Knowledge on the male reproductive tract and testicular cancer among adolescents in Austria.

PURPOSE: Testicular cancer is the most frequent malignant tumour among young adults. Therefore, regular self-examination for early detection is recommended by all guidelines. The fact that the knowledge of young adults living in Austria on this important topic is unknown, prompted the current investigation. MATERIALS AND METHODS: To evaluate the knowledge on anatomy and function of the male reproductive tract and of testicular cancer in particular a German questionnaire recently developed by Anheuser et al. (Urologe 2019;58:1331-1337) was applied. This 4-page questionnaire contains mainly multiple-choice questions. This questionnaire was distributed in three different schools to male and female students in the 11th and 12th school level. RESULTS: A total of 337 students (mean age: 17.3 years; male: n = 183; female: n = 154) completed the questionnaire. In a simple pictogramm, 63% were able to correctly identify the prostate, 87% the testis and 64% the epididymis. Half of the students (49.3%) could describe the function of the testis. The question regarding the age peak of testicular cancer was correctly answered by 81%, yet 18% believed that testicular cancer is caused by the sexual contact. The purpose of the testicular self-examination was correctly answered by only 54.9% with a higher rate for women (67.5% vs. 44.3%, p = 0.001). With a theoretical maximal score of 15, the students reached a mean overall of 10.4 with no sex difference (p > 0.05). Differences were noted for the school type: the highest score was present in the Gymnasium (11.2), followed by the Realgymnasium (10.8) and the HTL (9.8; p = 0.001). CONCLUSIONS: This survey demonstrates relevant knowledge deficits of young adults regarding the male reproductive tract, testicular cancer and self-examination.

Testicular Tumor Markers in the Spermatic Vein - Correlation to Pathology, Stage and Outcome.

OBJECTIVE: To report our findings in patients with determination of testicular tumor markers from the vena spermatica during inguinal orchiectomy. METHODS: In a retrospective setting, data of patients who underwent inguinal orchiectomy between January 2004 and December 2014 were analyzed. Cubital and testicular vein tumor markers were assessed and correlated to histology, clinical stage and outcome. RESULTS: A total of 90 patients (seminomatous: n = 53, non-seminomatous: n = 37) with a median age of 37 years were included. The mean follow-up was 109 months. Overall, 60% (n = 54) of patients had one or more positive tumor marker level in the cubital vein vs 88.9% (n = 80) in the testicular vein. Median tumor marker levels of hCGß in cubital and testicular vein were 1.9 U/l and 30.8U/l; the respective values for AFP were 2.9ng/ml and 2.4ng/ml and for hPLAP 49.9 mU/l and 418.9 mU/l. Differences in cubital vs testicular vein positivity were stage dependant and highest for pT1. Patients with seminomatous tumors had peripheral positivity of 59.3% vs 88.9% in the testicular vein (P = 0.003); in non-seminomatous patients the respective values were 61.1% and 88.9% (P = 0.02). All recurrent cancer patients under active surveillance (n = 5) were positive in the testicular vein. CONCLUSION: Virtually all testicular cancers shed tumor markers in the circulation. Differences in marker positivity (testicular vs testicular vein) were stage dependent (greatest in pT1), largely independent of histology and highest for hCGß. The prognostic value of testicular vein sampling remains speculative.

Is there a place for indwelling transurethral catheterization in women with febrile urinary tract infection? A prospective randomized trial.

PURPOSE: To assess the common practice to transiently place an indwelling transurethral catheter in case of hospitalization of women with febrile urinary tract infections. So far, this intervention has not been scientifically investigated. METHODS: Inclusion criteria were female gender, a leucocyte esterase-positive urine dipstick analysis (≥ 250) from urine obtained with a catheter and fever > 38 °C. Patients were randomized 1:1 to either receive an indwelling catheter French 16 or not. The catheter was removed after 24 h without fever (< 37.5 °C). Principal exclusion criteria were a post void residual volume exceeding 50 mL or abnormalities of the urinary tract. Hospital stay and fever in days, the amount of analgetic medication needed and the laboratory parameters WBC and CRP-measured on the day of admission and in predefined intervals thereafter-were study endpoints. RESULTS: 75 patients were included in the final analysis, 36 in the catheter group and 39 in the no-catheter group. Mean age was 39.4 ± 17.7 years and 39.8 ± 15.5 years, respectively (p > 0.05). The mean length of catheterisation was 3.6 ± 1.6 days in the catheter group. There were no differences between the two groups regarding duration of hospitalization and fever, or the amount of analgetic medication needed (all p > 0.05). Additionally, there was no difference in time to WBC < 10 G/L or CRP < 100 mg/L (all p > 0.05). CONCLUSIONS: This prospective, randomized trial provides no evidence to support routine insertion of an indwelling catheter in women with febrile urinary tract infection requiring hospital admission.

