Retrospective analysis of the learning curve in perineal robot-assisted prostate biopsy.

INTRODUCTION: Magnetic resonance imaging-transrectal ultrasound (MRI-TRUS)-fusion biopsy (FBx) of the prostate allows targeted sampling of suspicious lesions within the prostate, identified by multiparametric MRI. Due to its reliable results and feasibility, perineal MRI/TRUS FBx is now the gold standard for prostate cancer (PC) diagnosis. There are various systems for performing FBx on the market, for example, software-based, semirobotic, or robot-assisted platform solutions. Their semiautomated workflow promises high process quality independent of the surgeon's experience. The aim of this study was to analyze how the surgeon's experience influences the cancer detection rate (CDR) via targeted biopsy (TB) and the procedure's duration in robot-assisted FBx. PATIENTS AND METHODS: A total of 1716 men who underwent robot-assisted FBx involving a combination of targeted and systematic sampling between October 2015 and April 2022 were analyzed. We extracted data from the patients' electronic medical records retrospectively. Primary endpoints were the CDR by TB and the procedure's duration. For our analysis, surgeons were divided into three levels of experience: ≤20 procedures (little), 21-100 procedures (intermediate), and >100 procedures (high). Statistical analysis was performed via regression analyses and group comparisons. RESULTS: Median age, prostate-specific antigen level, and prostate volume of the cohort were 67 (±7.7) years, 8.13 (±9.4) ng/mL, and 53 (±34.2) mL, respectively. Median duration of the procedure was 26 (±10.9) min. The duration decreased significantly with the surgeon's increasing experience from 35.1 (little experience) to 28.4 (intermediate experience) to 24.0 min (high experience) (p < 0.001). Using TB only, significant PC (sPC) was diagnosed in 872/1758 (49.6%) of the men. The CDR revealed no significant correlation with the surgeon's experience in either group comparison (p = 0.907) or in regression analysis (p = 0.65). CONCLUSION: While the duration of this procedure decreases with increasing experience, the detection rate of sPC in TB is not significantly associated with the experience of the surgeon performing robot-assisted FBx. This robot-assisted biopsy system's diagnostic accuracy therefore appears to be independent of experience.

Extended Safety and Tolerability of Darolutamide for Nonmetastatic Castration-Resistant Prostate Cancer and Adverse Event Time Course in ARAMIS.

BACKGROUND: Patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) are usually asymptomatic and seek treatments that improve survival but have a low risk of adverse events. Darolutamide, a structurally distinct androgen receptor inhibitor (ARi), significantly reduced the risk of metastasis and death versus placebo in ARAMIS. We assessed the extended safety and tolerability of darolutamide and the time-course profile of treatment-emergent adverse events (TEAEs) related to ARis and androgen-suppressive treatment. PATIENTS AND METHODS: Patients with nmCRPC were randomized 2:1 to darolutamide (n = 955) or placebo (n = 554). After trial unblinding, patients could receive open-label darolutamide. Tolerability and TEAEs were assessed every 16 weeks. Time interval-specific new and cumulative event rates were determined during the first 24 months of the double-blind period. RESULTS: Darolutamide remained well tolerated during the double-blind and open-label periods, with 98.8% of patients receiving the full planned dose. The incidence of TEAEs of interest in the darolutamide group was low and ≤2% different from that in the placebo group, except for fatigue. When incidences were adjusted for exposure time, there were minimal differences between the darolutamide double-blind and double-blind plus open-label periods. The rate of initial onset and cumulative incidence of grade 3/4 TEAEs and serious TEAEs were similar for darolutamide and placebo groups over 24 months. CONCLUSION: Extended treatment with darolutamide was well tolerated and no new safety signals were observed. Most ARi-associated and androgen-suppressive treatment-related TEAEs occurred at low incidences with darolutamide, were similar to placebo, and showed minimal increase over time with continued treatment. TRIAL NUMBER: ClinicalTrials.gov identifier NCT02200614.

Declining utilization of urodynamic studies in urological care in Germany: time to say goodbye?

