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Objective: To compare toxicity and response of docetaxel chemotherapy between metastatic hormone-sensitive prostate cancer (mHSPC) and castration-resistant metastatic prostate cancer (mCRPC) patients of the same therapeutic era for assessing of upfront docetaxel against the benchmark of docetaxel in the castrate resistant stage in the setting outside of clinical trials.Methods: A prospectively collected database of real-world prostate cancer patients receiving docetaxel was divided in mHSPC and mCRPC cases and retrospectively analyzed. Principal objectives were toxicity measured by the common criteria of adverse events terminology and response characterized by Prostate specific antigen decline and radiographic progression-free disease at restaging. The prognostic value of suspected variables for grade 3 to 5 toxicity and response was investigated by logistic regression analysis.Results: Of 72 patients 34 (47%) were treated for mHSPC and 38 (53%) for mCRPC. Patients with mCRPC were older and had worse performance status (P< 0.01). In mHSPC total number of grade 3 to 5 adverse events (24, median 0, interquartile range 0-1) was significantly less than in mCRPC (46, median 1, interquartile range 1-2) (P = 0.01). Multivariable analysis revealed age as independent predictive variable for grade 3 to 5 toxicity (P = 0.03) but not disease stage, Prostate specific antigen predocetaxel, volume of disease, and Eastern Cooperative Oncology Group performance status (P > 0.05). Objective response was significantly higher in mHSPC compared to mCRPC patients (P < 0.01). Multivariable analysis confirmed mHSPC stage as independent prognostic factor for radiographic progression free disease at restaging (P < 0.01).Conclusions: The association of age with toxicity and of mHSPC stage with response resulted in significantly fewer grade 3 to 5 adverse events but higher response rates for upfront docetaxel in mHSPC compared with docetaxel in the later mCRPC stage. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the capacity of stone clearance in common percutaneous nephrolithotomy (PCNL) systems achieved solely by hydrodynamic effects in an in vitro setting. Methods: A watertight cylindrical cast with a caliceal void served as an in vitro model. Various instruments for percutaneous renal surgery working with both continuous flow (fCF) and open Rutner sidearm (fCO) were tested. The model was loaded with standardized artificial stone material (2 mm in diameter) to examine stone removal by the vacuum cleaner effect and with sand (0.1-0.5 mm in diameter) to measure the washout effect caused by irrigation backflow. The association between washout of gravel and irrigation pressure was analyzed using ANOVA. Regression analysis was performed to assess the influence of the instruments' hydrodynamic characteristics-effective cross section of the outflow and irrigation flow volume. Results: Provoking the vacuum cleaner effect removal of stones was only effective in fCF but not in fCO instruments. Depending on irrigation pressure, the volumetric flow rate and effective cross section of the outflow clearance of sand could be observed in various medium- and large-sized fCF and fCO instruments, whereas in small-sized systems, clearance effects were negligible. Regression analysis showed clearance of stone dust strongly associated with an instrument's volumetric flow rate. Conclusions: This in vitro study demonstrated that the application of medium- and large-sized fCF PCNL systems removes both 'insignificant' stones and dust solely by hydrodynamic effects. Further studies have to show if these effects also occur in the in vivo situation. [ABSTRACT FROM AUTHOR]

Purpose: To widen the understanding of the fluid mechanics during percutaneous nephrolithotomy (PCNL), a new in vitro model for empiric studies was developed. Our first aim was to characterize common PCNL systems with regard to their intrapyelocaliceal pressure and their irrigation flow volume as possible parameters of hydrodynamic invasiveness. Materials and Methods: The model is based on a watertight cylindrical cast. Low pressure miniaturized PCNL (miniPCNL) systems and conventional PCNL systems were tested. Intrapelvic pressure and the total of irrigation flow volume per minute were measured for each PCNL system at 10 predefined levels of irrigation pressure between 40 and 130 cm H2O. Results: Linear regression showed a linear relation between irrigation pressure and intrapelvic pressure. Compared with miniPCNL systems, conventional PCNL sheaths with closed Rutner sidearm generate significantly higher intrapelvic pressures. Opening the Rutner sidearm leads to a decrease in intrapelvic pressure to the level of the open mini PCNL systems. Polynomal regression revealed a square root relation between irrigation pressure and irrigation flow volume. Conclusions: Our in vitro model is suitable for obtaining reliable and valid data of intrapelvic pressure and irrigation flow volume of commonly used PCNL systems. Conventional PCNL sheaths with opened Rutner sidearm provide intrapelvic pressure and irrigation volume similar to miniPCNL. Consequently, a relevant difference of the hydrodynamic impact between conventional and miniPCNL systems are not necessarily to be assumed. Regression analysis revealed a new starting point for further empiric research of fluid mechanics during PCNL. [ABSTRACT FROM AUTHOR]