Abiraterone acetate, enzalutamide and their sequence for castration-resistant prostate cancer : Adherence, survival and hospitalization analysis of a medical claims database.

OBJECTIVE: To analyze drug adherence, overall survival (OS) and hospitalization rates of patients with castration-resistant prostate cancer (CRPC) treated with arbiraterone acetate (AA), enzalutamide (ENZ) and their sequence in a real-life setting. METHODS: The database of the largest public insurance company in Austria was analyzed. All CRPC patients with at least one prescription of AA and/or ENZ between September 2013 and August 2016 in the pre-chemotherapy and post-chemotherapy setting were extracted and matched to the Austrian death and hospital admission statistics. Drug adherence was estimated by the medication possession ratio (MPR). RESULTS: Data of 457 patients (mean age: 74.4 ± 8.5 years) were analyzed. The mean MPR was 90% for AA, 85% for ENZ and 88% for the sequence therapy cohort. The median overall survival (OS) of the entire cohort was 21 months: 15 months for AA, 24 months for ENZ, 26 months for the sequence group, and 10 months for the sequence group after switching. In the post-chemotherapy setting, the median OS was 14 months in AA treatment (mean: 15.8 ± 0.9 months), 19 months in the ENZ treatment (mean: 17.2 ± 1.4 months) and 25 months in the sequence group (mean: 22.7 ± 0.8 months). Median OS in the pre-chemotherapy setting was 25 months (mean: 21.5 ± 1.1 months), 18 months in AA treatment group (mean: 18.9 ± 1.5 months) and 17 months in ENZ treatment group (mean: 18.2 ± 1.9 months). Only 43 (9.4%) patients were not hospitalized during the course of the study. On average patients spent 13% of their remaining life span in hospital care (median 8%, range: 1-34%). CONCLUSION: This Austrian prescription database allows some insights into the outcome of CRPC patients treated with AA and ENZ and their sequence in a real-life setting. Drug adherence was satisfactory, OS was shorter for AA and ENZ as compared to the pivotal phase III trials.

Reoperation Rates and Mortality After Transurethral and Open Prostatectomy in a Long-term Nationwide Analysis: Have We Improved Over a Decade?

OBJECTIVE: To assess long-term reoperation rates and mortality after transurethral resection of the prostate (TURP) and open prostatectomy (PE) as therapy for lower urinary tract symptoms due to benign prostatic enlargement. METHODS: The present study analyzes a nationwide database of all patients who underwent TURP/open PE during 2002-2006 and who were followed up for 8 years. Actuarial cumulative incidences of reoperation (TURP, urethrotomy, bladder neck incision) and death were calculated. Data were provided by the Austrian Public Health Institute. This series was compared with a previously published almost equally sized nationwide cohort that underwent surgery during 1992-1996 in Austria. RESULTS: Between 2002 and 2006, a total of 21,674 patients underwent TURP (n = 20,388) or open PE (n = 1,286). At 8 years, the re-TURP rate after primary TURP was 8.3% vs 4.3% after open PE. The re-TURP rate was higher in the 80+ cohort. The overall endourological reintervention rate at 8 years was 12.7% for TURP and 8.8% for open PE. Reintervention rates did not improve compared with the 1992-1996 series. The 30-day in-hospital mortality rate was 0.1% for TURP and 0.2% for open PE. Mortality rates improved by approximately 20% compared with the 1992-1996 series. CONCLUSION: In Austria, TURP rates remained stable between 1992 and 2006, paralleled by a 50% decline of open PE. Within a decade, mortality rates declined by 20%, yet reintervention rates remained unchanged.

A Relevant Midterm (12 Months) Placebo Effect on Lower Urinary Tract Symptoms and Maximum Flow Rate in Male Lower Urinary Tract Symptom and Benign Prostatic Hyperplasia-A Meta-analysis.