INTRODUCTION: The number of urodynamic studies (UDS) has been declining steadily in recent decades, yet the reasons behind this trend remain poorly understood. This study aims to investigate the structural aspects of UDS in urology and explore the factors contributing to this decline. MATERIAL & METHODS: We surveyed all urological departments performing UDS as well as a representative sample of private practices in Germany in 2023. We examined structural situation, waiting times, capacities and limitations of UDS. All invasive urodynamic examinations were defined as UDS. RESULTS: In 2019, 259/474 (55%) urological departments in Germany performed UDS. 206/259 (80%) urological departments responded to the survey. 163/200 (82%) urological departments stated that their capacities were exhausted, a main reason being lack of medical and nursing staff. 54.8% urological departments performed more than 50% of their UDS for referring physicians. Urological departments with a low number of UDS/year (≤ 100) showed a shorter waiting time (up to 4 weeks: 49% vs. 30%; p = 0.01), reduced UDS capacities (55% vs. 12%; p < 0.001) and these capacities were often not fully utilized (25% vs. 9%; p = 0.007). 122/280 (44%) office urologists responded to the survey. 18/122 (15%) office urologists performed UDS. Main reasons for not offering UDS were lack of personnel and low reimbursement. CONCLUSION: In German urological departments, UDS capacities are consistently fully utilized, primarily due to staffing shortages. This trend towards centralization prompts questions about the role of UDS in urologists' training.

Aquablation versus HoLEP in patients with benign prostatic hyperplasia: a comparative prospective non-randomized study.

PURPOSE: The question of best surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) remains controversial. We compared the outcomes of aquablation and holmium laser enucleation of the prostate ("HoLEP") in a prospective cohort. METHODS: Patients with BPH underwent aquablation or HoLEP according to their preference between June 2020 and April 2022. Prostate volume ("PV"), laboratory results, postvoid residual volume, uroflowmetry, IPSS, ICIQ-SF, MSHQ-EjD, EES and IIEF were evaluated preoperatively and at three, six and 12 months postoperatively. We also analyzed perioperative characteristics and complications via the Clavien Dindo ("CD") classification. RESULTS: We included 40 patients, 16 of whom underwent aquablation and 24 HoLEP. Mean age was 67 years (SD 7.4). Baseline characteristics were balanced across groups, except the HoLEP patients' larger PV. IPSS fell from 20.3 (SD 7.1) at baseline to 6.3 (SD 4.2) at 12 months (p < 0.001) without differences between aquablation and HoLEP. HoLEP was associated with shorter operation time (59.5 (SD 18.6) vs. 87.2 (SD 14.8) minutes, p < 0.001) and led to better PV reduction over all timepoints. At three months, aquablation's results were better regarding ejaculatory (p = 0.02, MSHQ-EjD) and continence function (p < 0.001, ICIQ-SF). Beyond three months, erectile, ejaculatory, continence function and LUTS reduction did not differ significantly between aquablation and HoLEP. CD ≥ grade 3b complications were noted in six patients in aquablation group while only one in HoLEP group (p = < 0.01). CONCLUSIONS: While aquablation revealed temporary benefits regarding ejaculation and continence at three months, HoLEP was superior concerning operation time, the safety profile and volumetric results.

Primary Results of Patients with Genitourinary Malignancies Presented at a Molecular Tumor Board.

INTRODUCTION: Personalized medicine poses great opportunities and challenges. While the therapeutic landscape markedly expands, descriptions about status, clinical implementation and real-world benefits of precision oncology and molecular tumor boards (MTB) remain sparse, particularly in the field of genitourinary (GU) cancer. Hence, this study characterized urological MTB cases to better understand the potential role of MTB in uro-oncology. METHODS: We analyzed patients with complete data sets being reviewed at an MTB from January 2019 to October 2022, focusing on results of molecular analysis and treatment recommendations. RESULTS: We evaluated 102 patients with GU cancer with a mean patient age of 61.7 years. Prostate cancer (PCa) was the most frequent entity with 52.9% (54/102), followed by bladder cancer (18.6%, 19/102) and renal cell carcinoma (14.7%, 15/102). On average, case presentation at MTB took place 54.9 months after initial diagnosis and after 2.7 previous lines of therapy. During the study period, 49.0% (50/102) of patients deceased. Additional MTB-based treatment recommendations were achieved in a majority of 68.6% (70/102) of patients, with a recommendation for targeted therapy in 64.3% (45/70) of these patients. Only 6.7% (3/45) of patients - due to different reasons - received the recommended MTB-based therapy though, with 33% (1/3) of patients reaching disease control. Throughout the MTB study period, GU cancer case presentations and treatment recommendations increased, while the time interval between initial presentation and final therapy recommendation were decreasing over time. CONCLUSION: Presentation of uro-oncological patients at the MTB is a highly valuable measure for clinical decision-making. Prospectively, earlier presentation of patients at the MTB and changing legislative issues regarding comprehensive molecular testing and targeted treatment approval might further improve patients' benefits from comprehensive molecular diagnostics.

