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Purpose: To investigate clinicopathologic characteristics and cancer-specific mortality (CSM) rates of ductal carcinoma (DC) versus the common acinar adenocarcinoma in nonmetastatic and metastatic (M1) prostate cancer patients., Patients and Methods: Within the Surveillance, Epidemiology, and End Results database (2004-2015), we identified patients with histologically confirmed prostate adenocarcinoma who harbored either DC (n = 581) or acinar adenocarcinoma (n = 489,296). Kaplan-Meier and 4:1 propensity score-matched multivariable Cox regression models adjusted for clinical and pathologic parameters were used to test for CSM differences. Three separate analyses were performed on all patients with nonmetastatic disease, patients with nonmetastatic patients treated with radical prostatectomy only, and patients with metastatic disease., Results: DC was identified in 502 (0.10%) of 469,946 patients with nonmetastatic disease and 79 (0.39%) of 19,931 patients with metastatic disease. In patients with nonmetastatic disease, 253 (50.4%) DC patients underwent radical prostatectomy, 61 (12.2%) DC patients received external-beam radiotherapy, and 188 (37.4%) received other treatment modalities. In multivariable analyses, DC was associated with higher CSM in the overall nonmetastatic patient population (hazard ratio [HR] = 1.8; 95% confidence interval [CI], 1.3-2.6; P = .001), in the nonmetastatic radical prostatectomy population (HR = 2.8; 95% CI, 1.3-6.0; P < .01), and in the M1 population (HR = 1.6; 95% CI, 1.1-2.2; P < .01)., Conclusion: Prostate cancers of ductal origin represent a rare entity among patients with nonmetastatic disease as well as among patients with metastatic disease, and regardless of stage, DC behaves more aggressively., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The role of robot assistance is increasingly gaining importance among all major surgical uro-oncological procedures (MSUPs). However, contemporary analyses showed that total hospital charges (THCGs) related to robot-assisted procedures exceed those of open procedures. Based on increasing familiarity with robot-assisted surgery, we postulated that THCGs may have decreased over the past half-decade. Thus, we tested contemporary trends and THCGs related to robot-assisted vs nonrobot-assisted MSUPs. Materials and Methods: Within the National Inpatient Sample database (2009-2015), we identified patients who underwent robot-assisted vs nonrobot-assisted (open or laparoscopic) MSUPs, which included radical prostatectomy (RP), radical nephrectomy (RN), partial nephrectomy (PN), and radical cystectomy (RC). Rates of robot-assisted MSUPs were evaluated using estimated annual percentage changes (EAPCs) analyses. The t -test was used to examine statistically significant differences between mean THCGs according to either robot-assisted or nonrobot-assisted approach. Finally, linear regression analyses were tested for annual variation in the mean THCGs. Results: Of 128,367 MSUPs, 47.7% were robot-assisted. Overall, robot-assisted surgery rates among MSUPs increased from 40.3% to 57.6% (EAPC: +6.3%, p  < 0.001) between 2009 and 2015. The mean THCGs for robot-assisted RP, RN, PN, and RC were $13,799, $18,789, $16,574, and $33,575, respectively. The observed mean THCGs differences between robot-assisted and nonrobot-assisted MSUPs were +$1594, +$1592, and +$1829 for RP, RN, and RC, respectively (all p  < 0.05). Conversely, no statistically significant difference in the mean THCGs was reported between robot-assisted and nonrobot-assisted PN (+$367, p  > 0.05). Finally, the annual observed mean THCGs linearly decreased for all robot-assisted MSUPs during the study period. Conclusions: Rates of robot-assisted MSUPs exponentially increased between 2009 and 2015. Although the mean THCGs decreased in a significant manner during the study period for all MSUPs, THCGs of robot-assisted RP, RN, and RC still exceed those of their respective nonrobot-assisted counterparts. Conversely, no differences in the mean THCGs were reported between robot-assisted vs nonrobot-assisted PN.

