[Digitalization in urology-challenge and opportunity]. / Digitalisierung in der Urologie ­ Herausforderung und Chance.

Digitalization is changing medicine. In Germany these changes are not highly accepted yet. Medical pathways should be supported and become safer by digital transformation. Furthermore, artificial intelligence (AI) applications are increasingly used in medicine. Only time will tell whether these will decrease the workload and make patient treatment easier, while increasing precision and individualization.. Urology must accept the upcoming new challenges. This can best be done by participating in the development.

Can transrectal prostate ultrasound compete with multiparametric MRI in the detection of clinically significant prostate cancer?

We consider the current and future role of transrectal ultrasound imaging in the diagnosis of prostate cancer, with a particular focus on the pre-biopsy localization and targeting role that multiparametric MRI (mpMRI) has come to occupy for some men in recent years. We draw a distinction between transrectal ultrasound (TRUS) used only as a means of distributing zonal biopsies with its employment as a means for identifying and targeting sonographically abnormal lesions. The role of AI in lesion identification and targeting will be reviewed. Comparisons of cost and availability, frequency of contraindications and diagnostic accuracy between these two imaging modalities will be drawn.

Innovative endoscopic enucleations of the prostate - Xie's Prostate Enucleations.

In the past 2 decades, endoscopic enucleation of the prostate has become a safe and effective surgical treatment for benign prostatic hyperplasia (BPH), with comparable outcomes to traditional surgeries. Transurethral vapor enucleation and resection of the prostate (TVERP), transurethral vapor enucleation of the prostate (TVEP), and ultrasound-navigated TVEP (US-TVEP) are new, innovative endoscopic enucleation procedures. These procedures are named Xie's Prostate Enucleations (Xie's Procedures for short). Current clinical data indicate that Xie's Procedures are safe and effective treatment options for patients with BPH, especially for patients with larger prostates. Further prospective, randomized clinical trials compared with traditional transurethral resection of prostate (TURP) are still needed.

Internal Fusion: exact correlation of transrectal ultrasound images of the prostate by detailed landmarks over time for targeted biopsies or follow-up.

PURPOSE: Innovative imaging modalities are applied for diagnosing and follow-up of prostate cancer (PCa). To perform authentic targeted biopsies and evaluate prostate changes, it is essential to reliably identify and hit targets in their true anatomical location over time. A newly described image correlation method (Internal Fusion) allows precise correlation of serial transrectal ultrasound (TRUS) images in vitro and vivo. Identifiable morphologic structures such as prostatic calcifications define internal anchor points (Internal Landmarks) to facilitate exact correlation. METHODS: After verification of Internal Fusion in vitro, 83 patients were included from January to August 2017 with at least one prior series of 5-mm spaced TRUS images stored as computed tomographic (US-CT) online data set. Two experienced operators collected new images in correlation with each cross-section of the previous examinations based on Internal Landmarks. RESULTS: Of the 83 patients, fifty (60%) had prior negative biopsies. Fourteen (17%) wished US-CT targeted biopsies and PCa were detected in 7/14 patients (50%). Overall, accurate imaging correlations were attained in 369/397 slices (93%). In initial and repeat biopsy, 31/31 and 35/35 images could be correlated detecting PCa in 5/8 (63%) and 2/6 patients (33%). The longest observation of prostate changes over time (Trend Monitoring) with accurate image correlation was 8 years and 6 months. CONCLUSIONS: Internal Fusion by Internal Landmarks ensures exact correlation in long-term follow-up. It is possible to precisely monitor trends in prostate tissue changes. In case of PCa suspicion, biopsies could be targeted with high accuracy by Internal Fusion, even over time.

A 12-year follow-up of ANNA/C-TRUS image-targeted biopsies in patients suspicious for prostate cancer.

