In vitro blood sample assessment: investigating correlation of laboratory hemoglobin and spectral properties of dual-energy CT measurements (ρ/Z).

OBJECTIVES: Our study comprised a single-center retrospective in vitro correlation between spectral properties, namely ρ/Z values, derived from scanning blood samples using dual-energy computed tomography (DECT) with the corresponding laboratory hemoglobin/hematocrit (Hb/Hct) levels and assessed the potential in anemia-detection. METHODS: DECT of 813 patient blood samples from 465 women and 348 men was conducted using a standardized scan protocol. Electron density relative to water (ρ or rho), effective atomic number (Zeff), and CT attenuation (Hounsfield unit) were measured. RESULTS: Positive correlation with the Hb/Hct was shown for ρ (r-values 0.37-0.49) and attenuation (r-values 0.59-0.83) while no correlation was observed for Zeff (r-values -0.04 to 0.08). Significant differences in attenuation and ρ values were detected for blood samples with and without anemia in both genders (p value < 0.001) with area under the curve ranging from 0.7 to 0.95. Depending on the respective CT parameters, various cutoff values for CT-based anemia detection could be determined. CONCLUSION: In summary, our study investigated the correlation between DECT measurements and Hb/Hct levels, emphasizing novel aspects of ρ and Zeff values. Assuming that quantitative changes in the number of hemoglobin proteins might alter the mean Zeff values, the results of our study show that there is no measurable correlation on the atomic level using DECT. We established a positive in vitro correlation between Hb/Hct values and ρ. Nevertheless, attenuation emerged as the most strongly correlated parameter with identifiable cutoff values, highlighting its preference for CT-based anemia detection. CLINICAL RELEVANCE STATEMENT: By scanning multiple blood samples with dual-energy CT scans and comparing the measurements with standard laboratory blood tests, we were able to underscore the potential of CT-based anemia detection and its advantages in clinical practice. KEY POINTS: Prior in vivo studies have found a correlation between aortic blood pool and measured hemoglobin and hematocrit. Hemoglobin and hematocrit correlated with electron density relative to water and attenuation but not Zeff. Dual-energy CT has the potential for additional clinical benefits, such as CT-based anemia detection.

Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Obstruction: 5-year Outcomes of a Randomised, Open-label, Noninferiority Trial.

BACKGROUND AND OBJECTIVE: Prostatic artery embolisation (PAE) and transurethral resection of the prostate (TURP) are two of the surgical options for treatment of lower urinary tract symptoms/benign prostatic obstruction (LUTS/BPO). Our aim was to compare the efficacy and safety of PAE and TURP for LUTS/BPO treatment at long-term follow-up. METHODS: We conducted a randomised, open-label, single-centre trial at a Swiss tertiary care centre. The main outcome was the change in International Prostate Symptom Score (IPSS) after PAE versus TURP. Secondary outcomes included patient-reported outcomes, functional measures, and adverse events assessed at baseline and at 3, 6, 12, 24, and 60 mo. Between-group differences in the change from baseline to 5 yr were tested using two-sided Mann-Whitney and t tests. KEY FINDINGS AND LIMITATIONS: Of the 103 patients with refractory LUTS/BPO who were randomised between 2014 and 2017, 18/48 who underwent PAE and 38/51 who underwent TURP reached the 60-mo follow-up visit. The mean reduction in IPSS from baseline to 5 yr was -7.78 points after PAE and -11.57 points after TURP (difference 3.79 points, 95% confidence interval [CI] -0.66 to 8.24; p = 0.092). TURP was superior for most patient-reported secondary outcomes except for erectile function. At 5 yr, PAE was less effective than TURP regarding objective parameters, such as the improvement in maximum urinary flow rate (3.59 vs 9.30 ml/s, difference -5.71, 95% CI -10.72 to -0.70; p = 0. 027) and reduction in postvoid residual volume (27.81 vs 219.97 ml; difference 192.15, 95% CI 83.79-300.51; p = 0.001). CONCLUSIONS AND CLINICAL IMPLICATIONS: The improvement in LUTS/BPO at 5 yr after PAE was inferior to that achieved with TURP. The limitations of PAE should be considered during patient selection and counselling. PATIENT SUMMARY: In this study, we show the long-term results of prostate artery embolisation (PAE) in comparison to transurethral resection of the prostate (TURP) for the treatment of benign prostate enlargement causing urinary symptoms. PAE shows good long-term results in properly selected patients, although the improvements are less pronounced than with TURP. This trial is registered on ClinicalTrials.gov as NCT02054013.

