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.

Analysis of tripartite motif (TRIM) family gene expression in prostate cancer bone metastases.

Tripartite motif (TRIM) family proteins are post-translational protein modifiers with E3-ubiquitin ligase activity, thereby involved in various biological processes. The molecular mechanisms driving prostate cancer (PCa) bone metastasis (BM) are incompletely understood, and targetable genetic alterations are lacking in the majority of cases. Therefore, we aimed to explore the expression and potential functional relevance of 71 TRIM members in bone metastatic PCa. We performed transcriptome analysis of all human TRIM family members and 770 cancer-related genes in 29 localized PCa and 30 PCa BM using Nanostring. KEGG, STRING and Ubibrowser were used for further bioinformatic gene correlation and pathway enrichment analyses. Compared to localized tumors, six TRIMs are under-expressed while nine TRIMs are over-expressed in BM. The differentially expressed TRIM proteins are linked to TNF-, TGFß-, PI3K/AKT- and HIF-1-signaling, and to features such as proteoglycans, platelet activation, adhesion and ECM-interaction based on correlation to cancer-related genes. The identification of TRIM-specific E3-ligase-substrates revealed insight into functional connections to oncogenes, tumor suppressors and cancer-related pathways including androgen receptor- and TGFß signaling, cell cycle regulation and splicing. In summary, this is the first study that comprehensively and systematically characterizes the expression of all TRIM members in PCa BM. Our results describe post-translational protein modification as an important regulatory mechanism of oncogenes, tumor suppressors, and pathway molecules in PCa progression. Therefore, this study may provide evidence for novel therapeutic targets, in particular for the treatment or prevention of BM.

New computed tomographic predictors of complicated perioperative course of 17.5F mini-percutaneous nephrolithotomy (mini-PNL).

PURPOSE: Radiological parameters predicting a postoperative stone-free status (SFS) or a complicated perioperative course of mini-PNL, are scarce. Our aim was to identify such factors for prone 17.5F mini-PNL. METHODS: A monocentric cohort of 103 cases was retrospectively analysed for factors predicting SFS and relevant complications, i.e. Clavien-Dindo (CD) ≥ 2. Parameters measured on preoperative supine CT included maximal stone diameter, skin-to-stone distance (SSD), ideal tract length (ITL), access angle, minimal T12-Lower Kidney Pole distance (T12LP) and minimal Iliac Crest-Lower Kidney Pole distance (ICLP). Infundibulopelvic angle (IPA) was measured on intraoperative pyelography. RESULTS: The median maximal stone diameter was lower in cases with postoperative SFS [16 mm (Min. 10; Max. 35) vs. 20 mm (Min. 6; Max. 85), p = 0.0052]. CD ≥ 2 was more frequent in cases with a bigger stone burden [19 mm (Min. 13; Max. 85) vs. 16 mm (Min. 6; Max. 49), p = 0.0056] and with the ribs in the access angle [7/23 (30.43%) vs. 8/76 (10.53%); p = 0.0454]. T12LP significantly differed in cases with and without CD ≥ 2 [80.48 mm (± 21.31) vs. 90.43 mm (± 19.42), p = 0.0397]; however, it had no influence on SFS (p > 0.05). SSD, ITL, IPA and ICLP were significant regarding neither SFS nor CD ≥ 2 prevalence (p > 0.05). Using multivariate logistic regression, T12LP was confirmed as an independent predictor on CD ≥ 2 prevalence. CONCLUSIONS: Preoperative computed tomographic factors indicating elevated kidney position influence perioperative course of mini-PNL. T12LP and the presence of ribs in the access angle are, apart from stone diameter, the most useful indicators for cases at risk of CD ≥ 2.

Risk Factors for a Complicated Postoperative Course in Flexible Ureteroscopy.