PURPOSE: PSA screening has been rehabilitated. PSA is not specific and can be elevated by benign reasons. Additionally, a subgroup of patients with prostate hyperplasia may harbor prostate cancer (PCa). During monitoring, the clinician aims to detect significant tumors in time, submitting patients to minimal psychological and physical burden, especially in men with high serum PSA and repeat biopsies. We aimed to determine long-term outcomes with respect to ANNA/C-TRUS ability to detect PCa with six targeted biopsies. METHODS: A subset of 71 patients were enrolled. During monitoring, they were subjected to primary, secondary, or even multiple prostate biopsies when needed. Protocol monitoring included PSA measurements, digital rectal examination (DRE) and imaging. RESULTS: The median follow-up was 12 years. Forty-one patients had a history of negative systematic random biopsies (1-3 sessions). Their age ranges 62-85 years, PSA 0.5-47.3 ng/ml, and the median prostate volume 11-255 cc. During monitoring, 15 patients were diagnosed with PCa. Only two harbored aggressive tumors. The median time to diagnosis was 6 years. All PCa patients are free from biochemical relapse. From the remaining 56 patients, 11 did not have any biopsies, 12 had one, 13 had two, and 20 had three or more biopsy sessions. CONCLUSIONS: ANNA/C-TRUS is a useful method monitoring patients with a risk of PCa. 50-75% of the usually performed biopsy cores could be spared and, after 12 years, 97% of the patients were either without evidence of a PCa or were diagnosed with a good prognosis tumor.

Ensuring Consistent European-Wide Urological Care by the Use of Evidence-Based Clinical Practice Guidelines: Can We Do Better.

The European Association of Urology (EAU) annually updates 21 clinical practice guidelines in which summaries of the evidence base and best practice recommendations are made. The methodology applied to achieve this and integrate stakeholder opinion is continuously improving. However, there is evidence to suggest wide variation in clinical practice indicating that many patients receive suboptimal and heterogeneous care. Studies from certain countries suggest that 2 out of 5 patients do not receive care according to the current scientific evidence, and in 1 out of 4 cases the care provided is potentially harmful. Clearly, the harmonisation of care in alignment with evidence-based best practice recommendations is something to strive for. Development of robust methods to disseminate and implement guideline recommendations and measure their impact is an objective the EAU is committed to improving. An important strategy for achieving harmonisation in urological care across Europe is to ensure the availability of high-quality clinical practice guidelines and to actively promote their implementation by clinicians and healthcare providers.

EAU standardised medical terminology for urologic imaging: a taxonomic approach.

BACKGROUND: The terminology and abbreviations used in urologic imaging have generally been adopted on an ad hoc basis by different speciality groups; however, there is a need for shared nomenclature to facilitate clinical communication and collaborative research. OBJECTIVE: This work reviews the current nomenclature for urologic imaging used in clinical practice and proposes a taxonomy and terminology for urologic imaging studies. DESIGN, SETTING, AND PARTICIPANTS: A list of terms used in urologic imaging were compiled from guidelines published by the European Association of Urology and the American Urological Association and from the American College of Radiology Appropriateness Criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Terms searched were grouped into broad categories based on technology, and imaging terms were further stratified based on the anatomic extent, contrast or phases, technique or modifiers, and combinations or fusions. Terms that had a high degree of utilisation were classified as accepted. RESULTS AND LIMITATIONS: We propose a new taxonomy to define a more useful and acceptable nomenclature model acceptable to all health professionals involved in urology. The major advantage of a taxonomic approach to the classification of urologic imaging studies is that it provides a flexible framework for classifying the modifications of current imaging modalities and allows the incorporation of new imaging modalities. The adoption of this hierarchical classification model ranging from the most general to the most detailed descriptions should facilitate hierarchical searches of the medical literature using both general and specific terms. This work is limited in its scope, as it is not currently all-inclusive. This will hopefully be addressed by future modification as others embrace the concept and work towards uniformity in nomenclature. CONCLUSIONS: This paper provides a noncomprehensive list of the most widely used terms across different specialties. This list can be used as the basis for further discussion, development, and enhancement. PATIENT SUMMARY: In this paper we describe a classification system for urologic imaging terms with the aim of aiding health professionals and ensuring that the terms used are more consistent.

Increasing the dose of vardenafil on a daily basis does not improve erectile function after unilateral nerve-sparing radical prostatectomy.

