Prospective evaluation of an intraoperative urodynamic stress test predicting urinary incontinence after robot-assisted laparoscopic radical prostatectomy.

Introduction: Multiple factors influence postprostatectomy incontinence (PPI). This study evaluates the association between an intraoperative urodynamic stress test (IST) with PPI. Materials and Methods: This is an observational, single-center, prospective evaluation of 109 robot-assisted laparoscopic radical prostatectomies (RALPs) performed between July 2020 and March 2021. All patients underwent an intraoperative urodynamic stress test (IST) in which the bladder is filled up to an intravesical pressure of 40 cm H2O to evaluate whether the rhabdomyosphincter is capable of withstanding the pressure and ensure continence. Early PPI was evaluated using a standardized 1-h pad test performed the day after removal of the urinary catheter. The association of IST and PPI was evaluated using univariate and multivariable logistic regression models. Results: Nearly 76.6% of the patients showed no urine loss during the IST ("sufficient" population group). There was no significant correlation between this group and PPI after catheter removal (P = 0.5). Subgroup analyses of the "sufficient" patient population showed a 3.1 higher risk of PPI when no nerve sparing was performed (95% confidence interval: 1.05-9.70, P = 0.045). Conclusion: A sufficient IST, as a surrogate variable for a fully obtained rhabdomyosphincter, has no significant predictive value on its own but seems to be the optimal prerequisite for continence, since the data shows that the lack of neurovascular supply required for a functioning sphincter leads up to a 3.1 times higher risk for PPI.

Patterns of Peripheral Blood B-Cell Subtypes Are Associated With Treatment Response in Patients Treated With Immune Checkpoint Inhibitors: A Prospective Longitudinal Pan-Cancer Study.

Background: Immune checkpoint inhibitors (ICIs) have revolutionized systemic anti-tumor treatments across different types of cancer. Nevertheless, predictive biomarkers regarding treatment response are not routinely established yet. Apart from T-lymphocytes, the humoral immunity of B-lymphocytes is studied to a substantially lesser extent in the respective setting. Thus, the aim of this study was to evaluate peripheral blood B-cell subtypes as potential predictors of ICI treatment response. Methods: Thirty-nine cancer patients receiving ICI therapy were included into this prospective single-center cohort study. All had a first blood draw at the date before treatment initiation and a second at the time of first response evaluation (after 8-12 weeks). Seven different B-cell subtypes were quantified by fluorescence-activated cell sorting (FACS). Disease control- (DCR) and objective response rate (ORR) were co-primary study endpoints. Results: Overall, DCR was 48.7% and ORR was 25.6%, respectively. At baseline, there was no significant association of any B-cell subtype with neither DCR nor ORR. At the first response evaluation, an increase in the frequency of CD21- B-cells was a statistically significant negative predictor of response, both regarding DCR (OR=0.05, 95%CI=0.00-0.67, p=0.024) and ORR (OR=0.09, 95%CI=0.01-0.96, p=0.046). An increase of the frequency of switched memory B-cells was significantly associated with reduced odds for DCR (OR=0.06, 95%CI=0.01-0.70, p=0.025). Patients with an increased frequency of naïve B-cells were more likely to benefit from ICI therapy as indicated by an improved DCR (OR=12.31, 95%CI=1.13-134.22, p=0.039). Conclusion: In this study, certain B-cell subpopulations were associated with ICI treatment response in various human cancer types.

[Contemporary surgical management of benign prostatic obstruction in Germany : A population-wide study based on German hospital quality report data from 2006 to 2019]. / Die operative Therapie des benignen Prostatasyndroms in Deutschland : Eine Darstellung der Versorgungssituation auf Basis der Qualitätsberichte von 2006 bis 2019.

