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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.

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.

Although outpatient provision of services is economically desirable, many minor urological interventions in Germany are currently carried out on an inpatient basis. The aim of our study is to investigate whether the current health policy framework contributes to more outpatient treatment.We used a sample of 4.9 million anonymous, insured persons representative according to age and region provided by the Institute for Applied Health Research (InGef GmbH). We report extrapolations for the number of outpatient and inpatient services throughout Germany between 2013 and 2018. In addition, we performed an economic analysis for two selected interventions.During the study period, the total number of prostate biopsies declined from 184,573 to 174,558 cases. The share of outpatient biopsies declined continuously by 0.9% per year from 81% to 76% (p 0.001). For botulinum toxin injection into the bladder, the total increased from 15,630 to 26,824 cases. The share of outpatient treatments increased by 2.7% per year from 3% to 19% (p = 0.01). For the other examined interventions (insertion of suprapubic urinary catheters, the insertion, removal, and changing of ureteral stents, cystoscopies and urethral dilatation), there were no significant changes in the share of outpatient procedures.The significant increase of outpatient botulinum toxin injections shows the successful control effect through adapted remuneration options. A shift to the inpatient sector was observed for prostate biopsies. This may be due to higher hygienic standards and technical requirements for MRI fusion.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.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.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 0,001). Bei der Injektion von Botulinumtoxin in die Blase (Botox-Injektion) stieg die Gesamtzahl von 15.630 auf 26.824. Der ambulant durchgeführte Anteil stieg dabei um 2,7 % pro Jahr von 3 % auf 19 % (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.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.

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.

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.We defined FT as high-intensity focused ultrasound (HIFU), hyperthermia ablation, cryotherapy, transurethral ultrasound ablation (TULSA) or vascular-targeted photodynamic therapy (VTP) TOOKADWe identified 23,677 cases of FT from 2006 to 2019. Considering all PCa cases with surgery, radiotherapy or FT, the share of FT was stable at 4%. The annual caseload of FT increased to a maximum of 2653 cases in 2008 (p 0.001) and then decreased to 1182 cases in 2014 (p 0.001). Since 2015, the cases of FT remained on a plateau around 1400 cases per year. The share of HIFU was stable at 92-96% from 2006 to 2017 and decreased thereafter to 75% in 2019 (p = 0.015). In 2019, VTP-TOOKADThe 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

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

Nephron-sparing surgery (NSS) is the treatment of choice for T1 renal tumors. This study compared the implementation of NSS in the United States and Germany. Data were derived from the National Inpatient Sample and from the Nationwide German Hospital Billing Database. All cases of NSS and radical nephrectomy from 2006 to 2014 were analyzed. To assess tumor stage distribution, data from the Surveillance, Epidemiology, and End Results database (United States) and from German cancer registries were used. The study identified 74,663 cases in the United States and 130,051 cases in Germany. The proportion of NSS for T1 tumors increased from 30.6 to 57% in the United States compared with 38.5 to 72.9% (estimation) in Germany (p

Retroperitoneal lymph node dissection (RPLND) is a standard treatment in the management of metastatic testicular cancer. Due to modified treatment algorithms, it is becoming less frequent.We analyzed data from the nationwide German hospital billing database covering 2006-2015. Cases with a testicular cancer diagnosis combined with RPLND were included. We assessed the length of hospital stay (LOS), blood transfusion, and in-hospital mortality stratified for surgical approach, hospital characteristics, and annual caseload. Annual hospital caseload categories were defined as low ( 4), medium (4-10), and high ( 10). We supplemented tumor incidence and staging data from the German cancer registry (60% of population).4926 cases were included with decreasing annual caseload numbers from 623 in 2006 to 382 in 2015. The incidence of testicular cancer and higher tumor stages remained stable. High-volume hospitals performed 19.4%, medium-volume hospitals 43.7%, and low-volume hospitals 36.8% RPLNDs. Low- abd medium-volume hospitals declined, while high-volume hospitals (n = 5) maintained their annual caseload. Overall in-hospital mortality was 0.47%. Blood transfusion rates were higher in high-volume centers assumedly due to selection of more complex cases. However, high-volume hospitals showed a shorter LOS with 10.5 vs. 11.2 (medium volume), and 12.7 days (low volume).Total numbers of RPLND have declined from 2006 to 2015, while tumor incidences and stages remained fairly stable. Constant reduction of indication in guidelines contributes to this finding. High-volume hospitals achieve shorter hospital stays in spite of assumedly more complex and extensive cases. There is a modest trend towards unregulated centralization.

