PI-RADS upgrading as the strongest predictor for the presence of clinically significant prostate cancer in patients with initial PI-RADS-3 lesions.

PURPOSE: Unclear lesions on multiparametric magnetic resonance tomography (mpMRI) are challenging for the indication of biopsy in patients with clinical suspicion of prostate cancer (PCa). The aim of this study is the validation of the detection rate of clinically significant PCa (csPCa) in patients with PI-RADS 3 findings and to determine the appropriate follow-up strategy. METHODS: In this retrospective single-center study, patients with maximum PI-RADS 3 lesions underwent targeted MRI/ultrasound-fusion biopsy (tPbx) combined with systematic 12-core biopsy (sPbx) and follow-up mpMRI with further control biopsy. We assessed the evolution of MRI findings (PI-RADS, volume of the lesion), clinical parameters and histopathology in follow-up MRI and biopsies. The primary objective is the detection rate of csPCa, defined as ISUP ≥ 2 findings. RESULTS: A total of 126 patients (median PSA 6.65 ng/ml; median PSA-density (PSAD) 0.13 ng/ml2) were included. The initial biopsy identified low-risk PCa in 24 cases (19%). During follow-up biopsy, 22.2% of patients showed PI-RADS upgrading (PI-RADS > 3), and 29 patients (23%) exhibited a tumor upgrading. Patients with PI-RADS upgrading had a higher risk of csPCa compared to those without PI-RADS upgrading (42.9% vs. 9.18%, p < 0.05). PI-RADS upgrading was identified as an independent predictor for csPCa in follow-up biopsy (OR 16.20; 95% CI 1.17-224.60; p = 0.038). CONCLUSION: Patients with stable PI-RADS 3 findings may not require a follow-up biopsy. Instead, it is advisable to schedule an MRI, considering that PI-RADS upgrading serves as an independent predictor for csPCa.

Follow-up of vascular-targeted photodynamic therapy in a real-world setting.

PURPOSE: Vascular-targeted photodynamic therapy (VTP) is an approved treatment option for unilateral low-risk prostate cancer (PCa). METHODS: Patients with unilateral low- or intermediate-risk PCa undergoing hemiablation by VTP were evaluated in a real-world setting. Oncological outcome after VTP was measured by MRI-based re-biopsy at 12 and 24 months. Functional outcome after 1 year was investigated by IIEF-5 and IPSS questionnaires. Progression was defined as the evidence3 of ISUP ≥ 2 PCa. RESULTS: At any control biopsy (n = 46) after VTP, only 37% of patients showed no evidence of PCa. Recurrence-free survival was 20 months (95% CI 4.9-45.5) and progression-free survival was 38.5 months (95% CI 33.5-43.6 months). In-field and out-field recurrent PCa occurs in 37% (55% ISUP ≥ 2 PCa) and 35% (56% ISUP ≥ 2 PCa). Seventy-nine percent of patients preserved erectile function, respectively. Ten percent of patients presented long-term bladder outlet obstruction. None of the patients presented incontinence. CONCLUSION: Due to the high-recurrence in- and out-field recurrence rate in a mainly low-risk prostate cancer cohort, VTP has to be regarded critically as a therapy option in these patients. Pre-interventional diagnostic evaluation is the main issue before focal therapy to reduce the risk of tumor recurrence and progression.

Treatment trends for undescended testis and impact of guideline changes a medical health care analysis of orchidopexy and cryptorchidism in Germany between 2006 und 2020.

BACKGROUND: The last decades revealed new scientific knowledge regarding the fertility and potential malignancy of undescended testis AQ2(UDT). Accordingly, many guidelines changed their recommendation concerning timing of therapy, with the goal of an earlier time of surgery. METHODS: We analyzed the number of new diagnosis and performed surgeries in predefined age groups provided by the obligatory annual reports of German hospitals in the reimbursement.INFO"-tool between 2006 and 2020. RESULTS: Overall, 124,741 cases were analyzed. We showed a slight increase in performed surgeries in the first year by 2% per year with a main increase till 2011, a constant number of surgeries between first and 4th year and a decrease of surgeries between 5 and 14th year of living with a main decrease till 2009 by 3% per year. CONCLUSION: Even if our results illustrate an increasing adaption of the guideline's recommendation, there is still a significant number of patients who receive later treatment. More research about the reasons and circumstances for the latter is needed.