INTRODUCTION: Several treatment regimens for rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) are currently discussed. The optimal and most cost-effective therapy is still not found yet. AIM: To evaluate the effect of vardenafil, a PDE5 inhibitor, dose escalation on recovery of EF after unilateral nsRP. METHODS: Thirty-six sexually active patients received a unilateral nsRP. All patients completed an International Index of Erectile Function-5 items (IIEF-5) questionnaire concerning EF preoperatively. Group 1 (N = 12 patients) received vardenafil 5 mg/day vs. group 2 (N = 12) who received vardenafil 10 mg/day at night beginning the day of catheter removal. A control of 12 patients underwent follow-up without PDE5 inhibitors. MAIN OUTCOME MEASURE: The IIEF-5 was the primary end point. IIEF-5 questionnaires were completed at baseline, 3, 6, and 12 months after nsRP. RESULTS: In group 1 (5 mg/day vardenafil) the IIEF-5 score decreased from a preoperative 22.4 mean score to 4.2 at 3 months, 8.9 at 6 months, and 13.4 mean score at 12 months after nsRP vs. preoperative 22.8, 4.1 at 3 months, 7.9 at 6 months, and 12.8 mean score at 12 months in group 2 (10 mg/day vardenafil). In the control group the preoperative IIEF-5 mean score of 21.9 decreased to 3.8 at 3 months, 6.1 at 6 months, and 8.9 at 12 months. Statistical evaluation showed significant difference in IIEF-5 score and time to recovery of EF between groups 1 and 3 and between groups 2 and 3 (P < 0.01). No statistical differences were found between groups 1 and 2. CONCLUSIONS: Daily low-dose vardenafil lead to significant improvement of recovery of EF. In this study doubling the dosage did not improve the recovery of EF further.

Prostate cancer diagnostics: innovative imaging in case of multiple negative biopsies.

OBJECTIVE: According to international guidelines, a primary set of TRUS-guided systematic biopsy should consist of 10-12 tissue samples. If a clinical suspicion of a prostate carcinoma persists, a secondary biopsy session should also involve 10-12 samples. However, if there still is a clinical suspicion of prostate cancer is there a role for innovative imaging guided biopsies? MATERIALS AND METHODS: The available innovative imaging techniques range from MRI, Doppler techniques with and without contrast agents, a renaissance of elastography to computer-assisted evaluation of TRUS signal information. RESULT: All of these methods attempt to make more specific statements on the imaged tissue. Before routine clinical use, a review of the literature is recommended to be able to differentiate between the different methods. Sophisticated modern MRI techniques allow for excellent high-resolution prostate imaging. However, MRI guided biopsies so far are not routine practice and are not recommended in urological guidelines. A literature review reflects differences in stage of development, biopsy performance and clinical validity of the different imaging modalities. Elastography, contrast imaging and C-TRUS/ANNA guided biopsies have been investigated in clinical trails suggesting possible benefits over additional systematic random biopsies alone. Because of the differences in design and clinical maturity of the innovative imaging methods, it is essential to be able to inform the patients about individual evidence-based performance prior to its clinical utilization. CONCLUSION: The ideal time for innovative imaging techniques seems to be in patients with multiple series of negative systematic biopsies possibly leading to a more specific PCa detection. However, patients often ask for a qualitative diagnostic approach right from the beginning. This should only be performed after educating the patient on the experimental and 'non-guideline-conform' character of such a proceeding.

Computerized transrectal ultrasound of the prostate in a multicenter setup (C-TRUS-MS): detection of cancer after multiple negative systematic random and in primary biopsies.