Background: Multiple experimental approaches are meanwhile available for progressive metastatic castration resistant prostate cancer (mCRPC) patients after failure of guideline recommended therapy (i. e., chemotherapy and/or hormonal treatment). We evaluated the outcome of metronomic chemotherapy with cyclophosphamide (CY) in combination with low-dose prednisolone., Materials and Methods: A total of 14 mCRPC-patients were treated with CY 50 mg/day (plus prednisolone 10 mg/day) between November 2012 and September 2017 after being resistant or unfit for chemotherapy and/or further hormonal treatment. Time to progression and overall survival (OS) were retrospectively determined by using Kaplan-Meier curves., Results: Eight of 14 (57.1%) patients had undergone radical prostatectomy and 2 (14.3%) external beam radiation. All patients had at least three therapy lines and 50% had ≥5 mCRPC therapies. The median time from first diagnosis to mCRPC was 88 months; the median age was 78 years with a median baseline serum prostate-specific antigen (PSA) level of 341 ng/ml. With a median follow-up of 16.4 months, progression-free survival (PFS) was 71, 64, and 43% after 2, 4, and 6 months, respectively. Median OS was 8.1 months. No relevant adverse events occurred., Conclusion: Since CY is a well-tolerated medication with partially good clinical tumor control, it seems to be a convenient, individual treatment option in progressive mCRPC patients after failure of guideline recommended therapy.

Background: We analysed contemporary pelvic lymph node dissection (PLND) trend during radical cystectomy (RC) for urothelial carcinoma of urinary bladder (UCUB), as well as PLND association with cancer specific mortality (CSM) and complications after stratification according to octogenarian vs. younger age., Materials and Methods: Within the SEER and NIS databases, respectively 10,427 (T2 and T3 stages) and 19,203 (all T-stages) RC patients (2004-2015) for UCUB were identified. Univariable and multivariable analyses focused on PLND rates, CSM after inverse probability of treatment weighting (IPTW) adjustment, complication rates, length of stay (LOS) and total hospital charge (THC)., Results: Within the SEER database, RC and PLND was performed in 9,406 patients (87.4%), 981 (10.4%) octogenarians and 8,227 younger patients (at, respectively, 83 and 89% PLND). PLND rates increased over time in both patients groups (p < 0.05). PLND was independently associated with lower CSM in both age groups (octogenarians: hazard ratio [HR] 0.51, p < 0.001; younger patients: HR 0.56, p < 0.001). Within the NIS database, PLND was marginally higher associated with overall complications in octogenarians than in younger patients (odd ratio [OR]: 1.32 vs. 1.23, both p < 0.001), with longer LOS (OR: 1.20 vs. 1.08, both p < 0.001), higher THC (relative increase: 6933 vs. 4484, both p < 0.001), but not with higher in-hospital mortality., Conclusions: PLND is associated with lower CSM, but its rate lags in octogenarian vs. younger patients. In both age groups, PLND leads to marginally higher complications, longer LOS and higher THC, but not to higher in-hospital mortality., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Patients with organ confined muscle-invasive bladder cancer (MIBC) who are candidates for radical cystectomy (RC) should receive neoadjuvant chemotherapy (CHT). However, the most contemporary CHT use rates indicate low adherence to these guidelines. We tested contemporary neoadjuvant CHT rates and associated cancer-specific mortality (CSM) and overall mortality (OM) in pT2N0 MIBC patients treated with RC., Materials and Methods: Within the SEER database (2004-2015), we identified patients with pT2N0 MIBC patients who underwent RC. CHT administration rates were evaluated using estimated annual percentage changes (EAPCs) analyses. After inverse probability of treatment weighting (IPTW), Kaplan-Meier (KM) analyses and Cox regression models (CRMs) were used to test the effect of CHT vs no CHT on survival. Landmark analyses tested for immortal time bias., Results: Of 3978 RC patients, 38.2% of patients received CHT. Between 2004 and 2015, CHT rates increased from 15.9% to 66.2% (EAPC: +14.2%; p < 0.001). IPTW-adjusted KM showed 10-year CSM-free survival rates of 78.9% for CHT vs 76.7% for no CHT patients (p = 0.6). Similarly, IPTW-adjusted KM showed 10-year OM-free survival rates of 54.6% for CHT vs 57.9% for no CHT patients (p = 0.8). In IPTW-adjusted