The Role of Multiparametric MRI (mpMRI) in the Prediction of Adverse Prostate Cancer Pathology in Radical Prostatectomy Specimen.

INTRODUCTION: Prostate cancer (PCa) risk stratification is essential in guiding therapeutic decision. Multiparametric magnetic resonance tomography (mpMRI) holds promise in the prediction of adverse pathologies (AP) after prostatectomy (RP). This study aims to identify clinical and imaging markers in the prediction of adverse pathology. METHODS: Patients with PCa, diagnosed by targeted biopsy after mpMRI and undergoing RP, were included. The predictive accuracy of mpMRI for extraprostatic extension (ECE), seminal vesicle infiltration (SVI), and lymph node positivity was calculated from the final histopathology. RESULTS: 846 patients were involved. Independent risk parameters include imaging findings such as ECE (OR 3.12), SVI (OR 2.55), and PI-RADS scoring (4: OR 2.01 and 5: OR 4.34). mpMRI parameters such as ECE, SVI, and lymph node metastases showed a high prognostic accuracy (73.28% vs. 95.35% vs. 93.38%) with moderate sensitivity compared to the final histopathology. The ROC analysis of our combined scoring system (D'Amico classification, PSA density, and MRI risk factors) improves the prediction of adverse pathology (AUC: 0.73 vs. 0.69). CONCLUSION: Our study supports the use of mpMRI for comprehensive pretreatment risk assessment in PCa. Due to the high accuracy of factors like ECE, SVI, and PI-RADS scoring, utilizing mpMRI data enabled accurate prediction of unfavorable pathology after RP.

Retroperitoneal lymph node dissection for testicular cancer is a demanding procedure: detailed real-life data of complications and additional surgical procedures in 295 cases.

PURPOSE: Retroperitoneal lymph node dissection (RPLND) for germ cell tumours is a challenging procedure that may present relevant complications. The purpose was to analyse postoperative complications and identify risk factors for major complications. METHODS: This is a retrospective unicentric analysis of a large cohort of 295 RPLNDs from 1992 to 2020. Early complications (30 days) and late complications (31-180 days) were classified according to the Clavien‒Dindo classification. The influence of surgical, patient-specific, and tumour-specific parameters on grade III-V complications was analysed in univariate and multivariate logistic regression models. RESULTS: A total of 232 were postchemotherapy RPLNDs, and 63 were primary RPLNDs. Early postoperative complications were found to be grades I-II in 58.6% (173/295), grades III-IV in 9.8% (29/295), and grade V in 0.3% (1/295). In 20% (58/295), additional surgical procedures were needed. Grade III-V complications were associated with ≥ 4 cycles of preoperative chemotherapy (OR 3.7 (1.5-8.9); p = 0.004), RPLND specimen (nonseminoma or immature teratoma) (OR 3.1 (1.4-6.6); p = 0.005), transfusions (OR 2.4 (1.1-5.4); p = 0.03), salvage RPLND (OR 4.1 (1.8-9.3); p < 0.001), and preoperatively elevated AFP (OR 5 (2.2-11.7); p < 0.001). In multivariate analysis, the only independent predictor for grade III-V complications was preoperative AFP elevation (OR 3.3 (1.2-9.2); p = 0.02). Limitations include the retrospective study design. CONCLUSIONS: Our results demonstrate that RPLND is a demanding surgical procedure. Patients with a complex tumour history have a higher risk of complications. We recommend treatment of these complex cases in high-volume centres.

Insufficient utilization of care in male incontinence surgery: health care reality in Germany from 2006 to 2020 and a systematic review of the international literature.