Purpose: Pre-operative assessment of surgical risk is essential for patient counselling in the elderly patient population. Our purpose was to compare validated geriatric assessment scores (GAS) in predicting postoperative morbidity and mortality in patients ≥ 80 years. Methods: Overall, eight preoperative GAS were assessed for each patient who received RC from 2016 to 2021. Postoperative morbidity was recorded according to the Clavien-Dindo classification (CDC) of surgical complications. Binary logistic regression analyses were used to determine prediction of 30-d morbidity and 90-d mortality in patients ≥ 80 years. Results: In total, 424 patients were analysed (77.4% male) with median age of 71 years (IQR: 68.82;70.69), of which 67 (15.8%) were ≥ 80 years. Patients age ≥ 80 years showed more 30-d CDC grade ≥ IIIb (41.07% vs. 27.74% compared to < 80 years, p <.001) and worse 90-d mortality (26.87% vs. 4.76%, p <.001). In patients ≥ 80 years, morbidity was predicted by simplified Frailty Index (sFI) ≥ 2 (OR: 2.06, 95% CI: 1.27–3.34, p =.004), Eastern Cooperative Oncology Group (ECOG) performance status ≥ 2 (OR: 2.78, 95% CI: 1.18–6.54, p =.019) and severe Adult Comorbidity Evaluation (ACE)-27 score (OR: 2.07, 95% CI: 1.13–3.79, p =.019), while 90-d mortality was predicted by CDC grade ≥ IIIb (OR: 22.91, 95% CI: 8.74–60.09, p <.001) and ECOG ≥ 2 (OR: 2.87, 95% CI: 1.05–7.86, p =.04). Conclusion: Even in a high-volume center of RC, 90-d mortality is significantly higher in patients age ≥ 80. Our results suggest in patient age ≥ 80, sFI ≥ 2, ECOG performance status ≥ 2 and severe ACE-27 score as clinical cut-off value to evaluate alternative bladder-sparing concepts. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study is to address if detection rates of clinically significant prostate cancer (csPCa) can be increased by additional perilesional biopsies (PB) in magnetic resonance (MR)/ultrasound fusion prostate biopsy in biopsy-naïve men. Methods: This prospective, non-randomized, surgeon-blinded study was conducted between February 2020 and July 2022. Patients were included with PSA levels < 20 ng/ml and ≥ one PI-RADS lesion (grades 3–5) per prostate lobe. Prostate biopsy was performed by two urologists. The first performed the MR-fusion biopsy with 3–5 targeted biopsies (TB) and 6 PB in a standardized pattern. The second performed the systematic (12-fold) biopsy (SB) without knowledge of the MR images. Primary outcome of this study is absence or presence of csPCa (≥ ISUP grade 2) comparing TB, PB and SB, using McNemar test. Results: Analyses were performed for each PI-RADS lesion (n = 218). There was a statistically significant difference in csPC detection rate of TB + SB between PI-RADS 3, 4 and 5 lesions (18.0% vs. 42.5% vs. 82.6%, p < 0.001) and TB + PB (19.7% vs. 29.1% vs. 78.3%). Comparing only maximum ISUP grade per lesion, even SB plus TB plus PB did not detect more csPCa compared to SB plus TB (41.3% vs. 39.9%, p > 0.05). Conclusion: We present prospective study data investigating the role of perilesional biopsy in detection of prostate cancer. We detected no statistically significant difference in the detection of csPCa by the addition of PB. Therefore, we recommend continuing 12-fold bilateral SB in addition to TB. [ABSTRACT FROM AUTHOR]

