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Purpose: Contrast-enhanced CT scan is the standard staging modality for patients with bladder cancer undergoing radical cystectomy (RC). Involvement of lymph nodes (LN) determines prognosis of patients with bladder cancer. The detection of LN metastasis by CT scan is still insufficient. Therefore, we investigated various CT scan characteristics to predict lymph node ratio (LNR) and its impact on survival. Also, pre-operative CT scan characteristics might hold potential to risk stratify cN+ patients. Materials and Methods: We analyzed preoperative CT scans of patients undergoing RC in a tertiary high volume center. Retrospectively, local tumor stage and LN characteristics such as size, morphology (MLN) and number of loco-regional LN (NLN) were investigated and correlation to LNR and survival was analyzed. CT scan characteristics were used to develop a risk stratification using Kaplan-Maier and multivariate analysis. Results: 764 cN0 and 166 cN+ patients with complete follow-up and imaging data were included in the study. Accuracy to detect LN metastasis and locally advanced tumor stage in CT scan was 72% and 62%. LN larger than 15mm in diameter were significantly associated with higher LNR (p=0.002). Increased NLN correlated with decreased CSS and OS (p=0.001: p=0.002). Furthermore, CT scan based scoring system precisely differentiates low-risk and high-risk profiles to predict oncological outcome (p 15mm significantly correlated with higher LNR. Identification of increased loco-regional LN was associated with worse survival. For the first time, precise risk stratification based on computed-tomography findings was developed to predict oncological outcome for clinical lymph node-positive patients undergoing RC.

Lukas Rath, Friedrich Jokisch, Gerald Bastian Schulz, Alexander Kretschmer, Alexander Buchner, Christian G Stief, Philipp Weinhold Department of Urology, Ludwig-Maximilians-University, Munich, GermanyCorrespondence: Philipp WeinholdDepartment of Urology, Ludwig-Maximilians-University, Marchioninistrasse 15, Munich, 81377, GermanyTel +4989-4400-73528Fax +49894400-78735Email philipp.weinhold@med.uni-muenchen.dePurpose: There are only a few case reports and case series that investigated combined laparoscopic or robotic surgery for simultaneous prostate and kidney cancer. In this study, we want to close a gap in existing research to assess the feasibility and oncological outcome of combined open prostatectomy and kidney surgery.Methods: We retrospectively analyzed patients who underwent a combined open prostatectomy and either a partial or complete nephrectomy from 2013 to 2020. Descriptive statistics were used to assess perioperative parameters and the 12-month functional and oncological outcomes after combined surgery.Results: We identified 10 patients undergoing combined open surgery. Partial nephrectomy was performed in 4, radical nephrectomy in 6 patients. For prostate cancer, histopathological analysis showed a tumor stage ≥ pT2c in all 10 patients. For renal tumors, histopathological analysis showed clear cell renal cell carcinoma in 8 patients and oncocytoma in 2 patients. Operating time was 177 ± 36 minutes. Two perioperative complications (Clavien 2a and 3) were observed. Three months postoperatively, the International Index of Erectile Function (IIEF-5) score was 5.6 ± 5.9, the ICIQ-SF score was 7.3 ± 5.6 and were using 1.9 ± 2.2 pads per day. This improved after 12 months postoperatively, as patients had an IIEF-5 score of 6.33 ± 6.5, an ICIQ-SF score of 4.4 ± 5.7 and were using pads 0.9 ± 1.7 per day.Conclusion: In this study, we showed that open surgery is a safe and valid approach for combined prostatectomy and renal surgery with acceptable complications and oncological outcomes. The combined open approach could be a good alternative to combined laparoscopic/robotic surgery in this field, especially to treat patients with advanced renal tumors or previous abdominal surgery or radiation.Keywords: retropubic prostatectomy, kidney surgery, simultaneous prostate and kidney cancer, combined surgery

In the future, precision medicine with agents targeting specific genetic alterations will play an important role in bladder cancer. This includes both single genetic alterations (e.g. FGFR3) and gene panel analyses in patients with no further therapeutic options, rare cancer subtypes or unusual clinical courses. These molecular analyses can be carried out on formalin-fixed paraffin-embedded tumor samples and the results should be discussed in interdisciplinary molecular tumor boards in order to either recommend approved targeted therapies or suggest patients for molecular-based clinical trials, compassionate use programs or off-label use of drugs. The remuneration of molecular diagnostics is largely well-represented for the outpatient sector in Germany; however, the covering of treatment costs must currently be approved by the health insurances.