Prostatic Artery Embolization in Patients with Advanced Prostate Cancer: A Prospective Single Center Pilot Study.

PURPOSE: To assess efficacy and safety of prostatic artery embolization (PAE) in patients with advanced prostate cancer (PCa). MATERIALS AND METHODS: In this prospective single-center, single-arm, pilot study, 9 men with advanced PCa underwent PAE. PAE was performed with the use of 250-400 µm Embozene microspheres (Boston Scientific, Natick, Massachusetts, USA). International Prostate Symptoms Score (IPSS), urinary peak flow (Qmax) and post-void residual urine volume (PVR) was assessed at 12 weeks and up to 12 months. Changes in total prostate volume (TPV) and tumor responses by PSA, changes in tumor volume and evaluation of tumor regression by multiparametric magnetic resonance imaging were assessed at 12 weeks after PAE. RESULTS: IPSS reduction in median 6 points (0-19) and a significant decrease in PVR from median 70 (20-600) mL to 10 (0-280) mL could be achieved within 12 weeks after PAE. Median TPV and tumor volumes (TV) increased slightly from 19.7 (6.4-110.8) mL to 23.4 (2.4-66.3) mL and 6.4 (4.6-18.3) mL to 8.1 (2.4-25.6) mL at a median of 12 weeks after the procedure. Significant tumor necrosis (≥ 50%) was found in one patient. Eight patients showed > 50% of viable tumor on post-PAE MRI according to MRI. Only one Clavien-Dindo Grade 1 adverse event related to PAE occurred. CONCLUSIONS: PAE with the use of 250-400 µm microspheres is feasible, safe and effective in some patients with advanced PCa regarding functional outcomes. A cytoreductive effect might be achieved in individual patients but must be further assessed. TRIALS REGISTRATION: NCT03457805.

Clinical symptoms of SARS-CoV-2 breakthrough infection during the Omicron period in relation to baseline immune status and booster vaccination-A prospective multicentre cohort of health professionals (SURPRISE study).

The effects of different types of pre-existing immunity on the frequency of clinical symptoms caused by the SARS-CoV-2 breakthrough infection were prospectively assessed in healthcare workers during the Omicron period. Among 518 participants, hybrid immunity was associated with symptom reduction for dizziness, muscle or limb pain and headache as compared to vaccination only. Moreover, the frequencies of dizziness, cough and muscle or limb pain were lower in participants who had received a booster vaccine dose. Thus, hybrid immunity appeared to be superior in preventing specific symptoms during breakthrough infection compared to vaccination alone. A booster vaccine dose conferred additional symptom reduction.

Farmland practices are driving bird population decline across Europe.

Declines in European bird populations are reported for decades but the direct effect of major anthropogenic pressures on such declines remains unquantified. Causal relationships between pressures and bird population responses are difficult to identify as pressures interact at different spatial scales and responses vary among species. Here, we uncover direct relationships between population time-series of 170 common bird species, monitored at more than 20,000 sites in 28 European countries, over 37 y, and four widespread anthropogenic pressures: agricultural intensification, change in forest cover, urbanisation and temperature change over the last decades. We quantify the influence of each pressure on population time-series and its importance relative to other pressures, and we identify traits of most affected species. We find that agricultural intensification, in particular pesticides and fertiliser use, is the main pressure for most bird population declines, especially for invertebrate feeders. Responses to changes in forest cover, urbanisation and temperature are more species-specific. Specifically, forest cover is associated with a positive effect and growing urbanisation with a negative effect on population dynamics, while temperature change has an effect on the dynamics of a large number of bird populations, the magnitude and direction of which depend on species' thermal preferences. Our results not only confirm the pervasive and strong effects of anthropogenic pressures on common breeding birds, but quantify the relative strength of these effects stressing the urgent need for transformative changes in the way of inhabiting the world in European countries, if bird populations shall have a chance of recovering.