Introduction: The aim of the study was to investigate prevalence and impact of incidental renal masses (IRMs) accompanying increasing computed tomography (CT) work-up for symptomatic aortic valve stenosis (sAVS) of the elderly with regard to the relevance of urological consultation for overall survival (OS). Methods: A retrospective analysis of pre-transcatheter aortic-valve implantations (TAVIs) CT scans of patients with sAVS (N = 1,253) harboring IRM was performed for 2014–2019. According to the clinical management, groups 1 (urologic consultation) and 2 (findings ignored) were formed and analyzed in terms of OS. Results: The prevalence of IRM was 9% (119/1,253). In 19% (23/119), urological advice was sought (group 1). At baseline, group 1 showed a significantly higher rate of malignancy-specific lesions compared to 2 (p < 0.01). Other clinical parameters (e.g., age, cardiological scores, comorbidities) did not differ between groups (p > 0.05). In group 1, 4 (17%) findings were histologically confirmed, of which 3 (13%) underwent surgery. There was no significant difference in median OS at a median follow-up of 24.7 months between groups 1 and 2 with 35.7 (95% CI, 5.9; 65.4) and 47.4 months (95% CI, 33.0; 61.7), respectively (p = 0.4). In Cox regression analysis, chronic kidney disease but not urologic work-up or chronic obstructive pulmonary disease or heart failure emerged as an independent unfavorable predictor of OS (HR 2.44, 95% CI 1.37; 4.36, p = 0.003). Conclusion: For the first time, a TAVI population with IRM was analyzed from the urologist's perspective. Urologic co-evaluation and work-up does not confer a significant benefit in terms of OS in this particular population. [ABSTRACT FROM AUTHOR]

Purpose: We evaluate differences of patient-reported outcome measurements (PROM) based urinary continence and sexual function 12 months after radical prostatectomy (RPE) based on perioperative, surgical, and patient-specific characteristics in a large European academic urology center. Materials and methods: All men enrolled in the Prostate Cancer Outcome Study (PCO) study who were treated with RPE between 2017 and 2021 completed EPIC-26 information surveys before and 12 months after RPE. Survey data were linked to clinical data of our institution. Logistic regression analyses were performed to examine the correlation between individual surgeons, patient characteristics, patient clinical data, and their urinary continence and sexual function. Results: In total, data of 429 men were analyzed: unstratified mean (SD) EPIC-26 domain score for urinary function decreased from 93.3 (0.7) to 60.4 (1.5) one year after RPE, respectively for sexual function from 64.95 (1.6) to 23.24 (1.1). Patients with preoperative adequate urinary function (EPIC-26 score > 80) reported significantly different mean urinary function scores between 53.35 (28.88) and 66.25 (25.15), p= 0.001, stratified by surgeons experience. On binary logistic regression analyses, only nerve sparing techniques (OR: 1,83, 95% CI: 1.01;3.21; p = 0.045) and low body mass index (OR: 0.91, CI: 0.85;0.99, p= 0.032) predicted adequate postoperative urinary function. Conclusions: The results show how using provider-specific data from a larger cohort study enables to develop institution-specific analysis for functional outcomes after RPE. These models can be used for internal quality improvement as well as enhanced and provider-specific patient communication and shared decision making. [ABSTRACT FROM AUTHOR]

Extensive hemangioma of the prostate and the bladder is rare. In most cases, patients present for hematuria, hematospermia, or lower urinary tract symptoms. Confined lesions treatable with transurethral resection are most common but large hemangiomas requiring partial cystectomy are reported as well. Endoscopic or open surgery implies the risk for postoperative functional disability that is not reasonable for young patients. We present a case of an extensive symptomatic hemangioma of the periprostatic venous plexus and the bladder neck in a 46-year-old man, which was treated by superselective coiling of the arterial feeder with no recurrence at 6-month follow-up. [ABSTRACT FROM AUTHOR]

