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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 177Lu-PSMA RLTs, which increased to 36% (16/44) in 2020 (p 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.

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.

Purpose To report contemporary epidemiological data and treatment trends for upper tract urothelial carcinoma (UTUC) in Germany over a 14-year period. Methods We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2018/2019. The significance of changes over time was evaluated via regression analysis. Survival outcomes were calculated using the Kaplan–Meier method. Results There was a non-significant increase in the age-standardized incidence rate from 2.5/100,000 in 2006 to 2.9/100.000 in 2018. 13% of patients presented with lymph node metastasis and 7.6% of patients presented with distant metastasis at primary diagnosis. The 5-year overall survival was estimated at 45% and the 10-year overall survival at 32%. Endoscopic biopsies of the renal pelvis and ureter as well as ureteroscopies with excision/destruction of UTUC all increased significantly over the study period. The number of radical nephroureterectomies (RNU) for UTUC steadily increased from 1643 cases in 2006 to 2238 cases in 2019 (p Conclusion Diagnostic and therapeutic procedures for UTUC have increased and minimally invasive nephroureterectomy is the predominant approach concerning radical surgery in 2019.

Zusammenfassung Hintergrund und Fragestellung Obwohl eine ambulante Leistungserbringung ökonomisch erstrebenswert ist, erfolgen viele kleine urologische Eingriffe in Deutschland aktuell noch stationär. Ziel unserer Analyse ist zu prüfen, ob der aktuelle gesundheitspolitische Rahmen zu einer Ambulantisierung beiträgt. Material und Methode Datenbasis ist eine nach Alter und Regionen repräsentative Stichprobe von 4,9 Mio. Versichertenanonymen aus der Forschungsdatenbank des Instituts für angewandte Gesundheitsforschung GmbH (InGef). Wir berichten Hochrechnungen für die Anzahl ambulanter und stationärer Leistungen in ganz Deutschland zwischen 2013 und 2018. Ergänzend führen wir eine ökonomische Analyse für zwei ausgewählte Eingriffe durch. Ergebnisse Im Studienzeitraum fiel die Gesamtzahl der Prostatastanzbiopsien (Prostatabiopsien) von 184.573 auf 174.558. Der Anteil ambulanter Biopsien fiel kontinuierlich um 0,9 % pro Jahr von 81 % auf 76 % (p p = 0,01). Für die übrigen untersuchten Eingriffe (Anlage suprapubischer Blasenkatheter, das Einlegen, Entfernen und Wechseln von Ureterschienen, Zystoskopien und die Harnröhrenbougierung) zeigten sich keine signifikanten Veränderungen beim Anteil der ambulanten Leistungserbringung. Schlussfolgerung Die deutliche Zunahme ambulant erbrachter Botox-Injektionen zeigt den erfolgreichen Steuerungseffekt durch angepasste Vergütungsoptionen. Bei den Prostatabiopsien konnte eine Verschiebung in den stationären Sektor beobachtet werden. Möglicherweise ist dies auf höhere hygienische Standards sowie gestiegene technische Anforderungen im Rahmen der MRT-Fusion zurückzuführen.

Zusammenfassung Einleitung Die Zirkumzision Minderjähriger aus kulturellen und religiösen Gründen ist umstritten. Bei der Diskussion zum Beschneidungsgesetz von 2012 wurde eine Zunahme der Zirkumzision Minderjähriger ohne medizinische Indikation befürchtet. Ziel der Arbeit war es daher, die Entwicklung der Fallzahlen zu analysieren. Material und Methoden Auf Basis der Forschungsdatenbank des Instituts für angewandte Gesundheitsforschung GmbH (InGef) mit nach Alter und Region repräsentativen 4,9 Mio. Versichertenanonymen schätzten wir die jährlichen Zirkumzisionszahlen in Deutschland von 2013 bis 2018. Dabei stratifizierten wir die Daten nach Alter ( Ergebnisse Im Studienzeitraum wurden insgesamt 673.819 Beschneidungen durchgeführt. Ab 2014 kam es zu einem signifikanten Rückgang der Fallzahlen in allen Altersgruppen (p = 0,049). Dabei haben während des gesamten Studienzeitraums die Beschneidungen bei Minderjährigen signifikant zugenommen (p = 0,002) und die Eingriffe bei Erwachsenen signifikant abgenommen (p = 0,01). Die Zahl der männlichen Minderjährigen stieg um 4 % von 6.709.137 (2013) auf 6.992.943 (2018). Die entsprechende bevölkerungsbezogene Zahl stieg von 7,5 Beschneidungen pro 1000 Minderjährige im Jahr 2013 auf 8 im Jahr 2018 (p = 0,037). Schlussfolgerung Nach der Verabschiedung des Beschneidungsgesetzes 2012 kam es zu einer moderaten Zunahme der Zirkumzisionen in der Altersgruppe

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 p 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.