Spindle cell/pleomorphic lipoma of the seminal vesicle: First description of a rare benign mesenchymal tumor.

We describe the first case of a spindle cell/pleomorphic lipoma of the seminal vesicle. A 6.2cm large mass originating from the left seminal vesicle was incidentally detected on imaging for peripheral arterial disease. A transrectal ultrasound-guided biopsy was negative for malignancy. We proceeded with a robotic tumor resection due to the size of the mass and sarcomatoid features present on MR imaging. The final pathological work-up revealed a spindle cell/pleomorphic lipoma, immunohistochemical staining was performed with no malignant features detected, in particular no signs of an atypical lipomatous tumor. Ejaculatory function was preserved with reduced volume at 6-weeks follow-up.

Ventral-inlay buccal mucosal graft urethroplasty in a 44-year old female patient with recurrent urethral stricture.

Female urethral stricture is a rare manifestation of bladder outlet obstruction in women. According to the current guidelines of the European Association of Urology, urethral dilatation should be offered as first line treatment. Intermittent self-dilatation (ISD) in case of recurrence is recommended. However, if patients wish definitive surgical treatment or are not able to perform ISD, urethroplasty can be considered. So far, there are little data available on urethroplasty in female patients. We present a case of a 44-year old female patient with a postoperative urethral stricture who underwent ventral-inlay buccal mucosal graft urethroplasty due to inability to perform ISD.

Prostatic Artery Embolization in Patients with Prostate Cancer: A Systematic Review.

CONTEXT: Prostatic artery embolization (PAE) is increasingly performed worldwide for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). In contrast, the role of PAE in patients with prostate cancer (PCa) is unclear. OBJECTIVE: This systematic review summarizes the current available literature on PAE in patients with PCa regarding oncological and functional outcome. EVIDENCE ACQUISITION: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A structured search for the relevant literature from 1985 to 2022 was performed in Medline, Embase, and York CRD. Risk of bias and confounding assessments were performed using the ROBINS tool. EVIDENCE SYNTHESIS: Thirteen trials (12 case series and one animal study using a canine model) were included in this systematic review. Four studies had a prospective study design. The risk of bias was rated moderate to serious in all the studies. CONCLUSIONS: PAE in patients with PCa seems to be a safe procedure and effective regarding the improvement of LUTS. Despite PAE having been shown to be feasible in different treatment scenarios of localized or advanced PCa, the oncological benefits are debatable due to an unreliable tumor response and a lack of controlled trials including long-term follow-up. PATIENT SUMMARY: We investigated the literature to determine the role of prostatic artery embolization (PAE) in patients with prostate cancer regarding oncological and functional outcomes. The results suggest a similar safety profile and efficacy in terms of functional outcomes to those reported earlier for PAE in patients with lower urinary tract symptoms due to benign prostatic hyperplasia. The role of PAE regarding oncological outcomes has to be assessed further.

Comparison of traditional outcome measures and self-assessed goal achievement in patients treated surgically for benign prostatic hyperplasia.

