Development and outcomes of surgical and urological kidney transplantation programs in Germany: a total population analysis from 2006 to 2021.

PURPOSE: Kidney transplantation (KT) is the most frequently performed organ transplantation. In Germany, KT is performed in urology and surgery departments with unknown consequences of this parallel structure. The aim of the study was to compare the development and outcome of KT in urology and surgery departments. METHODS: On an institutional level, we analyzed the annual caseload from 2006 to 2021 with the reimbursement. INFO tool based on hospitals' quality reports (Reimbursement Institute, Hürth, Germany). For outcome comparison we extracted raw data from the transplantation centers' quality reports (Deutsche Stiftung Organtransplantation, DSO). RESULTS: A total of 23,599 cases (17,781 deceased donor and 5,818 living donor KTs) were included. The total number of KTs decreased from 1851 in 2006 to 1701 in 2021 (- 8%; p = 0.12). The total number of urological KTs decreased from 592 cases in 2006 to 395 cases in 2021 (- 33.3%; p = 0.01). Further analysis revealed no significant differences between intra- and postoperative complications and graft quality at one year for deceased donor KTs (DDKT) although differences in immediate renal function and graft quality at discharge could be observed. There were no significant differences in immediate renal function and graft quality at discharge for living donor KTs (LDKT) between the specialties. CONCLUSION: KTs performed in urology departments declined between 2006 and 2021. Nevertheless, intra- and postoperative complications as well as long-term function did not differ between surgical and urological KT programs. Hence, an interdisciplinary approach, especially considering the upcoming challenges in KT as, e.g., robot-assisted surgery seems reasonable.

Trends in kidney transplantation and living donor nephrectomy in Germany: a total population analysis from 2006 to 2021.

PURPOSE: To analyze recent trends of surgical access routes, length of hospital stay (LOS), and mortality in kidney transplantation (KT) and living donor nephrectomy (LDN) in Germany. MATERIALS AND METHODS: We studied the nationwide German hospital billing database and the German hospital quality reports from 2006 to 2021. RESULTS: There were a total of 35.898 KTs. In total, 9044 (25%) were living donor transplantations, while 26.854 (75%) were transplantations after donation after brain death (DBD). The share of open LDN decreased from 82% in 2006 to 22% in 2020 (- 4%/year; p < 0.001). The share of laparoscopic LDN increased from 18% in 2006 to 70% in 2020 (+ 3%/year; p < 0.001). The share of robotic LDN increased from 0% in 2006 to 8% in 2020 (+ 0.6%/year; p < 0.001). Robotic-assisted KT increased from 5 cases in 2016 to 13 procedures in 2019 (p = 0.2). LOS was shorter after living donor KT, i.e., 18 ± 12.1 days versus 21 ± 19.6 days for DBD renal transplantation (p < 0.001). Moreover, LOS differed for open versus laparoscopic versus robotic LDN (9 ± 3.1 vs. 8 ± 2.9 vs. 6 ± 2.6; p = 0.031). The overall in-hospital mortality was 0.16% (n = 5) after LDN, 0.47% (n = 42) after living donor KT and 1.8% (n = 475) after DBD KT. CONCLUSIONS: There is an increasing trend toward minimal-invasive LDN in recent years. Overall, in-hospital mortality was low after KT. However, 5 deceased healthy donors after LKD caution that the risks of this procedure should also be taken very seriously.

Trends in the use of testicular prostheses in Germany: a total population analysis from 2006-2021.

INTRODUCTION: Testicular tumors are the most common malignancies in young adults and their incidence is growing. The implantation of a testicular prosthesis, for example, during orchiectomy is a standard procedure but its frequency in Germany is unknown. This study aims to analyze trends of testicular prosthesis implantation in recent years in Germany. MATERIAL AND METHODS: The nationwide German hospital billing database and the German hospital quality reports from 2006 to 2021 were studied. RESULTS: A total of 12,753 surgical procedures with implantation of testicular prosthesis and 1,244 procedures with testicular prosthesis explantation were included. Testicular prosthesis implantation increased in total from 699 cases in 2006 to 870 cases in 2020 (+11.4 cases/year; p < 0.001). The share of implantation of testicular prosthesis due to testicular tumor decreased from 72.6% in 2006 to 67.5% in 2020 (p < 0.001). The share of implantation due to gender affirming surgery increased from 6.8% in 2006 to 23.3% in 2020 (p < 0.001). The share of implantation due to testicular atrophy decreased from 11.4% in 2006 to 3.4% in 2020 (p < 0.001). Simultaneous implantation of testicular prosthesis during orchiectomy for testicular cancer increased from 7.8% in 2006 to 11.4% in 2020 (p < 0.001). In 2006, 146 hospitals (85%) performed < 5 testicular prosthesis implantation, while 20 hospitals (12%) performed 5-15 implantation procedures and 6 hospitals (3%) performed > 15 testicular implantation surgeries. In 2021, 115 hospitals (72%) performed < 5 testicular prosthesis implantation, while 39 hospitals (25%) performed 5-15 implantation procedures and 5 hospitals (3%) performed > 15 testicular implantation surgeries. CONCLUSION: This study shows that implantation of testicular prostheses is steadily increasing. Explantation rates are low. Besides testicular cancer transgender surgeries were the main driver for increasing case numbers in recent years.