OBJECTIVE: To improve prostate cancer diagnostic imaging, a computer-based analysis of the transrectal ultrasound signal (C-TRUS) was developed. Until recently, the C-TRUS existed only as a stand-alone device. Now, C-TRUS was developed into a network-compatible module (C-TRUS-MS). This new technology allows users to transmit C-TRUS images from any internet platform to C-TRUS-MS investigation. After analysis, the cancer-suspicious marked images are then retransmitted via internet. Targeted biopsies can then be taken at the urologists' office remotely. MATERIALS AND METHODS: This prospective study investigates whether the rates of prostate cancer detection with C-TRUS-MS "multicenter online" are comparable with those achieved by the stand-alone unit. In addition to patients with a history of multiple systematic random biopsies, a group of patients who had not undergone systematic random biopsies were analyzed. RESULTS: A total of 1,545 digital images (2-23 per patient, median 6) from 57 urologists were transmitted to the analysis center. After analysis, the color-coded images were sent back electronically and utilized for a maximum of six targeted biopsies. C-TRUS-MS was able to detect prostate cancer in 91 patients. In addition, we evaluated 75 patients without any previous random biopsies. In this group, C-TRUS-MS was able to detect prostate cancer in 31 out of 75 patients (41%). CONCLUSION: The results indicate that C-TRUS-MS "online" achieves similar results as the stand-alone system, independent of the user even with little experience in the method. Furthermore, C-TRUS-MS for the first time is able to detect carcinomas in patients without prior biopsies in a high number by taking only six targeted biopsies.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Rare and challenging tumor entity: phyllodes tumor of the prostate.

Cystic epithelial-stromal tumors of the prostate are rare, with 82 cases reported in literature. These cases have been published under a variety of diagnoses, including phyllodes tumor and prostatic stromal proliferation of uncertain malignant potential as well as a malignant tumor called "prostatic stromal sarcoma". We report a case of a 60-year-old man with the histological diagnosis of phyllodes tumor of the prostate in transurethral resection specimen.

The European Association of Urology (EAU) guidelines methodology: a critical evaluation.

OBJECTIVES: Guidelines can be produced and written in numerous ways. The aim of the present article is to describe and evaluate the method currently used to produce the European Association of Urology (EAU) guidelines. DESIGN, SETTING, AND PARTICIPANTS: The methodology is described in detail, compared to other urologic guidelines by members of the EAU Guidelines Office Board. MEASUREMENTS: The new methodology is evaluated by the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. RESULTS AND LIMITATIONS: The currently used methodology is adapted to the aims and objectives as established by the EAU for their guidelines; wide coverage (essentially all fields of urology) and useful to urologists all over Europe. The frequent updates are easily accessible in a printed and electronic format. The AGREE instrument supports these strong points, but also identifies potentially weak points, such as no patient involvement, no formal validation of the guidelines texts prior to publication, and lack of discussion of organisational barriers and cost implications. CONCLUSION: The currently used methodology for the production of EAU guidelines fulfils the association's main objectives related to their guidelines, but the texts will benefit from the inclusion of country-specific cost and organisational data. For the practising clinician, these guidelines will help to take science into clinical practice.

Technical and anatomical essentials for transrectal ultrasound of the prostate.

Transrectal ultrasound (TRUS) of the prostate is a specific urological examination. This morphological imaging technique is often capable of identifying the cause for raised values of prostate-specific antigen (PSA) or of clarifying hard tissue regions found during rectal palpation. Particulary in view of constantly increasing number of patients undergoing PSA tests, there is a rising need for further prostate diagnostics in otherwise asymptomatic men. Especially in the gray zone between 4 and 10 ng/ml the tissue marker PSA is frequently influenced by benign alterations, so that it is not possible--on the basis of the PSA value alone--to differentiate between benign and malignant causes. Only a clearly increased serum PSA value (>20 ng/ml) indicates the presence of a prostate carcinoma at a very high probability. However, it is necessary that all patients whose PSA is elevated, undergo a bioptical tissue sample procedure in order to try to diagnose prostate cancer. Today, we regard the technique of TRUS-based transrectal prostate biopsy, carried out with a semi-automatic coil spring device and an 18-gauge needle, as the gold standard. The core problem of visual TRUS assessment lies in its lack of specificity, especially if the examiner has only limited experience. There can be low-echo, cancer-suspicious areas that may be histologically either benign or malignant. Benign prostatic hyperplasia (BPH), vessels, centers of prostatitis as well as shadows and artefacts can often also be low in echo-density. Only adequate application of this technology and experience with this method can lead to satisfying biopsy and diagnostic results.