PURPOSE: To determine self-assessed goal achievement (SAGA) outcomes in men treated surgically for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and compare them to the traditional outcome measures. METHODS: Single-center analysis of prospective database of men undergoing surgical treatment of LUTS/BPO at a single institution between July 2019 and March 2021. We assessed individual goals, traditional questionnaires, and functional outcomes prior to treatment, and at first follow-up after 6-12 weeks. We compared SAGA outcomes 'overall goal achievement' and 'satisfaction with treatment' to subjective and objective outcomes using Spearman's rank correlations (rho). RESULTS: A total of sixty-eight patients completed the individual goal formulation prior to surgery. Preoperative goals varied between different treatments and individuals. IPSS correlated with 'overall goal achievement' (rho = - 0.78, p < 0.001) and 'satisfaction with treatment' (rho = - 0.59, p < 0.001). Similarly, the IPSS-QoL was correlated with overall goal achievement (rho = - 0.79, p < 0.001) and satisfaction with treatment (rho = - 0.65, p < 0.001). No correlation was seen between SAGA outcomes and functional outcomes Qmax and PVR. CONCLUSIONS: SAGA represents a uniquely patient-specific outcome measure. Our study is, to our knowledge, the first to assess patient-specific goals prior to surgery and examine SAGA outcomes following treatment in men suffering from LUTS/BPO. The correlation of SAGA outcomes with IPSS and IPSS-QoL highlight the importance of this well-established questionnaire. Functional outcomes do not necessarily reflect patient's goals and may rather be considered physician-directed outcomes.

Standardized evaluation of satisfaction within urology residents during clinical training: Implementation of a new urological residency rotation program at the university hospital Frankfurt.

Background: Structured curricula are demanded to improve training programs of future urologists. This study aimed to evaluate the acceptance of the newly implemented residency rotation program at the University Hospital Frankfurt. Primary endpoint was resident's satisfaction with the current residency rotation program. Secondary endpoint was the fulfilment of the objectives and expectations by residents. Methods: A standardized 15-item, online-based survey was sent to every urologic resident of the University Hospital Frankfurt, completing their rotation between August 2020 and August 2022. In addition to baseline characteristics, training and working conditions were assessed. Descriptive statistics were applied. Results: In total 15 rotations of the Residency Rotation Program at the University Hospital Frankfurt were evaluated, including urologic practice (5/15), Intermediate Care Unit (4/15), urooncology (4/15) and clinical exchange to St. Gallen (2/15). Overall, the majority were very (67%) or rather satisfied (2%) with their rotation. Of the pre-rotation defined objectives, 71% were fulfilled, 18% partially fulfilled and 8% not fulfilled. With respect to the expectations, 67% were fulfilled, 19% partly fulfilled and 4% were not fulfilled. All residents would recommend their respective rotations. Conclusion: Our results demonstrate that the residency rotation program at the University Hospital Frankfurt enjoys a high level of acceptance as well as a positive impact on urologic training. Satisfaction with the completed rotation was convincing, most of the expectations and objectives for the respective rotation could be fulfilled. These results help to ensure the quality of urologic curricula and to improve the structure of training programs for future urologists.

Risk and symptoms of COVID-19 in health professionals according to baseline immune status and booster vaccination during the Delta and Omicron waves in Switzerland-A multicentre cohort study.