BACKGROUND: The surgical management of benign prostatic obstruction (BPO) has greatly evolved in recent years. OBJECTIVES: The aim of this study is to present contemporary management and trends for surgical BPO therapy in Germany. MATERIALS AND METHODS: Disease and procedure rates were extracted using the online platform reimbursement.INFO that is based on German hospital quality report data. For the diagnosis of benign prostate hyperplasia (BPH), the ICD codes N40 and D29.1 were used. For evaluation of the surgical procedures OPS codes 5­600.0, 5­601, 5­603, 5­609.4 and 5­609.8 including their subcodes were used. In addition to descriptive analyses, trend and correlation analyses were performed. RESULTS: In 2019, a total of 83,687 procedures for BPO in 473 urological departments were performed. The most common (71.7%) surgery was transurethral resection of the prostate (TUR-P). Holmium laser enucleation of the prostate (HoLEP; 9.5%) and surgical adenomectomy (5.6%) were the second and third most common procedures. Less often thulium laser enucleation (ThuLEP; 3.1%), laser vaporisation (2.9%) and electrical vaporisation (2.8%) were performed. All other techniques were performed in < 1%. Rates of HoLEP, ThuLEP and electrovaporisation have increased since 2006 (HoLEP: +42.42%/year, p < 0.001; ThuLEP: +20.6%/year, p = 0.99; electrovaporisation +43.42%/year, p < 0.001), while surgical adenomectomy decreased (-1.66%/year, p < 0.01). In 2019 mean length of hospital stay was 5.1 ± 0.1 days. CONCLUSIONS: TUR­P remains the most often performed surgical treatment for BPO. Laser therapy-especially in centers-is increasing, while surgical adenomectomy continues to abate.

A call for HoLEP: en-bloc vs. two-lobe vs. three-lobe.

PURPOSE: Holmium Laser Enucleation of the Prostate (HoLEP) is widely accepted as standard laser enucleation technique for patients with benign prostate obstruction (BPO). Initially developed as a three-lobe enucleation technique, several modifications have been published. Comparison of the enucleation techniques is lacking. Therefor we aimed to compare outcomes of three enucleation techniques (en-bloc vs. two-lobe vs. three-lobe). MATERIAL AND METHODS: We prospectively collected data of 600 patients treated between 01/2017 and 12/2017 with HoLEP for BPO. Patients were randomised to either enbloc, two-lobe, or three-lobe enucleation, respectively. Data collection consisted of parameters on operation time, perioperative parameters, and functional outcomes. Univariate and multivariate analyses (ANOVA-test for continuous variables; Chi2-test for categorical variables) were performed regarding differences between the three enucleation techniques. RESULTS: Patient characteristics were not significantly different (all p > 0.05). Significant differences were observed with respect to overall operation time (en-bloc vs. two-lobe vs. three-lobe: 40.5 vs. 40.7 vs. 47.9, respectively; p < 0.001), speed (g/min.) (en-bloc vs. two-lobe vs. three-lobe, 1.82 vs. 1.76 vs. 1.67, respectively; p 0.006), and enucleation time (en-bloc vs. two-lobe vs. three-lobe: 31.7 vs. 32 vs. 37.7, respectively; p < 0.001). When solely comparing en-bloc vs. two-lobe enucleation, differences in terms of enucleation time, operation time, and speed were not significantly different (p 0.8, 0.9, and 0.2, respectively). Postoperative outcomes were not significantly different. CONCLUSION: All three HoLEP enucleation techniques show similar postoperative outcomes. However, enbloc and two-lobe enucleation are significantly faster with respect to enucleation, overall operation time, and speed compared to the three-lobe technique.

The Silent Operation Theatre Optimisation System (SOTOS©) to reduce noise pollution during da Vinci robot-assisted laparoscopic radical prostatectomy.

To reduce noise pollution and consequently stress during robot-assisted laparoscopic radical prostatectomy (RALP) the aim of our study was to evaluate the silent operation theatre optimisation system (SOTOS) in its effectiveness. In the operating room (OR) the noise level is between 80 and 85 decibel (dB). Noise corresponds to a major stress factor for surgical teams and especially surgeons. The use of the da Vinci surgical system entails an additional aspect of noise in the OR. The SOTOS surgical team used wired or wireless headphone/microphone combinations to communicate. We measured sound pressure levels in two different locations in the OR and the heart rate of every surgical team member as an indicator of the stress level. We further captured subjective acceptance of SOTOS as well as perioperative data such as surgical time. We prospectively randomised 32 RALP patients into two study arms. Sixteen surgeries were performed using SOTOS and 16 without (control). Overall, the mean sound pressure level in the SOTOS group was 3.6 dB lower compared to the control (p < 0.001). The highest sound pressure level measured was 96 dB in the control group. Mean heart rates were 81.3 beats/min for surgeons and 90.8 beats/min for circulating nurses. SOTOS had no statistically significant effect on mean heart rates of the operating team. Subjective acceptance of SOTO was high. Our prospective evaluation of SOTOS in RALP could show a significant noise reduction in the OR and a high acceptance by the surgical stuff.