INTRODUCTION: The goal was to determine risk factors for Clavien-Dindo (CD) grade ≥2 complications, with special focus on early postoperative systemic inflammatory response syndrome (SIRS), for flexible ureteroscopy (fURS). MATERIALS AND METHODS: A retrospective monocentric statistical analysis relating to 32 factors was performed with the χ2 test, Mann-Whitney U tests, and multivariate logistic regression. RESULTS: In total, 416 consecutive fURS performed between September 2013 and June 2017 were analyzed; 283 (68.03%) of these were for stone surgery and 133 (31.97%) for diagnostic purposes. In 43 cases (10.34%), CD ≥2 occurred; 31 cases (72.09%) of these were SIRS. On multivariate logistic regression, positive preoperative urine culture and steep pyelographic and CT-based infundibulopelvic angle (IPA) have been confirmed as independent risk factors for both CD ≥2 and SIRS. Greater maximal median stone diameter and female gender were significantly associated only with a higher CD ≥2 prevalence, but not with SIRS. The influence of ureteral access sheath (UAS) on CD ≥ 2 or SIRS occurrence could not be confirmed on multivariate analysis. Perioperative antibiotic prophylaxis for patients with negative urine culture showed no difference regarding SIRS prevalence. CONCLUSION: Steep CT-based IPA can be considered as a new radiologic predictor of complicated postoperative course and SIRS. The role of UAS as well as indications for perioperative antibiotic prophylaxis should be determined in prospective studies.

Increased mediator complex subunit CDK19 expression associates with aggressive prostate cancer.

The Mediator complex is a transcriptional regulator interacting with transcription factors and RNA-polymerase-II. Recently, we identified its subunit CDK19 to be specifically expressed in prostate cancer (PCa) and to be functionally implicated in PCa aggressiveness. Aim of our study was to comprehensively characterize the protein expression of CDK19 and its paralog CDK8 in PCa. We performed immunohistochemistry (IHC) for CDK19/CDK8 on a large cohort including needle biopsies from 202 patients, 799 primary tumor foci of radical prostatectomy specimens from 415 patients, 120 locally advanced tumor foci obtained by palliative transurethral resection, 140 lymph node metastases, 67 distant metastases and 82 benigns. Primary tumors were stained for the proliferation marker Ki67, androgen receptor (AR) and ERG. For 376 patients, clinic-pathologic data were available. Primary endpoint was disease-recurrence-free survival (DFS). Nuclear CDK19 and CDK8 expression increases during progression showing the highest intensity in metastatic and castration-resistant tumors. High CDK19 expression on primary tumors correlates with DFS independently from Gleason grade and PSA. Five-year-DFS rates of patients with primary tumors expressing no, moderate and high CDK19 are 73.7, 56.9 and 30.4%, respectively. CDK19 correlates with Gleason grade, T-stage, Ki67 proliferation-index, nuclear AR expression and ERG-status. Therapeutic options for metastatic and castration-resistant PCa remain limited. In the current study, we confirmed an important role of the Mediator subunit CDK19 in advanced PCa supporting current developments to target CDK19 and its paralog CDK8. Furthermore, CDK19 protein expression has the potential to predict disease recurrence independently from established biomarkers thus contributing to individual management for PCa patients.

Impact of double J stenting or nephrostomy placement during transurethral resection of bladder tumour on the incidence of metachronous upper urinary tract urothelial cancer.

BACKGROUND: Whether or not double J (DJ) stenting during transurethral resection of a bladder tumour (TURBT) harms patients with regard to possible metachronous upper urinary tract urothelial cancer (UUTUC) development remains controversial. This study evaluated the impact of DJ compared to nephrostomy placement during TURBT for bladder cancer (BCa) on the incidence of metachronous UUTUCs. METHODS: We retrospectively analysed 637 patients who underwent TURBT in our department between 2008 and 2016. BCa, UUTUC and urinary drainage data (retrograde/anterograde DJ and percutaneous nephrostomy) were assessed, along with the prevalence of hydronephrosis, and mortality. Chi-square and Fisher's exact test was performed for univariate analyses. Survival analysis was performed by the Kaplan-Meier method and log-rank tests. RESULTS: UUTUC was noted in 28 out of 637 patients (4.4%), whereas only eight (1.3%) developed it metachronously to BCa. Out of these, four patients received DJ stents, while four patients received no urinary drainage of the upper urinary tract. Placement of urinary drainage significantly correlated with UUTUC (50.0% vs. 17.9%; p = 0.041). DJ stenting significantly correlated with UUTUC (50.0% vs. 11%; p <  0.01), while no patient with a nephrostomy tube developed UUTUC. UUTUC-free survival rates were significantly lower for patients with DJ stents than for all other patients (p = 0.001). Patients with or without DJ stents had similar overall survival (OS) rates (p = 0.73), whereas patients with nephrostomy tubes had significantly lower OS rates than all other patients (p <  0.001). CONCLUSIONS: Patients with DJ stenting during TURBT for BCa might have an increased risk of developing metachronous UUTUC. This study indicated advantages in placing nephrostomy tubes rather than DJ stents; however, confirmation requires investigation of a larger cohort. Even so, the increased mortality rate in the nephrostomy group reflected hydronephrosis as an unfavourable prognostic factor.

