQR 4-10) and those without BNC recurrence (10 months; IQR 6-20; p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months; IQR 6-9) compared to those treated successfully (median 12 months; IQR 9-25; p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months; IQR 2-12) and those without a recurrence (6 months; IQR 6-10; p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%; p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. CONCLUSIONS: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts.

Perioperative and Pathological Outcome of Nerve-Sparing Radical Cystectomy With Ileal Neobladder.

Purpose: So far, it has not been described whether the perioperative course and the pathologic outcome of patients who undergo radical cystectomy (RC) with orthotopic bladder substitution differs if nerve sparing (NS) is performed or not. Material and Methods: In all, there were 472 patients who underwent RC between 2012 and 2019 at our department. We performed a retrospective analysis of 116 patients who underwent RC with ileal neobladder. We analyzed perioperative complications according to the Clavien-Dindo classification system, as well as the pathological outcome. Results: Of 116 patients, 68 (58.6%) underwent RC, and 48 (41.4%) underwent NS RC. Clavien-Dindo complications ≥3b occurred in 15 (12.9%) of all patients. Only infectious complications differed among the groups [NS RC: 25 patients (52.1%) vs. RC: 20 patients (29.4%); p = 0.02]. There was no significant difference concerning tumor stage. Concomitant Cis was present in 24 patients (35.3%) of the RC group and in 27 patients (56.3%) of the NS RC group (p = 0.036). Nodal status and positive surgical margin status of the bladder tumor did not differ among the groups. In all, 42 of all male patients (45.7%) had an incidental prostatic carcinoma. Positive surgical margins concerning the prostate carcinoma occurred in six patients, with all cases in the RC group (p = 0.029). Conclusions: Our data suggest that performing NS during RC in carefully selected patients is a safe procedure and does not impair perioperative outcome. Pathological outcome of NS RC is comparable as well.