Trends in Selective Internal Radiation Therapy (SIRT) for Treating Hepatocellular Carcinoma, Cholangiocarcinoma, and Liver Metastasis: A Total Population Analysis from 2006 to 2021 in Germany.

The aim of this study was to investigate trends in selective internal radiation therapy (SIRT) for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCC), and liver metastasis in Germany. We analyzed the nationwide German hospital billing database from 2006 to 2019 for the diagnosis of HCC, CCC or liver metastasis in combination with SIRT. For analyses of SIRT on the hospital level, we used the reimbursement.INFO tool based on German hospitals' quality reports from 2008 to 2021. Linear regression analysis was performed to detect changes over time. We included a total of 14,165 SIRT procedures. The annual numbers increased from 99 in 2006 to 1605 in 2015 (p < 0.001; increase by 1521%), decreasing to 1175 cases in 2019 (p < 0.001). In 2008, 6 of 21 hospitals (28.6%) performed more than 20 SIRTs per year, which increased to 19 of 53 (35.8%) in 2021. The share of SIRT for HCC increased from 29.8% in 2006 to 44.7% in 2019 (p < 0.001) and for CCC from 0% in 2006 to 9.5% in 2019 (p < 0.001), while the share of SIRT for liver metastasis decreased from 70.2% in 2006 to 45.7% in 2019 (p < 0.001). In-hospital mortality was 0.2% after the SIRT procedure. Gastritis (2.7%), liver failure (0.4%), and sepsis (0.3%) were the most common in-hospital complications reported. We observed an increase in SIRT procedures in Germany, with the number of hospitals offering the procedure going up from 21 in 2008 to 53 in 2021. While the treatment of liver metastasis remains the most common indication, SIRT for HCC and CCC increased significantly over the last few years. The mortality and complication rates show that SIRT is a relatively safe procedure.

Insufficient utilization of care in male incontinence surgery: health care reality in Germany from 2006 to 2020 and a systematic review of the international literature.

PURPOSE: Data suggest that the utilization of care in male incontinence surgery (MIS) is insufficient. The aim of this study was to analyse the utilization of care in MIS from 2006 to 2020 in Germany, relate this use to the number of radical prostatectomies (RP) and provide a systematic review of the international literature. METHODS: We analysed OPS codes using nationwide German billing data and hospitals' quality reports from 2006 to 2020. A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). RESULTS: MIS increased by + 68% from 2006 to 2011 (1843-3125; p = 0.009) but decreased by - 42% from 2011 to 2019 (3104-1799; p < 0.001). In 2020, only 1435 MISs were performed. In contrast, RP increased from 2014 to 2019 by 33% (20,760-27,509; p < 0.001). From 2012 to 2019, the number of artificial urinary sphincters (AUSs) changed minimally (- 12%; 1291-1136; p = 0.02). Sling/sling systems showed a decrease from 2011 to 2019 (- 68% 1632-523; p < 0.001). In 2019, 63% of patients received an AUS, 29% sling/sling systems, 6% paraurethral injections, and 2% other interventions. In 2019, few high-volume clinics [n = 27 (13%)] performed 55% of all AUS implantations, and few high-volume clinics [n = 10 (8%)] implanted 49% of retropubic slings. CONCLUSION: MIS have exhibited a relevant decrease since 2011 despite the increase in RP numbers in Germany, indicating the insufficient utilization of care in MIS. The systematic review shows also an international deficit in the utilization of care in MIS.

Outpatient care concept and potential inpatient cost savings associated with the administration of dalbavancin - A real-world data and retrospective cost analysis.