Aims Radical cystectomy and urinary diversion impact various dimensions of patients' health-related-quality-of-life (HRQOL). Yet, less is known about salvage cystectomy as a last-line option for treatment-refractory benign diseases. Therefore, our aim is to provide HRQOL data from a contemporary cohort of open salvage cystectomies for benign conditions. Methods Fifty-four consecutive patients were enrolled in one single tertiary referral center. Analysis was limited to patients undergoing urinary diversion via ileal conduit (IC). Complications were assessed via Clavien-Dindo-scale. HRQOL was measured using the validated European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-BLM30 questionnaire. HRQOL QLQ-C30 domains were measured preoperatively and up to 3 years postoperatively. Longitudinal changes were analyzed using Friedman's rank test. Primary endpoint was good general HRQOL based on QLQ-C30 global health status (GHS). Multivariate analysis was performed using logistic regression models with a step-wise backward selection procedure. Results Longitudinal analysis of HRQOL subdomains revealed significantly improved pain (p = .005) and fatigue (p = .002) scores as well as improved social functioning (p = .038). Furthermore, general HRQOL (GHS scores) improved significantly during the follow-up period (28.0 vs. 50.6 [36 months], p = .045). In multivariate analysis, the indication for salvage cystectomy could not be identified as an independent predictor for good general HRQOL. We observed a total number of 10 (41.7%) high-grade (Clavien ≥III) 90 day-complications. Limitations include limited follow-up rates at respective time-points. Conclusion Salvage cystectomy and IC can be safely performed as a last-line treatment for benign conditions and increases general HRQOL in the long-term follow-up. Thus, it can play a role in a holistic approach for a challenging clinical setting.

Aim of the study Next-generation sequencing (NGS) might represent a valuable diagnostic tool to identify somatic alterations and enable personalised medicine in uro-oncology. We aim to determine feasibility and impact of routine NGS in clinical practice. Methods Tumours from patients with genitourinary cancers were subjected to NGS. Results were discussed in a dedicated molecular tumour board. Statistical analyses included chi-square test and Mann-Whitney U test. Results Between 2017 and 2020, 65 patients with advanced genitourinary cancers were consecutively enrolled. Number of tests increased (28 tests in 2020) and diagnostic turnaround time for generating output decreased (17.5 days [range 13–35]). Median patient's age was 62 years (range 33–84), and most NGS assays were performed upon start of systemic treatment (range 0–6 of treatment lines). 62/66 sequenced samples generated a report. Fifty samples (80.6%) showed at least one molecular alteration. Most prevalent alterations were TP53 (32.3%), PIK3CA (14.5%) and TMPRSS2-ERG (9.7%). Sequencing revealed potentially druggable targets in 29 samples (46.8%). Based on NGS results, six patients underwent therapy change, whereas for three patients, coverage of recommended off-label therapy was denied by health insurances. Conclusions NGS is increasingly feasible in clinical routine for patients with genitourinary cancers. Number of performed analyses is constantly growing, and turnaround time to therapy recommendation is decreasing. While the majority of tumours harbour clinically relevant mutations, alterations related to urologic cancers are underrepresented, thus treatment changes occurred only in a minority of patients. Further, access to target agents remains a considerable obstacle in the consequent implementation of precision uro-oncology.

Die radikale Zystektomie (RC) hat unter den urologischen Eingriffen mit die hochste Komplikationsrate. In Anlehnung an die breite, seit mehreren Jahren bestehende Evidenz in der kolorektalen Chirurgie wurden Fast-track‑/ERAS®-Protokolle („Enhanced Recovery After Surgery“) entwickelt, um die perioperative Versorgung zu verbessern. Die aktuelle Studienlage und Evidenz der einzelnen ERAS®-Bestandteile bei der RC werden beurteilt. Es wird eine systematische Literaturrecherche unter Einbindung der aktuell gultigen Leitlinien durchgefuhrt. Die meisten Empfehlungen fur die RC basieren auf der Extrapolation von Studien fur die Abdominalchirurgie. Insgesamt liegen 4 randomisiert-kontrollierte Studien sowie eine Leitlinie speziell fur die RC vor. Unter ERAS® kann die Gesamtliegedauer verkurzt werden, ohne die Komplikationsrate zu erhohen. Zentrale Bestandteile sind der Verzicht auf eine praoperative Darmvorbereitung, fruhzeitige Entfernung der Magensonde, eine optimierte Flussigkeitssubstitution, multimodales Schmerzmanagement, sowie eine fruhzeitige Mobilisation und Kostaufbau. Die Implementierung eines ERAS®-Programms bedarf einer engen multidisziplinaren Zusammenarbeit. Individualisierung, Identifikation wichtiger Einzelbestandteile und die spezifische Anpassung an die RC sind zukunftige Ziele.