PURPOSE: Data suggest that the utilization of care in male incontinence surgery (MIS) is insufficient. The aim of this study was to analyse the utilization of care in MIS from 2006 to 2020 in Germany, relate this use to the number of radical prostatectomies (RP) and provide a systematic review of the international literature. METHODS: We analysed OPS codes using nationwide German billing data and hospitals' quality reports from 2006 to 2020. A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). RESULTS: MIS increased by + 68% from 2006 to 2011 (1843-3125; p = 0.009) but decreased by - 42% from 2011 to 2019 (3104-1799; p < 0.001). In 2020, only 1435 MISs were performed. In contrast, RP increased from 2014 to 2019 by 33% (20,760-27,509; p < 0.001). From 2012 to 2019, the number of artificial urinary sphincters (AUSs) changed minimally (- 12%; 1291-1136; p = 0.02). Sling/sling systems showed a decrease from 2011 to 2019 (- 68% 1632-523; p < 0.001). In 2019, 63% of patients received an AUS, 29% sling/sling systems, 6% paraurethral injections, and 2% other interventions. In 2019, few high-volume clinics [n = 27 (13%)] performed 55% of all AUS implantations, and few high-volume clinics [n = 10 (8%)] implanted 49% of retropubic slings. CONCLUSION: MIS have exhibited a relevant decrease since 2011 despite the increase in RP numbers in Germany, indicating the insufficient utilization of care in MIS. The systematic review shows also an international deficit in the utilization of care in MIS.

Upper tract urothelial carcinoma in Germany: epidemiological data and surgical treatment trends in a total population analysis from 2006 to 2019.

PURPOSE: To report contemporary epidemiological data and treatment trends for upper tract urothelial carcinoma (UTUC) in Germany over a 14-year period. METHODS: We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2018/2019. The significance of changes over time was evaluated via regression analysis. Survival outcomes were calculated using the Kaplan-Meier method. RESULTS: There was a non-significant increase in the age-standardized incidence rate from 2.5/100,000 in 2006 to 2.9/100.000 in 2018. 13% of patients presented with lymph node metastasis and 7.6% of patients presented with distant metastasis at primary diagnosis. The 5-year overall survival was estimated at 45% and the 10-year overall survival at 32%. Endoscopic biopsies of the renal pelvis and ureter as well as ureteroscopies with excision/destruction of UTUC all increased significantly over the study period. The number of radical nephroureterectomies (RNU) for UTUC steadily increased from 1643 cases in 2006 to 2238 cases in 2019 (p < 0.005) with a shift from open surgery towards minimally invasive surgery. Complex reconstructive procedures like ileal ureter replacement or autotransplantation are rarely performed for urothelial carcinoma of the ureter. CONCLUSION: Diagnostic and therapeutic procedures for UTUC have increased and minimally invasive nephroureterectomy is the predominant approach concerning radical surgery in 2019.

Hospital rating websites play a minor role for uro-oncologic patients when choosing a hospital for major surgery: results of the German multicenter NAVIGATOR-study.

PURPOSE: Hospital rating websites (HRW) offer decision support in hospital choice for patients. To investigate the impact of HRWs of uro-oncological patients undergoing elective surgery in Germany. METHODS: From 01/2020 to 04/2021, patients admitted for radical prostatectomy, radical cystectomy, or renal tumor surgery received a questionnaire on decision-making in hospital choice and the use of HRWs at 10 German urologic clinics. RESULTS: Our study includes n = 812 completed questionnaires (response rate 81.2%). The mean age was 65.2 ± 10.2 years; 16.5% were women. Patients were scheduled for prostatectomy in 49.1%, renal tumor surgery in 20.3%, and cystectomy in 13.5% (other 17.1%). Following sources of information influenced the decision process of hospital choice: urologists' recommendation (52.6%), previous experience in the hospital (20.3%), recommendations from social environment (17.6%), the hospital's website (10.8%) and 8.2% used other sources. Only 4.3% (n = 35) used a HRW for decision making. However, 29% changed their hospital choice due to the information provided HRW. The most frequently used platforms were Weisse-Liste.de (32%), the AOK-Krankenhausnavigator (13%) and Qualitaetskliniken.de (8%). On average, patients rated positively concerning satisfaction with the respective HRW on the Acceptability E-Scale (mean values of the individual items: 1.8-2.1). CONCLUSION: In Germany, HRWs play a minor role for uro-oncologic patients undergoing elective surgery. Instead, personal consultation of the treating urologist seems to be far more important. Although patients predominantly rated the provided information of the HRW as positive, only a quarter of users changed the initial choice of hospital.

Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct?

PURPOSE: To describe the change in upper urinary tract stone management in Germany over a 14-year period. METHODS: Using remote data processing we analyzed the nationwide German billing data from 2006 to 2019. To analyze the clinics' case numbers and regional trends, we used the reimbursement.INFO tool based on standardized quality reports of all German hospitals. To also cover shock wave lithotripsy (SWL) as an outpatient procedure, we analyzed the research database of the Institute for Applied Health Research with a representative anonymous sample of 4 million insured persons. RESULTS: The number of inpatient interventional therapies for upper tract urolithiasis in Germany increased from 70,099 cases in 2006 to 94,815 cases in 2019 (trend p < 0.0001). In-hospital SWL declined from 41,687 cases in 2006 to 10,724 cases in 2019 (decline of 74%; trend p < 0.0001). The percentage of SWL as an outpatient procedure increased between 2013 and 2018 from 36 to 46% of all performed SWL, while total SWL case numbers declined. Contrarily, the number of ureteroscopies increased from 32,203 cases in 2006 to 78,125 cases in 2019 (increase of 143%; trend p < 0.0001). The number of percutaneous nephrolithotomy also increased from 1673 cases in 2006 to 8937 in 2019 (increase of 434%; trend p < 0.0001). CONCLUSION: We observed an increase in interventional therapy for upper tract urolithiasis in Germany with a dramatic shift from SWL to endoscopic/percutaneous treatment. These changes may be attributed to enormous technological advances of the endoscopic armamentarium and to reimbursement issues.

Decreasing Number of Urodynamics in Urological and Gynaecological Clinics Reflects Decreased Importance for Surgical Indications: German Population-Based Data from 2013 to 2019.

INTRODUCTION: The routine use of urodynamic studies (UDS) has been questioned. Additionally, the material and personnel costs are poorly remunerated. We aimed to analyse the UDS utilization in Germany. METHODS: We analysed UDS performed by hospitals based on quality reports from 2013 to 2019. A representative sample of 4 million insured persons was used to estimate outpatient UDS utilization from 2013 to 2018. RESULTS: There was an overall decrease of 14% in UDS in Germany from 2013 to 2018 (60,980 to 52,319; p = 0.003). In the outpatient sector, there was a slight non-continuous drop of 11% from 34,551 to 30,652 from 2013 to 2018 (p = 0.06). UDS utilization in hospitals decreased by 26% from 26,429 in 2013 to 19,453 in 2019 (p = 0.004). University hospitals showed a smaller decrease (3,007 to 2,685; p = 0.02). In urology, the number of UDS (11,758 to 6,409; p < 0.001) and the number of performing departments (328 to 263 clinics; p < 0.001) decreased. Gynaecological departments also showed a decrease in UDS (1,861 to 866; p < 0.001) and performing departments (159 to 68; p < 0.001). However, in paediatrics, there was an increase in UDS (1,564 to 2,192; p = 0.02). By age, the number of children remained constant (1,371 to 1,252; p = 0.2), but there was a strong decrease seen in 60- to 79-year-olds (9,792 to 5,564; p < 0.001). CONCLUSION: UDS appear to be less important in the indication for surgery. Despite high resource expenditure and low remuneration, the decrease in urodynamics in the outpatient sector is less pronounced, indicating a trend to perform UDS in an outpatient setting.

Decision Regret and Quality of Life after Focal Therapy with Vascular-Targeted Photodynamic Therapy (TOOKAD®) for Localized Prostate Cancer.