Retrograde ejaculation after holmium laser enucleation of the prostate (HoLEP)-Impact on sexual function and evaluation of patient bother using validated questionnaires.

BACKGROUND: A vast body of literature has focused on erectile function after Holmium Laser Enucleation of the Prostate (HoLEP). Interestingly, retrograde ejaculation (RE), despite its frequency has sparsely been investigated. OBJECTIVES: To study patient perception and impact of RE on sexuality following HoLEP. MATERIALS AND METHODS: We retrospectively analyzed 2,131 patients undergoing HoLEP 2006-2015 at our institution. Patients were followed via standardized questionnaires namely International Index of Erectile Function (IIEF) as well as Male Sexual Health Questionnaire Ejaculatory Short Form (MSHQ-EjD-SF). Exclusion criteria were missing/follow-up <6 months, missing data on MSHQ-EjD-SF and IIEF score, resulting in 535 assessable patients. Multivariable logistic regression was employed to identify independent predictors of satisfaction with overall sex life (IIEF question 13). RESULTS: Median follow-up was 50 months (IQR: 30-78). Overall, 495 (92.5%) patients reported RE. Patients differed significantly with respect to age (P = .036), IPSS at follow-up (P = .01), and erectile function (P < .001), whereas no other statistically significant differences were observed. In multivariable logistic regression analyses, presence of RE was not independently associated with satisfaction with overall sex life (OR: 2.7, 95% CI: 0.70-10.5, P = .1). However, in the cohort of patients exhibiting RE, patients who stated "feeling bothered by RE" had lower satisfaction with overall sex life (OR: 0.23, 95% CI: 0.13-0.38, P < .001). Bother by RE varied according to erectile function and did not impact overall satisfaction in men with superior erectile function. CONCLUSIONS: RE is a very common event after HoLEP but in this retrospective analysis was not associated with overall satisfaction with sex life. Contrary, satisfaction with sex life is impaired in patients who feel bothered by RE. Proper patient selection will pose key to identify patients in which RE bother will offset the benefits of LUTS relief.

Super early detailed assessment of lower urinary tract symptoms after holmium laser enucleation of the prostate (HoLEP): a prospective study.

PURPOSE: To prospectively investigate early and consecutive changes of lower urinary tract symptoms (LUTS), specifically storage symptoms after holmium laser enucleation of the prostate (HoLEP). METHODS: Patients referred for HoLEP completed the International Prostatic Symptom Score (IPSS) the day before, at discharge, and 1, 2, 3, 4, 6, 8, 12, 16, 20, 24, and 52 weeks after HoLEP. Total IPSS was stratified into mild (score 0-7), moderate (8-19), and severe (20-35) LUTS. Storage symptoms were sub-stratified into storage "negative" and "positive". IPSS changes served as the main postoperative outcome. Mixed linear models identified risk factors affecting postoperative recovery of LUTS. RESULTS: Between December 2010 and 2012, 144 consecutive HoLEP patients were prospectively included in the study. Preoperatively 57.6% of the cohort reported severe storage symptoms (mean total IPSS: 22.6 ± 5.0). Total IPSS decreased significantly immediately after surgery (p < 0.001). Patients with severe LUTS, storage-positive sub-score, and high maximum urinary flow rate were affected by a rebound of mainly storage symptoms 6-8 weeks after HoLEP and prolonged recovery from LUTS. Of these, about 7.4% presented persisting urge complaints. Finally, 12 weeks following HoLEP, the vast majority of patients were symptom-free. Limitations of this study include missing urodynamic workup and a comparative patient cohort. CONCLUSION: Immediately after HoLEP, patients experience a significant decrease of LUTS. Continuous symptom recovery seems to be hampered in patients with severe and storage-positive baseline symptoms. (De-novo) storage symptoms slightly affect postoperative recovery. Quality of life is restored to a stable and significantly improved status 3 months after surgery.

Substitution Urethroplasty with Closure Versus Nonclosure of the Buccal Mucosa Graft Harvest Site: A Randomized Controlled Trial with a Detailed Analysis of Oral Pain and Morbidity.