OBJECTIVE: To assess the mid- to long-term placebo effect of the medical and instrumental management of male lower urinary tract symptoms. This is generally a long-term treatment strategy. Therefore, knowledge on the mid- to long-term placebo effect is of considerable interest. The paucity of data on this topic prompted us to investigate this issue in a meta-analysis. METHODS: All randomized controlled trials (RCTs) with the indication of benign prostatic hyperplasia and lower urinary tract symptoms containing a placebo- or sham treatment arm and with a follow-up of 12 months were eligible. The 12-month effect of placebo or sham treatment on the International Prostate Symptom Score (the quality-of-life question was not analyzed herein) and the American Urological Association Symptom Score and on the maximum flow rate was quantified. RESULTS: A total of 25 RCTs with 10.587 patients were eligible. Twenty-three studies were placebo controlled (plant extracts: n = 4, 5α-reductase inhibitors [5ARIs]: n = 9, α-blocker: n = 5, combination therapy of 5ARI and α-blocker: n = 3, and intraprostatic botulinum toxin A injection: n = 2), and 2 RCTs with transurethral microwave thermotherapy (TUMT) had a sham treatment arm. At 12 months, the mean International Prostate Symptom Score improved by a mean of 4.4 points under placebo or sham treatment with a range of 0.7-6.8 points: plant extracts, -3.6; 5ARI, -3.4; α-blocker, -4.3; combination therapy, -4.3; botulinum toxin A, -3.9; and TUMT, -6.8. The mean maximum flow rate improvement at 12 months under placebo or sham was not relevant (+0.8 mL/s), yet there were remarkable differences between trials: plant extracts, -0.3 mL/s; 5ARI, +0.8 mL/s; α-blocker, +1.1 mL/s; combination therapy, +1.4 mL/s; and TUMT, +1.0 mL/s. CONCLUSION: This meta-analysis demonstrates the mid-term placebo effect on lower urinary tract function, particularly concerning subjective improvement. The degree of the placebo effect varies considerable between studies even at 12 months.

10 years follow-up after mid-urethral sling implantation: high rate of cure yet a re-occurrence of OAB-symptoms.

AIMS: To assess the long-term outcome of mid-urethral slings regarding urinary incontinence (UI) and lower urinary tract symptoms and to identify risk factors for an unsatisfactory outcome. METHODS: Analysis of a prospective institutional database. For the current analysis only women who reached the 10 years follow-up were eligible. Outcome was assessed using a detailed, non-validated questionnaire on continence status and on several aspects of lower urinary tract function. RESULTS: A total of 256 women were operated during 1999-2004, in 139 (54.3%), a 10 years follow-up was available and these patients were included. Mean age at surgery was 63 years. At the 2, 5, and 10 years follow-up, the percentages of women reporting 0-1 pads/day were 96.4%, 97.1% and 88.5%, respectively. More than 95% of the patients reported no stress UI at the 2, 5, and 10 years follow-up. At baseline, urgency was reported by 61.2%, this figure dropped to 17.3% at 2 years and increased thereafter to 32.4% (5 years) and 41.7% (10 years). De novo urgency was present in 3.6% after 2 years, in 10.8% after 5 years, and 14.4% after 10 years. The percentage of patients with a high degree of treatment satisfaction declined from 79.1% at 2 years to 70.5% at 5 years, and 62.6% at 10 years. Risk factors for an unsatisfactory long-term outcome were advanced age, the presence of urgency, nocturia, and decreased bladder capacity at baseline. CONCLUSIONS: This study confirms the excellent long-term efficacy of mid-urethral slings regarding the management of stress UI. A substantial number of women develop OAB-symptoms after the procedure that largely contribute to outcome dissatisfaction. Neurourol. Urodynam. 36:614-619, 2017. © 2016 Wiley Periodicals, Inc.

Impact of gender on tumor stage and survival of upper urinary tract urothelial cancer : A population-based study.

BACKGROUND: The aim of this study was to analyze the impact of gender on tumor stage, overall and cancer-specific mortality of upper urinary tract urothelial cancer (UTUC) in a population-based, nationwide analysis. METHODS: All Austrian patients with UTUC diagnosed between 1983 and 2010 were included in this study. Overall mortality was estimated by the Kaplan-Meier method. Cancer-specific (UTUC) mortality was estimated by cumulative incidence with mortality due to other causes as a competing risk. The effect of age was adjusted in a descriptive as well as a statistical inferential way. RESULTS: This study included 2066 patients (men n = 1169, mean age 68.3 ±11.5 years, women n = 897, 72.6 ±10.4 years). Tumor stage distribution was as follows: pT1: men n = 411, women n = 268, pT2: men n = 263, women n = 187, pT3: men n = 382, women n = 328 and pT4: men n = 113, women n = 114. The male:female ratio continuously declined from 1.5 for pT1 tumors to 1.4 for pT2 tumors, 1.2 for pT3 tumors and 1.0 for pT4-tumors. In the entire cohort the 5­year cumulative overall mortality was 57 % for women versus 50 % for men (p = 0.0002). For pT1 (women 33 %, men 31 %) and pT2 stage tumors (women 45 %, men 45 %) the 5­year overall mortality was comparable between both sexes. In pT3 (women 68 %, men 62 %) and pT4 (women 95 %, men 87 %) tumors women had a higher overall mortality rate. The 5­year cancer-specific mortality (CSM) of the entire cohort was 12 % for women and 10 % for men (p = 0.067): pT1 women 5 % men 3 %, pT2 women 9 % men 10 %, pT3 women 14 % men 11 % and pT4 women 29 % men 27 %. CONCLUSIONS: In this population-based nationwide analysis, sex differences were notable for UTUC. Women tended to have more advanced tumor stages at diagnosis and a higher overall and cancer-specific mortality in advanced tumor stages.

