Infection rate and complications after 621 transperineal MRI-TRUS fusion biopsies in local anesthesia without standard antibiotic prophylaxis.

PURPOSE: The aim of this study was to assess the post biopsy infection rate, feasibility and prostate cancer (PCa) detection rate (CDR) by performing transperineal MRI-TRUS fusion biopsy of the prostate (TPBx) under local anesthesia (LA) without antibiotic prophylaxis (AP). METHODS: We prospectively screened 766 men with suspicious lesions on mpMRI, an elevated PSA level or a suspect digital examination undergoing MRI-TRUS-TPBx in LA, from May 2019 to July 2020. Patients with the need for antibiotic prophylaxis or without a PI-RADS target lesion were excluded from final analyses. We reported CDR, perioperative pain (0-10) and postoperative complications. PCa with an ISUP grade ≥ 2 was classified as clinically significant PCa (csPCa). RESULTS: We included 621 patients with a median age of 68 years (IQR 62-74), a PSA of 6.43 ng/mL (IQR 4.72-9.91) and a prostate volume of 45 cc (IQR 32-64). In median, 4 targeted (TB) (IQR 3-4) and 6 (IQR 5-7) systematic biopsies (SB) detected in combination overall 416 (67%) PCa and 324 (52%) csPCa. Overall CDR of TB for PI-RADS 3, 4 and 5 was 26%, 65% and 84%, respectively. Patients reported a median perioperative pain level of 2 (IQR 1-3). Four patients (0.6%) developed a post biopsy infection, one experienced urosepsis. CONCLUSION: Our results demonstrate that transperineal MRI-TRUS fusion-guided prostate biopsy under LA without AP is feasible, safe and well tolerated.

Pre-operative assessment of living renal transplant donors with state-of-the-art imaging modalities: computed tomography angiography versus magnetic resonance angiography in 118 patients.

PURPOSE: To compare current technology multislice computed tomography angiography (CTA) with magnetic resonance angiography (MRA) in the pre-operative evaluation of vascular anatomy of living renal transplant donors. METHODS AND MATERIALS: Two hundred and thirty-six kidneys were included in the CTA and MRA analysis. Renal vasculature was evaluated independently by two readers in each modality with a delay of 4 weeks between reading sessions. Surgical correlation on the operated side was available in all patients. The reference standard was defined by surgical correlation and consensus reading of both modalities. RESULTS: Detection rate of CTA for arteries was 99.1 and 95.0 % for reader 1 and reader 2, respectively. Detection rate of MRA for arteries was 95.0/94.3 %. Most of the undetected arteries were ≤ 1 mm diameter (reader 1: 2 of 3 in CTA and 9 of 16 in MRA; reader 2: 11 of 16 in CTA, and 8 of 18 in MRA). Detection rates for arteries ≥ 2 mm for reader 1/reader 2 were 99.7/98.7 % in CTA and 99.1/97.8 % in MRA, respectively. Detection rates for veins were 99.6/97.4 % in CTA and 97.8/96.9 % in MRA, respectively. Both readers misdiagnosed between 0 and 1 non-present arteries and between 2 and 3 non-present veins in both modalities. CONCLUSIONS: Modern multislice CT and MRI scanners allow highly accurate evaluation of the vascular anatomy, especially for vessels of ≥ 2 mm diameter. CTA may provide slightly better depiction of very small arteries; however, this may be reader-dependent. Additional factors affecting the choice of imaging modality should include local availability, cost, and the desire to avoid ionizing radiation in healthy transplant donors.

Impact of obstructive interval and sperm granuloma on patency and pregnancy after vasectomy reversal.

The objective of this study was to determine the effect of the obstructive interval and the presence of a sperm granuloma on vas patency and pregnancy rate following vasectomy reversal. We identified 334 patients with complete follow-up who met the inclusion criteria. There were significant associations between the obstructive interval and procedure performed as well as with patient age. Patients with longer obstructive intervals were more often older (p < 0.001) and more likely to have a vaseoepididymostomy performed (p < 0.001). There was no association between the presence of a sperm granuloma or the length of the obstructive interval with post-operative vas patency and pregnancy rates. The only independent predictor of post-operative fertility was age of the female partner (p = 0.015). Our data clearly demonstrates that when state of the art surgical techniques are used, neither the presence of a sperm granuloma nor the obstructive interval serve as prognosticators of post-operative vas patency and pregnancy rates. However, when counselling patients and their female partners, it is of utmost importance to stress that the age of the female partner is an independent predictor of successful vasectomy reversal.