MCRMs, CHT was not significantly associated with lower CSM (HR 0.97, CI 0.82-1.14; p = 0.7) or OM (HR 1.02, CI 0.90-1.16; p = 0.7). Virtually the same CSM and OM rates were recorded after landmark analyses., Conclusions: CHT use in pT2N0 MIBC RC patients sharply increased over the study span. However, neoadjuvant CHT was not associated with better survival in this patient group., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The objective of this study was to investigate positive surgical margin (PSM) rates in patients with prostate cancer treated with radical prostatectomy (RP) and assess PSM impact on cancer-specific mortality (CSM)., Patients and Methods: Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015), we identified men who underwent RP with pathologic T2 or T3a stage. Annual trends of PSM rates were plotted. Subgroups focused on geographic regions, namely the North Central, Northeast, South, and West. Cumulative incidence plots depicted other-cause mortality-adjusted CSM rates. Multivariable competing risks regression models tested the relationship between PSM and CSM. Subgroup analyses focused on pathologic stage, Gleason score, and geographic region., Results: Of 153,329 patients treated with RP, 12.3% (n = 18,935) exhibited PSM. Overall, in pathologic T2 stage and pathologic T3a stage, PSM rates decreased during the study period from 18.7% to 9.7% (P < .001), 15.7% to 7.3% (P < .001), and 39.0% to 18.0% (P < .001), respectively. In subgroup analyses focusing on geographic regions, PSM rates universally decreased. However, the magnitude differed. In multivariable competing risks regression models, PSM rates were associated with higher CSM (hazard ratio, 1.45; P < .001). However, geographic regions failed to reach independent predictor status. Insufficient information about PSM focality, length, and associated Gleason score represent important limitations., Conclusion: It is encouraging that PSM rates decreased during the study period, even after stratification according to tumor stage. PSM decreased within the 4 examined geographic regions. However, the rate of decrease varied in magnitude, but geographic regions did not represent an independent predictor of PSM., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The decision-making process for treatment of prostate cancer should not be based on a single parameter such as patient age but should account for cancer characteristics, life expectancy, comorbidities, and patient expectation. Local treatment might be beneficial in selected elderly men with aggressive disease and a long life expectancy., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To assess the current treatment of benign prostatic obstruction (BPO) in patients on ongoing oral anticoagulation (OA)., Methods: An Internet survey was sent to all active members of the Endourological Society. The survey contained 32 questions regarding transurethral treatment of BPO in patients on ongoing OA, different techniques, and arising complications., Results: Out of all members (n = 2000) of the Endourological Society, 133 participated in our survey. Eighty-eight percent of the participants indicated to perform transurethral therapy of BPO on ongoing OA, whereas 60% of this group temporarily pause the OA during the intervention. Sixteen percent perform >30 transurethral interventions of BPO on ongoing OA per year. Most operations are performed under continuation of aspirin (58.2%). The continuation of adenosine diphosphate (ADP)-receptor inhibitors (22.1%), vitamin K antagonists (18.9%), factor Xa inhibitors (15.6%), or the combination of two oral anticoagulants (16.4%) is continued less often. The decision for the operation on ongoing OA is usually approved by the cardiologist (58%) or it cannot be stopped in case of emergency (29%). GreenLight laser (39%) was the most frequently used technique on ongoing OA, followed by monopolar or bipolar transurethral resection of the prostate (35%) as well as other sources of laser [holmium (12%), thulium (12%), diode laser (2%)]. Although OA was continued during the interventions, cardiovascular complications were observed in 31.6%., Conclusions: Current practice shows that the majority of a representative group of the Endourological Society members perform transurethral therapy of BPO in patients on ongoing OA. The incidence of perioperative complications under transurethral therapy of BPO on ongoing OA is lower than previously assumed.