With around 30,000 new cases annually bladder cancer (BC) is one of the most frequent cancers in Germany and the incidence is associated with advanced age and nicotine use. Urothelial carcinoma is the most frequent histological variant of BC in Central Europe. Nonmuscle-invasive BC can be resected endourologically and treated with intravesical instillation therapy. In the case of progression to nonmetastatic muscle-invasive disease radical cystectomy with accompanying neoadjuvant or adjuvant chemotherapy can be curative. Systemic treatment is the standard of care in metastatic disease. Although immunotherapy has made great progress in recent years, palliative chemotherapy remains the gold standard in first-line treatment. The armamentarium is continuously evolving: systemic immunotherapy is currently being investigated in nonmuscle-invasive BC as well as in perioperative and maintenance treatment after first-line chemotherapy and several studies are testing new targeted agents in palliative systemic therapy. This article gives an overview of current innovations and the expected paradigm shift in systemic treatment of BC.

Objective: The aim of this study was to assess the security, value, and efficacy of the second-generation AdVance male sling XP (Boston Scientific®), after implementation in 2010 with advantageous modifications in the sling structure and needle shape, in a prospective multicenter long-term follow-up study. Methods: In total, 115 patients were included. Exclusion criteria were earlier incontinence (UI) surgery, nocturnal UI, former radiotherapy, or night-time incontinence. We also excluded patients with a functional urethra Results: The 24-month follow-up (114 patients) revealed 64.0% cured and 28.8% improved patients. Mean urine loss was reduced significantly to 19.0 g (p < 0.001). A mean PGI score of 1.5 and a mean VAS score of 0.2 were obtained. The 60-month follow-up (59 patients) revealed 57.6% cured and 25.4% improved patients. Mean urine loss was reduced significantly to 18.3 g (p < 0.001). A mean PGI score of 1.6 and a mean VAS score of 0.2 were obtained. Conclusions: The AdVance XP displays excellent continence results and secure effectiveness over a 5-year period. Moreover, these data are demonstrating low complication rates and improved quality of life in the long-term use of AdVance XP.

Objective: To conduct a systematic review of whether blood transfusions may be associated with worse outcomes for patients with bladder cancer treated with radical cystectomy (RC), as there has been a recent increase in studies addressing this clinically relevant topic. Methods: PubMed, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), Google Scholar, and the ClinicalTrials.gov databases were searched with pre-specified search terms for studies published between January 2010 and May 2020. The systemic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 17 studies with 19 627 patients were included after 183 records were screened for eligibility. In all, 10 studies proposed perioperative blood transfusion to be associated with impaired prognosis regarding overall survival, nine studies regarding cancer-specific and four studies regarding recurrence-free survival. The timing of blood transfusion might affect patient outcomes. Notably, several studies did not find a significant correlation between blood transfusions and prognosis. As all studies to date are of retrospective design, the grade of evidence is still limited. Conclusions: Despite the lack of prospective trials, perioperative blood transfusion may lead to worse oncological outcomes. These results, as well as known non-oncological side-effects and associated costs, are important arguments to carefully consider the indication for blood transfusion. Abbreviations BCa: bladder cancer; CSS: cancer-specific survival; HR: hazard ratio; (N)MIBC: (non-) muscle-invasive BCa; OS: overall survival; PBT, perioperative blood transfusion; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; RFS: recurrence-free survival.

Purpose Non-invasive high-grade (HG) bladder cancer is a heterogeneous disease that is characterized insufficiently. First-line Bacillus Calmette-Guérin instillation fails in a substantial amount of cases and alternative bladder-preserving treatments are limited, underlining the need to promote a further molecular understanding of non-invasive HG lesions. Here, we characterized pure HG papillary urothelial bladder cancer (pure pTa HG), a potential subgroup of non-invasive HG bladder carcinomas, with regard to molecular subtype affiliation and potential for targeted therapy. Methods An immunohistochemistry panel comprising luminal (KRT20, ERBB2, ESR2, GATA3) and basal (KRT5/6, KRT14) markers as well as p53 and FGFR3 was used to analyze molecular subtype affiliations of 78 pure pTa HG/papillary pT1(a) HG samples. In 66 of these, ERBB2 fluorescence in situ hybridization was performed. Additionally, targeted sequencing (31 genes) of 19 pTa HG cases was conducted, focusing on known therapeutic targets or those described to predict response to targeted therapies noted in registered clinical trials or that are already approved. Results We found that pure pTa HG/papillary pT1(a) HG lesions were characterized by a luminal-like phenotype associated with frequent (58% of samples) moderate to high ERBB2 protein expression, rare FGFR3 alterations on genomic and protein levels, and a high frequency (89% of samples) of chromatin-modifying gene alterations. Of note, 95% of pTa HG/papillary pT1 HG cases harbored at least one potential druggable genomic alteration. Conclusions Our data should help guiding the selection of targeted therapies for investigation in future clinical trials and, additionally, may provide a basis for prospective mechanistic studies of pTa HG pathogenesis.