Purpose: Focal therapy (FT) for localized prostate cancer (PCa) is only recommended within the context of clinical trials by international guidelines. We aimed to investigate oncological follow-up and safety data of focal high-intensity focused ultrasound (HIFU) treatment. Methods: We conducted a single-center prospective study of 29 patients with PCa treated with (focal) HIFU between 2016 and 2021. Inclusion criteria were unilateral PCa detected by mpMRI-US-fusion prostate biopsy and maximum prostate specific antigen (PSA) of 15 ng/ml. Follow-up included mpMRI-US fusion-re-biopsies 12 and 24 months after HIFU. No re-treatment of HIFU was allowed. The primary endpoint was failure-free survival (FFS), defined as freedom from intervention due to cancer progression. Results: Median follow-up of all patients was 23 months, median age was 67 years and median preoperative PSA was 6.8 ng/ml. One year after HIFU treatment PCa was still detected in 13/ 29 patients histologically (44.8%). Two years after HIFU another 7/29 patients (24.1%) were diagnosed with PCa. Until now, PCa recurrence was detected in 11/29 patients (37.93%) which represents an FFS rate of 62%.One patient developed local metastatic disease 2 years after focal HIFU. Adverse events (AE) were low with 70% of patients remaining with sufficient erectile function for intercourse and 97% reporting full maintenance of urinary continence. Conclusion: HIFU treatment in carefully selected patients is feasible. However, HIFU was oncologically not as safe as expected because of progression rates of 37.93% and risk of progression towards metastatic disease. Thus, we stopped usage of HIFU in our department. [ABSTRACT FROM AUTHOR]

Introduction: To investigate the efficacy and safety of multi‐tract percutaneous nephrolithotomy (PNL) against the benchmark of the single‐tract approach. Methods: A retrospective analysis of 391 consecutive PNL procedures was conducted in our tertiary referral center between April 2016 and March 2020. Clinical outcome parameters such as stone‐free rate, operation time, postoperative complications according to Clavien–Dindo, length of hospital stay and time to ipsilateral recurrence resulting in active treatment were assessed. Results: Multi‐tract PNL and single‐tract PNL were performed in 37 (9%) and 354 (91%) cases respectively. At baseline, compared to single‐tract PNL, multi‐tract PNL cases were characterized by significantly larger stone burden (2.62 vs 0.97 cm3, P <.00), lower Hounsfield units (HU) (751 vs 1017 HU, P <.01), a more complex S.T.O.N.E. (size, tract length, obstruction, number of calyces, essence) score (P <.00) and a higher rate of high‐risk stone formers (59 vs 19%, P <.00). Analysis of outcome revealed shorter operation time and length of hospital stay for single‐tract PNL compared to multi‐tract PNL (P <.01). However, the difference in terms of stone‐free rates (92% vs 88%), complication rates (43% vs 28%) and time to active retreatment due to ipsilateral recurrence was not statistically significant (P >.05). Conclusion: In this retrospective single‐center analysis, a multi‐tract PNL has been proved to be an efficient and safe expansion of single‐tract PNL for large stone burden and complex kidney stone disease. Future prospective research should focus on the procedure's potential effectiveness in reducing the number of interventions until stone‐free status in patients with massive stone disease. [ABSTRACT FROM AUTHOR]

Abstract: Context: Locally advanced renal cell carcinoma (RCC) is associated with a poor prognosis despite radical surgery. The surgical approach can differ according to tumour size, location, and vascular involvement. The development of molecular targeted therapies aroused new interest in adjuvant and neoadjuvant strategies. Objective: The aim of this article was to review trends in surgical approaches for locally advanced RCC as well as to discuss the role of targeted therapies in an adjuvant and neoadjuvant setting. Evidence acquisition: A PubMed search performed in September 2011 was used to identify relevant literature regarding locally advanced RCC. Evidence synthesis: An aggressive surgical approach is essential in locally advanced RCC. Nevertheless, the necessity of simultaneous ipsilateral adrenalectomy and extended lymphadenectomy in RCC is put into question. The presence of a tumour thrombus in the inferior vena cava requires special surgical techniques for thrombus control. The role of adjuvant and neoadjuvant molecular targeted therapies is investigated in ongoing trials. Phase 3 results of an adjuvant tumour cell vaccine are promising. Conclusions: Radical surgical resection remains mandatory in locally advanced RCC. The role of adjuvant and neoadjuvant therapy in these patients remains unknown until the data from ongoing trials become available. [Copyright &y& Elsevier]