Laser fibre, rather than the stone, may harm the scope: retrospective monocentric analysis of 26 pre- and intraoperative factors of flexible ureteroscope (fURS) damage.

PURPOSE: The increasing number of flexible ureteroscopy procedures, the fragility of devices and their repair costs are a burden for urological departments worldwide. The objective was to investigate the impact of 26 pre- and intraoperative factors on reusable flexible ureteroscope (fURS) damage. METHODS: All procedures were conducted with reusable fURS: Karl Storz Flex-X2 or Olympus URF-V. Statistical analysis was performed in RStudio (1.0.136) with Chi-square test and Mann-Whitney U tests (MWU). RESULTS: In total, 416 flexible ureteroscopies, performed between September 2013 and June 2017, were analysed. 283 (68.03%) of these were for kidney stone surgery, and 133 (31.97%) for diagnostic purposes. In total, 39 (9.38%) devices were postoperatively deemed defective. The application of reusable laser fibre through fURS was more common in cases with documented defects [17/39 (43.59%) vs. 102/377 (27.06%), p = 0.047]. Other factors such as application of nitinol basket, biopsy via fURS, insertion of access sheath (UAS), as well as stone burden [median kidney stone maximal diameter: 6 mm (min 2.0; max 30.0) vs. 6 mm (min 1.0 vs. max 30.0)] showed no influence on fURS damage rate (p > 0.05). The infundibulopelvic angle (IPA) was steeper in cases with fURS damage as compared to cases without damage [median 44.0° (min 20.0; max 81.0) vs. 55.0 (min 7.0; max 122.0), p < 0.001]. CONCLUSIONS: Application of laser fibre via fURS can be considered as a risk factor of fURS damage. Stone burden, as well as the usage of not-sharp ended devices as nitinol baskets or forceps, is primarily not responsible for fURS damage.

The Impact of Endourological Experience on Flexible Ureteroscopy Outcomes and Performance at Different Levels of Expertise: Retrospective Multifactorial Analysis.

INTRODUCTION: The aim of this study was to analyze the influence of residents' participation in flexible ureteroscopy (fURS) on intra- and postoperative outcomes. MATERIALS AND METHODS: Intra- and postoperative parameters were compared in a retrospective monocentric setting between 3 groups: "resident group" (47 cases) for surgeries performed by experienced residents alone, "consultant group" (245 cases) for surgeries performed by consultants alone, "resident plus consultant group" (124 cases) for training surgeries between September 2013 and June 2017. RESULTS: Patients operated by residents alone had a significantly smaller median kidney stone diameter (5.0 vs. 7.0 mm for "consultant group" and 6.0 mm for "resident plus consultant group," p = 0.011), shorter operating time (median 47.0 vs. 63.0 and 77.0 min, p < 0.001) and fluoroscopy time (median 39.0 vs. 69.5 and 89.0 s, p < 0.001), as well as shorter postoperative hospital stay (p = 0.013). The laser application rate was the smallest in the "resident group" (10.64 vs. 31.43 and 29.84%, p = 0.009). Univariate analysis revealed no relevant differences regarding flexible ureteroscope defect rate, postoperative stone-free rate, or ≥2 Clavien-Dindo classification complications between the groups (p > 0.05). CONCLUSION: A proper case selection of less complicated cases, especially without laser application, could balance the experience deficit of the residents. fURS can be incorporated as a part of residents' training without an impact on fURS device defect rate or clinical outcomes.

The BET-inhibitor PFI-1 diminishes AR/AR-V7 signaling in prostate cancer cells.

