Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions.

PURPOSE: An abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult. METHODS: The indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up. RESULTS: Of 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4). CONCLUSION: The mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

Old for young kidney transplantation: a responsible option for our patients to reduce waiting time?

PURPOSE: The Eurotransplant Senior program allocating grafts from donors ≥ 65 years to recipients aged ≥ 65 years has proven good results within the last 20 years. However, "old" grafts are also allocated to younger recipients < 65 years, and this outcome of "old for young" kidney transplantations (KT) still lacks detailed investigations. METHODS: All "old for young" KT performed at four tertiary referral centers were retrospectively compared including a recent follow-up, stratifying for "old for young" (donor ≥ 65 years to recipient < 65 years) vs. "very old for young" KT (donor ≥ 70 years to recipient < 65 years). RESULTS: Overall, 99 patients were included with 56 (56.6%) "old for young" and 43 (43.4%) "very old for young" KT. The median waiting time did not differ (60.7 vs. 45.8 months, respectively) at comparable living donation rates (57.1% vs. 44.2%) as well as intra- and postoperative results. At a median follow-up of 44 months (range 1; 133), the 3-year graft survival of 91% vs. 87% did not significantly vary. In subgroup analyses assessing living donation or donation after brain death (DBD) KT only, the graft survival was significantly longer for "old for young" KT within the living donation subgroup. In multivariate Cox regression analyses, the presence of panel-reactive antibodies was the only significant impact factor on graft survival (HR 8.32, p = 0.001). CONCLUSION: This analysis clearly demonstrates the effectiveness of the "old for young" approach, enabling favorable perioperative results as well as comparable data of graft- and overall survival, while reducing waiting time for eligible patients.

Emergency treatment of symptomatic ureteral calculi: predictors of prolonged hospital stay.

PURPOSE: To assess differences in the length of hospital stay (LOS) in patients who present emergently versus electively for a symptomatic ureteral stone and to explore underlying risk factors. METHODS: Billing data were analyzed from patients with symptomatic ureteral calculi at our department from 2010 to 2021. Statistical analysis (U test, logistic regression) was performed. RESULTS: 2274 patients (72% male, 28% female) with ureteral stones were analyzed (mean age of 52.9y). 1578 patients (69.4%) presented in an emergency setting and 696 patients (30.6%) electively. Arterial hypertension was seen in 31%, diabetes mellitus in 11% and hyperuricemia in 5% of the whole cohort. 46.5% of emergency patients were desobstructed (DJ/PCN), 35.4% underwent emergency ureteroscopy (URS), 13.4% had spontaneous passage (SP), and 4.8% underwent emergency shock wave lithotripsy (SWL). Of the electively treated patients, 58.6% underwent URS, 21.3% SWL, 18.5% DJ/PCN, and 1.6% had SP. Emergency stone treatment was associated with a significantly longer LOS when compared to primary desobstruction for patients admitted emergently. Also, LOS was significantly longer for each intervention of stone treatment in emergency patients vs. electively treated patients. Arterial hypertension was associated with a 1.8-fold increased risk of a hospital stay longer than 3 days, irrespective of hospital admission mode, whereas metabolic disorders did not influence LOS in this cohort. CONCLUSION: For emergency patients in contrast to the electively treated patients, the type of procedure had a significant impact on the length of hospital stay. Arterial hypertension is an independent significant risk factor for prolonged hospital stay.

Retroperitoneal lymph node dissection for testicular cancer is a demanding procedure: detailed real-life data of complications and additional surgical procedures in 295 cases.

PURPOSE: Retroperitoneal lymph node dissection (RPLND) for germ cell tumours is a challenging procedure that may present relevant complications. The purpose was to analyse postoperative complications and identify risk factors for major complications. METHODS: This is a retrospective unicentric analysis of a large cohort of 295 RPLNDs from 1992 to 2020. Early complications (30 days) and late complications (31-180 days) were classified according to the Clavien‒Dindo classification. The influence of surgical, patient-specific, and tumour-specific parameters on grade III-V complications was analysed in univariate and multivariate logistic regression models. RESULTS: A total of 232 were postchemotherapy RPLNDs, and 63 were primary RPLNDs. Early postoperative complications were found to be grades I-II in 58.6% (173/295), grades III-IV in 9.8% (29/295), and grade V in 0.3% (1/295). In 20% (58/295), additional surgical procedures were needed. Grade III-V complications were associated with ≥ 4 cycles of preoperative chemotherapy (OR 3.7 (1.5-8.9); p = 0.004), RPLND specimen (nonseminoma or immature teratoma) (OR 3.1 (1.4-6.6); p = 0.005), transfusions (OR 2.4 (1.1-5.4); p = 0.03), salvage RPLND (OR 4.1 (1.8-9.3); p < 0.001), and preoperatively elevated AFP (OR 5 (2.2-11.7); p < 0.001). In multivariate analysis, the only independent predictor for grade III-V complications was preoperative AFP elevation (OR 3.3 (1.2-9.2); p = 0.02). Limitations include the retrospective study design. CONCLUSIONS: Our results demonstrate that RPLND is a demanding surgical procedure. Patients with a complex tumour history have a higher risk of complications. We recommend treatment of these complex cases in high-volume centres.