Background: Purpose of this work is to compare the outcome of ureterorenoscopy (URS) with regard to stone-free rates (SFR) and complication rates (CR) in patients with different body mass index (BMI) scores for the treatment of kidney stones., Materials and Methods: A retrospective chart review of all patients with known BMI, who underwent URS for kidney stones between 2006 and 2012 at our institution, was performed (n = 556 patients). The SFR and CR of obese patients were compared to overweight and normal weight patients., Results: Mean age was 52.51 years and the average BMI 27.74 kg/m 2 . Of the patients, 34.2 % had normal weight (22.59 ± 1.91 kg/m 2 ), 39.6 % were overweight (27.30 ± 1.42 kg/m 2 ), and 26.3 % were obese (35.09 ± 5.93 kg/m 2 ). The mean ASA score differed significantly between normal weight (1.99 ± 0.57), overweight (2.03 ± 0.62), and obese (2.22 ± 0.63) patients (p ≤ 0.036). The mean stone size was 8.51 ± 6.84 mm and the mean number of stones per patient 1.9 ± 2.41, whereby the differences between groups was not significant. There were no differences between the groups regarding the use of preoperative (94.8 %) and postoperative ureteral stents (60.3 %), the Ho:YAG laser (33.6 %), the use of flexible (16.2 %) or semirigid/flexible URS (59.4 %), and the mean operative time (52.04 ± 34.55 min). There were no differences in the SFR for the upper (90 %), mid (94.7 %), and lower pole (90.2 %), multiple location (68.6 %) or the total SFR (86.3 %). Total SFR of 95.7, 88.4, and 73.7 % for urinary calculi < 5 mm, 5-9 mm, and ≥ 10 mm, respectively, were found and the differences between the patient groups was not significant. The CR was 10.4 % (differences between the patient groups not significant)., Conclusion: URS is an appropriate treatment for renal stones with high SFR and low CR regardless of patient's BMI.

Objective: To determine the impact of duration of ureteroscopy for urolithiasis on complication rates (CRs) of the procedure., Methods: A retrospective analysis of 2,010 patients, treated between 2006 and 2011, was done. The operation time (OT) and the occurrence of complications were compared., Results: The overall CR was 14.3% [298 complications, minor complications (Clavien I-II) 91.7%]. The median OT was 35 min [interquartile range (IQR) 20-61]. The OT differed significantly between those without complications [34 min (IQR 20-60)] and those with complications [45 min (IQR 25-76)] (p < 0.0001). The correlation between the OT and the occurrence of complications (r = -0.009648, p < 0.0001) was very weak and passed the level of significance (r = 0.2). The effect size was of minor relevance (Cohen's d = 0.27972)., Conclusions: Longer OT correlates significantly with a higher CR. The effect is however shown to be minor and the overall rate of complications, especially severe ones, is low., (© 2015 S. Karger AG, Basel.)

Objective: The Holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the standard lithotrite for ureteroscopy. This paper is to evaluate a Ho:YAG laser with a novel effect function  in vitro , which allows a real-time variation of pulse duration and pulse peak power., Methods: Two types of phantom calculi with four degrees of hardness were made for fragmentation and retropulsion experiments. Fragmentation was analysed at 5 (0.5 J/10 Hz), 10 (1 J/10 Hz), and 20 (2 J/10 Hz) W in non-floating phantom calculi, retropulsion in an ureteral model at 10 (1 J/10 Hz) and 20 (2 J/10 Hz) W using floating phantom calculi. The effect function was set to 25%, 50%, 75%, and 100% of the maximum possible effect function at each power setting. Primary outcomes: fragmentation (mm 3 ), the distance of retropulsion (cm); ≥5 measurements for each trial., Results: An increase of the effect feature (25% vs. 100%), i.e., an increase of pulse peak power and decrease of pulse duration, improved Ho:YAG laser fragmentation. This effect was remarkable in soft stone composition, while there was a trend for improved fragmentation with an increase of the effect feature in hard stone composition. Retropulsion increased with increasing effect function, independently of stone composition. The major limitations of the study are the use of artificial stones and the in vitro setup., Conclusion: Changes in pulse duration and pulse peak power may lead to improved stone fragmentation, most prominently in soft stones, but also lead to increased retropulsion. This new effect function may enhance Ho:YAG laser fragmentation when maximum power output is limited or retropulsion is excluded.