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.

To compare long-term functional outcomes after robotic vs. retropubic RP for patients with localized prostate cancer in routine care. “HAROW” was a large German noninterventional health services research study that prospectively evaluated the treatment of patients with localized prostate cancer (≤ T2c). We sent validated questionnaires to 1260 patients who underwent RP to evaluate long-term outcomes. After a median follow-up of 6.3 [interquartile range (IQR) 4.8–7.6] years, 42 (3%) patients had died. The return rate of the questionnaire was 76.8% (936/1218). The approach was robotic in 404 and retropubic in 532 patients. In the multivariate analysis, lack of postoperative radiotherapy [odds ratio (OR) 3.1], younger patient age (

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.

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.

Background Vascular-targeted photodynamic therapy (VTP) is an approved treatment option for unilateral low-risk prostate cancer (PCa). Objective Herein, we report our initial experience of patients treated by VTP. We compared short-term functional and oncological outcomes with those of a consecutive cohort of patients undergoing radical prostatectomy (RP) for unilateral low-risk PCa. Design, setting, and participants Patients with unilateral low-risk PCa undergoing VTP (n = 41) and RP (n = 49) were evaluated in a real-world setting. Outcome measurements and statistical analysis Oncological outcome after VTP was measured by magnetic resonance imaging–based rebiopsy at 12 and 24 mo. Functional outcome after 1 yr was investigated by International Index of Erectile Function 5 and International Prostate Symptom Score questionnaires. Continence was evaluated by pad use. Results and limitations In 12- and 24-mo control biopsy (n = 22) after VTP, 45% of VTP patients showed no evidence of PCa. Both low- and intermediate-risk PCa were detected in 27% of patients. None of the RP patients had a PCa recurrence. Of VTP and RP patients, 71% and 30%, respectively, preserved erectile function. Of VTP patients, 88% had no bladder outlet obstruction. Of RP patients, 96% and 4% used zero to one and two or more pads per day, respectively. Data acquisition was performed outside of a clinical trial. The short-term follow-up and the small number of rebiopsied patients have to be considered. Conclusions VTP is a promising treatment option in unilateral low-risk PCa presenting a lower complication profile than RP in a real-world setting. However, recurrence and progression after VTP are common in this low-risk PCa cohort, and have to be discussed critically with patients who wish VTP instead of active surveillance. Therefore, a rigorous surveillance strategy with multiparametric magnetic resonance imaging and control biopsy is required. Patient summary Vascular-targeted photodynamic therapy (VTP) is a promising therapy option in patients with unilateral low-risk prostate cancer. However, tumour recurrence has to be taken into account. Noninferiority of VTP to standard curative treatment options still has to be confirmed.

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.