Purpose: To assess the impact of perioperative chemotherapy on survival in cN+ BCa patients and analyze it according to the pN status. Methods: A retrospective analysis was conducted on639 BCa patients with cTanyN1-3M0 BCa treated with radical cystectomy (RC) and bilateral lymph node dissection (LND) with or without perioperative chemotherapy in ten tertiary referral centers from 1990 to 2017. Selected cN+ patients received induction chemotherapy (IC), whereas adjuvant chemotherapy (ACT) was delivered to selected pN+ patients. Univariable and multivariable Cox regression analyses were used to predict overall mortality (OM) after surgery, adjusting for clinicopathological confounders. Kaplan–Meier analyses assessed OM according to the treatment modality. Results: Overall, 356 (56%) patients were treated with surgery alone, 155 (24%) with IC followed by surgery, and 128 (20%) with ACT following surgery. Over a median follow-up of 25months, 316 deaths were recorded. At univariable analysis, patients treated with IC and surgery had lower OM both considering cN+ [hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.49–0.87, p = 0.004] and cN+pN− patients (HR 0.61, 95% CI 0.37–0.99, p = 0.05) compared to those treated with surgery alone. cN+pN+ patients treated with ACT experienced lower OM compared to those treated with IC or surgery alone at multivariable analysis (HR 0.40, 95% CI 0.22–0.74, p = 0.003). Conclusion: Patients with cTany cN+ cM0 BCa benefit more in terms of OS when treated with IC followed by RC + LND compared to RC + LND alone, regardless of LNMs at final histopathology examination. More data are needed to assess the role of ACT in the management of cN+ patients.

Purpose: With a median age at diagnosis of 73 years, bladder cancer has the highest median age of all cancers. Age alone seems to be an independent risk factor for developing the disease with peak age advancing into the range of 85 years. As demographic changes will lead to an ever more aging population in western countries, incidence of advanced age malignancies will rise. We, therefore, analyzed a contemporary radical cystectomy (RC) series at a single high-volume center on patients undergoing RC for urothelial carcinoma of the bladder (UCB). We aim to evaluate the feasibility of RC in the oldest-old patient cohort by assessing perioperative complications and long-term outcome. Materials and Methods: We retrospectively analyzed data of 1,278 consecutive patients who underwent RC for UCB at our tertiary referral center between 2004 and 2019. A total of 408 patients were aged 75–97 years at the time of RC and were further divided into 2 groups: 75–84 years of age (group 1) and ≥85 years of age (group 2). Median follow-up was 23 months. Outcome was analyzed using the χ2 test, Mann-Whitney U test, Kaplan-Meier method, and log-rank test. Results: Perioperative Clavien-Dindo grade ≥III complications were seen in 25.1% (92/366) of group 1 patients and 35.7% (15/42) of group 2 patients (p = 0.073). Thirty- and 90-day mortality was 3.3 and 8.7% in group 1 and 4.8 and 14.3% in group 2 (p = 0.617 and p = 0.242, respectively). Three-year overall survival was 54.6% in group 1 and 31.3% in group 2 (p = 0.03). Three-year cancer-specific survival was 64.8% in group 1 and 38.8% in group 2 (p = 0.037). Recurrence-free survival was 105 months in group 1 and 12 months in group 2 (p = 0.039). Conclusion:In light of increasing life expectancy in western nations, we sought to evaluate the impact of age in a large series of elderly patients undergoing RC for UCB. We found that RC offers acceptable perioperative complication rates in the oldest-old patient cohort (≥85 years). Therefore, RC for UCB can be offered as a viable treatment option even in the oldest patients.

INTRODUCTION AND OBJECTIVE:The decompression of the upper urinary tract (UUT) in patients with ureteral obstruction may be performed through ureteral stenting (US) or percutaneous nephrostomy (PN)....

INTRODUCTION AND OBJECTIVE:At present no clear indication exists regarding the optimal treatment for non-muscle invasive micropapillary bladder cancer (NMI-MPBC). We compared cancer-specific surviv...