OBJECTIVE: The bromodomain and extra-terminal (BET) family of proteins provides a scaffolding platform for the recruitment and tethering of transcription factors to acetylated chromatin, thereby modulating gene expression. In this study, we evaluated the efficacy of the BET-inhibitor PFI-1 to diminish AR/AR-V7 signaling and proliferation in castration-resistant prostate cancer cells. METHODS: Prostate-specific antigen and androgen receptor (AR) protein were quantified by means of two commercial ELISAs. Transactivation of the AR, AR-V7 and Q641X was determined by reporter gene assays. Cell proliferation was measured using a colorimetric MTT-assay. RESULTS: PFI-1 dose-dependently inhibited transactivation of full-length AR (non- mutated, i.e., wild-type or point-mutated/promiscuous forms) without affecting their cellular protein levels. Moreover, PFI-1 was active against C-terminally truncated constitutively active ARs like AR-V7 and Q641X. Prostate cancer cells exhibiting a transcriptionally active AR-signaling complex (LNCaP, 22Rv1) were more susceptible to the growth-inhibitory effects than the AR-negative PC-3 cells. CONCLUSION: The quinazolinone PFI-1 is a highly efficient inhibitor of AR-signaling-competent prostate cancer cells in vitro. PFI-1 could serve as a lead compound for the development of new therapeutics able to block AR/AR-V7 signaling in advanced prostate cancer.

Extended Techniques of Minimally Invasive Surgery in the Retroperitoneum: Practice Pattern in German Urology Departments.

INTRODUCTION: Laparoendoscopic single-site surgery (LESS), robot-assisted (RA), and retroperitoneoscopic (R) surgery expand the armamentarium of minimally invasive surgery (MIS). As information on the use of these surgical approaches in daily routine is limited, we conducted a survey among German urologists. MATERIALS AND METHODS: In 2017, all urology departments in Germany received a questionnaire evaluating practice patterns of MIS in the retroperitoneum. Chi-Square test was performed for statistical analyses. The response rate was 51.1% (162/311) including 23 universities. RESULTS: R adrenalectomy and (partial) nephrectomy are performed by 32.7-40.1% of all departments. Transperitoneal LESS adrenalectomy and nephrectomy are performed by 8.6-11.7%. Retroperitoneal RA adrenalectomy and (partial) nephrectomy are performed by 6.2-13.0%. There was no difference in the R and LESS approach between (non)-university departments. Retroperitoneal RA access is more frequently used in university hospitals (all p < 0.01). If performed, mean counts within the last 12 months were < 5 for R, LESS, and RA adrenalectomy; and < 20 for R, LESS, and RA (partial) nephrectomy. CONCLUSION: Our survey provides a detailed insight into MIS in the retroperitoneum in German urology departments. Numbers of adrenalectomies as well as R, transperitoneal LESS and retroperitoneal RA procedures are low. Retroperitoneal RA surgery is more common in universities. Comprehensively, our survey proves that these approaches are not standard approaches yet.

Minimally invasive approaches to adrenal tumors: an up-to-date summary including patient position and port placement of laparoscopic, retroperitoneoscopic, robot-assisted, and single-site adrenalectomy.

PURPOSE OF REVIEW: There are multiple minimal invasive approaches to remove the adrenal gland. The purpose of this review is to summarize the most up-to-date findings about laparoscopic, retroperitoneoscopic, robot-assisted, and single-site adrenalectomy, and to define the most common approaches to the adrenal gland. RECENT FINDINGS: Laparoscopic adrenalectomy is the gold standard to remove adrenal tumors. New approaches are being explored to outperform the advantages of laparoscopic adrenalectomy. SUMMARY: Retroperitoneoscopic adrenalectomy, when performed by skilled surgeons, offers an alternative to the conventional laparoscopic approach, with better outcome. The robot-assisted and single-site approaches still need further studies to fully identify their roles in adrenalectomy.

Successful Pregnancy and Neobladder Subsequent to Muscle Invasive Bladder Cancer and Fertility Preserving Surgery: Case Report and Review of the Literature.

We report a successful pregnancy and birth subsequent to fertility-preserving cystectomy and neobladder formation in a muscle-invasive sarcomatoid urothelial carcinoma.

Impact of 2004 ISUP/WHO classification on bladder cancer grading.