Discrepancy between German S3 Guideline Recommendations and Daily Urologic Practice in the Management of Nonmuscle Invasive Bladder Cancer: Results of a Binational Survey.

INTRODUCTION: Guideline recommendations are meant to help minimize morbidity and to improve the care of nonmuscle invasive bladder cancer (NMIBC) patients but studies have suggested an underuse of guideline-recommended care. The aim of this study was to evaluate the level of adherence of German and Austrian urologists to German guideline recommendations. METHODS: A survey of 27 items evaluating diagnostic and therapeutic recommendations (15 cases of strong consensus and 6 cases of consensus) for NMIBC was administered among 14 urologic training courses. Survey construction and realization followed the checklist for reporting results of internet e-surveys and was approved by an internal review board. RESULTS: Between January 2018 and June 2019, a total of 307 urologists responded to the questionnaire, with a mean response rate of 71%. The data showed a weak role of urine cytology (54%) for initial diagnostics although it is strongly recommended by the guideline. The most frequently used supporting diagnostic tool during transurethral resection of the bladder was hexaminolevulinate (95%). Contrary to the guideline recommendation, 38% of the participants performed a second resection in the case of pTa low-grade NMIBC. Correct monitoring of Bacille Calmette-Guérin (BCG) response with cystoscopy and cytology was performed by only 34% of the urologists. CONCLUSIONS: We found a discrepancy between certain guideline recommendations and daily routine practice concerning the use of urine cytology for initial diagnostics, instillation therapy with a low monitoring rate of BCG response, and follow-up care with unnecessary second resection after pTa low-grade NMIBC in particular. Our survey showed a moderate overall adherence rate of 73%. These results demonstrate the need for sharpening awareness of German guideline recommendations by promoting more intense education of urologists to optimize NMIBC care thus decreasing morbidity and mortality rates.

Impact of COVID-19 crisis on medical care of patients with metastasized uro-oncologic disease under systemic cancer therapy: a multicenter study in German university hospitals.

PURPOSE: To date, over 4.2 million Germans and over 235 million people worldwide have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Uro-oncology (UO) patients are particularly vulnerable but in urgent need of life-saving systemic treatments. Our multicentric study examined the impact of the COVID-19 crisis on the medical care of UO patients in German university hospitals receiving ongoing systemic anti-cancer treatment and to detect the delay of medical care, defined as deferred medical treatment or deviation of the pre-defined follow-up assessment. METHODS: Data of 162 UO patients with metastatic disease undergoing systemic cancer treatment at five university hospitals in Germany were included in our analyses. The focus of interest was any delay or change in treatment between February 2020 and May 2020 (first wave of the COVID-19 crisis in Germany). Statistical analysis of contingency tables were performed using Pearson's chi-squared and Fisher's exact tests, respectively. Effect size was determined using Cramér's V (V). RESULTS: Twenty-four of the 162 patients (14.8%) experienced a delay in systemic treatment of more than 2 weeks. Most of these received immuno-oncologic (IO) treatments (13/24, 54.2%, p = 0.746). Blood tests were delayed or canceled significantly more often in IO patients but with a small effect size (21.1%, p = 0.042, V = 0.230). Treatment of patients with renal cell carcinoma (12/73, 16.4%) and urothelial carcinoma (7/32, 21.9%) was affected the most. CONCLUSIONS: Our data show that the COVID-19 pandemic impacted the medical care of UO patients, but deferment remained modest. There was a tendency towards delays in IO and ADT treatments in particular.

Five-Year Results of a Prospective Multicenter Trial: AdVance XP for Postprostatectomy-Incontinence in Patients with Favorable Prognostic Factors.