Zusammenfassung Hintergrund Die operative Therapie des benignen Prostatatsyndroms (BPS) hat in den letzten Jahren an Diversität gewonnen. Ziel der Arbeit Ziel dieser Studie ist die Darstellung aktueller Therapietrends sowie der Versorgungssituation in Deutschland. Material und Methoden Auf Basis der Qualitätsberichte der Krankenhäuser wurden mithilfe der Onlineplattform reimbursement.INFO Diagnose- wie Eingriffszahlen erhoben. Für die benigne Prostatahyperplasie (BPH) wurden die ICD-Codes N40 und D29.1 ausgewertet. Die Prozeduren wurden mittels der OPS-Codes 5‑600.0, 5‑601, 5‑603, 5‑609.4 und 5‑609.8 inklusive Subcodierungen extrahiert. Es erfolgten eine deskriptive Darstellung, Trend- und Korrelationsanalysen. Ergebnisse Insgesamt wurden 2019 83.687 BPS-Operationen in 473 urologischen Fachabteilungen durchgeführt. Am häufigsten wurde die transurethrale Prostataresektion (TURP; 71,7 %) angewendet. Die Holmiumlaserenukleation (HoLEP; 9,5 %) bzw. die chirurgische Adenomektomie (5,6 %) waren das zweit- bzw. dritthäufigste Verfahren. Seltener wurden Thuliumlaserenukleation (ThuLEP; 3,1 %), Laservaporisation (2,9 %) und elektrische Vaporisation (2,8 %) durchgeführt. Alle weiteren Verfahren machten jeweils p p = 0,99; elektrische Vaporisation: +43,42 %/Jahr, p p Schlussfolgerung Die TURP bleibt das am häufigsten durchgeführte Operationsverfahren. Während, insbesondere in Zentren, die Lasertherapien zunehmen, geht die chirurgische Adenomektomie zurück.

Purpose Hospital rating websites (HRW) offer decision support in hospital choice for patients. To investigate the impact of HRWs of uro-oncological patients undergoing elective surgery in Germany. Methods From 01/2020 to 04/2021, patients admitted for radical prostatectomy, radical cystectomy, or renal tumor surgery received a questionnaire on decision-making in hospital choice and the use of HRWs at 10 German urologic clinics. Results Our study includes n = 812 completed questionnaires (response rate 81.2%). The mean age was 65.2 ± 10.2 years; 16.5% were women. Patients were scheduled for prostatectomy in 49.1%, renal tumor surgery in 20.3%, and cystectomy in 13.5% (other 17.1%). Following sources of information influenced the decision process of hospital choice: urologists’ recommendation (52.6%), previous experience in the hospital (20.3%), recommendations from social environment (17.6%), the hospital's website (10.8%) and 8.2% used other sources. Only 4.3% (n = 35) used a HRW for decision making. However, 29% changed their hospital choice due to the information provided HRW. The most frequently used platforms were Weisse-Liste.de (32%), the AOK-Krankenhausnavigator (13%) and Qualitaetskliniken.de (8%). On average, patients rated positively concerning satisfaction with the respective HRW on the Acceptability E-Scale (mean values of the individual items: 1.8–2.1). Conclusion In Germany, HRWs play a minor role for uro-oncologic patients undergoing elective surgery. Instead, personal consultation of the treating urologist seems to be far more important. Although patients predominantly rated the provided information of the HRW as positive, only a quarter of users changed the initial choice of hospital.

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.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.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).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.HINTERGRUND: Die konservative und chirurgische Behandlung von Kindern ist in der urologischen Facharztweiterbildung fest verankert und stellt eine Kernkompetenz der urologischen Versorgung dar. Berufspolitisch wird seit vielen Jahren ein zunehmender Verlust dieses Schwerpunkts befürchtet. Ziel dieser Studie ist es, reale Fallzahlen und eine mögliche Dynamik in der Verteilung kinderurologischer Eingriffe auf die Fachabteilungen für Urologie und Kinderchirurgie in Deutschland zu prüfen.Als Index-Eingriffe definierten wir Operationen des Hodenhochstands, der Hypospadie und des vesikoureteralen Refluxes (VUR). Mithilfe der Software reimbursement.INFO (RI Innovation GmbH, Hürth) werteten wir die öffentlich zugänglichen Qualitätsberichtsdaten der deutschen Krankenhäuser von 2006 bis 2019 aus und wiesen sie den entsprechenden Fachrichtungen zu.Die Orchidopexie erfolgt häufiger in der Urologie, wohingegen die Hypospadiekorrektur und die operative Therapie des VUR häufiger in der Kinderchirurgie durchgeführt werden. Anteilig zeigte sich für die Orchidopexie und die operative Refluxtherapie keine relevante Verschiebung zwischen urologischen und kinderchirurgischen Kliniken im Untersuchungszeitraum. Bei den Hypospadiekorrekturen nimmt der Anteil der Operationen in kinderchirurgischen Einheiten zu (p 0,0001). In der Kinderchirurgie erfolgen 84–93 % der analysierten Eingriffe in High-volume-Abteilungen während dieser Anteil in der Urologie bei 56–73 % liegt. Insbesondere die operative Refluxtherapie in der Urologie erfolgt zu einem hohen Anteil als Gelegenheitseingriff (30 % „very low volume“).Die Qualitätsberichtsdaten ermöglichen die Erfassung der Fallzahlen und die Analyse der Verteilung zwischen Urologie und Kinderchirurgie in Deutschland. Dabei ist für die Hypospadiekorrektur eine relevante Verschiebung in Richtung der Kinderchirurgie zu beobachten. Die Ursachen und möglichen berufspolitischen Konsequenzen dieser ersten Erhebung sind komplex und bedürfen weiterer Analysen.