Medical treatment of lower urinary tract symptoms/benign prostatic hyperplasia: anything new in 2015.

PURPOSE OF REVIEW: The purpose of this study is to provide an update on recent developments regarding the medical management of male lower urinary tract symptoms (LUTS). RECENT FINDINGS: Silodosin improves storage/voiding symptoms and nocturia and is effective within the framework of a trial without a catheter. 5α-reductase inhibitors (5ARIs) are not associated with male breast cancer development. Alcohol consumption seems to increase the risk of high-grade prostate cancer under 5ARIs. The combination of α-blocker and 5ARIs remains a well established concept for benign prostatic hyperplasia/LUTS patients with an enhanced risk of disease progression. Tadalafil 5 mg/day monotherapy is a valid option particularly for men with LUTS and erectile dysfunction; the combination of Tadalafil 5 mg/day with a 5ARI is an interesting approach. The fixed-dose combination of α-blocker and antimuscarinic provides advantages regarding storage symptom improvement. This approach is currently primarily recommended as an add-on strategy. Mirabegron opens new horizons in the management of male LUTS and has no negative (but also no positive) urodynamic effects. Several encouraging novel approaches are currently in the experimental phase and might enhance our therapeutic armamentarium in the near future. SUMMARY: The recent literature refines our knowledge on current therapeutic options and provides further evidence for an individualized, risk-adapted approach for male LUTS mainly depending on symptoms status, comorbidities (i.e. erectile dysfunction) and risk of disease progression.

Use of self-retaining barbed sutures decreases cold ischemia time in open nephron-sparing surgery.

PURPOSE: In the present study, we aimed to determine whether the use of self-retaining barbed sutures (SRBS) instead of conventional sutures during open partial nephrectomy leads to improved surgical outcomes. PATIENTS, MATERIALS AND METHODS: A retrospective analysis of 50 consecutive patients who underwent open partial nephrectomy for a unicentric renal tumor was performed. In 15 patients, SRBS were used for parenchymal repair during open partial nephrectomy, and in 35 patients, conventional sutures were used. The parameters related to surgical outcomes were recorded and analysis of the total patient population and subgroup analysis according to the preoperative aspects and dimensions used for an anatomical (PADUA) score classification was performed. RESULTS: The preoperative baseline values did not statistically differ between the groups. Analysis of the total patient population showed a significant difference regarding ischemia time (mean ± standard deviation) between the SRBS group (15.2 ± 6.9 min), and the conventional suture group (25.7 ± 11.8 min). There was no significant difference between the barbed and conventional sutures with regard to postoperative hemoglobin levels, decline in hemoglobin percentage, or renal function parameters. In subgroup-analysis, a significant difference in ischemia time was only found for PADUA scores 6 and 7, without any effect on the outcome parameters. CONCLUSIONS: The use of SRBS in parenchymal repair during open partial nephrectomy appears to be a safe and feasible option with decreased cold ischemia time when compared with conventional sutures. In PADUA subgroup-analysis this difference was only observed for PADUA scores 6 and 7.

Intravesical hemostatic gelatin matrix instillation in the management of intractable hematuria.