OBJECTIVE: The aim of this study was to assess the security, value, and efficacy of the second-generation AdVance male sling XP (Boston Scientific®), after implementation in 2010 with advantageous modifications in the sling structure and needle shape, in a prospective multicenter long-term follow-up study. METHODS: In total, 115 patients were included. Exclusion criteria were earlier incontinence (UI) surgery, nocturnal UI, former radiotherapy, or night-time incontinence. We also excluded patients with a functional urethra <1 cm in a preoperatively performed repositioning test. A consistent 24-h pad test, International Quality of Life (IQOL) score, visual analog pain scale (VAS), International Consultation-Incontinence Questionnaire (ICIQ-UI SF), International Index of Erectile Function (IIEF-5), International Prostate Symptom Score (IPSS), and Patient Global Impression of Improvement (PGI-I) scores were requested postoperatively. RESULTS: The 24-month follow-up (114 patients) revealed 64.0% cured and 28.8% improved patients. Mean urine loss was reduced significantly to 19.0 g (p < 0.001). A mean PGI score of 1.5 and a mean VAS score of 0.2 were obtained. The 60-month follow-up (59 patients) revealed 57.6% cured and 25.4% improved patients. Mean urine loss was reduced significantly to 18.3 g (p < 0.001). A mean PGI score of 1.6 and a mean VAS score of 0.2 were obtained. CONCLUSIONS: The AdVance XP displays excellent continence results and secure effectiveness over a 5-year period. Moreover, these data are demonstrating low complication rates and improved quality of life in the long-term use of AdVance XP.

Comprehensive analysis of Twitter activity on #Incontinence.

AIM: The aim of this study is comprehensive analysis of the Twitter activity on #Incontinence. MATERIAL AND METHODS: The following six functional-urology hashtags on Twitter were analyzed from 2015 to 2018 to gain a comprehensive insight into the topic: #Incontinence, #InterstitialCystitis, #OAB, #FPMRS, #BPH, and #UroBPH. For the Twitter analysis, Symplur Signals was used, which is a health care social media analytics tool. RESULTS: In total 191 383 tweets by 54 094 users in 2015 through 2018 were analyzed. A rise in the number of tweets could be identified for all six analyzed hashtags on functional urology, in summary, the numbers raised from 25 629 tweets in 2015 to 66 551 tweets in 2018. For the hashtag incontinence (#Incontinence), the number of tweets raised from 13 823 in 2015 to 19 996 in 2018 (+44.7%). Main influencers on functional urology topics identified by the Symplur algorithm were individuals from the health care sector in 44.6% of the cases and health care organizations in 36.5% of the cases, whereas for #Incontinence, only 7% of influencers were patients in 2018. The ten most common words connected to #Incontinence were Incontinence, Urinary, Women, Help, New, Bladder, Stress, Treatment, Pelvic, and Sex. Of the tweets, 66% were categorized as positive statements and 34% were categorized as negative. CONCLUSION: Social media is an emerging tool of communication in urology, whereas discussions on #Incontinence are underrepresented compared to the high prevalence of urinary incontinence. In addition, patients' activity is low.

Retropubic vs transobturator Argus adjustable male sling: Results from a multicenter study.

AIMS: To comparatively analyse outcomes after ARGUS classic and ArgusT adjustable male sling implantation in a real-world setting. METHODS: Inclusion criteria encompassed: non-neurogenic, moderate-to-severe stress urinary incontinence (≥2 pads), implantation of an ARGUS classic or ArgusT male sling between 2010 and 2012 in a high-volume center (>150 previous implantations). Functional outcomes were assessed using daily pad usage, 24-hour pad testing, and International Consultation on Incontinence (ICIQ-SF) questionnaires. Continence was defined as zero pads per 24 hours. Complications were graded using Clavien-Dindo scale. For multivariate analysis, binary logistic regression models were used (P < .05). RESULTS: A total of 106 patients (n = 74 [ARGUS classic], n = 32 [ArgusT]) from four centers were eligible. Median follow-up was 44.0 months (24-64). Patient cohorts were well-balanced. We observed a statistical trend in favor of ARGUS classic regarding postoperative urine loss based on standardized 24-hour pad test (71 ± 162 g [ARGUS classic] vs 160 ± 180 g [ArgusT]); P = .066]. Dry rates were 33.3% (ARGUS classic) and 11.8% (ArgusT, P = .114). In multivariable analysis, ArgusT male sling could not be confirmed as an independent predictor of decreased success (OR, 0.587; 95% CI; 0.166-2.076, P = .408). There were no Clavien IV and V complications. Inguinal pain was significantly higher after ArgusT implantation (P = .033). Explantation rates were higher for ArgusT compared to ARGUS classic (14.0 vs 23.3%; P = .371). Longer device survival for the ARGUS classic male sling was observed in Kaplan-Meier analysis (P = .198). CONCLUSIONS: In the largest comparative analysis of ARGUS classic and ArgusT male sling with the longest follow-up to date, we observed low continence rates with superior functional outcomes and decreased explantation rates after ARGUS classic implantation.

Patient Selection in Surgical Centers of Expertise in the Treatment of Patients with Moderate to Severe Male Urinary Stress Incontinence.