Obwohl urologische maligne Erkrankungen mit etwa 100.000 Neuerkrankungen pro Jahr eine relevante gesundheitsokonomische Aufgabe darstellen, existieren kaum Erkenntnisse uber die Struktur und Entwicklung der entsprechenden tumorchirurgischen Eingriffe an den mehr als 400 urologisch-chirurgisch tatigen Kliniken in Deutschland. Somit erfassten wir mittels Datenbankabfrage der DRG-Datenbank („diagnosis related groups“) des statistischen Bundesamtes samtliche Falle von 5 grosen tumorchirurgischen Eingriffen in Deutschland (Prostatektomie, Zystektomie, Nierentumoroperation, retroperitoneale Lymphadenektomie, penischirurgische Eingriffe) von 2006 bis 2013 (bzw. 2016) und untersuchten die Einflusse von technischen Neuerungen sowie Leitlinienanderungen auf die Entwicklungen der Fallzahlen. Zudem analysierten wir die Zusammenhange zwischen jahrlicher Fallzahl und perioperativem Ergebnis. Die Ergebnisse zeigten eine deutliche Korrelation zwischen Fallzahlvolumen (und damit Expertise) einer Klinik und einem verbesserten perioperativen Ergebnis. Dennoch existiert kaum Tendenz zur Zentralisierung bei diesen uroonkologischen Eingriffen. Die Fallzahlentwicklungen scheinen vielmehr vom Werbeeffekt durch technische Innovationen oder auch vom regionalen Bezug der Patienten zu einer bestimmten Klinik abhangig zu sein. Zentral gesteuerte Versuche mittels Einfuhrung von Mindestfallzahlen oder der freiwilligen Zertifizierung von Zentren hatten in der Vergangenheit nur geringen Einfluss auf die Fallzahlverteilungen.

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 p p p 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.

Purpose The assistance of robotic systems raises the concern of whether there is an improved learning in robotic-assisted radical prostatectomy (RARP) compared to open retropubic radical prostatectomy (ORP). Methods We retrospectively analyzed data from 1438 patients who underwent ORP (n = 735) or RARP (n = 703). For each procedure, the level of experience of three different surgeons was summarized. Perioperative and pathological parameters reflecting surgical performance were compared between both learning curves. RARP data were influenced by new introduction of the robotic system. Results The median patient age at surgery was 66 years (IQR 42–80). Patients in the RARP group were younger (p p p = 0.03) than inexperienced ORP surgeons. After 100 procedures, RARP and ORP surgeons had the same pT2-PSM rate (8% vs. 8%; p = 0.8) and lymph node yield (15.4 ± 5.4 vs. 15.4 ± 5.1; p = 1.0). In multivariate analysis for ORP, surgical inexperience (≤ 100 cases) was an independent predictor of a longer operating time (OR 9.0; p p p p = 0.004), higher pT2-PSM rate (OR 1.6; p = 0.03), and lower lymph node yield (OR 0.6; p = 0.001). Conclusions Surgical experience has a relevant impact on perioperative and pathological parameters RARP has a higher initial pT2-PSM rate and lower lymph node yield than ORP. This is relevant for patient selection for novice teaching in RARP.

Zusammenfassung Hintergrund Die Behandlung von Harninkontinenz und erektiler Dysfunktion verbessert die Lebensqualität vieler Patienten. Insbesondere die Endoprothetik mit Sphinkter- und Penisprothesen erzielt hierbei sehr gute Ergebnisse, wenn konservative Therapieoptionen ausgeschöpft sind. Ziel dieser Studie ist eine Darstellung der Entwicklung und aktuellen Versorgungslage der Sphinkter- und Penisprothesenimplantation in Deutschland. Material und Methoden Wir führten eine Analyse der Diagnosis-Related-Groups-Abrechnungsdaten in Deutschland im Zeitraum von 2006 bis 2016 durch. Die Versorgungslage im Jahr 2016 beschrieben wir auf Basis der Qualitätsberichtsdaten der deutschen Krankenhäuser. Ergebnisse Von 2006 bis 2012 stieg die Zahl der implantierten Sphinkterprothesen in Deutschland von 739 auf 1112 (p p p p p = 0,9) und die Zahl der implantierenden Kliniken (p = 0,5). Der Anteil implantierter Penisprothesen im Rahmen von Geschlechtsumwandlungen stieg von 17 % im Jahr 2006 auf 25 % im Jahr 2016 (p = 0,03). Im Jahr 2016 implantierten 83 (85 %) urologische Kliniken 1–6 Penisprothesen und 14 (15 %) Kliniken ≥ 7 Prothesen. Die 7 Top-Kliniken (≥20 Prothesen/Jahr) implantierten 232/448 (52 %) der Prothesen. Diskussion Der Versorgungsstand der urologischen Endoprothetik in Deutschland zeigt eine deutliche Zentrenbildung, aber auch eine große Zahl von Kliniken mit geringer Fallzahl. Seit 2012/2013 zeigt sich eine Stagnation der Fallzahlen von Penis- und Sphinkterprothesenimplantationen, die in Zusammenschau mit den Prostatektomiefallzahlen eine Unterversorgung vermuten lässt.