[Initial results of perineal MRI/ultrasound fusion biopsies under local anesthesia without standard perioperative antibiotic prophylaxis]. / Etablierung der perinealen MRT­/Ultraschallfusionsbiopsien in Lokalanästhesie ohne standardmäßige, perioperative Antibiotikaprophylaxe.

The perineal approach for prostate biopsy (PB) is a sterile alternative to conventional transrectal PB. Targeted local anesthesia allows perineal prostate biopsy (pPB) to be performed without general anesthesia. This paper presents the first results after establishing perineal MRI/ultrasound fusion biopsy (pFB) under local anesthesia without standard perioperative antibiotic prophylaxis. For this purpose, 144 patients were included in the study after pFB at the Vivantes Klinikum am Urban. No peri-interventional antibiotic prophylaxis was applied. Peri- and postoperatively, the pain sensation, measured using an analogue pain scale from 0-10, and complications were recorded. The median patient age was 68 and the median prostate-specific antigen (PSA) value 7.07 ng/ml. In all, 49% of the patients received primary PB. The overall detection rate for prostate cancer (PCa) was 71% and for PI-RADS 3, 4 and 5 was 44, 71 and 92%, respectively. The median pain sensation during biopsy was 2. Furthermore, 63% of patients with a transrectal prebiopsy considered this to be more painful and another 20% expressed similar pain levels. Only 1 patient developed a febrile urinary tract infection. The pFB of the prostate under local anesthesia without antibiotic, perioperative prophylaxis is a suitable alternative to the transrectal PB with regard to the detection rate of PCa, the side effect profile and the subjective pain perception of the patients during the intervention.

Use of heart rate variability analysis to determine the risk of cardiac ischaemia in high-risk patients undergoing general anaesthesia.

The aim of this study was to investigate the use of pre-operative heart rate variability analysis to predict postoperative cardiac events (identified by 24 h Holter-ECG recording and an increase of creatine kinase MB) in high-risk cardiac patients. Length of hospital stay, the incidence of postoperative cardiac ischaemia and cardiac events after discharge were recorded. Fifty patients were assigned by the presence of cardiac events and the heart rate variability in 17 patients with an event was compared with 33 patients without. Total power was identified as a predictive parameter. The usefulness of this test was assessed in a second group of 50 patients. The incidence of cardiac events detected by Holter-ECG recording or an increased creatine kinase MB was greater and the duration of hospital stay longer in the 26 patients with total power < 400 ms(2).Hz(-1) compared with those with total power > 400 ms(2).Hz(-1) (eight and four patients and 10 (7) days (mean (SD)), vs 1 (p < 0.05) and 0 (p < 0.05) patients and 6 (2) days (p < 0.05), respectively). The total power of high-risk cardiac patients predicted postoperative cardiac events and extended length of hospital stay.

[Propensity score comparison of the various radical surgical techniques for high-risk prostate cancer]. / Propensity Score Vergleich der verschiedenen radikalen Operationstechniken beim high risk Prostatakarzinom.

INTRODUCTION: The optimal surgical treatment of patients with a high risk prostate cancer (PCa) in terms of radical prostatectomy (RP) is still controversial: open retropubic RP (RRP), laparoscopic RP (LRP), or robot-assisted (RARP). We aimed to investigate the influence of the different surgical techniques on pathologic outcome and biochemical recurrence. PATIENTS AND METHODS: A total of 805 patients with a high risk PCa (PSA >20 ng/mL, Gleason Score ≥8, or clinical stage ≥cT2c) were included. A comparison of 407 RRP patients with 398 minimally invasive cases (LRP+RARP) revealed significant confounders. Therefore all 110 RARP cases were propensity score (PS) matched 1:1 with LRP and RRP patients. PS included age, clinical stage, preoperative PSA, biopsy Gleason score, surgeon's experience and application of a nerve sparing technique. Comparison of overall survival (OS) and recurrence-free survival (RFS) was done with the log rank test. Predictors of RFS were analyzed by means of Cox regression models. RESULTS: Within the post-matching cohort of 330 patients a pathologic Gleason score < 7, = 7 and > 7 was found in 1.8, 55.5 and 42.7% for RARP, in 8.2, 36.4, 55.5% for LRP and in 0, 60.9 and 39.1% for RRP (p=0.004 for RARP vs. LRP and p=0.398 for RARP vs. RRP). Differences in histopathologic stages were not statistically significant. The overall positive surgical margin rate (PSM) as well as PSM for ≥ pT3 were not different. PSM among patients with pT2 was found in 15.7, 14.0 and 20.0% for RARP, LRP and RRP (statistically not significant). The respective mean 3-year RFS rates were 41.4, 77.9, 54.1% (p<0.0001 for RARP vs. LRP and p=0.686 for RARP vs. RRP). The mean 3-year OS was calculated as 95.4, 98.1 and 100% respectively (statistically not significant). CONCLUSION: RARP for patients with a high risk PCa reveals similar pathologic and oncologic outcomes compared with LRP and RRP.