OBJECTIVE: To analyze decision-making in patients with male urinary incontinence (SUI) in centers of expertise. The artificial urinary sphincter (AUS) remains the gold standard for male patients with moderate to severe SUI but adjustable male slings are a minimally invasive treatment option with good results, hence without a high level of evidence regarding the optimal patient selection. MATERIALS AND METHODS: In total, 220 patients (88 AUS; 132 adjustable slings) were investigated from the DOMINO database that underwent surgery between 2010 and 2012 in 5 urological departments that offer adjustable sling systems as well as AUS systems for patients with moderate to severe urinary incontinence. For statistical analysis, the Mann-Whitney U test was used to identify differences between both groups. RESULTS: Patients selected for an adjustable male sling were less likely to have a neurological disease (5.3 vs. 9.1%; p = 0.030), a prior urethral stricture (22.7 vs. 50.0%; p = 0.001), a prior incontinence surgery (24.4 vs. 45.5%; p = 0.01), or a prior radiation therapy (26.5 vs. 40.1%; p = 0.001). The severity of preoperative incontinence was higher in patients selected for an AUS with a mean pad usage per day of 7.60 versus 5.80 (p < 0.001). Mean postoperative pad usage and patients' subjective perception were comparable in both groups. CONCLUSION: In centers offering both options, the decision-making is mainly based upon presence of radiation therapy and previous failed incontinence surgery. Despite the more complex patient cohort selected for an AUS implantation with a possible impact on the postoperative outcome, the functional results seem to be comparable indicating a proper preoperative patient assessment and selection in this cohort.

Secondary Sling Implantation after Failure of Primary Surgical Treatment for Male Stress Urinary Incontinence: A Retrospective Study.

OBJECTIVE: The artificial urinary sphincter (AUS) is the surgical gold standard after previously failed surgical treatment for male urinary stress incontinence. The evidence for a male sling as salvage treatment is poor, but there is a proportion of patients that refuse implantation of an AUS or have a relative contraindication. The goal of our retrospective study was an analysis of outcome and complications of patients with a secondary sling after previously failed surgery for stress urinary incontinence (SUI). MATERIALS AND METHODS: Data on 186 patients who had a prior incontinence surgery were extracted from the DOMINO database. 139 patients (74.7%) received an AUS and 41 patients (22.0%) who had received a secondary sling system between 2010 and 2012 after previously failed surgery for male urinary incontinence could be identified and were further analyzed. RESULTS: Eight patients (19.5%) received a secondary repositioning sling and 33 patients (80.5%) received a secondary adjustable sling system. A prior surgery for urethral stricture was performed in 4 patients (9.8%). No major intraoperative complications were reported. A simultaneous explantation was performed in 12 patients (29.3%). The mean number of pad reductions was 4.93 (p = 0.026). No intraoperative complications and no postoperative surgical revisions were reported. The mean follow-up of the patient cohort with a secondary sling was 16 months. CONCLUSION: We provide the largest cohort of male patients up to date with a secondary sling after primary failure of surgery for male SUI. Although the procedure is a rarely performed surgery and without a high level of evidence, a secondary adjustable male sling system might be a feasible option in selected patients with acceptable complication rates, whereas a valuable outcome regarding continence rates cannot be sufficiently supplied by our data.

Predictors of thrombosis in testicular cancer during platinum-based chemotherapy.

PURPOSE: To identify potential risk factors for the development of venous thromboembolic events in testicular cancer patients receiving platinum-based chemotherapy. METHODS: We performed a retrospective analysis including 255 patients with testicular germ cell tumors who received platinum-based chemotherapy from 2003 to 2018 as a multi-center observational cohort study. Patient and tumor characteristics of patients with and without a thromboembolic event were analyzed. RESULTS: 49 (19%) patients experienced a venous thromboembolic event, with the majority representing pulmonary embolism and deep venous thrombosis (47%). There were no significant differences regarding the development of a venous thromboembolic event between first- and second-line regimes. Multivariate analysis showed an increased risk for a venous thromboembolic event in patients with clinical stage ≥ IIC disease (OR 2.259 [95% CI 1.105-4.618], p = 0.026), elevated serum LDH (OR 2.162 [95% CI 1.018-4.593], p = 0.045), febrile neutropenia (OR 2.973 [95% CI 1.363-6.487], p = 0.006) and central venous access (OR 3.465 [95% CI 1.068-11.243], p = 0.039). Patients suffering from a venous thromboembolic event revealed a significantly reduced overall survival (p = 0.033) during a median follow-up of 8 months [IQR 2-18]. CONCLUSIONS: 19% of all patients treated by platinum-based chemotherapy due to testicular cancer suffered from a venous thromboembolic event, associated with reduced overall survival. As a result, monitoring of cancer patients at risk as well as the improvement of patients' awareness of a thromboembolic event should thus be the main goal of their treating physicians.