PURPOSE: The aim of the study was to assess quality of life (QoL), decision involvement, and decisional regret after treatment with vascular-targeted photodynamic therapy (VTP) (TOOKAD®) for unilateral low-risk prostate cancer. METHODS: Validated questionnaires (EORTC QLQ-C30 and QLQ-PR25) capturing QoL post-treatment, involvement in decision-making (Control Preferences Scale) and decision regret (Decisional Regret Scale), were given to patients at the 12-month visit after undergoing VTP at our institution between May 2018 and February 2021. RESULTS: Out of 44 patients, 36 patients were included in this study and 31 (86.1%) responded to the questionnaires. Mean overall health score capturing QoL at 12 months was 79.3 (standard deviation: ±18.1). 70.9% of the patients (n = 22) had no decision regret, and 67.8% of men (n = 21) had an active role in decision-making. In control biopsy at 12 months post-treatment, 19.4% of patients (n = 7) presented with local recurrence and progression to higher Gleason score (GS) was found in 13.8% of patients (n = 5). Patients (n = 3) presenting with tumor recurrence or progression to higher GS in control biopsy showed a significantly higher level of decision regret (p < 0.009). CONCLUSION: Only 9.7% of men (n = 3) felt a strong emotion of regret at 12 months after VTP. Level of decision regret was significantly higher in patients with local recurrence or tumor progression detected in control biopsy. QoL was stable after VTP.

Development of Incidence and Surgical Treatment of Penile Cancer in Germany from 2006 to 2016: Potential Implications for Future Management.

BACKGROUND: Penile cancer is a rare disease and surgical treatment often entails a significant impact on quality of life. The aim of this study was to analyze trends in surgical treatment patterns in Germany. METHODS: We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2016. All penile cancer cases with penile surgery or lymph node dissection (LND) were included. We also analyzed the distribution of cases, extent of surgery, and length of hospital stay, stratified for annual caseload. The geographical distribution of centers for 2016 was presented. RESULTS: During the investigated timespan, tumor incidences increased from 748 to 971 (p = 0.001). We identified 11,353 penile surgery cases, increasing from 886 to 1196 (p < 0.001), and 5173 cases of LND, increasing from 332 to 590 (p < 0.001). Cases of partial amputation increased from 45.8 to 53.8% (p < 0.001), while total amputation remained stable at 11.2%. Caseload in high-volume hospitals increased from 9.0 to 18.8% for penile surgery (p < 0.001) and from 0 to 13.1% for LND (p < 0.001). The increase in LND caseload was caused by an increase in inguinal LND, from 297 to 505 (p < 0.001), with increasing sentinel LND, from 14.2 to 21.9% (p = 0.098). The assessment of geographical distribution of cases in Germany revealed extensive areas without sufficient coverage by experienced centers. CONCLUSIONS: We saw consistent increases in penile surgery and LND, with a growing number of cases in high-volume hospitals, and, accordingly, an increase in tumor incidence. The increasing use of inguinal LND and organ-preserving surgery reflect the adaptation of current guidelines; however, geographical distribution of experienced centers could be improved.

Robotic radical prostatectomy: difficult to start, fast to improve? Influence of surgical experience in robotic and open radical prostatectomy.

PURPOSE: The assistance of robotic systems raises the concern of whether there is an improved learning in robotic-assisted radical prostatectomy (RARP) compared to open retropubic radical prostatectomy (ORP). METHODS: We retrospectively analyzed data from 1438 patients who underwent ORP (n = 735) or RARP (n = 703). For each procedure, the level of experience of three different surgeons was summarized. Perioperative and pathological parameters reflecting surgical performance were compared between both learning curves. RARP data were influenced by new introduction of the robotic system. RESULTS: The median patient age at surgery was 66 years (IQR 42-80). Patients in the RARP group were younger (p < 0.001) and had a lower oncological risk (p < 0.001). Inexperienced RARP surgeons had a higher pT2-PSM rate and lower lymph node yield (13.8 ± 4.7 vs. 14.7 ± 4.8; p = 0.03) than inexperienced ORP surgeons. After 100 procedures, RARP and ORP surgeons had the same pT2-PSM rate (8% vs. 8%; p = 0.8) and lymph node yield (15.4 ± 5.4 vs. 15.4 ± 5.1; p = 1.0). In multivariate analysis for ORP, surgical inexperience (≤ 100 cases) was an independent predictor of a longer operating time (OR 9.0; p < 0.001) and higher amount of blood loss (OR 2.9; p < 0.001). For RARP, surgical inexperience (≤ 100 cases) was a predictor of a longer operating time (OR 3.9; p < 0.001), higher amount of blood loss (OR 1.9; p = 0.004), higher pT2-PSM rate (OR 1.6; p = 0.03), and lower lymph node yield (OR 0.6; p = 0.001). CONCLUSIONS: Surgical experience has a relevant impact on perioperative and pathological parameters RARP has a higher initial pT2-PSM rate and lower lymph node yield than ORP. This is relevant for patient selection for novice teaching in RARP.