BACKGROUND: Optimal surgical management of the buccal mucosa harvest site in patients with urethral stricture disease during buccal mucosa graft urethroplasty (BMGU) remains controversial. OBJECTIVE: To analyze in detail intensity and quality of pain as well as oral morbidity following closure (C) versus nonclosure (NC) of the donor site. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial on 135 patients treated with BMGU between October 15, 2014 and December 18, 2015. INTERVENTION: Following computer-based randomization, 63 and 72 patients, respectively, received C and NC of the donor site at the inner cheek. Preoperatively, on days 1, 5, and 21 as well as at 3 and 6 mo postoperatively, patients completed standardized questionnaires, including validated questions on intensity and quality of pain as well as oral morbidity. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The coprimary end points were intensity and quality of oral pain. Secondary end points included oral morbidity and intensity of pain of the perineogenital region. Generalized linear mixed models evaluated the effect of various covariates on intensity and quality of oral pain, oral morbidity, as well as intensity of pain of the perineogenital region. RESULTS AND LIMITATIONS: There was noninferiority for NC versus C in intensity and affective quality of oral pain at every time point following BMGU. Oral morbidity and complications included pain, bleeding, swelling, numbness, alteration of salivation and taste, as well as impairment of mouth opening, smiling, whistling, diet, and speech. Time from BMGU had significant effects on intensity (p<0.001) and quality of oral pain (sensory pain: p<0.001, affective pain: p<0.001, total pain: p<0.001). Length of buccal mucosa graft had significant effects on intensity (p=0.001) and quality of oral pain (sensory pain: p=0.020, total pain: p=0.042). CONCLUSIONS: NC is noninferior to C of the donor site in intensity and quality of oral pain, and offers a treatment alternative. Time from BMGU and length of the buccal mucosa graft have effects on oral morbidity and complications. PATIENT SUMMARY: We investigated pain, morbidity, and complications following closure (C) versus nonclosure (NC) of the buccal mucosa harvest site in patients undergoing buccal mucosa graft urethroplasty (BMGU). We found that NC is not worse than C regarding oral pain. In addition, time from BMGU and length of the buccal mucosa graft have effects on oral morbidity and complications.

Management of Anterior Urethral Strictures in Adults: A Survey of Contemporary Practice in Germany.

INTRODUCTION: Treatment methods of anterior urethral strictures in adults have undergone considerable changes in the recent past. Our goal was to determine national practice patterns among German urologists and to compare results with the results of prior international surveys. METHODS: We conducted a survey on the management of urethral strictures among German urologists. RESULTS: Eight hundred forty-five urologists, representing about 14.6% of German urologists, answered the survey. Most common procedures were direct vision internal urethrotomy (DVIU; 87.2%), blind internal urethrotomy (57.5%), dilatation (56.3%), ventral buccal mucosa graft urethroplasty (31.6%) and excision and primary anastomosis (28.9%). In case of a 3.5-cm bulbar stricture and in the case of a 1-cm bulbar stricture after 2 failed DVIUs, a consecutive urethroplasty was significantly more often favoured compared to transurethral treatment options (44.9 vs. 21.3% and 59.4 vs. 8.3%, both p < 0.001). CONCLUSION: Open urethral reconstruction reveals to be a more common method in practice nowadays. Adherence to recommended treatment algorithms improved in comparison to prior surveys.

Retinal toxicity after cisplatin-based chemotherapy in patients with germ cell cancer.

PURPOSE: Visual impairment represents an infrequent form of cisplatin-induced neurotoxicity; however, visual deterioration has been reported in several studies. To evaluate potential morphological and functional retinal alterations in patients with germ cell cancer (GCC) treated with cisplatin-based chemotherapy (CBC). METHODS: Multi-disciplinary and multi-institutional study design. Examination of 28 eyes of 14 male GCC patients, who had received at least one cycle of CBC. A matched control group of healthy, untreated patients were included in this study. Subjects underwent a retinal nerve fiber thickness (RNFL) measurement, color vision, visual acuity testing, full-field electroretinograms (ff-ERG). To assess a correlation between cumulative cisplatin dose and measured RNFL and ff-ERG Pearson correlation coefficient analysis was performed. RESULTS: Both study groups (CBC recipients vs. healthy controls) consisted each of 14 participants with a median patient age of 30 years (interquartile range (IQR) 26-37 years). Tumor histology was seminoma in 6 of 14 patients (43%), and non-seminomatous GCC in 8 of 14 patients (57%). Median cumulative cisplatin dosis at examination was 627 mg/m2 (IQR 413-1013 mg/m2). Morphological assessment revealed reduced RNFL in 11 of 14 patients (78.6%). Reduction in RNFL was significantly correlated to the cumulative CBC dose received (rho = + 0.70; p = 0.004). ff-ERG showed significant differences between CBC recipients and the control group in 2 of 5 tested categories (all p values <0.001). CONCLUSION: This study represents first evidence of chronic subclinical retinal toxicity due to cisplatin-based chemotherapy in patients with GCC. The reduction of RNFL might become clinically relevant in upcoming age-related chronic degenerative disorders such as glaucoma.