BACKGROUND: The treatment of acute bacterial skin and skin structure infections (ABSSSI) usually involves intravenous (i.v.) antibiotics requiring hospitalisation and increasing hospital costs. Since 2014, dalbavancin is approved for ABSSSIs treatment. However, evidence of its health economic impact on the German healthcare system is still limited. METHODS: Diagnosis-related groups (DRG) based cost analysis was used to evaluate real-world data (RWD) from a German tertiary care center. All patients treated with i.v. antibiotics in the Department of Dermatology and Venereology at the University Hospital of Cologne were included to detect potential cost savings from a payer perspective. Thus, for the inpatient care German diagnosis-related groups (G-DRG) tariffs, length of stay (LOS), main- and secondary DRG-diagnoses and for the outpatient setting 'Einheitlicher Bewertungsmaßstab' (EBM) codes were evaluated. RESULTS: This retrospective study identified 480 inpatient cases treated for ABSSSI between January 2016 until December 2020. Complete cost data were available for 433 cases and the detection of long-hospital-stay patients based on surcharges for exceeding the upper limit LOS led to 125 cases (29%) including 67 females (54%) and 58 males (46%) with an overall mean age of 63.6 years; all treated for International Classification of Diseases (ICD -10th revision) code A46 'erysipelas'. A sub-analysis focussed on DRG J64B with a total of 92 cases exceeding the upper limit LOS by a median of 3 days resulted in a median surcharge of €636 (mean value €749; SD €589; IQR €459-€785) per case. In comparison, we calculated outpatient treatment costs of approximately €55 per case. Thus, further treatment of these patients in an outpatient setting before exceeding the upper limit LOS might result in a cost-saving potential of approximately €581 per case. CONCLUSION: Dalbavancin appears a cost-efficient option to reduce inpatient treatment costs by transitioning to an outpatient setting of patients with ABSSSI potentially exceeding the upper limit LOS.

Adoption of Lutetium-177 PSMA radioligand therapy for metastatic castration resistant prostate cancer: a total population analysis in Germany from 2016 to 2020.

PURPOSE: This study is to investigate the adoption and current trends of Lutetium-177 PSMA RLT for mCRPC in Germany. METHODS: We analyzed data from the reimbursement.INFO tool based on German hospitals' quality reports for Lutetium-177 PSMA RLT from 2016 to 2020 and from the nationwide German hospital billing database (Destatis) for general therapy with open radionuclides in combination with prostate cancer from 2006 to 2020. For validation of these billing data, we included the 177Lu-PSMA RLT cycles from two participating institutions from 2016 to 2020. For detection of trends over time we applied linear regression models. RESULTS: General therapy with open radionuclides increased from 2006 to 2020. We identified a total of 12,553 177Lu-PSMA RLT cycles. The number of 177Lu-PSMA RLTs steadily increased from a total of 1026 therapies in 2016 to 3328 therapies in 2020 (+ 576 RLT/year; p < 0.005). In 2016, 25 departments of nuclear medicine offered this treatment, which increased to 44 nuclear medicine departments in 2020. In 2016, 16% of nuclear medicine departments (4/25) performed more than 100 177Lu-PSMA RLTs, which increased to 36% (16/44) in 2020 (p < 0.005). In 2016, 88% (22/25) of 177Lu-PSMA RLTs were performed at a university hospital, which decreased to 70% (31/44) in 2020. The proportion of patients older than 65 years receiving 177Lu-PSMA RLT increased from 78% in 2016 to 81% in 2020. CONCLUSION: Treatment of mCRPC with 177Lu-PSMA RLT has been rapidly increasing in Germany in the recent years providing an additional therapy option. This development is remarkable, because of outstanding formal EMA approval.

Focal Therapy for Renal Cancer: Comparative Trends in the USA and Germany from 2006 to 2020 and Analysis of the German Health Care Landscape.

INTRODUCTION: The aim of the study was to investigate trends of FT for in-patient treatment of renal RCC in the USA and Germany. METHODS: We analyzed the SEER database for the USA and the nationwide German hospital billing database each from 2006 to 2019 for a RCC diagnosis in combination with FT, radical nephrectomy, and partial nephrectomy. FT was defined as radiofrequency ablation (RFA) or cryotherapy. Linear regression analysis was performed to detect changes over time. RESULTS: For the USA, we included 7,318 FT cases. The share of FT increased from 2.4% in 2006 to 6.4% in 2019 (p < 0.001). For Germany, we identified 2,920 FT cases. The share of FT increased from 0.7% in 2006 to 2.0% in 2019 (p < 0.001). The number of RFAs in the USA steadily increased by 227% from a total of 93 in 2006 to 304 in 2019 while the number of cryotherapies in the USA steadily increased by 289% from a total of 127 in 2006 to 494 in 2019 (p < 0.001). The number of RFAs in Germany increased by 344% from a total of 59 in 2006 to 262 in 2019 (p < 0.001) while the number of cryotherapies steadily increased by 43% from a total of 54 in 2006 to 77 in 2019 (p < 0.001). In Germany, RFA is significantly more performed than cryotherapy while in the USA cryotherapy is more frequently applied. CONCLUSION: We observed a constant increase of FT in the USA and Germany for RCC in-patient treatment with a higher share in the USA.