PURPOSE Profound endourological skills are required for optimal postoperative outcome parameters after transurethral resection of the prostate (TURP). We investigated the Karl Storz (Tuttlingen, Germany) UroTrainer for virtual simulation training of the TURP. MATERIALS AND METHODS Twenty urologists underwent a virtual reality (VR) TURP training. After a needs analysis, performance scores and self-rated surgical skills were compared before and after the curriculum, the realism of the simulator was assessed, and the optimal level of experience for VR training was evaluated. Statistical testing was done with SPSS 25. RESULTS Forty percent of participants indicated frequent intraoperative overload during real-life TURP and 80% indicated that VR training might be beneficial for endourological skills development, underlining the need to advance classical endourological training. For the complete cohort, overall VR performance scores (P = 0.022) and completeness of resection (P < 0.001) significantly improved. Self-rated parameters including identification of anatomical structures (P = 0.046), sparing the sphincter (P = 0.002), and handling of the resectoscope (P = 0.033) became significantly better during the VR curriculum. Participants indicated progress regarding handling of the resectoscope (70%), bleeding control (55%), and finding the correct resection depth (50%). Although overall realism and handling of the resectoscope was good, virtual bleeding control and correct tissue feedback should be improved in future VR simulators. Seventy percent of participants indicated 10 to 50 virtual TURP cases to be optimal and 80% junior residents to be the key target group for VR TURP training. CONCLUSIONS There is a need to improve training the TURP and VR simulators might be a valuable supplement, especially for urologists beginning with the endourological desobstruction of the prostate.

Die Nachsorge des muskelinvasiven Harnblasenkarzinoms gliedert sich in die onkologische und die funktionelle Nachsorge. Uber 80 % aller Lokalrezidive und Fernmetastasen treten innerhalb der ersten 2 Jahre auf. Rezidive des verbleibenden Urothels treten auch mehrere Jahre nach radikaler Zystektomie auf. Die Urinzytologie und die Computertomographie (CT) des Thorax/Abdomens mit Urographiephase sind die Diagnostik der Wahl bei der Tumornachsorge. Der onkologische Nutzen der Diagnose eines asymptomatischen gegenuber einem symptomatischen Rezidiv ist bisher nicht zweifelsfrei nachgewiesen. Nach partieller Zystektomie oder trimodaler Therapie existieren keine etablierten Nachsorgeschemata. Es sollte jedoch die relativ hohe Inzidenz intravesikaler Rezidive beachtet werden, da hierfur kurative Therapiekonzepte wie die Salvage-Zystektomie zur Verfugung stehen. Die funktionelle Nachsorge beinhaltet die Pravention und die Diagnostik von metabolischen Komplikationen, urethralen/ureteralen Strikturen, Stomaveranderungen, Harninkontinenz, sexueller Dysfunktion und Harnwegsinfekten und sollte lebenslang durchgefuhrt werden.

Background: Preoperative thrombocytosis (PTC) is frequently observed in various solid malignancies and often associated with an unfavourable oncological outcome. Objectives: The aim of this study was to investigate the influence of PTC in patients undergoing radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder on the oncological prognosis and additionally on perioperative blood transfusions (PBT). Method: A retrospective analysis of 866 patients undergoing RC in a tertiary care centre was performed. PTC was defined as a platelet count >400 G/L. A chi-square test and Mann-Whitney test were used to investigate the association of PTC with categorical clinicopathological variables. A logrank test and multivariable Cox regression analyses were used to assess the association of PTC with cancer-specific survival. Results: PTC was detected in 8% (n = 67) of the patients and was significantly associated with muscle invasion (p = 0.004), advanced tumour stages (p = 0.003) and nodal metastases (p < 0.001) and with a higher rate of PBT (p< 0.001). In the multivariate analysis, PTC was significantly related to poor oncological survival (hazard ratio 2.23, 95% CI 1.51–3.30, p < 0.001). Conclusion: PTC is significantly associated with an impaired oncological outcome in patients undergoing RC for UC. PTC therefore represents an independent and easy to determine prognostic parameter for patients’ oncological outcome. Intriguingly, PTC is significantly associated with an increased rate of PBT.

Die Tumornachsorge des NMIBC („non-muscle invasive bladder cancer“) ist eine Abwagung zwischen der Belastung durch die Diagnostik sowie dem Risiko fur Rezidiv und insbesondere Progress. Die Einteilung in Hoch‑, Intermediar- und Niedrigrisikotumoren ermoglicht eine risikoadaptierte Tumornachsorge. Durch die Verwendung von Risikokalkulatoren lasst sich das individuelle Rezidiv- und Progressionsrisiko abschatzen. Die Nachsorge basiert v. a. auf der Zystoskopie, welche bei Hoch- und Intermediarrisikotumoren lebenslang, bei Low-risk-Tumoren bis zum 5. tumorfreien Jahr durchgefuhrt werden soll. Die Zytologie besitzt hohe Sensitivitat und Spezifitat fur High-grade-Tumoren und wird in der Nachsorge dieser empfohlen. Aufgrund der unzureichenden Evidenz kann bisher kein kommerziell erhaltlicher Urinmarker in der Nachsorge empfohlen werden. Fur die Abklarung synchroner und metachroner Tumoren des oberen Harntrakts wird die CT(Computertomographie)-, alternativ die MR(Magnetresonanz)-Urographie empfohlen.