Treatment of post-prostatectomy urinary incontinence and erectile dysfunction: there is insufficient utilisation of care in German cancer survivors.

PURPOSE: Treatment of post-prostatectomy urinary incontinence (UI) and erectile dysfunction (ED) increases quality of life (QoL). Aim of our study was to evaluate the utilisation of care among patients with post-prostatectomy UI and ED in Germany. METHODS: The HAROW study documented treatment of patients with localised prostate cancer (≤ T2c) in Germany. 1260 patients underwent radical prostatectomy (RP). Patients answered validated questionnaires after a median follow-up of 6.3 years. Response rate was 76.8%. RESULTS: Median age at RP was 65 (IQR 60-69) years. 14% (134/936) used more than one pad per day for UI. 25% (26/104, 30 missing) of UI patients underwent surgery to improve continence. Of patients without surgery, 41% (31/75) reported a moderate-to-severe issue concerning their incontinence with worse mental health and QoL. 81% (755/936) patients were unable to have an erection firm enough for sexual intercourse. Of all ED patients, 40% (319/793) used ED treatment regularly or tried it at least once. 49% (243/499) of patients with interest in sex never tried ED treatment. In multivariate analysis, patients not using ED treatments were older (≥ 70 years OR 4.1), and more often had preoperative ED (OR 2.3) and less interest in sex (OR 2.2). Nevertheless, 30% (73/240) of these patients had moderate-to-severe issues with their ED reporting worse mental health and QoL. CONCLUSION: Almost half of the patients without post-prostatectomy UI and ED treatment reported moderate-to-severe issues with a significant decrease in QoL. This indicates an insufficient utilisation of care in Germany.

Decision Regret after Radical Prostatectomy does Not Depend on Surgical Approach: 6-Year Followup of a Large German Cohort Undergoing Routine Care.

PURPOSE: Numerous studies have compared the outcomes of open and robot-assisted radical prostatectomy but to our knowledge only 1 study has focused on patient satisfaction and regret. We evaluated intermediate term decision regret after open and robot-assisted radical prostatectomy. MATERIALS AND METHODS: The HAROW (Hormonal Therapy, Active Surveillance, Radiation, Operation, Watchful Waiting) study analyzed localized prostate cancer treatments (T2c N0 M0 or less) in Germany from 2008 to 2013. We collected intermediate term followup data on 1,260 patients after retropubic open or robot-assisted radical prostatectomy. RESULTS: The response rate was 76.8% (936 of 1,218 cases). A total of 404 patients underwent robot-assisted radical prostatectomy and 532 underwent open radical prostatectomy. Patients treated with the robot-assisted procedure showed more self-determined behavior. They reported an active role in surgical decision making and the surgical approach (robot-assisted radical vs open prostatectomy 39% vs 24% and 52% vs 18%, respectively, each p <0.001). Patients treated with the robot-assisted procedure more often participated actively in selecting the treating hospital (25% vs 11%), used the Internet often (87% vs 72%) and traveled an increased distance (63 vs 42 km, all p <0.001). Overall decision regret was low with a mean ± SD score of 14 ± 19 on a scale of 0-no regret to 100-high regret. Multivariate analysis showed that erectile function (OR 3.2), urinary continence (OR 1.8), freedom from recurrence (OR 1.6), an active decision making role (OR 2.2) and shorter followup (OR 0.9 per year) predicted low decision regret (score less than 15). CONCLUSIONS: Intermediate term functional and oncologic outcomes as well as autonomous decision making and followup time influenced decision regret after radical prostatectomy. The surgical approach was not associated with intermediate term decision regret.