Purpose Treatment of post-prostatectomy urinary incontinence (UI) and erectile dysfunction (ED) increases quality of life (QoL). Aim of our study was to evaluate the utilisation of care among patients with post-prostatectomy UI and ED in Germany. Methods The HAROW study documented treatment of patients with localised prostate cancer (≤ T2c) in Germany. 1260 patients underwent radical prostatectomy (RP). Patients answered validated questionnaires after a median follow-up of 6.3 years. Response rate was 76.8%. Results Median age at RP was 65 (IQR 60–69) years. 14% (134/936) used more than one pad per day for UI. 25% (26/104, 30 missing) of UI patients underwent surgery to improve continence. Of patients without surgery, 41% (31/75) reported a moderate-to-severe issue concerning their incontinence with worse mental health and QoL. 81% (755/936) patients were unable to have an erection firm enough for sexual intercourse. Of all ED patients, 40% (319/793) used ED treatment regularly or tried it at least once. 49% (243/499) of patients with interest in sex never tried ED treatment. In multivariate analysis, patients not using ED treatments were older (≥ 70 years OR 4.1), and more often had preoperative ED (OR 2.3) and less interest in sex (OR 2.2). Nevertheless, 30% (73/240) of these patients had moderate-to-severe issues with their ED reporting worse mental health and QoL. Conclusion Almost half of the patients without post-prostatectomy UI and ED treatment reported moderate-to-severe issues with a significant decrease in QoL. This indicates an insufficient utilisation of care in Germany.

Different patients want to take different roles in the treatment decision-making process; these roles can be classified as passive, collaborative, and active. The aim of this study was to investigate the correlation between decision-making preferences among patients with prostate cancer and personal, disease-related, and structural factors. In four survey studies, we asked 7169 prostate cancer patients about their decision-making preferences using the Control Preferences Scale (CPS) and collected clinical, psychological, and quality-of-life measures. Most patients (62.2%) preferred collaborative decision-making, while 2322 (32.4%) preferred an active role, and only 391 (5.5%) preferred a passive role. Age (p p p = 0.018), treatment status (p p p = 0.001), and quality of life (p

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.

Background Penile cancer is a rare disease and surgical treatment often entails a significant impact on quality of life. The aim of this study was to analyze trends in surgical treatment patterns in Germany. Methods We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2016. All penile cancer cases with penile surgery or lymph node dissection (LND) were included. We also analyzed the distribution of cases, extent of surgery, and length of hospital stay, stratified for annual caseload. The geographical distribution of centers for 2016 was presented. Results During the investigated timespan, tumor incidences increased from 748 to 971 (p = 0.001). We identified 11,353 penile surgery cases, increasing from 886 to 1196 (p < 0.001), and 5173 cases of LND, increasing from 332 to 590 (p < 0.001). Cases of partial amputation increased from 45.8 to 53.8% (p < 0.001), while total amputation remained stable at 11.2%. Caseload in high-volume hospitals increased from 9.0 to 18.8% for penile surgery (p < 0.001) and from 0 to 13.1% for LND (p < 0.001). The increase in LND caseload was caused by an increase in inguinal LND, from 297 to 505 (p < 0.001), with increasing sentinel LND, from 14.2 to 21.9% (p = 0.098). The assessment of geographical distribution of cases in Germany revealed extensive areas without sufficient coverage by experienced centers. Conclusions We saw consistent increases in penile surgery and LND, with a growing number of cases in high-volume hospitals, and, accordingly, an increase in tumor incidence. The increasing use of inguinal LND and organ-preserving surgery reflect the adaptation of current guidelines; however, geographical distribution of experienced centers could be improved.