[Outpatient before inpatient treatment?-Reality of care and economic analysis for minor urological interventions in Germany between 2013 and 2018]. / Ambulant vor stationär? ­ Versorgungswirklichkeit und ökonomische Analyse von kleinen urologischen Eingriffen in Deutschland von 2013 bis 2018.

BACKGROUND: Although outpatient provision of services is economically desirable, many minor urological interventions in Germany are currently carried out on an inpatient basis. The aim of our study is to investigate whether the current health policy framework contributes to more outpatient treatment. MATERIALS AND METHODS: We used a sample of 4.9 million anonymous, insured persons representative according to age and region provided by the Institute for Applied Health Research (InGef GmbH). We report extrapolations for the number of outpatient and inpatient services throughout Germany between 2013 and 2018. In addition, we performed an economic analysis for two selected interventions. RESULTS: During the study period, the total number of prostate biopsies declined from 184,573 to 174,558 cases. The share of outpatient biopsies declined continuously by 0.9% per year from 81% to 76% (p < 0.001). For botulinum toxin injection into the bladder, the total increased from 15,630 to 26,824 cases. The share of outpatient treatments increased by 2.7% per year from 3% to 19% (p = 0.01). For the other examined interventions (insertion of suprapubic urinary catheters, the insertion, removal, and changing of ureteral stents, cystoscopies and urethral dilatation), there were no significant changes in the share of outpatient procedures. CONCLUSIONS: The significant increase of outpatient botulinum toxin injections shows the successful control effect through adapted remuneration options. A shift to the inpatient sector was observed for prostate biopsies. This may be due to higher hygienic standards and technical requirements for MRI fusion.

Alternative- and focal therapy trends for prostate cancer: a total population analysis of in-patient treatments in Germany from 2006 to 2019.

PURPOSE: Focal therapy (FT) offers an alternative approach for prostate cancer (PCa) treatment in selected patients. However, little is known on its actual establishment in health care reality. PATIENTS AND METHODS: We defined FT as high-intensity focused ultrasound (HIFU), hyperthermia ablation, cryotherapy, transurethral ultrasound ablation (TULSA) or vascular-targeted photodynamic therapy (VTP) TOOKAD®. We analyzed the nationwide German hospital billing database for a PCa diagnosis in combination with FT. For analyses on the hospital level, we used the reimbursement.INFO tool based on hospitals' quality reports. The study period was 2006 to 2019. RESULTS: We identified 23,677 cases of FT from 2006 to 2019. Considering all PCa cases with surgery, radiotherapy or FT, the share of FT was stable at 4%. The annual caseload of FT increased to a maximum of 2653 cases in 2008 (p < 0.001) and then decreased to 1182 cases in 2014 (p < 0.001). Since 2015, the cases of FT remained on a plateau around 1400 cases per year. The share of HIFU was stable at 92-96% from 2006 to 2017 and decreased thereafter to 75% in 2019 (p = 0.015). In 2019, VTP-TOOKAD® increased to 11.5% and TULSA to 6%. In 2006, 21% (62/299) of urological departments performed FT and 20 departments reached > 20 FT procedures. In 2019, 16% (58/368) of urological departments performed FT and 7 departments reached > 20 FT. In 2019, 25 urological departments offered FT other than HIFU: 5 centers hyperthermia ablation, 11 centers VTP TOOKAD®, 3 centers cryotherapy, 6 centers TULSA. CONCLUSION: The FT development in Germany followed the Gartner hype cycle. While HIFU treatment is the most commonly performed FT, the share of newer FT modalities such as VTP-TOOKAD® and TULSA is remarkably increasing.

[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.

Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct?