Trends in Renal Tumor Surgery in the United States and Germany Between 2006 and 2014: Organ Preservation Rate Is Improving.

BACKGROUND: Nephron-sparing surgery (NSS) is the treatment of choice for T1 renal tumors. This study compared the implementation of NSS in the United States and Germany. METHODS: Data were derived from the National Inpatient Sample and from the Nationwide German Hospital Billing Database. All cases of NSS and radical nephrectomy from 2006 to 2014 were analyzed. To assess tumor stage distribution, data from the Surveillance, Epidemiology, and End Results database (United States) and from German cancer registries were used. RESULTS: The study identified 74,663 cases in the United States and 130,051 cases in Germany. The proportion of NSS for T1 tumors increased from 30.6 to 57% in the United States compared with 38.5 to 72.9% (estimation) in Germany (p < 0.001). The proportion of robotic NSS increased from 0 to 54.5% in the United States (p < 0.001) and from 0.2 to 8.6% in Germany (p < 0.001). In a multivariate model, hospitals with higher annual caseloads and a surgical robot favored NSS. CONCLUSION: Patients with renal tumors might receive inhomogeneous care based on the resources of the treating institution. The robotic approach is a key driver for better implementation of NSS in the United States, and relevant potential still may exist for more organ preservation.

Long-term functional outcomes after robotic vs. retropubic radical prostatectomy in routine care: a 6-year follow-up of a large German health services research study.

PURPOSE: To compare long-term functional outcomes after robotic vs. retropubic RP for patients with localized prostate cancer in routine care. METHODS: "HAROW" was a large German noninterventional health services research study that prospectively evaluated the treatment of patients with localized prostate cancer (≤ T2c). We sent validated questionnaires to 1260 patients who underwent RP to evaluate long-term outcomes. RESULTS: After a median follow-up of 6.3 [interquartile range (IQR) 4.8-7.6] years, 42 (3%) patients had died. The return rate of the questionnaire was 76.8% (936/1218). The approach was robotic in 404 and retropubic in 532 patients. In the multivariate analysis, lack of postoperative radiotherapy [odds ratio (OR) 3.1], younger patient age (< 60 years: OR 2.8; 60-69 years: OR 2.1), preoperative urinary continence (OR 2.4), and higher annual hospital caseload (≥ 200 cases: OR 1.6) were independent predictors of urinary continence. The potency rate after nerve-sparing RP in preoperatively potent men was 40.5% (111/274). In the multivariate analysis, younger patient age (< 60 years: OR 17.9; 60-69 years: OR 8.0), lower oncologic risk (OR 2.8), and lack of postoperative radiotherapy (OR 2.2) were independent predictors of potency. CONCLUSION: Younger age and lack of postoperative radiotherapy were associated with better urinary continence and erectile function. Additionally, a high annual caseload (≥ 200 RP/year) was associated with better urinary continence. Younger age, low or intermediated oncological risk and lack of postoperative radiotherapy were independent predictors for a trifecta outcome. The surgical approach did not affect long-term functional outcomes.

Centralization tendencies of retroperitoneal lymph node dissection for testicular cancer in Germany? A total population-based analysis from 2006 to 2015.