Radiotherapy is one of the curative treatment options for localized prostate cancer (PCa). The curative potential of radiotherapy is mediated by irradiation-induced oxidative stress and DNA damage in tumor cells. However, PCa radiocurability can be impeded by tumor resistance mechanisms and normal tissue toxicity. Metabolic reprogramming is one of the major hallmarks of tumor progression and therapy resistance. Specific metabolic features of PCa might serve as therapeutic targets for tumor radiosensitization and as biomarkers for identifying the patients most likely to respond to radiotherapy. The study aimed to characterize a potential role of glutaminase (GLS)-driven glutamine catabolism as a prognostic biomarker and a therapeutic target for PCa radiosensitization. Methods: We analyzed primary cell cultures and radioresistant (RR) derivatives of the conventional PCa cell lines by gene expression and metabolic assays to identify the molecular traits associated with radiation resistance. Relative radiosensitivity of the cell lines and primary cell cultures were analyzed by 2-D and 3-D clonogenic analyses. Targeting of glutamine (Gln) metabolism was achieved by Gln starvation, gene knockdown, and chemical inhibition. Activation of the DNA damage response (DDR) and autophagy was assessed by gene expression, western blotting, and fluorescence microscopy. Reactive oxygen species (ROS) and the ratio of reduced glutathione (GSH) to oxidized glutathione (GSSG) were analyzed by fluorescence and luminescence probes, respectively. Cancer stem cell (CSC) properties were investigated by sphere-forming assay, CSC marker analysis, and in vivo limiting dilution assays. Single circulating tumor cells (CTCs) isolated from the blood of PCa patients were analyzed by array comparative genome hybridization. Expression levels of the GLS1 and MYC gene in tumor tissues and amino acid concentrations in blood plasma were correlated to a progression-free survival in PCa patients. Results: Here, we found that radioresistant PCa cells and prostate CSCs have a high glutamine demand. GLS-driven catabolism of glutamine serves not only for energy production but also for the maintenance of the redox state. Consequently, glutamine depletion or inhibition of critical regulators of glutamine utilization, such as GLS and the transcription factor MYC results in PCa radiosensitization. On the contrary, we found that a combination of glutamine metabolism inhibitors with irradiation does not cause toxic effects on nonmalignant prostate cells. Glutamine catabolism contributes to the maintenance of CSCs through regulation of the alpha-ketoglutarate (α-KG)-dependent chromatin-modifying dioxygenase. The lack of glutamine results in the inhibition of CSCs with a high aldehyde dehydrogenase (ALDH) activity, decreases the frequency of the CSC populations in vivo and reduces tumor formation in xenograft mouse models. Moreover, this study shows that activation of the ATG5-mediated autophagy in response to a lack of glutamine is a tumor survival strategy to withstand radiation-mediated cell damage. In combination with autophagy inhibition, the blockade of glutamine metabolism might be a promising strategy for PCa radiosensitization. High blood levels of glutamine in PCa patients significantly correlate with a shorter prostate-specific antigen (PSA) doubling time. Furthermore, high expression of critical regulators of glutamine metabolism, GLS1 and MYC, is significantly associated with a decreased progression-free survival in PCa patients treated with radiotherapy. Conclusions: Our findings demonstrate that GLS-driven glutaminolysis is a prognostic biomarker and therapeutic target for PCa radiosensitization.

Radiotherapy is one of the curative treatment options for localized prostate cancer (PCa). The curative potential of radiotherapy is mediated by irradiation-induced oxidative stress and DNA damage in tumor cells. However, PCa radiocurability can be impeded by tumor resistance mechanisms and normal tissue toxicity. Metabolic reprogramming is one of the major hallmarks of tumor progression and therapy resistance. Here, we found that radioresistant PCa cells and prostate cancer stem cells (CSCs) have a high glutamine demand. Glutaminase (GLS)-driven catabolism of glutamine serves not only for energy production but also for the maintenance of the redox state. Consequently, glutamine depletion or inhibition of critical regulators of glutamine utilization, such as glutaminase (GLS) and the transcription factor MYC results in PCa radiosensitization. On the contrary, we found that a combination of glutamine metabolism inhibitors with irradiation does not cause toxic effects on nonmalignant prostate cells. Glutamine catabolism contributes to the maintenance of CSCs through regulation of the alpha-ketoglutarate (α-KG)-dependent chromatin-modifying dioxygenase. The lack of glutamine results in the inhibition of CSCs with a high aldehyde dehydrogenase (ALDH) activity, decreases the frequency of the CSC populations in vivo and reduces tumor formation in xenograft mouse models. Moreover, this study shows that activation of the ATG5-mediated autophagy in response to a lack of glutamine is a tumor survival strategy to withstand radiation-mediated cell damage. In combination with autophagy inhibition, the blockade of glutamine metabolism might be a promising strategy for PCa radiosensitization. High blood levels of glutamine in PCa patients significantly correlate with a shorter prostate-specific antigen (PSA) doubling time. Furthermore, high expression of critical regulators of glutamine metabolism, GLS1 and MYC, is significantly associated with a decreased progression-free survival in PCa patients treated with radiotherapy. Our findings demonstrate that GLS-driven glutaminolysis is a prognostic biomarker and therapeutic target for PCa radiosensitization.