Tumor volume improves the long-term prediction of biochemical recurrence-free survival after radical prostatectomy for localized prostate cancer with positive surgical margins.

PURPOSE: To develop a novel application evaluating the effect of tumor volume (TV) and percentage of high-grade tumor volume (%HGTV) on long-term biochemical recurrence-free survival rate (BCRFS) after radical prostatectomy (RP) in patients with pT2 PCa. METHODS: Retrospective analysis of 903 men with pT2 PCa between 1992 and 2004 at a single European tertiary care center was performed. Cox regression models identified risk factors for BCR. A nomogram was developed to predict the BCRFS at 5, 10 and 15 years after RP. Decision curve analyses were performed to identify the net increase in cases identified by the full model. RESULTS: BCR-free survival rates at 5, 10 and 15 years were 94, 90 and 86 %. In Cox regression analyses, TV, %HGTV and positive surgical margin status (SM) were independent predictors of BCR. Predictive accuracies (PA) at 5, 10 and 15 years of the base model (PSA, Gleason score, SM) were 76.8 % (95 % CI 67.9-78.2 %), 70.5 % (95 % CI 64.9-75.0 %) and 68.1 % (95 % CI 60.6-73.5 %). The full model, including TV and %HGTV, achieved 76.9, 72.4 and 70.7 %. These PA differences were statistically significant at 10 and 15 years (p < 0.001). CONCLUSIONS: TV and %HGTV could potentially serve as valuable measures to stratify patients at high risk of BCR. The use of our nomogram should be considered to counsel patients with pT2 disease and SM and to design appropriate follow-up or treatment regimens.

Outcomes of single- vs double-cuff artificial urinary sphincter insertion in low- and high-risk profile male patients with severe stress urinary incontinence.

OBJECTIVES: To evaluate continence and complication rates of bulbar single-cuff (SC) and distal bulbar double-cuff (DC) insertion in male patients with severe stress urinary incontinence (SUI) according to whether the men were considered low or high risk for unfavourable artificial urinary sphincter (AUS) outcomes. PATIENTS AND METHODS: In all, 180 male patients who underwent AUS implantation between 2009 and 2013 were followed according to institutional standards. Patients with previous pelvic radiation therapy, open bulbar urethral or UI surgery ('high risk') underwent distal bulbar DC (123 patients) insertion, all others ('low risk') had proximal bulbar SC (57) insertion. Primary and secondary endpoints consisted of continence and complication rates. Kaplan-Meier analysis determined explantation-free survival, and Cox regression models assessed risk factors for persistent UI and explantation. RESULTS: The median follow-up was 24 months. Whereas there was no significant difference in pad usage/objective continence after SC vs DC insertion, superior rates of subjective/social continence and less persistent UI were reported by the patients with DC devices (all P ≤ 0.02). Overall, device explantation (erosion, infection or mechanical failure) occurred in 12.8% of patients. While early (<6 weeks) complication rates compared with SC patients were similar (P > 0.05), DC patients had a 5.7-fold higher risk of device explantation during late follow-up (P = 0.02) and significantly shorter explantation-free survival (log-rank, P = 0.003). CONCLUSIONS: Distal bulbar DC insertion in patients with a 'high-risk' profile (previous pelvic radiation, urethral surgery) leads to similar objective continence, but higher explantation rates when compared with patients considered 'low risk' with proximal bulbar SCs. Randomised controlled trials comparing both devices will be needed to determine whether the higher explanations rates are attributable to the DC device or to underlying risk factors.

Psychometric validation of a German language version of a PROM for urethral stricture surgery and preliminary testing of supplementary ED and UI constructs.