To objectively quantify continence rates and to correlate continence outcomes with health-related quality of life (HRQOL) after radical cystectomy and orthotopic ileal neobladder (ONB). Questionnaires were sent to 244 patients who underwent radical cystectomy with ONB between 2004 and 2015, and information about the current continence status was retrieved. To objectify postoperative urine loss, daytime and nocturnal pad tests were performed. Continence was defined as need of up to one safety pad. HRQOL was assessed using EORTC QLQ-C30 scoring with global health status being the primary endpoint. Statistical analysis included Fisher’s test, Mann–Whitney U test, Pearson’s rank correlation, and binary regression models (p

Staging und Nachsorge von Harnblasentumoren, Hamaturie und die Diagnostik von Raumforderungen des oberen Harntraktes (OHT) sind haufige Indikationen fur eine Abklarung von Nieren, Nierenbeckenkelchsystem und Ureteren. Die direkte visuelle Beurteilung des OHT ist im Vergleich zur Diagnostik der Harnblase deutlich invasiver. Hieraus ergibt sich die Frage nach der optimalen Bildgebung und deren Effektivitat. Sowohl in der CT-Bildgebung (Computertomographie), aber auch in der Magnetresonanztomographie (MRT) kam es in den letzten Jahren zu deutlichen technischen Verbesserungen. Die verschiedenen Bildgebungsmodalitaten und deren Limitationen bei der Detektion von Tumoren des OHT werden verglichen. Es wird eine systematische Literaturrecherche und ein Vergleich der deutschen, europaischen und amerikanischen Leitlinien zum Blasenkarzinom, Urothelkarzinom des OHT und der Hamaturie durchgefuhrt. Die CT-Urographie hat das Ausscheidungsurogramm (AUG) abgelost und ist der derzeitige Goldstandard in der Bildgebung des OHT. Bei Kontraindikationen zur CT ist die MRT eine alternative bildgebende Methode. In jedem Fall sollte das Untersuchungsprotokoll eine Urographiephase beinhalten. Die radiologische Bildgebung sollte sinnvoll in eine Sequenz bestehend aus endourologischen und zytologischen Verfahren intergiert werden. Neue bildgebende Verfahren wie die optische Koharenztomographie, konfokale Laserendomikroskopie oder wissenschaftliche Neuerungen aus dem Themengebiet „Radiomics“ konnten die Abklarung und Differentialdiagnose von Lasionen des OHT in Zukunft verbessern.

The purpose of this study was to investigate major complications and risk factors for adverse clinical outcome in surgical high-risk (American Society of Anesthesiologists [ASA] 3-4) patients undergoing radical cystectomy (RC) in a high-volume setting.A total of 1206 patients underwent RC between 2004 and 2017 in our institution and were included. We assessed complications graded by the Clavien-Dindo-Classification system (CDC) in addition to the 90-day mortality rate and stratified results by the ASA classification. In a multivariate analysis, risk factors for high-grade complications (CDC ≥ 3) were tested. Additionally, outcome parameters were compared between 2004 to 2010 and 2010 to 2017.Patients with ASA ≥ 3 presented with more locally advanced tumors pT ≥ 3 (52.1% vs. 42.4%; P = .002) and positive lymphatic spread N1 (27.2% vs. 23.5%; P = .001) compared with patients with ASA ≤ 2. High-grade complications were significantly (P .001) more prevalent in patients with ASA ≥ 3 compared with patients with ASA ≤ 2: CDC3 (14.6% vs. 9.4%), CDC4 (10.2% vs. 5.4%), and CDC5 (2.5% vs. 1.0%). The 90-day mortality rate (7.6% vs. 3.2%; P = .002) and perioperative reinterventions (23.5% vs. 13.1%; P .001) were elevated in patients with ASA ≥ 3. ASA (odds ratio [OR], 2.701, 95% confidence interval [CI], 1.089-6.703; P = .032), previous abdominal operations (OR, 1.683; 95% CI, 1.188-2.384; P = .003), and body mass index ≥ 30 (OR, 1.533; 95% CI, 1.021-2.304; P = .039) proved to function as independent predictors for major complications. CDC ≥ 3 complications (31.7% vs. 24.3%; P = .029) and 90-day mortality (10.4% vs. 5.6%; P = .018) were significantly lower in the second half of the study period.Mortality and morbidity in surgical high-risk patients with ASA 3 to 4 undergoing RC is about twice as high compared with patients with ASA 1 to 2. ASA, previous abdominal operations, and elevated body mass index independently predict adverse clinical outcome in patients with ASA 3 to 4. Our results may help to weigh the surgical risk of RC in multimorbid patients.