Treating urinary incontinence and erectile dysfunction improves quality of life for many patients. In particular, sphincter and penile prostheses achieve very good results when conservative therapy options are exhausted. The aim of this study is to present the development and current state of sphincter and penile prosthesis implantation in Germany.We carried out an analysis of the Diagnosis Related Groups billing data in Germany from 2006-2016. We described the state of care in 2016 based on the German hospitals' quality reports.Between 2006 and 2012 implantations of sphincter prostheses in Germany increased from 739 to 1112 (p 0.001), the amount of implanting hospitals also increased from 129 to 206 (p 0.001). From 2012-2016, the number of cases decreased to 980 and the number of hospitals to 198. In 2016, 168 (88%) urological hospitals implanted 1-9 sphincter prostheses and 23 (12%) hospitals implanted ≥ 10 sphincter prostheses. The top 10 hospitals (≥20 sphincters) implanted 34% (283/839) of all sphincters. Between 2006 and 2013 the number of implanted penile prostheses continuously increased from 263 to 503 (p 0.001), the number of implanting hospitals from 71 to 107 (p 0.001). From 2013-2016, the number of cases (p = 0.9) and the number of implanting hospitals (p = 0.5) stagnated. The proportion of penile prostheses implanted as part of gender reassignment surgery increased from 17% in 2006 to 25% in 2016 (p = 0.03). In 2016, 83 (85%) urological hospitals implanted 1-6 penile prostheses and 14 (15%) hospitals implanted ≥ 7 prostheses. The 7 top hospitals (≥20 prostheses/year) implanted 232/448 (52%) of the prostheses.The current state of urological endoprosthetics in Germany shows a small number of high-volume centers, but also a large number of hospitals with a small number of cases. Since 2012/2013, there has been a stagnation in the number of cases of penile and sphincter prosthesis implantations. In view of the number of radical prostatectomy cases, this development suggests an undersupply.HINTERGRUND: Die Behandlung von Harninkontinenz und erektiler Dysfunktion verbessert die Lebensqualität vieler Patienten. Insbesondere die Endoprothetik mit Sphinkter- und Penisprothesen erzielt hierbei sehr gute Ergebnisse, wenn konservative Therapieoptionen ausgeschöpft sind. Ziel dieser Studie ist eine Darstellung der Entwicklung und aktuellen Versorgungslage der Sphinkter- und Penisprothesenimplantation in Deutschland.Wir führten eine Analyse der Diagnosis-Related-Groups-Abrechnungsdaten in Deutschland im Zeitraum von 2006 bis 2016 durch. Die Versorgungslage im Jahr 2016 beschrieben wir auf Basis der Qualitätsberichtsdaten der deutschen Krankenhäuser.Von 2006 bis 2012 stieg die Zahl der implantierten Sphinkterprothesen in Deutschland von 739 auf 1112 (p 0,001) und die Zahl der implantierenden Kliniken von 129 auf 206 (p 0,001). Von 2012 bis 2016 fielen die Fallzahlen auf 980 und die Zahl der Kliniken auf 198. Im Jahr 2016 implantierten 168 (88 %) urologische Kliniken 1–9 Sphinkterprothesen und 23 (12 %) Kliniken ≥ 10 Sphinkterprothesen. Die 10 Top-Kliniken (≥20 Sphinkter) implantierten 34 % (283/839) aller Sphinkter. Von 2006 bis 2013 stieg die Zahl der implantierten Penisprothesen kontinuierlich von 263 auf 503 (p 0,001) sowie die Zahl der implantierenden Kliniken von 71 auf 107 (p 0,001). Von 2013 bis 2016 stagnierte die Fallzahl (p = 0,9) und die Zahl der implantierenden Kliniken (p = 0,5). Der Anteil implantierter Penisprothesen im Rahmen von Geschlechtsumwandlungen stieg von 17 % im Jahr 2006 auf 25 % im Jahr 2016 (p = 0,03). Im Jahr 2016 implantierten 83 (85 %) urologische Kliniken 1–6 Penisprothesen und 14 (15 %) Kliniken ≥ 7 Prothesen. Die 7 Top-Kliniken (≥20 Prothesen/Jahr) implantierten 232/448 (52 %) der Prothesen.Der Versorgungsstand der urologischen Endoprothetik in Deutschland zeigt eine deutliche Zentrenbildung, aber auch eine große Zahl von Kliniken mit geringer Fallzahl. Seit 2012/2013 zeigt sich eine Stagnation der Fallzahlen von Penis- und Sphinkterprothesenimplantationen, die in Zusammenschau mit den Prostatektomiefallzahlen eine Unterversorgung vermuten lässt.

Introduction: We characterize trends of metastasis-directed treatments in patients with metastatic renal cell carcinoma (mRCC) in Germany in the targeted therapy era. Methods: We identified all cases with a diagnosis of renal cell carcinoma (ICD-10: C.64) and site-specific codes for secondary malignant neoplasms (C79.x) in combination with procedural codes for resection and radiation from the Institute of Hospital Remuneration and the German Federal Statistical Office (Destatis) between 2006 and 2014. We assessed site-specific temporal trends using estimated annual percent change (EAPC) linear regression. Results: Overall, 15,742 resections and 21,224 radiation treatments were recorded. These targeted lung (44.1% resections; 22.0% radiations), lymph node (14.0% resections; 12% radiations), bone (21% resections; 38% radiations), liver (9% resections; 7% radiations), adrenal (11% resections; 3% radiations), and CNS metastases (2% resections; 19% radiations). There was a significantly increasing trend for resection of lung (EAPC +1.33, p = 0.011), bone (EAPC +2.48, p = 0.014), and adrenal (EAPC +3.4, p = 0.003) metastases, while trends for resection of CNS metastases significantly decreased (EAPC –7.93, p = 0.005). Between Western and Eastern Germany linear trends of resection (EAPC +2.75, p < 0.001; EAPC –0.44, p = 0.54) and radiation (EAPC +1.08, p = 0.15; –3.41, p = 0.03) differed significantly. Conclusion: We observed an increasing trend for metastasis-directed resections and slightly declining numbers for radiation therapy in Germany for mRCC in the targeted therapy era. Treatment differed by geography. These findings suggest more aggressive treatment algorithms following the availability of targeted therapies and a yet diverging treatment landscape needing further exploration.