PURPOSE: To validate a German language version of the patient-reported outcome measurement (PROM) following urethral stricture surgery (USS) in a cohort of men undergoing one-stage buccal mucosa graft urethroplasty (BMGU) for urethral stricture. Furthermore, to explore the responsiveness of erectile function (EF) and urinary incontinence (UI) constructs in the context of this intervention. METHODS: The USS-PROM captures voiding symptoms (ICIQ-MLUTS) and health-related quality of life (HRQoL) (EQ-5D). To evaluate EF and UI, the IIEF-5 and ICIQ-UI SF were included. Between March 2012 and April 2013, all patients undergoing BMGU at our institution were prospectively enrolled in this study. Psychometric assessment included internal consistency, test-retest reliability, criterion validity and responsiveness. RESULTS: Ninety-three men completed the USS-PROM before and 3 months after surgery, with 40 (43 %) also completing the USS-PROM 6 months after surgery to assess reliability. Internal consistency: for the ICIQ-MLUTS, Cronbach's α was 0.83. The test-retest intraclass correlation coefficient was 0.94. There was a negative correlation between change in ICIQ-MLUTS total score and change in Q max (r = -0.40). All values exceeded our predefined thresholds. Significant improvements of voiding symptoms and HRQoL demonstrate responsiveness to change (all p values <0.001). While ICIQ-UI scores did not change (p > 0.05), IIEF-5 scores improved significantly (p = 0.048). CONCLUSIONS: The German language USS-PROM shows similar psychometric properties to the English language version. This instrument can be improved by assessing EF by the use of IIEF-5. Further studies with larger patient cohorts are needed to evaluate the significance of measuring UI in urethroplasty patients.

Outcomes of Ventral Onlay Buccal Mucosa Graft Urethroplasty in Patients after Radiotherapy.

PURPOSE: We evaluated stricture-free survival and functional outcomes of buccal mucosa graft urethroplasty in patients with urethral stricture disease after radiotherapy. MATERIALS AND METHODS: We reviewed our urethroplasty database for patients with a radiotherapy history who underwent buccal mucosa graft urethroplasty between January 2009 and October 2013. We reviewed patient charts and the institutional, standardized, nonvalidated questionnaires administered to each patient postoperatively. Study end points included 1) the success rate, 2) continence status, 3) erectile function and 4) patient satisfaction postoperatively. Success was defined as stricture-free survival. RESULTS: Of 38 men included in the study prostate cancer was the most common indication for radiotherapy in 35 (92.1%). External beam radiotherapy was performed in 24 cases (64.9%), brachytherapy was done in 8 (21.6%) and a combination of the 2 treatments was performed in 6 (13.5%). Strictures were in the bulbar/bulbomembranous urethra and had a median length of 3.0 cm (range 1.0 to 8.0). The overall success rate was 71.1% at a median followup of 26.5 months (range 1.0 to 50.0). Median time to stricture recurrence was 17.0 months (range 3.0 to 44.0). De novo urinary incontinence was observed in 4 patients (10.5%). Erectile function remained mostly unchanged compared to preoperative status. Study limitations include the small sample size and the lack of validated questionnaires. CONCLUSIONS: At short-term to mid-term followup the success rate of ventral onlay buccal mucosa graft urethroplasty in patients with radiotherapy history seems acceptable. However, patients must be counseled about the increased risk of urinary incontinence. Longer followup is warranted to address long-term outcomes.

Internal urethrotomy in patients with recurrent urethral stricture after buccal mucosa graft urethroplasty.

PURPOSE: To determine the success rate of direct vision internal urethrotomy (DVIU) in the treatment of short stricture recurrence after buccal mucosa graft urethroplasty (BMGU). METHODS: Patients who underwent DVIU for the treatment of short, "veil-like" recurrent urethral strictures (<1 cm) after BMGU between October 2009 and 2013 were retrospectively identified within our urethroplasty database. Stricture recurrence was defined as maximum flow rate (Q max) <15 ml/s and a consecutively verified stricture in a combined retro- and antegrade voiding cystography or cystoscopy at a follow-up visit. The success rate of DVIU was assessed by Kaplan-Meier analysis. Univariable Cox regression analyses evaluated risk factors for stricture recurrence following DVIU. RESULTS: Forty-three patients underwent DVIU for short stricture recurrence after BMGU for bulbar (81.3 %), penile (14.0 %) and membranous (4.7 %) strictures. Relapse had occurred proximally to the buccal mucosa graft in 28 (65.1 %) and distally in 12 (27.9 %) patients, respectively. At a mean follow-up of 11.7 (±9.7) months, stricture recurrence was observed in 48.8 % of our patients. Stricture recurrence was significantly associated with weak urinary stream (9.3 ml/s vs. no recurrence 19.5 ml/s) and patient dissatisfaction (66.7 % vs. no recurrence 18.1 %; both p < 0.001). The overall success rate was 60.5 % 15 months after DVIU. The main limitations of this study are its retrospective design, the small sample size and the short follow-up. CONCLUSIONS: DVIU after BMGU showed a moderate success rate and therefore might be a viable treatment option in selected patients with very short strictures after BMGU. However, longer follow-up is warranted to prove long-term effectiveness.