PURPOSE: To determine whether implementation of the 2004 WHO/ISUP bladder cancer (BCa) grading system caused a grade migration, i.e., more tumors being graded as high grade (HG). METHODS: Data on 1040 BCa cases from 668 patients treated at our institution between 2000 and 2013 and reviewed by six pathologists were evaluated: low grade (LG): 249; HG: 791; Ta: 389; T1: 214; CIS: 95; ≥T2: 342. Differences in LG or HG cases (expressed as %BCa cases/year) were analyzed by Mann-Whitney test. Correlation between the year of diagnosis and clinical/pathological parameters was evaluated by logistic regression analyses. RESULTS: During the study period, BCa cases diagnosed as LG significantly decreased with a corresponding increase in HG cases. Nonlinear regression analysis indicated that ~2008 was the crossover point for grade migration; %LG: 31.8 ± 4.8 (2000-2007); 14.1 ± 7.0 (2008-2013); %HG: 68.2 ± 4.8 (2000-2007); 85.9 ± 6.9 (2008-2013), P = 0.004. The grade migration was confined to Ta cases with %LG Ta cases diagnosed decreasing by 3.6-fold from 2000-2007 to 2008-2013 (P = 0.004). Univariate and multivariate analyses confirmed the grade migration following the adoption of the 2004 system (P < 0.0001). Kaplan-Meier curves showed no significant differences between the two time intervals in terms of disease progression (P > 0.05). CONCLUSIONS: Implementation of the 2004 WHO/ISUP system caused a significant increase in pathologists grading Ta cases as HG; however, this increase did not seem to correlate with disease progression. Since LG and HG Ta tumors are treated differently, grade migration may impact the clinical management of BCa patients.

Preoperative and modifiable factors to lower postoperative complications after radical cystectomy.

Radical cystectomy is the gold standard for muscle-invasive bladder cancer. It is a challenging procedure comprising of two steps: removal of the bladder followed by construction of a new urinary diversion. Despite advances in surgical and postoperative management within the last decades, postoperative complication rates for this procedure are still considerably high. Many complications are avoidable in the pre-/intra-/postoperative setting by carefully selecting patients eligible for this procedure and by considering prophylactic measures. Fast-track concepts demonstrate current intentions to optimize perioperative management. This review summarizes the most recent studies and findings on how to lower postoperative complications with the help of preoperative and modifiable factors.

Differential expression of SDF-1 isoforms in bladder cancer.

PURPOSE: SDF-1 is a ligand of the chemokine receptors CXCR4 and 7. The 6 known SDF-1 isoforms are generated by alternative mRNA splicing. While SDF-1 expression has been detected in various malignancies, only few groups have reported differential expression of SDF-1 isoforms and its clinical significance. We evaluated the expression of 3 SDF-1 isoforms (α, ß and γ) in bladder cancer. MATERIALS AND METHODS: Using quantitative polymerase chain reaction we measured SDF-1α, ß and γ mRNA levels in 25 normal and 44 bladder cancer tissues, and in 210 urine specimens (28 normal, 74 benign, 57 bladder cancer, 35 bladder cancer history, 8 other cancer history and 8 other cancer) from consecutive patients. Levels were correlated with clinical outcome. RESULTS: Of the SDF-1 isoforms only SDF-1ß mRNA was significantly over expressed 2.5-fold to sixfold in bladder cancer compared to normal bladder tissues. SDF-1α was expressed in bladder tissues but SDF-1γ was undetectable. On multivariate analysis SDF-1ß was an independent predictor of metastasis and disease specific mortality (p=0.017 and 0.043, respectively). In exfoliated urothelial cells only SDF-1ß mRNA levels were differentially expressed with 91.2% sensitivity and 73.8% specificity for detecting bladder cancer. In patients with a bladder cancer history increased SDF-1ß levels indicated a 4.3-fold increased risk of recurrence within 6 months (p=0.0001). CONCLUSIONS: SDF-1 isoforms are differentially expressed in bladder tissues and exfoliated urothelial cells. SDF-1ß mRNA levels in bladder cancer tissues predict a poor prognosis. Furthermore, SDF-1ß mRNA levels in exfoliated cells detect bladder cancer with high sensitivity and they are a potential predictor of future recurrence.

Age--an independent prognostic factor of clinical outcome in renal malignancies: results of a large study over two decades.