Purpose: To evaluate the cost-effectiveness of robot-assisted partial nephrectomy (RAPN) and secondarily of laparoscopic PN (LPN) compared to the open procedure. Methods: Model-based cost-effectiveness analysis: The model was structured as decision tree. The model was populated with published data. We measured intraoperative, postoperative complications, and inhospital deaths. We expressed costs in US dollars ($).The reference analysis calculated the mean cost and the mean number of each endpoint over 5000 iterations using a second-order Monte Carlo simulation. We conducted extensive sensitivity analyses. Results: The mean inhospital costs were $13,186 for RAPN, $10,782 for LPN, and $12,539 for open partial nephrectomy (OPN), respectively. The incremental cost to prevent an inhospital event amounted to $5005 for RAPN compared to OPN. Lower RENAL scores were associated with lower incremental cost per avoided complications. Under assumption of 55 % higher costs in patients with complications, RAPN dominated OPN. LPN dominated OPN. We are aware of the following limitations: First, cost data for patients with and without complications were not available and we assumed the median cost for all cases, i.e., the analysis overestimated the cost associated with RAPN; second, we focused on inhospital estimates and did not apply a societal perspective. Conclusions: RAPN appears to be a cost-effective mean to avoid inhospital complications; however, these results might not apply to low-volume hospitals or to other health care systems. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract.Materials and methods: A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student’sttest, chi-squared test or Fisher’s exact test. Ap value less than 0.05 was considered statistically significant.Results: Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02).Conclusion: MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon’s preference. [ABSTRACT FROM PUBLISHER]

Background: Measurement of prostate-specific antigen (PSA) advanced the diagnostic and prognostic potential for prostate cancer (PCa). However, due to PSA's lack of specificity, novel biomarkers are needed to improve risk assessment and ensure optimal personalized therapy. A set of protein molecules as potential biomarkers was therefore evaluated in serum of PCa patients. Methods: Serum samples from patients undergoing radical prostatectomy (RPE) for biopsy-proven PCa without neoadjuvant treatment were compared to serum samples from healthy subjects. Preliminary screening of 119 proteins in 10 PCa patients and 10 controls was carried out by the Proteome Profiler Antibody Array. Those markers showing distinct differences between patients and controls were then further evaluated by ELISA in the serum of 165 PCa patients and 19 controls. Uni- and multivariate as well as correlation analysis were performed to test the capability of these molecules to detect disease and predict pathological outcome. Results: Screening showed that soluble (s)E-cadherin, E-selectin, MMP2, MMP9, TIMP1, TIMP2, Galectin and Clusterin warranted further evaluation. sE-Cadherin, TIMP1, Galectin and Clusterin were significantly over- and MMP9 under-expressed in PCa compared to controls. The concentration of sE-cadherin, MMP2 and Clusterin correlated negatively and that of MMP9 and TIMP1 positively with the Gleason Sum at prostatectomy. Only sE-cadherin significantly correlated with the highest Gleason pattern. Compared to serum PSA, sE-cadherin provided an independent and better matching predictive ability for discriminating PCas with an upgrade at RPE and aggressive tumors with a Gleason Sum≥7. Conclusions: sE-cadherin performed most favorably from a large panel of serum proteins in terms of diagnostic and predictive potential in curatively treatable PCa. sE-cadherin merits further investigation as a biomarker for PCa. [ABSTRACT FROM AUTHOR]

Dear Editor, The coronavirus disease 2019 (COVID-19) pandemic is disrupting urology healthcare worldwide [[1]]. Our single-institution data show that urological surgical caseload and resident training can be ramped up with decreasing COVID-19 infections, aiming to ensure perpetuation of adequate treatment for both oncological and non-oncological urology patients. [Extracted from the article]