Background Literature lacks clear evidence regarding the optimal treatment for non–muscle-invasive micropapillary bladder cancer (MPBC) due to its rarity and the presence of only small sample size and single-centre studies. Objective To assess cancer-specific mortality (CSM) and overall mortality (OM) between immediate radical cystectomy (RC) and conservative management among T1 high-grade (HG) MPBC. Design, setting, and participants We retrospectively analysed a multicentre dataset including 119 T1 HG MPBC patients treated between 2005 and 2019 at 15 tertiary referral centres. The median follow-up time was 35 mo (interquartile range: 19–64). Intervention Patients underwent immediate RC versus conservative management with bacillus Calmette-Guerin. Outcomes measurements and statistical analysis Cumulative incidence functions and Kaplan-Meier methods were applied to estimate survival outcomes. Multivariable Cox analyses were performed to assess independent predictors of disease recurrence and disease progression after conservative management; covariates consisted of pure MPBC, concomitant lymphovascular invasion (LVI), and carcinoma in situ at initial diagnosis. Results and limitations Immediate RC and conservative management were performed in 27% and 73% of patients, respectively. CSM and OM did not differ significantly among patient treated with immediate RC versus conservative management (Pepe-Mori test p = 0.5 and log-rank test p = 0.9, respectively). Overall, 66.7% and 34.5% of patients experienced disease recurrence and disease progression after conservative management, respectively. At multivariable Cox analyses, concomitant LVI was an independent predictor of disease recurrence (p = 0.01) and progression (p = 0.03), while pure MPBC was independently associated with disease progression (p = 0.03). The absence of a centralised re-review and the retrospective design represent the main limitations of our study. Conclusions Conservative management could achieve satisfactory results among T1 HG MPBC patients with neither pure MPBC nor LVI at initial diagnosis. Patient summary Bacillus Calmette-Guerin seems to be an effective therapy for T1 micropapillary bladder cancer patients with neither pure micropapillary disease nor lymphovascular invasion at initial diagnosis.

For cisplatin-ineligible patients, approval of first-line immune-checkpoint inhibitor therapy relies on the programmed death ligand 1 (PD-L1) expression assay employed, namely, the combined positive score (CPS) or immune cell (IC) score. This study compares PD-L1 diagnostic scores and positivity in primary and matched metastatic bladder cancer tissue.A total of 108 patients undergoing radical cystectomy for urothelial bladder cancer and lymphatic spread (pN+) were included. PD-L1 expression was compared by immunohistochemistry (IHC) between the primary bladder tumor and associated lymph node metastases using Ventana SP263 anti-PD-L1 antibody. In a subset of cases further IHC was performed with Ventana SP142 and Dako 22C3 antibodies. Second, the PD-L1 scoring algorithms for the CPS and IC score were compared. Correlation of PD-L1 positivity with clinical parameters and tumor stage was assessed. Intra- and intertissue analyses were performed with Pearson's chi square test, McNemar test and Spearman correlation employing IBM SPSS 25.PD-L1 expression did not correlate with clinicopathological parameters. The CPS (43.5% vs. 35.6%; P=0.006) and the IC score (28.7% vs. 21.2%; P=0.002) yielded PD-L1 positivity significantly more often in primary BC than in matched lymph node metastasis. Both the CPS (r=0.775; P0.001) and the IC score (r=0.711; P0.001) correlated between primary and metastatic bladder cancer tissue. Employing CPS vs. IC led to significantly more PD-L1-positive classified cases in primary BC (CPS vs. IC; 43.5% vs. 28.7%; P0.001) and lymph node metastasis (CPS vs. IC; 35.6% vs. 21.2%, P0.001).Compared to lymph node analysis, bladder tissue yields more PD-L1 positivity assessed with the CPS and IC scores. This is particularly evident when employing the CPS. The findings highlight that employing both PD-L1 assays may maximize eligibility for first-line checkpoint-inhibitors to treat bladder cancer patients unfit for cisplatin-based chemotherapy.