PURPOSE: Age has been linked to outcome in renal cancer patients, but mainly in North American cohorts. In this study, we hypothesized that age is correlated with metastasis and cancer-specific survival in a German cohort regardless of types of treatments. METHODS: A total of 1,538 patients treated for renal malignancies between 1991 and 2010 were evaluated. Mean age and median age are 61.9 ± 11.6 and 62.6 years. Clinicopathologic [tumor type, size, grade, stage and treatment (surgery, chemotherapy, radiation, immunotherapy)] and outcome parameters (metastasis and survival) were examined for an association with age using logistic regression and Cox proportional hazard model, and Kaplan-Meier plots. RESULTS: Age was associated with stage, metastasis, treatment, cancer-specific and overall mortality (p < 0.01). The metastasis-free and cancer-free survival rates for patients >63 years were lower than those for patients ≤63 years (p < 0.0001). In a multivariate analysis, age was an independent prognostic factor of metastasis, cancer-specific and overall mortality (p < 0.0001) even when data were stratified in different decades and treatment was included as one of the parameters. Patients >63 years of age had 29-35% higher risk of metastasis and cancer-specific mortality than younger patients. Median metastasis-free and cancer-specific survival for patients >63 years of age (months: 84.4; 70.3) was ~50% shorter than in patients ≤63 years (months: 151; 144.6). CONCLUSIONS: This large study shows that, despite advances in surgical and non-surgical treatment modalities over the two decades, age is an independent prognostic indicator of metastasis and cancer-specific mortality in renal cancer patients. Patients >63 years have ~30% increased risk for metastasis and ~50% shorter cancer-specific survival.

Comprehensive Nomogram for Prediction of the Uric Acid Composition of Ureteral Stones as a Part of Tailored Stone Therapy.

BACKGROUND: Oral chemolitholysis is a noninvasive therapy for uric acid (UA) stones. Proper patient selection is crucial for success of the therapy. OBJECTIVE: To develop a nomogram for prediction of UA stones using parameters gathered during emergency work-up for flank pain. DESIGN, SETTING, AND PARTICIPANTS: A single-center cohort (459 patients) with singular ureteral stones and available stone analysis was retrospectively reviewed for radiological, urinary, and serological findings indicating UA stones. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A Mann-Whitney U test or Kruskal-Wallis test was applied for univariate analysis. Categorical variables were compared using a χ2 test. Binary logistic regression of significant parameters was performed to design the nomogram. RESULTS AND LIMITATIONS: Univariate analysis revealed statistically significant differences in parameters between predominantly UA and non-UA groups, including median age (60 yr, interquartile range [IQR] 51.5-70.5 vs 51 yr, IQR 39-62; p < 0.001), body mass index (30.0 kg/m2, IQR 27.25-35.0 vs 26.6 kg/m2, IQR 24.0-30.467; p < 0.001), stone density (435.0 HU, IQR 329.0-528.0 vs 750.0 HU, IQR 548.0-995.0; p < 0.001), serum UA (437.5 µmol/l, IQR 374.25-478.0 vs 321.0 µmol/l, IQR 273.0-377.0; p < 0.001), and urine pH (5.5, IQR 5.0-5.5 vs 6.0, IQR 5.5-6.5; p < 0.001). Radiolucency was more frequent in the predominantly UA group (88.60% vs 32.70%; p < 0.001). Multivariate binary logistic regression confirmed age, body mass index, stone density, serum UA, urine pH, and radiolucency as independent predictors of UA stones and these parameters were used to design the nomogram. CONCLUSIONS: We present a nomogram for the prediction of uric acid stones. PATIENT SUMMARY: We developed a nomogram as a simple tool with potential to be useful in patient counseling regarding chemolitholysis as a tailored stone treatment for uric acid urinary stones.

Hemopatch® as a Hemostatic Agent is Safe in Partial Nephrectomy: A Large, Single-Surgeon Retrospective Evaluation.

INTRODUCTION: Partial nephrectomy (PN) has evolved into the surgical standard of care for localized renal lesions. Hemostatic agents (HA) support the surgeon in achieving local hemostasis during PN. We previously reported initial results with the HA Hemopatch® in PN. We now report our experiences with Hemopatch® in a larger and more challenging single-surgeon PN cohort. METHODS: Our study included 45 patients who underwent PN due to suspicious renal lesions between December 2013 and March 2018. All surgeries were performed by a single surgeon using the HA Hemopatch®. Preoperative, intraoperative, and postoperative parameters were assessed. RESULTS: Preoperative median tumor diameter was 27 mm. Median PADUA and RENAL nephrometry scores were 7 and 6, respectively. In 13.3% of the cases an additional HA was applied. Intraoperative and postoperative bleeding occurred in 2.2% and 8.9%, respectively. Median total blood loss was 200 ml. Urgent pedicle clamping due to bleeding was necessary in 2 (4.4%) patients. The transfusion rate was 8.9%. There were no conversions. CONCLUSION: We confirmed our initial results demonstrating feasibility and reliability of Hemopatch® during PN. Notably, the cohort consists of selected patients. Prospective randomized studies are needed for comparison of different types of HA with regard to perioperative outcome.