PURPOSE: To describe the change in upper urinary tract stone management in Germany over a 14-year period. METHODS: Using remote data processing we analyzed the nationwide German billing data from 2006 to 2019. To analyze the clinics' case numbers and regional trends, we used the reimbursement.INFO tool based on standardized quality reports of all German hospitals. To also cover shock wave lithotripsy (SWL) as an outpatient procedure, we analyzed the research database of the Institute for Applied Health Research with a representative anonymous sample of 4 million insured persons. RESULTS: The number of inpatient interventional therapies for upper tract urolithiasis in Germany increased from 70,099 cases in 2006 to 94,815 cases in 2019 (trend p < 0.0001). In-hospital SWL declined from 41,687 cases in 2006 to 10,724 cases in 2019 (decline of 74%; trend p < 0.0001). The percentage of SWL as an outpatient procedure increased between 2013 and 2018 from 36 to 46% of all performed SWL, while total SWL case numbers declined. Contrarily, the number of ureteroscopies increased from 32,203 cases in 2006 to 78,125 cases in 2019 (increase of 143%; trend p < 0.0001). The number of percutaneous nephrolithotomy also increased from 1673 cases in 2006 to 8937 in 2019 (increase of 434%; trend p < 0.0001). CONCLUSION: We observed an increase in interventional therapy for upper tract urolithiasis in Germany with a dramatic shift from SWL to endoscopic/percutaneous treatment. These changes may be attributed to enormous technological advances of the endoscopic armamentarium and to reimbursement issues.

Decreasing Number of Urodynamics in Urological and Gynaecological Clinics Reflects Decreased Importance for Surgical Indications: German Population-Based Data from 2013 to 2019.

INTRODUCTION: The routine use of urodynamic studies (UDS) has been questioned. Additionally, the material and personnel costs are poorly remunerated. We aimed to analyse the UDS utilization in Germany. METHODS: We analysed UDS performed by hospitals based on quality reports from 2013 to 2019. A representative sample of 4 million insured persons was used to estimate outpatient UDS utilization from 2013 to 2018. RESULTS: There was an overall decrease of 14% in UDS in Germany from 2013 to 2018 (60,980 to 52,319; p = 0.003). In the outpatient sector, there was a slight non-continuous drop of 11% from 34,551 to 30,652 from 2013 to 2018 (p = 0.06). UDS utilization in hospitals decreased by 26% from 26,429 in 2013 to 19,453 in 2019 (p = 0.004). University hospitals showed a smaller decrease (3,007 to 2,685; p = 0.02). In urology, the number of UDS (11,758 to 6,409; p < 0.001) and the number of performing departments (328 to 263 clinics; p < 0.001) decreased. Gynaecological departments also showed a decrease in UDS (1,861 to 866; p < 0.001) and performing departments (159 to 68; p < 0.001). However, in paediatrics, there was an increase in UDS (1,564 to 2,192; p = 0.02). By age, the number of children remained constant (1,371 to 1,252; p = 0.2), but there was a strong decrease seen in 60- to 79-year-olds (9,792 to 5,564; p < 0.001). CONCLUSION: UDS appear to be less important in the indication for surgery. Despite high resource expenditure and low remuneration, the decrease in urodynamics in the outpatient sector is less pronounced, indicating a trend to perform UDS in an outpatient setting.

[Health care reality of selected pediatric urologic surgeries in Germany from 2006 to 2019]. / Versorgungswirklichkeit ausgewählter kinderurologischer Eingriffe in Deutschland von 2006 bis 2019.

BACKGROUND: The conservative and surgical treatment of children is a fundamental pillar of the urological specialist training program and represents one of the core competencies within urological healthcare. The loss of this expertise has been a reoccurring topic within urologic occupational policy. The aim of this study is to analyse actual case numbers and to compare the distribution and dynamics of pediatric urologic surgeries between the specialist departments of urology and pediatric surgery in Germany. MATERIALS AND METHODS: We defined the surgical treatments of maldecensus testis, hypospadias, and vesicoureteral reflux (VUR) as index interventions. Using the tool reimbursement.INFO (RI Innovation GmbH, Hürth, Germany) we analysed publicly available quality report data of German hospitals between 2006 and 2019. RESULTS: While orchidopexy was more commonly performed in the field of urology, the correction of hypospadias and the surgical treatment of VUR showed higher case numbers in the field of pediatric surgery. Proportionally, there was no relevant shift between urologic and pediatric surgical clinics for orchidopexy and surgical VUR therapy during the study period. For hypospadias corrections, the proportion of surgeries performed in pediatric surgical units is increasing (p < 0.0001). In pediatric surgery 84-93% of the analyzed procedures are performed in high-volume units, while this proportion is 56-73% in urology. In particular, a high proportion of VUR therapy in urology is performed as an occasional procedure (30% very low volume). CONCLUSIONS: The quality report data enable the compilation of case numbers and the analysis of the distribution between urology and pediatric surgery in Germany. Merely the correction of hypospadias has shown a relevant shift towards pediatric surgery. The causes and possible consequences for professional policy of this preliminary investigation are complex and require further analysis.