Extended follow-up of the AdVance XP male sling in the treatment of male urinary stress incontinence after 48 months: Results of a prospective and multicenter study.

OBJECTIVE: To evaluate the efficacy and safety of the AdVance XP male sling in a midterm follow-up for the treatment of male urinary incontinence in a selected patient cohort. MATERIALS AND METHODS: In all, 115 patients with postprostatectomy incontinence were prospectively enrolled. A previous endoscopic evaluation of a sufficient coaptive zone in the repositioning test was mandatory. Patients with urine leakage in supine position or previous incontinence surgery were excluded. Postoperatively a standardized 24-hour pad test and pad usage were evaluated. To compare pre- and postoperative continence status nonparametric t test was used. A P-value of <.05 was seen as statistically significant. RESULTS: Median preoperative urine loss in the 24-hour pad test was 272 g (min. 42-max. 1600) and was significantly improved at any point in follow-up. Success was defined as 0 pads per day and a maximum of 5 g in the 24-hour pad test. After a follow-up of 48 months, 71.7% of the patients were cured, whereas 15.0% of patients had an improved continence situation and 13.3% were classified as failed. Mean urine loss decreased significantly to 24.4 g (P ≤ .001). No severe intra- or postoperative complications are to be reported. Median follow-up was 4.2 years. CONCLUSIONS: A stable effectiveness in a selected patient cohort can also be demonstrated in an extended follow-up. The complication rates are low and no late postoperative complications occurred, indicating the safety of the procedure.

Efficacy of the Oestrogen Antagonist Tamoxifen on Sperm Parameters in Patients with Idiopathic Oligoathenoteratozoospermia.

BACKGROUND: The oestrogen antagonist tamoxifen has been suggested as an empiric treatment option for treating idiopathic oligoathenoteratozoospermia (iOAT). OBJECTIVES: To analyse the use of tamoxifen in iOAT. METHOD: Fifty-seven men receiving tamoxifen for iOAT were recruited from 2016 to 2017 in a retrospective, single-centre setting. Hormone and semen analysis was performed before and after 3 months of treatment. RESULTS: After a 3-month treatment, serum levels of testosterone (3.4 ng/mL [2.7-4.8] vs. 5.3 [3.1-7.1]; p = 0.026), follicle stimulating hormone (FSH; 7.6 [5.9-11.5] vs. 15.9 mIU/mL [8.4-19.9]; p = 0.003) and luteinizing hormone (4.5 [3.3-6.6] vs. 7.6 mIU/mL [4.8-10.7]; p = 0.007) significantly increased. At a cut-off of >8.8 mIU/mL, serum levels of FSH were predictive for an improved sperm motility (OR 0.229 [95% CI 0.068-0.773]; p  = 0.018) and serum levels of inhibin B were predictive for an improved total sperm count at a cut-off of <82 ng/L (OR 18.0 [95% CI 1.267-255.744]; p = 0.033). During an 11 month-follow-up, patients receiving tamoxifen showed a clinical pregnancy rate of 42%, leading to a live birth rate of 56% of all pregnant women. Twenty-three per cent of all patients reported non-serious adverse events. CONCLUSIONS: Tamoxifen is effective in improving the total sperm count as well as motility and can thus be safely used as empiric medical therapy in iOAT.

Long-term functional outcome analysis in a large cohort of patients after radical prostatectomy.

INTRODUCTION: Goal of the study was an analysis of functional outcomes after radical prostatectomy (RP) in a large cohort of patients. METHODS: Functional outcomes were assessed with the ICIQ-SF questionnaire and daily pad-usage for the evaluation of stress urinary incontinence (SUI) as well as with the IIEF-5 score for the evaluation of erectile dysfunction (ED). Statistical analysis included log-rank test, Mann-Whitney-Test, ANOVA test and logistic regression (P < 0.05). RESULTS: In total 4003 patients were included in the study. Median follow-up was 42 months (min. 2-max. 147 mo.). Regarding ED, an IIEF-5 score of ≥20 was reached by 39% of patients. Regarding SUI, 55% stated that they needed no pads, 21% of patients needed one pad per day. 33% of patients reported of no incontinence (0 p. in ICIQ), 26% of patients reported of a mild incontinence (1-5 p. in ICIQ). Patients global impression of their overall health respectively patients subjective quality of life were assessed with the EORTC QLC-C30 and were both high with a median of six points (on a scale of 1-7). In multivariate analysis time since surgery could be identified as independent risk factors on QOL (P = 0.0028), IIEF-5 (P = 0.0149), ICIQ (P < 0.001), and pads per day (P < 0.001). CONCLUSIONS: Our data show a good continence status, a clearly impaired erectile function but overall a good quality of life after surgery. In summary older patients-with an advanced tumor and adjuvant radiation therapy-were at highest risk for an impaired functional outcome.