Our aim was to assess and compare trends of urinary diversion (UD) for patients receiving radical cystectomy for the treatment of bladder cancer in the US and Germany, and to investigate decisive predictors for the choice of UD. We analyzed the nationwide German hospital billing database and the Nationwide Inpatient Sample (NIS) from 2006 to 2014. Cases with a bladder cancer diagnosis combined with RC were included, and trends in the choice of UD, transfusion rates, length of stay, and mortality were assessed. From 2006 to 2014, the total number of RCs recorded within the NIS were 17,711, with a varying annual caseload of 1666–2009, while RC numbers increased from 5627 to 7390 in Germany (p

To investigate the usage and perceived usefulness of new media for educating urology residents in Canada and Germany.We designed an 11-item online survey to assess the use and perceived usefulness of new media for education. We performed a comparative analysis.The survey was distributed via e-mail to 143 Canadian and 721 German urology residents.The survey included 58 urology residents from Canada and 170 from Germany.A total of 58 residents from Canada (41% response rate) and 170 from Germany (24% response rate) responded to this survey. Residents spent 45% of their education time on new media. The Internet was used by 91% (n = 208) of the residents for professional education purposes, with a median time of 270 minutes (interquartile range [IQR]: 114-540) per month. Apps were used by 54% (n = 118) of the residents, with a median time of 101 minutes (IQR: 45-293) per month. A total of 23% (n = 47) of the residents used social media (SoMe) for education, with a median time of 90 minutes (IQR: 53-80) per month. In all, 100% (n = 228) rated the Internet, 76% (n = 173) apps, and 43% (n = 97) SoMe as being useful for professional education purposes. A total of 90% (n = 205) watched medical videos for education, and 89% (n = 203) of these videos were on surgical procedures. Canadian urology residents used more new media sources for professional education than did the Germans (58% vs. 41%, p0.001). The time spent for education on new media was higher among Canadian residents for the Internet (p0.001), apps (p0.001), and SoMe (p = 0.033). Canadian residents reported more privacy concerns (p0.001).New media play a dominant role in the education of urology residents. The primary source for personal education in urology is the Internet. Future studies and technological developments should investigate and improve new media tools to optimize education during residency.

Numerous studies have compared the outcomes of open and robot-assisted radical prostatectomy but to our knowledge only 1 study has focused on patient satisfaction and regret. We evaluated intermediate term decision regret after open and robot-assisted radical prostatectomy.The HAROW (Hormonal Therapy, Active Surveillance, Radiation, Operation, Watchful Waiting) study analyzed localized prostate cancer treatments (T2c N0 M0 or less) in Germany from 2008 to 2013. We collected intermediate term followup data on 1,260 patients after retropubic open or robot-assisted radical prostatectomy.The response rate was 76.8% (936 of 1,218 cases). A total of 404 patients underwent robot-assisted radical prostatectomy and 532 underwent open radical prostatectomy. Patients treated with the robot-assisted procedure showed more self-determined behavior. They reported an active role in surgical decision making and the surgical approach (robot-assisted radical vs open prostatectomy 39% vs 24% and 52% vs 18%, respectively, each p0.001). Patients treated with the robot-assisted procedure more often participated actively in selecting the treating hospital (25% vs 11%), used the Internet often (87% vs 72%) and traveled an increased distance (63 vs 42 km, all p0.001). Overall decision regret was low with a mean ± SD score of 14 ± 19 on a scale of 0-no regret to 100-high regret. Multivariate analysis showed that erectile function (OR 3.2), urinary continence (OR 1.8), freedom from recurrence (OR 1.6), an active decision making role (OR 2.2) and shorter followup (OR 0.9 per year) predicted low decision regret (score less than 15).Intermediate term functional and oncologic outcomes as well as autonomous decision making and followup time influenced decision regret after radical prostatectomy. The surgical approach was not associated with intermediate term decision regret.

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.