Objective: To evaluate the association between perioperative morbidity and prostate size in patients with benign prostatic obstruction treated with thulium:YAG vapoenucleation of the prostate (ThuVEP)., Methods: 687 patients were prospectively analyzed. Prostate size was <40 ml in 196 (group A), 40-79 ml in 336 (group B) and ≥80 ml in 155 (group C) patients., Results: The mean prostate sizes were 27.94 ± 6.77, 54.38 ± 10.54 and 109.8 ± 28.31 ml for groups A, B and C, respectively (p < 0.001). Hemoglobin loss (g/dl) differed significantly among group A (1.09 ± 1.02), group B (1.28 ± 1.27) and group C (1.62 ± 1.49) (p < 0.001). The correlation between hemoglobin loss and prostate size was very weak in all patients (r = 0.13, p ≤ 0.001). Peak urinary flow rates and post-voiding residual urine improved significantly (p < 0.001) without differences among the groups. The incidence of complications was low and not different among the groups (acute urinary retention 8%, urinary tract infection 4.66%, secondary apical resection 2.91%, transfusion rate 2.03%)., Conclusions: Perioperative morbidity and micturition improvement are not associated with prostate size in ThuVEP., (© 2014 S. Karger AG, Basel.)

The natural course of untreated asymptomatic caliceal calculi has not been clearly defined, especially in terms of disease progression, and the indications for and outcomes of surgical intervention are not precise. Caliceal stones may remain asymptomatic but, in case of migration, ureteral calculi can cause acute ureteric colic with severe complications. The decision for an active treatment of caliceal calculi is based on stone composition, stone size and symptoms. Extracorporal shock-wave lithotripsy (ESWL) has a low complication rate and is recommended by the current guidelines of the European Association of Urology as a first-line therapy for the treatment of caliceal stones <2 cm in diameter. However, immediate stone removal is not achieved with ESWL. The primary stone-free rates (SFR) after ESWL depend on stone site and composition and, especially for lower pole calculi, the SFR differ widely from other caliceal stones. Minimally-invasive procedures including percutaneous nephrolithotomy and ureteroscopy are alternatives for the treatment of caliceal stones, associated with low morbidity and high primary SFR when performed in centers of excellence.

Objective: To evaluate changes in erectile function after thulium VapoEnucleation of the prostate (ThuVEP) for the treatment of benign prostatic obstruction at 12-month follow-up., Materials and Methods: We prospectively evaluated 72 patients who underwent ThuVEP between January and July 2011. Preoperative evaluation included maximum urinary flow rate (Qmax), international prostate symptom score (IPSS), quality of life (QoL), postvoiding residual urine (PVR), and the Erectile function domain of the International Index of Erectile Function (IIEF-EF). According to preoperative IIEF-EF score, patients were classified into subgroup A (IIEF-EF ≥19, n = 38) and subgroup B (IIEF-EF <19, n = 34). All complications during the perioperative period were noted and classified according to the modified Clavien classification system. All patients were reassessed at 12-month follow-up by Qmax, IPSS, QoL, PVR, and IIEF-EF score. Patient data were expressed as median (interquartile range)., Results: Median patient age was 70 (65-73) years, and the median prostate volume was 52.5 (39.75-72) mL, respectively. At 12-month follow-up, IPSS (20 vs 4), QoL (4 vs 1), Qmax (9.7 vs 22.15 mL/s), and PVR (100 vs 15 mL) improved significantly in comparison with preoperative assessment (P ≤.001) without differences between subgroup A and B. A slight but not statistically significant increase of the IIEF-EF domain score was reported at 12-month follow-up (19.5 vs 20), which could be shown in subgroup A (25 vs 26) and B (6 vs 8)., Conclusion: ThuVEP is a safe and effective procedure for the treatment of benign prostatic obstruction. At 12-month follow-up, marginal