BACKGROUND: Knowledge about protection conferred by previous Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and/or vaccination against emerging viral variants allows clinicians, epidemiologists, and health authorities to predict and reduce the future Coronavirus Disease 2019 (COVID-19) burden. We investigated the risk and symptoms of SARS-CoV-2 (re)infection and vaccine breakthrough infection during the Delta and Omicron waves, depending on baseline immune status and subsequent vaccinations. METHODS AND FINDINGS: In this prospective, multicentre cohort performed between August 2020 and March 2022, we recruited hospital employees from ten acute/nonacute healthcare networks in Eastern/Northern Switzerland. We determined immune status in September 2021 based on serology and previous SARS-CoV-2 infections/vaccinations: Group N (no immunity); Group V (twice vaccinated, uninfected); Group I (infected, unvaccinated); Group H (hybrid: infected and ≥1 vaccination). Date and symptoms of (re)infections and subsequent (booster) vaccinations were recorded until March 2022. We compared the time to positive SARS-CoV-2 swab and number of symptoms according to immune status, viral variant (i.e., Delta-dominant before December 27, 2021; Omicron-dominant on/after this date), and subsequent vaccinations, adjusting for exposure/behavior variables. Among 2,595 participants (median follow-up 171 days), we observed 764 (29%) (re)infections, thereof 591 during the Omicron period. Compared to group N, the hazard ratio (HR) for (re)infection was 0.33 (95% confidence interval [CI] 0.22 to 0.50, p < 0.001) for V, 0.25 (95% CI 0.11 to 0.57, p = 0.001) for I, and 0.04 (95% CI 0.02 to 0.10, p < 0.001) for H in the Delta period. HRs substantially increased during the Omicron period for all groups; in multivariable analyses, only belonging to group H was associated with protection (adjusted HR [aHR] 0.52, 95% CI 0.35 to 0.77, p = 0.001); booster vaccination was associated with reduction of breakthrough infection risk in groups V (aHR 0.68, 95% CI 0.54 to 0.85, p = 0.001) and H (aHR 0.67, 95% CI 0.45 to 1.00, p = 0.048), largely observed in the early Omicron period. Group H (versus N, risk ratio (RR) 0.80, 95% CI 0.66 to 0.97, p = 0.021) and participants with booster vaccination (versus nonboosted, RR 0.79, 95% CI 0.71 to 0.88, p < 0.001) reported less symptoms during infection. Important limitations are that SARS-CoV-2 swab results were self-reported and that results on viral variants were inferred from the predominating strain circulating in the community at that time, rather than sequencing. CONCLUSIONS: Our data suggest that hybrid immunity and booster vaccination are associated with a reduced risk and reduced symptom number of SARS-CoV-2 infection during Delta- and Omicron-dominant periods. For previously noninfected individuals, booster vaccination might reduce the risk of symptomatic Omicron infection, although this benefit seems to wane over time.

Extraadrenal pheochromocytoma presenting with severe hematuria and postmicturition cephalgia, a case report of a rare bladder tumor entity.

Paraganglioma (PGL) of the urinary bladder are a very rare tumor entity. Treatment of a PGL requires a multidisciplinary approach. We report on a case of a malignant pheochromocytoma (PHEO) of the bladder in a male adult due to a succinate dehydrogenase B (SDHB) subunit gene mutation where a partial cystectomy was perfomed after preoperative alpha blocking.

[The future of affiliated physicians]. / Die Zukunft des Belegarztwesens.

The affiliated physician is one of the oldest types of self-employed physicians who work between outpatients and inpatient sectors. The number of physicians affiliated with hospitals in Germany has been decreasing steadily in recent decades. The reasons for this decline are diverse and include political and financial problems that need to be resolved. The new political changes aimed at the expansion of out-patient services in the sense of the AOP Catalog 115 b SGB V can be a new opportunity for affiliated physicians and the departments that they are affiliated with.

Analysis of Diagnostic Modalities in Hospital-admitted Patients Evaluated for COVID-19.

BACKGROUND/AIM: To assess the diagnostic performance of reverse transcriptase polymerase chain reaction (RT-PCR), low-dose chest computed tomography (CT), and serological testing, alone and in combinations, as well as routine inflammatory markers in patients evaluated for COVID-19 during the first wave in early 2020. PATIENTS AND METHODS: We retrospectively analyzed data of all patients who were admitted to the emergency department due to fever and/or respiratory symptoms. CT scans were rated using the COVID-19 Reporting and Data System (CO-RADS) suspicion score. True disease status (COVID-19 - positive vs. negative) was adjudicated by two independent clinicians. Receiver-operating characteristic curves and areas under the curves were calculated for inflammatory markers. Sensitivities and specificities were calculated for RT-PCR, CT, and serology alone, as well as the combinations of RT-PCR+CT, RT-PCR+serology, CT+serology, and all three modalities. RESULTS: Of 221 patients with a median age of 72 years, 113 were classified as COVID-19 positive. Among 180 patients from which data on CT and RT-PCR were available, RT-PCR had the highest sensitivity to detect COVID-19 (0.87; 95%CI=0.78-0.93). Notably, the addition of CT in the analysis increased sensitivity to 0.89 (95%CI=0.8-0.94), but lowered specificity from 1 (95%CI=0.96-1) to 0.9 (95%CI=0.83-0.95). The combination of RT-PCR, CT and serology (n=60 patients with complete dataset) yielded a sensitivity of 0.83 (95%CI=0.61-0.94) and specificity of 0.86 (95%CI=0.72-0.93). CONCLUSION: RT-PCR was the best single test in patients evaluated for COVID-19. Conversely, the routine performance of chest CT adds little sensitivity and decreases specificity.