With an incidence of approximately 60,000 per year prostate cancer is the most common malignant neoplasm in men with a relatively low mortality rate and a high mean age of primary diagnosis of about 70 years. The disease remains usually clinically occult over a long period of time and generally manifests primarily in a locally advanced or metastasized stage. Due to screening using the PSA level (prostate specific antigen) in blood serum, diagnosis and therapy nowadays are oftentimes possible at an early stage. The prostate carcinoma is classified using risk groups based on the level of PSA, the local tumor spread and the histological degree of differentiation (Gleason score). If no metastases are detected during staging a local curative therapy is indicated, provided that the patient is eligible for this due to age, comorbidity and life expectancy. Depending on the risk group of the patient, radical prostatectomy, percutaneous radiotherapy, brachytherapy or active surveillance are available as curative therapy concepts. Focal therapies such as HIFU, electrovaporization or cryotherapy are currently considered to be experimental. If metastases are already present at primary diagnosis, palliative, systemic therapy can be performed with an androgen deprivation therapy and chemotherapy. At an advanced and hormone refractory stage, treatment with an osteotropic radiotracer or palliative radiotherapy can reduce bone metastases and alleviate respective symptoms.

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.

The Internet is an important source of health information with relevant impact on the physician-patient relationship. The German urological associations host one of the most comprehensive platforms for patient information on urological diseases. The aim of the study was to characterise its users and their specific needs. We invited users of the website www.urologenportal.de via pop-up to complete a 26-item online survey to evaluate health-related behaviour, distress and decision-making preferences. We received n = 551 complete responses. The most frequently requested topics were from the field of andrology (45.4%, n = 250). Of these, the most popular topics were circumcision (28.9%, n = 159) and erectile dysfunction (18.1%; n = 100). Overall, 216 users (39.2%) searched for information prior to their first doctor's appointment, and 89.3% (n = 492) preferred autonomous or shared decision-making. Users seeking information on circumcision were less frequently under urological treatment (p < .001), and more self-determined regarding healthcare decisions (p = .01). Circumcision was the only information on the website, which received relevant critical comments. Andrology was the most frequently requested urological topic. The vast majority of patients wanted to take self-determined healthcare decisions and searched for information prior to a doctor's appointment. This might have an impact on the physician-patient relationship and causes a high demand for good-quality health information websites.

Outcomes of radical prostatectomy are prone to publication bias, because most of the data originated from highly specialized centers. We assessed in-hospital outcomes of all radical prostatectomies in Germany from 2006 to 2013 focusing on caseload volume, surgical approach, and certification status. We analyzed the nationwide German hospital billing data covering 221,331 radical prostatectomies from 2006 to 2013. Outcomes were in-hospital mortality, surgical revision, and transfusion rates and the length of stay. Multivariate models described the impact of these factors. The yearly number of radical prostatectomies declined from 28,374 to 21,850. While shares of all other approaches decreased, shares for robot-assisted prostatectomy increased from 0.6 to 25.2%. Hospitals with ≥100 cases a year reported lower in-hospital mortality with 0.08 versus 0.17% for hospitals with

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.

Testicular cancer has excellent cure rates; however, poor guideline adherence can lead to inappropriate management, with a detrimental effect on outcomes. Therefore, we aimed to investigate the current patterns of care for testicular cancer patients and to evaluate guideline adherence. A 19-item survey was distributed among German urologists between September 2015 and September 2016. The response rate was 45% (411/920). Staging imaging of the chest was performed by computed tomography (CT) in 85.5% and X-ray in 17.7%, and for the abdomen, by CT in 83.7% and by magnetic resonance imaging (MRI) in 21.1%. Areas of discrepancy with respect to guideline recommendations included underuse of MRI and infrequent follow-up examinations for changes in the cardiovascular, endocrine, neurological, and pulmonary systems, in addition to psychological burden. Further deviations of reported routine procedures from guideline recommendations were identified in the fields of active surveillance in Stage I seminoma, contralateral biopsies (63.1% overuse) and cryopreservation (19.2% underuse). Moreover, we found that hospital-based clinicians and younger specialists, with ≤5 years of practice following board certification, perform a more accurate and thorough follow-up. German urologists show relatively strong guideline adherence in staging patterns. Significant improvements are necessary in the following areas: recommending cryopreservation, imaging modalities and accurate follow-up examinations with a focus on late toxicities.

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.