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.

The Diagnostic Value of the Added MR Imaging of the Scrotum in the Preoperative Workup of Sonographically Indeterminate Testicular Lesions-A Retrospective Multicenter Analysis.

BACKGROUND: The purpose of this study was to retrospectively analyze the diagnostic accuracy of magnetic resonance imaging (MRI) examinations of the scrotum in comparison with standard ultrasound (US) and histopathology. METHODS: A retrospective multi-center analysis of MRI examinations of the scrotum performed between 06/2008 and 04/2021 was conducted. RESULTS: A total of n = 113 patients were included. A total of 53 histopathologies were available, with 52.8% malignant and 50.9% benign findings. Related to histopathology, imaging was true negative, false negative, false positive, and true positive in 4.1%, 2.1%, 25.0% and 37.5% for standard ultrasound (US) and 9.1%, 1.8%, 25.5% and 43.6% for MRI. Sensitivity, specificity, positive predictive value and negative predictive value were 94.7%, 20.0%, 36.0% and 88.9% for US and 85.7%, 72.8%, 52.1% and 93.7% for MRI, respectively. Benign lesions were significantly smaller than malignant ones in standard US (p = 0.001), histopathology (p = 0.001) and MRI (p = 0.004). The size of malignant tumors did not differ significantly between histopathology and standard US (0.72) and between histopathology and MRI (p = 0.88). CONCLUSIONS: MRI shows good sensitivity and specificity for the estimation of testicular tumors in this collective. Benign lesions are significantly smaller than malignant ones. Both MRI and US can estimate the size of malignant tumors adequately.

[Relevance of water-related rehabilitation measures for stoma patients : Results of a pilot project and review of the literature]. / Stellenwert wasserbezogener Rehabilitationsmaßnahmen bei Stomaträgern : Ergebnisse eines Pilotprojekts und Literaturübersicht.

BACKGROUND: The creation of a skin stoma after exenterative pelvic surgery drastically affects the physical health of patients. Being concerned with aesthetic and functional aspects, patients tend to not participate in offers for water-related rehabilitation, especially water gymnastics and swimming. OBJECTIVE: The aim of the pilot project "UROAquaFIT" was to evaluate the feasibility of water-related rehabilitation for patients after cystectomy with incontinent urinary diversion. METHODS: Patients after radical cystectomy with incontinent urinary diversion were offered the possibility to participate in the water-based rehabilitation program "UROAquaFIT". Split into small groups, a water gymnastics course took place under the guidance of a physiotherapist and a stoma therapist as well as under medical supervision. Data on quality of life and a personal assessment were collected using a questionnaire before and 6 months after the course. In addition, a MEDLINE-based search for aqua gymnastics in oncology was conducted. RESULTS AND CONCLUSION: All participants reported the course as being positive and enriching. The participants' well-being and self-esteem improved. Therefore, water gymnastics can be a highly effective method for rehabilitation of patients with incontinent urinary diversion. In addition, it improves the physical health of those affected and thus expands the possibilities for social reintegration. This form of therapy should be standard in the rehabilitation of patients with incontinent urinary diversion.

Inulin Clearance During Ex vivo Normothermic Machine Perfusion as a Marker of Renal Function.