Prostatic Artery Embolisation: Do We Still Need It and for Whom?

Prostatic artery embolisation (PAE) is now endorsed by international evidence-based guidelines as a treatment for lower urinary tract symptoms presumed secondary to benign prostatic obstruction (LUTS/BPO) for selected patients. PAE is a truly minimally invasive technique, with proven efficacy and safety demonstrated for the short- to mid-term. As it has a unique treatment approach (endovascular instead of transurethral), its profile and ideal application differ clearly from other treatments for LUTS/BPO, which must be considered for patient selection. This mini review examines the role of PAE in the treatment of LUTS/BPO on the basis of current evidence. PATIENT SUMMARY: For properly selected patients, prostatic artery embolisation (PAE), in which arteries feeding the prostate are blocked in a nonsurgical procedure, is one of the treatment options for obstruction of urine outflow caused by benign enlargement of the prostate. This article examines the role of PAE according to the evidence available in the literature.

In-hospital cost analysis of aquablation compared with transurethral resection of the prostate in the treatment of benign prostatic enlargement.

PURPOSE: To compare in-hospital treatment costs of aquablation and transurethral resection of the prostate (TURP) in the treatment of benign prostatic enlargement. PATIENTS AND METHODS: Patient data and procedural details were derived from a prospective database. In-hospital costs were calculated using detailed expenditure reports provided by the hospital accounts department. Total costs including those arising from surgical procedures, consumables, personnel and accommodation were analysed for 24 consecutive patients undergoing aquablation and compared with 24 patients undergoing TURP during the same period. Mean total costs and mean costs for individual expense items were compared between treatment groups with t-tests. RESULTS: Mean total costs per patient (± standard deviation) were higher for aquablation at EUR 10,994 ± 2478 than for TURP at EUR 7445 ± 2354. The mean difference of EUR 3549 was statistically significant (p <0.001). Although the mean procedural costs were significantly higher for aquablation (mean difference EUR 3032; p <0.001), costs apart from the procedure were also lower for TURP, but the mean difference of EUR 1627 was not significant (p <0.327). Medical supplies were mainly responsible (mean difference EUR 2057; p <0.001) for the difference in procedural costs. CONCLUSIONS: In-hospital costs are significantly higher for aquablation than for TURP, mainly due to higher costs of medical supplies for the procedure. This difference should be taken into consideration, at least in patients for whom the different side effect profiles of both treatments are irrelevant.

Symptoms Compatible With Long Coronavirus Disease (COVID) in Healthcare Workers With and Without Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection-Results of a Prospective Multicenter Cohort.

BACKGROUND: The burden of long-term symptoms (ie, long COVID) in patients after mild COVID-19 is debated. Within a cohort of healthcare workers (HCWs), frequency and risk factors for symptoms compatible with long COVID are assessed. METHODS: Participants answered baseline (August/September 2020) and weekly questionnaires on SARS-CoV-2 nasopharyngeal swab (NPS) results and acute disease symptoms. In January 2021, SARS-CoV-2 serology was performed; in March, symptoms compatible with long COVID (including psychometric scores) were asked and compared between HCWs with positive NPS, seropositive HCWs without positive NPS (presumable asymptomatic/pauci-symptomatic infections), and negative controls. The effect of time since diagnosis and quantitative anti-spike protein antibodies (anti-S) was evaluated. Poisson regression was used to identify risk factors for symptom occurrence. RESULTS: Of 3334 HCWs (median, 41 years; 80% female), 556 (17%) had a positive NPS and 228 (7%) were only seropositive. HCWs with positive NPS more frequently reported ≥1 symptom compared with controls (73% vs 52%, P < .001); seropositive HCWs without positive NPS did not score higher than controls (58% vs 52%, P = .13), although impaired taste/olfaction (16% vs 6%, P < .001) and hair loss (17% vs 10%, P = .004) were more common. Exhaustion/burnout was reported by 24% of negative controls. Many symptoms remained elevated in those diagnosed >6 months ago; anti-S titers correlated with high symptom scores. Acute viral symptoms in weekly questionnaires best predicted long-COVID symptoms. Physical activity at baseline was negatively associated with neurocognitive impairment and fatigue scores. CONCLUSIONS: Seropositive HCWs without positive NPS are only mildly affected by long COVID. Exhaustion/burnout is common, even in noninfected HCWs. Physical activity might be protective against neurocognitive impairment/fatigue symptoms after COVID-19.