INTRODUCTION: The objective of the present study was to evaluate the safety and feasibility of a novel and minimally invasive approach, namely, intravesical instillation of a gelatin matrix hemostatic sealant (GMHS) in the management of intractable hematuria. TECHNICAL CONSIDERATIONS: Six consecutive patients with intractable hematuria not responding to standard treatment underwent intravesical instillation of a hemostatic bovine-derived gelatin matrix mixed with a human-derived thrombin component. The technical aspects of this approach are described in detail. The mean age of the patients was 70 ± 4 years (median 71, range 50-79). All patients had pelvic malignancy: 5 had prostate cancer, and 1, cervical cancer. Mean duration of hematuria before intervention was 6 ± 1 days (median 6, range 2-9). Mean preoperative hemoglobin level was 9.2 ± 0.5 g/dL (median 9.0, range 8.0-10.2). Complete control of bleeding was achieved in 5 patients (83%) and all 6 patients (100%) on day 1 and 7, respectively. At a mean follow-up of 10 ± 6 months (median 13, range 1-15), permanent control of bleeding was achieved in 5 of 6 patients (83%). A second GMHS instillation was performed in 1 patient (17%) and it was successful. During the follow-up, there were no complications related to GMHS instillation. Two patients died because of their underlying malignant disease. CONCLUSION: Intravesical GMHS instillation appears to be a safe and feasible option in the management of intractable hematuria in the short-term.

Urethral buttressing in patients undergoing artificial urinary sphincter surgery.

PURPOSE: We evaluated the safety and feasibility of what we believe to be a novel technique of buttressing the urethra with a fibrin coated collagen fleece in patients undergoing artificial urinary sphincter surgery in the presence of urethral atrophy. MATERIALS AND METHODS: A total of 17 consecutive men were treated with urethral buttressing for urethral atrophy during artificial urinary sphincter surgery. Continence, complications and patient reported outcomes were assessed by preoperative and postoperative pad use, chart review, patient interview and validated questionnaires. RESULTS: Mean ± SD followup was 38 ± 3.0 months (median 34, range 23 to 71). One patient was excluded from further evaluation due to accidental iatrogenic urethral injury elsewhere. At 3-month followup the mean improvement in pad use was 5 ± 0.5 pads (median 5, range 2 to 9). Of 16 patients 9 (56%) and 2 (13%) used 1 and 0 pad per day, respectively. According to the Patient Global Impression of Improvement questionnaire, 12 of 16 patients (75%) described their condition as much or very much better after surgery. Mean ± SD postoperative Incontinence Impact Questionnaire and Urogenital Distress Index scores were 2 ± 0.8 (median 1, range 0 to 11) and 4 ± 1.0 (median 3, range 0 to 11), respectively. No intraoperative complications were observed. During followup 2 of 16 patients (13%) underwent placement of a second cuff due to unsatisfactory postoperative continence, 1 (6%) underwent artificial urinary sphincter revision for clean urethral erosion and 1 (6%) underwent revision for pump malfunction. CONCLUSIONS: Urethral buttressing with a collagen fleece appears to be a safe, feasible option for urethral atrophy in patients treated with artificial urinary sphincter implantation or revision.

The impact of varicocelectomy on sperm parameters: a meta-analysis.

PURPOSE: We determined the impact of 3 surgical techniques (high ligation, inguinal varicocelectomy and the subinguinal approach) for varicocelectomy on sperm parameters (count and motility) and pregnancy rates. MATERIALS AND METHODS: By searching the literature using MEDLINE and the Cochrane Library with the last search performed in February 2011, focusing on the last 20 years, a total of 94 articles published between 1975 and 2011 reporting on sperm parameters before and after varicocelectomy were identified. Inclusion criteria for this meta-analysis were at least 2 semen analyses (before and 3 or more months after the procedure), patient age older than 19 years, clinical subfertility and/or abnormal semen parameters, and a clinically palpable varicocele. To rule out skewing factors a bias analysis was performed, and statistical analysis was done with RevMan5(®) and SPSS 15.0(®). RESULTS: A total of 14 articles were included in the statistical analysis. All 3 surgical approaches led to significant or highly significant postoperative improvement of both parameters with only slight numeric differences among the techniques. This difference did not reach statistical significance for sperm count (p = 0.973) or sperm motility (p = 0.372). After high ligation surgery sperm count increased by 10.85 million per ml (p = 0.006) and motility by 6.80% (p <0.00001) on the average. Inguinal varicocelectomy led to an improvement in sperm count of 7.17 million per ml (p <0.0001) while motility changed by 9.44% (p = 0.001). Subinguinal varicocelectomy provided an increase in sperm count of 9.75 million per ml (p = 0.002) and sperm motility by 12.25% (p = 0.001). Inguinal varicocelectomy showed the highest pregnancy rate of 41.48% compared to 26.90% and 26.56% after high ligation and subinguinal varicocelectomy, respectively, and the difference was statistically significant (p = 0.035). CONCLUSIONS: This meta-analysis suggests that varicocelectomy leads to significant improvements in sperm count and motility regardless of surgical technique, with the inguinal approach offering the highest pregnancy rate.