Prognostic Features for Objectively Defined Urinary Continence after Radical Cystectomy and Ileal Orthotopic Neobladder in a Contemporary Cohort.

PURPOSE: We objectively quantified daytime and nocturnal continence rates, and defined predictive features for favorable continence outcomes after radical cystectomy and orthotopic ileal neobladder creation. MATERIALS AND METHODS: At 1 institution 1,012 cystectomies were performed between 2004 and 2015. Questionnaires evaluating the continence status were sent to 244 patients. To objectify postoperative urine loss daytime and nocturnal pad tests were performed. Continence was defined as the need for up to 1 safety pad and urine loss 10 gm or less per test. Predefined associative features were tested for an influence on continence outcomes. Statistical analysis was done with the Fisher exact and Mann-Whitney U tests, and linear logistic regression models. Significance was considered at p <0.05. RESULTS: A total of 188 patients (77.0%) returned the questionnaires. Median followup was 61 months. Median daytime pad use was 1 pad per day (range 0 to 9). Median daily urine loss based on standardized pad testing was 8 gm (range 0 to 2,400). During the night a median of 1 pad (range 0 to 7) was used and median nocturnal urine loss was 28.5 gm (range 0 to 1,220). The continence rate was 54.3% during the day and 36.3% at night. On multivariate analysis good preoperative ECOG (Eastern Cooperative Oncology Group) status (OR 2.987, p = 0.010), retained sensation of bladder filling (OR 6.462, p = 0.003) and preoperative coronary heart disease (OR 0.036, p = 0.002) were independent predictors of daytime success. Based on preoperative risk factors a simple predictive score for daytime continence was created (AUC 0.725, p <0.001). CONCLUSIONS: Continence rates after orthotopic ileal neobladder creation are lower than previously described when objective continence definitions are applied. Patients with good performance status, without coronary heart disease and with retained sensation of orthotopic ileal neobladder filling have better daytime continence outcomes.

36-month data for the AdVance XP® male sling: results of a prospective multicentre study.

OBJECTIVES: To evaluate the efficacy and safety of the AdVance XP® sling (Boston Scientific, formerly American Medical Systems) in male stress urinary incontinence (SUI) after radical prostatectomy in a prospective multicentre study, as in recent years several studies have shown the effectiveness and safety of the AdVance sling for treating male SUI and in 2010 the second-generation AdVance XP was introduced with several changes in the sling design and a new needle shape. PATIENTS AND METHODS: In all, 115 patients were included. Patients with nocturnal UI, previous UI surgery, previous radiotherapy and a coaptive zone of <1 cm in the preoperative repositioning test were excluded. Postoperatively, a standardised 24-h pad test, quality-of-life scores [International Quality of Life score (IQOL) and International Consultation on Incontinence Questionnaire short form (ICIQ-UI SF)], visual analogue scale (VAS) for pain, five-item version of the International Index of Erectile Function (IIEF-5), International Prostate Symptom Score (IPSS) and Patient Global Impression of Improvement (PGI-I) score, were performed. All patients with a 0-5 g pad test were defined as cured and improved with a reduction of urine loss of >50%. All others were classified as failures. Significance analysis was performed using the Wilcoxon test. RESULTS: The mean (median) preoperative urine loss in the 24-h pad test was 272.0 (272.0) g. After a follow-up of 3 months (114 patients), 64.9% of the patients were cured and 31.6% had an improved continence status. The mean urine loss decreased significantly to 34.9 g (P < 0.001), with a mean VAS score of 0.5, and mean PGI-I of 1.5. After a follow-up of 24 months (80 patients), 68.8% of the patients were cured and 22.5% had improved. The mean urine loss decreased significantly to 19.1 g (P < 0.001), with a mean VAS score of 0.3, and mean PGI-I of 1.5. After a follow-up of 36 months (47 patients), 66.0% of the patients were cured and 23.4% had improved. The mean urine loss decreased significantly to 21.8 g (P < 0.001), with a mean VAS score of 0.0, and mean PGI-I of 1.6. The mean IQOL and ICIQ-UI SF improved significantly (both P < 0.001) after 36 months. There were no significant postoperative changes in IIEF-5 and IPSS. No intraoperative and no long-term complications occurred. No erosion or explanations occurred. CONCLUSION: The AdVance XP shows good and stable effectiveness and low complication rates even at a mid-term follow-up of up to 36 months.