INTRODUCTION: Retroperitoneal lymph node dissection (RPLND) is a standard treatment in the management of metastatic testicular cancer. Due to modified treatment algorithms, it is becoming less frequent. MATERIALS AND METHODS: We analyzed data from the nationwide German hospital billing database covering 2006-2015. Cases with a testicular cancer diagnosis combined with RPLND were included. We assessed the length of hospital stay (LOS), blood transfusion, and in-hospital mortality stratified for surgical approach, hospital characteristics, and annual caseload. Annual hospital caseload categories were defined as low (< 4), medium (4-10), and high (> 10). We supplemented tumor incidence and staging data from the German cancer registry (60% of population). RESULTS: 4926 cases were included with decreasing annual caseload numbers from 623 in 2006 to 382 in 2015. The incidence of testicular cancer and higher tumor stages remained stable. High-volume hospitals performed 19.4%, medium-volume hospitals 43.7%, and low-volume hospitals 36.8% RPLNDs. Low- abd medium-volume hospitals declined, while high-volume hospitals (n = 5) maintained their annual caseload. Overall in-hospital mortality was 0.47%. Blood transfusion rates were higher in high-volume centers assumedly due to selection of more complex cases. However, high-volume hospitals showed a shorter LOS with 10.5 vs. 11.2 (medium volume), and 12.7 days (low volume). CONCLUSION: Total numbers of RPLND have declined from 2006 to 2015, while tumor incidences and stages remained fairly stable. Constant reduction of indication in guidelines contributes to this finding. High-volume hospitals achieve shorter hospital stays in spite of assumedly more complex and extensive cases. There is a modest trend towards unregulated centralization.

Testicular cancer guideline adherence and patterns of care in Germany: A nationwide survey.

Testicular cancer has excellent cure rates; however, poor guideline adherence can lead to inappropriate management, with a detrimental effect on outcomes. Therefore, we aimed to investigate the current patterns of care for testicular cancer patients and to evaluate guideline adherence. A 19-item survey was distributed among German urologists between September 2015 and September 2016. The response rate was 45% (411/920). Staging imaging of the chest was performed by computed tomography (CT) in 85.5% and X-ray in 17.7%, and for the abdomen, by CT in 83.7% and by magnetic resonance imaging (MRI) in 21.1%. Areas of discrepancy with respect to guideline recommendations included underuse of MRI and infrequent follow-up examinations for changes in the cardiovascular, endocrine, neurological, and pulmonary systems, in addition to psychological burden. Further deviations of reported routine procedures from guideline recommendations were identified in the fields of active surveillance in Stage I seminoma, contralateral biopsies (63.1% overuse) and cryopreservation (19.2% underuse). Moreover, we found that hospital-based clinicians and younger specialists, with ≤5 years of practice following board certification, perform a more accurate and thorough follow-up. German urologists show relatively strong guideline adherence in staging patterns. Significant improvements are necessary in the following areas: recommending cryopreservation, imaging modalities and accurate follow-up examinations with a focus on late toxicities.

In-Hospital Outcomes after Radical Cystectomy for Bladder Cancer: Comparing National Trends in the United States and Germany from 2006 to 2014.

BACKGROUND: Radical cystectomy (RC) still poses a significant risk for mortality and morbidity. OBJECTIVES: We compared in-hospital outcomes after RC in the United States and -Germany using population-based data. METHODS: We compared data from the US Nationwide Inpatient Sample to the German hospital billing database. Mortality and transfusion during hospital stay and length of stay (LOS) were evaluated. RESULTS: In all, 17,711 (the United States) and 60,447 (-Germany) cases were included. The share of robot-assisted RC increased to 20.5% in the United States vs. 2.3% in Germany (p < 0.001). In-hospital mortality was 1.9% (the United States) vs. 4.6% (Germany), transfusion rates were 34.2% (the United States) vs. 58.7% (Germany), and LOS was 10.7 (the United States) vs. 25.1 days (Germany; all p < 0.001). On multivariate analysis, higher patient age and lower annual hospital caseload were associated with increased mortality and longer LOS. Minimal-invasive surgery was associated with less blood transfusion and shorter LOS in the United States vs. hospital caseload and choice of urinary diversion in Germany. CONCLUSIONS: Healthcare systems might exert a relevant impact on outcomes of oncologic surgery. Increased in-hospital mortality rates in Germany seem to be partly explained by much longer LOS compared to those in the United States. Annual caseload seems to be influential on in-hospital outcomes raising the question of centralization of RC.