nonsignificant erectile function improvement was reported after surgery., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Thulium vapoenucleation of the prostate (ThuVEP) has been introduced as a minimally invasive treatment for benign prostatic obstruction (BPO)., Objective: To analyze immediate outcomes and the institutional learning curve of ThuVEP, and to report its standardized complication rates, using the modified Clavien classification system (CCS) to grade perioperative complication rates., Design, Settings, and Participants: A prospective evaluation of 1080 patients undergoing ThuVEP from January 2007 until May 2012 at our institution., Intervention: ThuVEP was performed using the 2-μm, continuous-wave, thulium:yttrium-aluminum-garnet laser., Outcome Measurements and Statistical Analysis: Preoperative status, surgical details, and immediate outcome were recorded for each patient. Perioperative complications were classified according to the modified CCS., Results and Limitations: Median prostate size was 51 ml (interquartile range [IQR]: 36-78.7). Median operation time was 56 min (IQR: 40-80), and median enucleation time was 32.5 min (IQR: 22-50). Median catheterization time was 2 d (IQR: 2-2); median length of hospital stay was 4 d (IQR: 3-5). Median resected tissue weight was 30 g (IQR: 16.00-51.25). Incidental carcinoma of the prostate was detected in 59 (5.5%) patients. Median maximum urinary flow rate (8.9 vs 18.4 ml/s) and postvoid residual urine volume (120 vs 20 ml) changed significantly (p<0.001). Minor complications occurred in 24.6% of the patients (Clavien 1: 20.8%; Clavien 2: 3.8%). Early reinterventions were necessary in 6.6% of the patients (Clavien 3a: 0.6%; Clavien 3b: 6%). One Clavien 4 complication occurred (0.09%). The overall complication rates decreased significantly over time due to decreasing Clavien 1, 2, and 3b events. The major limitations of the study are the prospective, unicentric study design, the lack of a control group, and that only short-term data were documented on morbidity and efficacy of the ThuVEP procedure., Conclusions: ThuVEP is a safe and effective procedure for the treatment of symptomatic BPO, with low perioperative morbidity., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To determine the effect of preoperative ureteral stenting on success rates of ureteroscopy (URS) for nephroureterolithiasis., Materials and Methods: We retrospectively evaluated patients who underwent URS for nephroureterolithiasis without preoperative indwelling ureteral stents. These patients were matched according to age, sex, body mass index, and stone side, size, site, and number of stones per patient, with patients who had been prestented before URS. Patient data, stone-free rates (SFRs), and complications were compared., Results: The study included 286 patients (143 stented vs 143 nonstented). The mean stone size was 5.69 ± 3 mm. The mean number of stones per patient was 1.35 ± 0.7. The overall SFR after 1 URS procedure was 90.9% and higher in prestented than in nonstented patients (95.1% vs 86.7%, P ≤ .013). For ureteral stones, the SFR was 99% in prestented and 90% in nonstented patients (P ≤ .0048). The SFR did not differ between the groups for ureteral stones <5 mm, but was higher in prestented than in nonstented patients for ureteral calculi ≥ 5 mm (98.2% vs 83.3%, P ≤ .0105). For urinary calculi ≥ 5 mm, the overall SFR was higher in prestented than in nonstented patients (93.3 vs 78.3%, P ≤ .0054). Perioperative complications occurred in 27 patients (9.4%; Clavien I, 6.6%; Clavien IIIb, 2.8%) without differences between the groups., Conclusion: URS is a safe and efficacious procedure for the treatment of nephroureterolithiasis. Preoperative ureteral stent placement is associated with higher SFRs compared with nonstented patients for urinary calculi ≥ 5 mm. Nonstented patients with urinary calculi ≥ 5 mm should be informed about the risk for a second-look URS procedure., (Copyright © 2012 Elsevier Inc. All rights reserved.)