Background: Radical cystectomy (RC) still poses a significant risk for mortality and morbidity. Objectives: We compared in-hospital outcomes after RC in the United States and ­Germany using population-based data. Methods: We compared data from the US Nationwide Inpatient Sample to the German hospital billing database. Mortality and transfusion during hospital stay and length of stay (LOS) were evaluated. Results: In all, 17,711 (the United States) and 60,447 (­Germany) cases were included. The share of robot-assisted RC increased to 20.5% in the United States vs. 2.3% in Germany (p < 0.001). In-hospital mortality was 1.9% (the United States) vs. 4.6% (Germany), transfusion rates were 34.2% (the United States) vs. 58.7% (Germany), and LOS was 10.7 (the United States) vs. 25.1 days (Germany; all p < 0.001). On multivariate analysis, higher patient age and lower annual hospital caseload were associated with increased mortality and longer LOS. Minimal-invasive surgery was associated with less blood transfusion and shorter LOS in the United States vs. hospital caseload and choice of urinary diversion in Germany. Conclusions: Healthcare systems might exert a relevant impact on outcomes of oncologic surgery. Increased in-hospital mortality rates in Germany seem to be partly explained by much longer LOS compared to those in the United States. Annual caseload seems to be influential on in-hospital outcomes raising the question of centralization of RC.

Objectives: We compared the transperineal MRI/ultrasound-fusion biopsy (fusPbx) to transrectal systematic biopsy (sysPbx) in patients with previously negative biopsy and investigated the prediction of tumour aggressiveness with regard to radical prostatectomy (RP) specimen. Material and Methods: A total of 710 patients underwent multiparametric magnetic resonance imaging (mpMRI), which was evaluated in accordance with Prostate Imaging Reporting and Data System (PI-RADS). The maximum PI-RADS (maxPI-RADS) was defined as the highest PI-RADS of all lesions detected in mpMRI. In case of proven prostate cancer (PCa) and performed RP, tumour grading of the biopsy specimen was compared to that of the RP. Significant PCa (csPCa) was defined according to Epstein criteria. Results: Overall, scPCa was detected in 40% of patients. The detection rate of scPCa was 33% for fusPbx and 25% for sysPbx alone (p < 0.005). Patients with a maxPI-RADS ≥3 and a prostate specific antigen (PSA)-density ≥0.2 ng/mL2 harboured more csPCa than those with a PSA-density < 0.2 ng/mL2 (41% [33/81] vs. 20% [48/248]; p < 0.001). Compared to the RP specimen (n = 140), the concordance of tumour grading was 48% (γ = 0.57), 36% (γ = 0.31) and 54% (γ = 0.6) in fusPbx, sysPbx and comPbx, respectively. Conclusions: The combination of fusPbx and sysPbx outperforms both biopsy modalities in patients with re-biopsy. Additionally, the PSA-density may represent a predictor for csPCa in patients with maxPI-RADS ≥3.

Introduction: Targeted biopsy of tumour-suspicious lesions detected in multiparametric magnetic resonance imaging (mpMRI) plays an increasing role in the active surveillance (AS) of patients with low-risk prostate cancer (PCa). The aim of this study was to compare MRI/ultrasound-fusion biopsy (fusPbx) with systematic biopsy (sysPbx) in patients undergoing biopsy for AS. Methods: Patients undergoing mpMRI and transperineal fusPbx combined with transrectal sysPbx (comPbx) as surveillance biopsy were investigated. The detection of Gleason score upgrading and reclassification according to Prostate Cancer Research International Active Surveillance criteria were evaluated. Results: Eighty-three patients were enrolled. PCa upgrading was detected in 39% by fusPbx and in 37% by sysPbx (p = 1.0). The percentage of patients who were reclassified in fusPbx and sysPbx (p = 0.45) were 64 and 59% respectively. ComPbx detected more frequently tumour upgrading than fusPbx (71 vs. 64%, p = 0.016) and sysPbx (71 vs. 59%, p < 0.001) and more patients had to be reclassified after comPbx than after fusPbx or sysPbx alone. Conclusions: The combination of fusPbx and sysPbx outperforms both modalities alone with regard to the detection of upgrading and reclassification in patients under AS. Because a high missing rate of significant PCa still exists in both biopsy modalities, a combination of fusPbx and sysPbx should be recommended in these patients.

Aus Patientensicht ist die Therapieentscheidung beim nichtmetastasierten Prostatakarzinom komplex. Zu ihrer Unterstutzung werden im angelsachsischen Raum zunehmend EDV-gestutzte Entscheidungshilfen eingesetzt, die eine Personalisierung der Information ermoglichen. Um die didaktischen Moglichkeiten und Grenzen kennenzulernen, identifizierten wir entsprechende patientenorientierte Entscheidungshilfen. Einschlusskriterium war die Moglichkeit zur Eingabe personlicher oder krankheitsbezogener Daten als Grundvoraussetzung einer Personalisierung. Mittels systematischer Literatur- und Internetrecherche bis 11/2013 sowie durch Gesprache mit Experten identifizierten wir insgesamt 10 Entscheidungshilfen von denen 6 wissenschaftlich evaluiert sind. Vergleichend bewerteten wir die einzelnen Entscheidungshilfen sowie Design und Ergebnisse der Evaluationsstudien. Die Entscheidungshilfen beschreiben zwei bis sieben Therapieoptionen, wobei die radikale Prostatektomie und die perkutane Radiatio stets dargestellt sind. Auch Anzahl und Art der erfassten Parameter unterscheiden sich deutlich. Aus den Angaben leiten zwei Entscheidungshilfen eine konkrete Therapieempfehlung ab. Die wissenschaftliche Evaluation zeigt nach der Nutzung ein erhohtes Wissen uber die Erkrankung und eine grosere Zuversicht bei der Therapiewahl. Die Zufriedenheit mit der Entscheidungshilfe war in allen Studien uberwiegend hoch. Fur Patienten mit nichtmetastasiertem Prostatakarzinom existieren ausschlieslich englischsprachige personalisierte Entscheidungshilfen. Sie konnen die partizipative Entscheidungsfindung fur Patienten und Arzte erleichtern, sodass hier mittelfristig Handlungsbedarf besteht.