Normothermic machine perfusion (NMP) offers a unique opportunity to objectively assess donor organ quality. This study describes the evaluation of inulin clearance as a potential marker for the ex vivo function of porcine kidneys during NMP. The function assessment was performed in both kidneys from slaughterhouse pigs (n = 20) and kidneys from pigs in a laboratory setting (n = 28). The kidneys were exposed to different warm ischemia times (WIT). After a period of static cold storage, the kidneys underwent a 4-hour NMP with autologous whole blood. Inulin clearance, hemodynamic parameters, and urine output were measured. Based on the inulin excretion behavior laboratory pig kidneys were assigned to three classes (functional, limited functional, and nonfunctional), slaughterhouse pig kidneys to two classes (limited functional and nonfunctional), respectively. Contrary to the marginal kidneys of the slaughterhouse pigs, the functional variation of kidneys of the laboratory pigs was associated with the WIT. A correlation between functional kidneys and a WIT less than 25 min was shown. Because none of the slaughterhouse pig kidneys could be assigned to the functional class, only the laboratory pig kidneys were used for examinations with functional markers. Renal blood flow and urine output during NMP correlated significantly ( p < 0.01) with ex vivo kidney function. This study demonstrated that inulin is a marker of high quality for the evaluation of suggested kidney function after NMP with whole blood. Furthermore, surrogate markers measured during NMP can be used to describe and predict the physiologic behavior of kidneys before transplantation.

Symptomatic Nephroptosis of the Transplant: First Report of Diagnostic Workup and Successful Minimal-Invasive Treatment.

The symptomatic nephroptosis of a kidney transplant is a rare and potentially fatal complication and requires fast diagnosis and treatment. In this report, we describe a case in which intermittent symptomatic hydronephrosis and an increase of the creatinine levels were the leading symptoms of nephroptosis. Moreover, we describe the diagnostic procedures and the successful minimal-invasive treatment. To our knowledge, this is the first report of a symptomatic transplant nephroptosis with consecutive intermittent hydronephrosis and without complications of perfusion solved with a minimal-invasive approach.

Systemic Triple Therapy in Metastatic Hormone-Sensitive Prostate Cancer (mHSPC): Ready for Prime Time or Still to Be Explored?

For decades, mono androgen deprivation therapy (ADT) has been the gold standard for metastatic hormone-sensitive prostate cancer (mHSPC) treatment. Several studies have been published within the last seven years demonstrating a significant survival advantage by combination treatment with standard ADT plus docetaxel or androgen receptor-axis-targeted therapy (ARAT) compared to ADT monotherapy. As a result, overall survival can be prolonged by at least 18 months. Recently published congress data of the PEACE-1 study suggests that in the future, triple therapy might be the new gold standard. In addition to this study, which has shown that triple treatment with standard ADT plus docetaxel plus abiraterone is superior to standard ADT plus docetaxel, several other phase III triple therapy studies are currently ongoing. The different modes of action that are investigated reach from AR-targeting over mitotic inhibition and immunotherapy to PARP and AKT inhibition. In this review we will explore if triple therapy has the potential to be the new standard for mHSPC treatment in the near future.

High-urgency kidney transplantation in the Eurotransplant Kidney Allocation System: success or waste of organs? The Eurotransplant 15-year all-centre survey.

BACKGROUND: In the Eurotransplant Kidney Allocation System (ETKAS), transplant candidates can be considered for high-urgency (HU) status in case of life-threatening inability to undergo renal replacement therapy. Data on the outcomes of HU transplantation are sparse and the benefit is controversial. METHODS: We systematically analysed data from 898 ET HU kidney transplant recipients from 61 transplant centres between 1996 and 2010 and investigated the 5-year patient and graft outcomes and differences between relevant subgroups. RESULTS: Kidney recipients with an HU status were younger (median 43 versus 55 years) and spent less time on the waiting list compared with non-HU recipients (34 versus 54 months). They received grafts with significantly more mismatches (mean 3.79 versus 2.42; P < 0.001) and the percentage of retransplantations was remarkably higher (37.5 versus 16.7%). Patient survival (P = 0.0053) and death with a functioning graft (DwFG; P < 0.0001) after HU transplantation were significantly worse than in non-HU recipients, whereas graft outcome was comparable (P = 0.094). Analysis according to the different HU indications revealed that recipients listed HU because of an imminent lack of access for dialysis had a significantly worse patient survival (P = 0.0053) and DwFG (P = 0.0462) compared with recipients with psychological problems and suicidality because of dialysis. In addition, retransplantation had a negative impact on patient and graft outcome. CONCLUSIONS: Facing organ shortages, increasing wait times and considerable mortality on dialysis, we question the current policy of HU allocation and propose more restrictive criteria with regard to individuals with vascular complications or repeated retransplantations in order to support patients on the non-HU waiting list with a much better long-term prognosis.