Perioperative patient education improves long-term satisfaction rates of low-risk prostate cancer patients after radical prostatectomy.

PURPOSE: To evaluate patient-reported functional outcomes after radical prostatectomy (RP) and to analyse the effect of perioperative patient education on satisfaction rates among low-risk prostate cancer patients. METHODS: Inclusion criteria encompassed low-risk prostate cancer patients as defined by the D'Amico criteria, undergoing nerve-sparing RP without pelvic lymph node dissection. Patient-centred functional outcomes, subjective evaluation of perioperative counselling, and patient satisfaction rates were documented. Stress urinary incontinence (SUI) was assessed by daily pad usage. Erectile dysfunction (ED) was assessed using IIEF5 score. Patients' histories were attained from the electronic medical records. The effect of pre-defined predictive features for satisfaction rates was analysed in low-risk patients. Statistical analyses included Fisher's exact test, Mann-Whitney-U test, and binary logistic regression models (p < 0.05). RESULTS: 266 patients met the inclusion criteria. Median follow-up was 94 months (68-118). The global satisfaction rate was 75.1%. Regarding SUI, 69.5% of patients required no pads. 67.1% felt very well informed, while 11.7% felt poorly educated about postoperative SUI. Regarding ED, an IIEF score of ≥18 was reached by 33.7%. 59.6% felt very well educated, while 13.0% felt poorly informed. Poor patient counselling regarding SUI and ED led to significantly decreased long-term satisfaction rates [40.7, 33.3% (p < 0.001)]. In multivariate analysis, poor ED patient counselling [OR 0.190, 95% CI 0.055-0.652 (p = 0.008)], and postoperative IIEF5 score [OR 3.061, 95% CI 1.013-3.111 (p = 0.013)] could be confirmed as independent predictors for patient satisfaction. CONCLUSIONS: Patient-centred functional outcome analysis has illustrated the importance of perioperative patient education on long-term patient satisfaction rates after RP in low-risk prostate cancer patients.

Prospective evaluation of health-related quality of life after radical cystectomy: focus on peri- and postoperative complications.

OBJECTIVES: To analyse the impact of perioperative complications and complex treatment courses on postoperative health-related quality of life (HRQOL) after radical cystectomy (RC) and continent (ONB) or incontinent (IC) urinary diversion at multiple prospective time points. METHODS: A total of 121 consecutive patients underwent RC with curative intent between 2013 and 2014. HRQOL was prospectively assessed preoperatively, after 3 and 12 months, using the QLQ-C30 questionnaire. The impact of complex perioperative treatment courses including cases requiring surgical re-interventions was retrospectively assessed using Martin criteria and the Clavien-Dindo scale. Urinary continence was determined using the validated ICIQ-SF questionnaire. Statistical analysis included Kruskal-Wallis ANOVA, Spearman's rank correlation, and ordinal regression models (p < 0.05). RESULTS: A total of 100 patients underwent further analysis. Physical functioning (PF), role functioning (RF), and global health status (GHS) scores were higher in the ONB subgroup both preoperatively (p < 0.001, 0.010, 0.048) and 3 months after RC (p = 0.003, 0.048, 0.019). Clavien complications ≥III led to reduced PF levels after 3 months (p = 0.050) without effect on GHS (p = 0.825). Operating time and length of critical care monitoring correlated with 3 months pain scores in the ONB subgroup (p = 0.003, 0.009) without affecting GHS (p = 0.603, 0.653). Continent urinary diversion was an independent predictor of increased HRQOL after 3 months (p = 0.021), however, not after 12 months (p = 0.803). CONCLUSIONS: Patients receiving an IC have lower PF, RF, and GHS scores than those receiving ONB. Perioperative complications and complicated treatment courses can affect HRQOL subdomains but do not significantly impact the GHS. ONB is an independent predictor for better overall HRQOL 3 months, but not 12 months after RC.