Introduction Pathophysiological conditions within the tumour microenvironment induce metabolic adaptations of cancer cells. These metabolic features correlating with aggressive tumour growth pattern and the relapse risk after radiotherapy. Beside glucose, fast-growing cancer cells consume glutamine for energy production. Within the presented project we investigated the potential of the glutamine metabolism as putative therapeutic target and predictive biomarker for an individualised radiotherapy of prostate cancer (PC) patients. Material and methods Genome and metabolome analysis of radioresistant PC cells identified the glutamine metabolism as regulator for intrinsic sensitivity to irradiation. Radiosensitizing effects of glutamine deprivation, molecular targeting and genetic suppression of key enzymes were determined for clonogenic survival, DNA repair and sphere-formation ability to determine the cancer stem cell (CSC) potential in PC cell lines, primary culture models and ex vivo treated primary biopsies. Analysis of tumour growth after glutamine deprivation were performed in xenograft models. The intracellular level of the glutamine metabolism and tricarboxylic acid cycle metabolites, reactive oxygen species (ROS) and glutathione (GSH) were determined. The clinical validation of the identified metabolic biomarkers was carried out with the NanoString technology. Results and discussions Radioresistant PC cells exhibit an accelerated glutaminolysis with enhanced α-ketoglutarate to succinate ratio. The elevated α-ketoglutarate is leading to GSH consumption, increased intracellular ROS level, modulated epigenetic regulators and induction of a CSC phenotype. Metabolic, chemical and genetic targeting of glutaminolysis results in the inhibition of mTOR signalling, enhanced endoplasmic reticulum stress and reduction of DNA repair. In combination with irradiation this targeting therapy is effectively radiosensitizing PC cells in vitro and in vivo . Moreover, the c-MYC gene expression, a key regulator of glutaminolysis, significantly correlates with the PSA-free survival after radiotherapy. Conclusion This study shows that the enhanced glutaminolysis of PC cells is conferring resistance to radiotherapy. The therapeutic targeting of the glutamine metabolism is elevating the cytotoxic effects of irradiation. In addition, metabolic enzymes involved in the glutamine metabolism can be potentially used to predict clinical outcome of PC patients after radiotherapy.

To assess trends in the distribution of patients for radical prostatectomy in Germany from 2006 to 2013 and the impact of robotic surgery on annual caseloads. We hypothesized that the advent of robotics and the establishment of certified prostate cancer centers caused centralization in the German radical prostatectomy market.Using remote data processing we analyzed the nationwide German billing data from 2006 to 2013. We supplemented this database with additional hospital characteristics like the prostate cancer center certification status. Inclusion criteria were a prostate cancer diagnosis combined with radical prostatectomy. Hospitals with certification or a surgical robot in 2009 were defined as 'early' group. Linear covariant-analytic models were applied to describe trends over time.Annual radical prostatectomy numbers declined from 28 374 (2006) to 21 850 (2013). High-volume hospitals (⩾100 cases) decreased from 87 (22.0%) in 2006 to 43 (10.4%) in 2013. Low-volume hospitals (50 cases) increased from 193 (48.7%) to 280 (67.4%). Mean radical prostatectomy caseloads of hospitals with early vs without certification declined from 155 to 130 vs 77 to 39 (P=0.021 for trend comparison). Early robotic hospitals maintained their volume200 cases per year contrary to the overall trend (P0.001 for trend comparison). A multivariate model for caseload numbers of 2013 indicated a robotic system to be the most important factor for higher caseloads (multiplication factor 7.3; 95% confidence interval: 6.6-8.0). A prostate cancer center certification (multiplication factor 1.6; 95% confidence interval: 1.50-1.59) had a much smaller impact.We found decentralization of radical prostatectomy in Germany. The driving force for this development might consist in the overall decline of radical prostatectomy numbers. The most important factor for achieving higher caseloads was the presence of a robotic system. In order to optimize outcomes of radical prostatectomy additional health policy measures might be necessary.

Novel particle therapy was implemented into standard-of-care for cancer patients during the last years. However, experimental studies investigating cellular and molecular mechanisms are lacking and prognostic biomarker are urgently needed. Cancer stem cell (CSC)-related biomarkers such as aldehyde dehydrogenase (ALDH) are known to cellular radiosensitivity by affecting defense against reactive oxygen species, DNA damage repair and cell survival. Within a previous study, we found that ionizing radiation itself enriches for ALDH-positive CSCs. Within the present study, we investigated CSC marker dynamics in prostate cancer, head and neck cancer and glioblastoma cells upon proton beam irradiation. We found that proton irradiation has an increased CSC targeting potential, reduced methylation of activating histone marks and a lower induction of cellular senescence compared to conventional photon irradiation. Interestingly, mathematical modeling indicated to differences in plasticity rates among ALDH-positive CSCs and ALDH-negative cancer cells between the two irradiation types.