[Introduction of interdisciplinary prostate cancer centers based on the recommendations of the German Cancer Society. A cost-benefit analysis 3 years after accreditation]. / Etablierung von interdisziplinären Prostatakrebszentren nach den Empfehlungen der DKG. Eine Kosten-Nutzen-Analyse 3 Jahre nach Zertifizierung.

The introduction of prostate cancer treatment centers according to the criteria of the German Cancer Society ("Deutsche Krebsgesellschaft", DKG) aims at improving the quality of care for patients with prostate cancer. Systematic analyses of the effects and costs are lacking as yet. Three years after certification of the Interdisciplinary Prostate Cancer Center at the Charité Hospital Berlin we observed a decrease in the rate of positive surgical margins (tumor stage pT2), but other parameters of treatment quality including patient satisfaction remained unchanged. A survey among urologists of the region showed a high acceptance of prostate cancer centers in general. The majority of participating urologists appreciated the work of the Charité center, in particular the treatment recommendations given by the center were mostly followed and the majority of urologists regularly use educational activities of the center. However, only 30% of the participating urologists confirmed short-term improvements in the quality of patient care. Yearly additional costs for the Charité prostate cancer center are estimated at 205,000 euro (precertification phase and certification) and 138,000 euro (monitoring phase), despite the initial drop in mean treatment costs per case (radical prostatectomy). The introduction of prostate cancer treatment centers certified by the DKG is cost intensive, increases in treatment efficiency notwithstanding. Short-term improvements in quality of care cannot be unequivocally demonstrated. Prostate cancer centers serve an important role in counseling and medical education and may thus help disseminate evidence-based treatment strategies.

[Evaluation of obstructive interval, presence of sperm granulomas and patient age as predictors of spermatogenesis in a cohort of men undergoing vasectomy reversal]. / Evaluation von Vasektomieintervall, Spermagranulom und Patientenalter als Prädiktoren der spermatogenetischen Aktivität vasektomierter Männer.

INTRODUCTION: For more than 50 years vasectomy reversal is a routinely performed procedure in the field of urology. However, there is no scientific agreement about morphological changes of the testes caused by vasectomy. The existing evidence for reduced fertility rates following vasectomy reversal demands a clear statement regarding potential histological changes and impaired spermatogenesis following vasectomy. Thus far there is little knowledge about potential histological changes of the testis caused by vasectomy. MATERIAL AND METHODS: 330 consecutive patients who underwent vasectomy reversal had bilateral testicular biopsies which were evaluated utilising semi-thin sections. The number of mature spermatids per seminiferous tubule was considered the variable of interest as it represents an objective and reproducible parameter of spermatogenesis. The number of mature spermatids per tubule was correlated with patient age, obstructive interval and the presence or absence of sperm granulomas via the chi-square test. RESULTS: Overall, 570 sections of 285 patients were eligible for evaluation. The mean patient age was 41.2 years (range 27-63 years, SD +/- 6.5 years) with a mean obstructive interval of 105.9 months (range 12-328, SD +/- 66.1). 56 patients (19.6 %) had a sperm granuloma on the right and 22 (11.6 %) on the left ductus deferens. There was no statistically significant correlation between the presence of a sperm granuloma with the number of mature spermatids per tubule (p = 0.717). Furthermore, there was neither an association of obstructive interval (p = 0.144) nor patient age (p = 0.168) with spermatogenesis. CONCLUSION: Regular spermatogenetic activity in all examined samples with development of mature spermatids was shown. Furthermore, for the first time we were able to demonstrate in a large cohort of patients that neither patient age nor obstructive interval nor sperm granuloma have a significant impact on spermatogenesis.