Does the Identification of a Minimum Number of Cases Correlate With Better Adherence to International Guidelines Regarding the Treatment of Penile Cancer? Survey Results of the European PROspective Penile Cancer Study (E-PROPS).

BACKGROUND: Penile cancer represents a rare malignant disease, whereby a small caseload is associated with the risk of inadequate treatment expertise. Thus, we hypothesized that strict guideline adherence might be considered a potential surrogate for treatment quality. This study investigated the influence of the annual hospital caseload on guideline adherence regarding treatment recommendations for penile cancer. METHODS: In a 2018 survey study, 681 urologists from 45 hospitals in four European countries were queried about six hypothetical case scenarios (CS): local treatment of the primary tumor pTis (CS1) and pT1b (CS2); lymph node surgery inguinal (CS3) and pelvic (CS4); and chemotherapy neoadjuvant (CS5) and adjuvant (CS6). Only the responses from 206 head and senior physicians, as decision makers, were evaluated. The answers were assessed based on the applicable European Association of Urology (EAU) guidelines regarding their correctness. The real hospital caseload was analyzed based on multivariate logistic regression models regarding its effect on guideline adherence. RESULTS: The median annual hospital caseload was 6 (interquartile range (IQR) 3-9). Recommendations for CS1-6 were correct in 79%, 66%, 39%, 27%, 28%, and 28%, respectively. The probability of a guideline-adherent recommendation increased with each patient treated per year in a clinic for CS1, CS2, CS3, and CS6 by 16%, 7.8%, 7.2%, and 9.5%, respectively (each p < 0.05); CS4 and CS5 were not influenced by caseload. A caseload threshold with a higher guideline adherence for all endpoints could not be perceived. The type of hospital care (academic vs. non-academic) did not affect guideline adherence in any scenario. CONCLUSIONS: Guideline adherence for most treatment recommendations increases with growing annual penile cancer caseload. Thus, the results of our study call for a stronger centralization of diagnosis and treatment strategies regarding penile cancer.

Stay cool! Special underwear for cyclic cooling significantly decreases scrotal skin temperature.

INTRODUCTION: Male reproductive health is rapidly declining during the past decades and it is well known that scrotal temperature is linked to male infertility. MATERIAL AND METHODS: We performed a prospective data evaluation within a counterfactual analysis study design. Scrotal cooling was performed using Snowballs™ underwear, scrotal temperature was monitored using a wireless temperature sensor (SensorPush, Brooklyn, NY, 11215). RESULTS: Overall, scrotal skin temperatures were monitored for 1008 hours. Median scrotal skin temperature was 34.6°C (IQR 33.1 to 35.3) and 35.3°C (IQR 34.4 to 35.9) in the experimental (SnowWedge™) period and control period, respectively, which was significantly different (P <0.001). CONCLUSIONS: Cyclic scrotal skin cooling using specialized underwear is feasible and efficacious without impairing the activities of daily living and reduces median scrotal skin temperature significantly by 0.7°C. Given the proven association of scrotal skin temperature and semen quality, cyclic scrotal skin cooling by a device such as Snowballs™ underwear may eventually increase semen quality and fertility.