Percentage of high-grade tumour volume does not meaningfully improve prediction of early biochemical recurrence after radical prostatectomy compared with Gleason score.

OBJECTIVE: To examine whether percentage of tumour volume (%TV) and percentage of high-grade tumour volume (%HGTV) help to better identify men at higher risk of early biochemical recurrence (BCR) after radical prostatectomy (RP) for non-metastatic high-risk prostate cancer, as early BCR after RP might be associated with higher risk of metastases and cancer-specific mortality. PATIENTS AND METHODS: We examined the data of 595 men treated with RP for non-metastatic high-risk prostate cancer between 1992 and 2011 at two European tertiary care centres. Kaplan-Meier analyses were used to graphically depict 2-year BCR-free survival. Multivariable Cox regression models addressed early BCR. We tested whether addition of %TV and %HGTV to a multivariable Cox regression model helps to increase a model's predictive accuracy (PA) for prediction of early BCR. RESULTS: In all, 32 men (10%) with specimen-confined prostate cancer (pT2-pT3a, negative surgical margin, pN0) and 67 men (24%) with non-specimen-confined prostate cancer had early BCR. After stratification according to %HGTV (%HGTV threshold: ≤33.33 vs >33.33%), the 2-year BCR-free survival rates were respectively 93 vs 60% (log-rank P < 0.001). In multivariable Cox regression models %HGTV emerged as an independent predictor of early BCR (P < 0.001), whereas %TV did not (P > 0.05). However, adding %HGTV (regardless of its coding) to other covariates in multivariable Cox regression analysis did not increase the model's PA in a meaningful fashion compared with the use of the detailed Gleason grading system (6 vs 7a vs 7b vs 8 vs 9-10). CONCLUSIONS: In a large cohort of patients with high-risk prostate cancer, %HGTV and %TV did not improve prediction of early BCR after RP substantially, although %HGTV was an independent predictor of early BCR. Therefore, sophisticated TV/HGTV measurements do not seem to have additional benefit for early BCR prediction relative to the use of Gleason grading. However, these results need to be confirmed in larger, prospective studies.

Holmium laser enucleation of the prostate is safe in patients with prostate cancer and lower urinary tract symptoms--a retrospective feasibility study.

OBJECTIVE: To evaluate the outcome of holmium laser enucleation of the prostate (HoLEP) in the known presence of prostate cancer (PCa) and concomitant lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: We retrospectively identified 62 patients who underwent HoLEP for LUTS in the known presence of PCa at our center. Perioperative data were assessed including complications, functional outcomes, and quality of life (QoL). Giving respect to different disease characteristics, patients were stratified according to treatment strategy setting into palliative (I), radiation (II), and surveillance (III) groups and compared accordingly. RESULTS: Median follow-up (FU) of the entire study cohort was 27 months (range 2-65 mos). Medians of functional parameters (International Prostate Symptom Score): 18.5 vs 4.5, QoL: 4 vs 1, maximal flow rate: 9.0 vs 18.8 mL/s and residual urine: 100 vs 0 mL, all P<0.05) improved significantly in all groups. Perioperative complications were low and without any statistically significant difference between the groups. Postoperatively, voiding was successful in 90.3% of all patients; at last FU, 17% had some degree of urinary incontinence. Treatment strategy groups showed comparable functional outcomes after HoLEP. CONCLUSION: In the presence of PCa and LUTS, HoLEP represents a feasible, safe, and effective treatment option for patients unfit or without indication for radical prostatectomy. This applies as well in a palliative situation of advanced, obstructive PCa as for patients with LUTS who are scheduled for radiation therapy or surveillance in presumably indolent disease.

Short-term outcome and morbidity of different contemporary urethroplasty techniques--a preliminary comparison.

BACKGROUND AND PURPOSE: Only few comparative reports about different urethroplasties have been published, addressing success rate (SR), adverse events (AE), and quality of life (QoL). Our purpose was to evaluate SR, AE, and QoL in a contemporary cohort of patients undergoing urethroplasty in the short-term follow-up (FU). PATIENTS AND METHODS: Between December 2008 and June 2010, 205 patients underwent urethroplasty for anterior urethral strictures at our institution. A standardized questionnaire was sent to all patients. The primary end point was SR. Secondary end points were AE and QoL. To assess the risk of SR, the Kaplan-Meier method and log-rank test were used. To assess risk factors for urethral stricture recurrence (SRec), univariable Cox regression analysis was used. RESULTS: Overall, 140 (68%) patients responded to our questionnaire and were used for analysis. Of these 9%, 85%, and 6% were treated by excision and primary anastomosis (EPA), buccal mucosa graft urethroplasty (BMGU), and mesh graft urethroplasty (MGU), respectively. At 10 months of FU, SR was 87.5%. SRs of EPA, BMGU, and MGU were 100% (n=13/13), 85.7% (n=102/119), and 87.5% (n=7/8), with no significant differences between the groups. In univariable analysis, ≥ 2 vs 1 previous urethroplasties showed a trend toward a reduced SR (hazard risk 2.95; P=0.057). Streaking the urethra (P=0.024) and penile curvature (P=0.026) were significantly more often associated with MGU compared with EPA and BMGU. Postoperative total median (mean) scores were 3.5 (4.8) for the International Consultation on Incontinence Questionnaire Male lower urinary tract symptoms, 15 (15.2) for the International Index of Erectile Function, and 80 (73) for EuroQol visual analogue score; there was no difference between urethroplasty types. CONCLUSION: In the short-term FU, urethroplasty demonstrates an excellent SR. Specific SRs of EPA, BMGU, and MGU seem comparable. Despite significant differences in AE, patient reported QoL is high with no difference between the applied techniques.

Initial prostate biopsy: development and internal validation of a biopsy-specific nomogram based on the prostate cancer antigen 3 assay.

BACKGROUND: Urinary prostate cancer antigen 3 (PCA3) assay in combination with established clinical risk factors improves the identification of men at risk of harboring prostate cancer (PCa) at initial biopsy (IBX). OBJECTIVE: To develop and validate internally the first IBX-specific PCA3-based nomogram that allows an individual assessment of a man's risk of harboring any PCa and high-grade PCa (HGPCa). DESIGN, SETTING, AND PARTICIPANTS: Clinical and biopsy data including urinary PCA3 score of 692 referred IBX men at risk of PCa were collected within two prospective multi-institutional studies. INTERVENTION: IBX (≥ 10 biopsy cores) with standard risk factor assessment including prebiopsy urinary PCA3 measurement. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: PCA3 assay cut-off thresholds were investigated. Regression coefficients of logistic risk factor analyses were used to construct specific sets of PCA3-based nomograms to predict any PCa and HGPCa at IBX. Accuracy estimates for the presence of any PCa and HGPCa were quantified using area under the curve of the receiver operator characteristic analysis and compared with a clinical model. Bootstrap resamples were used for internal validation. Decision curve analyses quantified the clinical net benefit related to the novel PCA3-based IBX nomogram versus the clinical model. RESULTS AND LIMITATIONS: Any PCa and HGPCa were diagnosed in 46% (n=318) and 20% (n=137), respectively. Age, prostate-specific antigen, digital rectal examination, prostate volume, and PCA3 were independent predictors of PCa at IBX (all p<0.001). The PCA3-based IBX nomograms significantly outperformed the clinical models without PCA3 (all p<0.001). Accuracy was increased by 4.5-7.1% related to PCA3 inclusion. When applying nomogram-derived PCa probability thresholds ≤ 30%, only a few patients with HGPCa (≤ 2%) will be missed while avoiding up to 55% of unnecessary biopsies. External validation of the PCA3-based IBX-specific nomogram is warranted. CONCLUSIONS: The internally validated PCA3-based IBX-specific nomogram outperforms a clinical prediction model without PCA3 for the prediction of any PCa, leading to the avoidance of unnecessary biopsies while missing only a few cases of HGPCa. Our findings support the concepts of a combination of novel markers with established clinical risk factors and the superiority of decision tools that are specific to a clinical scenario.