Immunosenescence might impact immunotherapy (IT) in patients with advanced age. However, pivotal studies were not powered for this clinical question. Our aim is to explore toxicity (primary objective) and activity (secondary objective) of immune checkpoint inhibitors (ICIs) in patients with renal cell (RCC) and urothelial carcinoma (UC) older than 75 years compared to the younger population.Patients treated at our tertiary care Uro-oncology Department with atezolizumab, pembrolizumab, nivolumab or ipilimumab were retrospectively analyzed. Immune-related adverse events (irAEs) were determined and graded using the Common Terminology Criteria for Adverse Events (CTCAE v.4.0). Disease Control rate (DCR) was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST v1.1). IrAEs and DCR were compared between patients ≥75 vs.75 years, chi-squared test. Impact of age and other key clinical parameters on irAEs and DCR were tested in a binary logistic regression employing a backward selection. Impact of irAEs on oncological prognosis was assessed in log-rank and Cox regression analyses.We included 99 patients treated between 11/2015 and 01/2019. Frequency of irAEs (36.4% vs. 39.4%) and DCR (59.4% vs. 41.0%) was comparable between patients ≥75 vs.75 years. Advanced age was not associated with irAEs or worse DCR. IrAEs occurrence correlated with better disease-specific survival in the univariate and multivariate analyses. IrAEs could be successfully treated with corticosteroids in 78.9% of cases.ICIs seem to be both safe and efficacious in an aging population with metastatic RCC or UC. Occurrence of irAEs predicted better prognosis.

Eine 23-jahrige Studentin stellt sich in der Hausarztpraxis vor. Am Vortag war sie mit Kommilitoninnen im Schwimmbad. Am heutigen Morgen habe sie dann ein ausgepragtes Brennen beim Wasserlassen verspurt, das nun zunehmend schmerzhaft sei.

Der Artikel gibt einen Uberblick uber Inzidenz‑, Mortalitats- und Uberlebensraten des Harnblasenkarzinoms in Deutschland, beruhend auf den Daten der epidemiologischen Krebsregister sowie der amtlichen Todesursachsenstatistik. Aufgrund der klinischen Relevanz werden auch histologisch nichtinvasive Formen, die fast die Halfte der jahrlich zuletzt knapp 30.000 Neuerkrankungen pro Jahr ausmachen, in die Analysen mit einbezogen, obwohl die nichtinvasiven papillaren Karzinome (Ta) ebenso wie die selteneren flachen In-situ-Karzinome (Tis) in der ICD-10 nicht zu den bosartigen Neubildungen gezahlt werden. Zusammen mit den T1-Tumoren werden beide Formen klinisch als nichtmuskelinvasive Harnblasenkarzinome zusammengefasst. Histologisch liegen in mindestens 94 % der Falle Urothelkarzinome vor, andere Formen wie Plattenepithel- und Adenokarzinome sind entsprechend selten. Das mittlere Erkrankungsalter liegt bei knapp 75 Jahren, Manner sind etwa dreimal haufiger betroffen als Frauen. Im Jahr 2015 sind etwa 5700 Menschen in Deutschland an einem Harnblasenkarzinom verstorben. Die altersstandardisierte Sterberaten sind in Deutschland deutlich rucklaufig und gehoren zu den niedrigsten in der Europaischen Union. Der internationale Vergleich von Inzidenz- und Uberlebensraten wird durch unterschiedliche Handhabung und Einbeziehung der nichtinvasiven Karzinome in den Krebsregistern erschwert. Die relativen Uberlebensraten in Deutschland sind jedoch gut vergleichbar mit den Ergebnissen aus den US-amerikanischen SEER-Registern und liegen 10 Jahre nach Erstdiagnose fur muskelinvasive Tumoren unter 40 %. Deutlich gunstiger ist die Prognose bei den nichtmuskelinvasiven Formen mit relativen Zehnjahresuberlebensraten zwischen 63 % und 94 %, je nach Tumorstadium und Differenzierungsgrad. Vor allem bei nichtinvasiven High-grade-Tumoren werden die Uberlebenschancen v. a. durch das Risiko der Progression zu muskelinvasiven Stadien bestimmt, das auch nach intensiver Therapie wahrscheinlich noch uber viele Jahre erhoht ist.

Background Currently, stratification of patients with bladder cancer (BC) mainly relies on histopathologic and clinical staging. Furthermore, inflammation plays an important role in the pathogenesis of BC. With the preoperative platelet-to-leukocyte ratio (PLR), we introduce a novel prognostic marker based on routine hematologic values in patients undergoing radical cystectomy (RC). Patients and Methods In our cohort of 665 patients undergoing RC (2004-2015) for urothelial carcinoma of the bladder (UCB), we analyzed a variety of preoperative hematologic parameters. We investigated the effect of thrombocytosis, leukocytosis, and the PLR on the oncologic outcomes, including cancer-specific survival (CSS), progression-free survival (PFS), and overall survival (OS). Both univariate (log-rank test) and multivariate (Cox regression) analysis were performed. The prevalence of thrombocytosis and leukocytosis and differences in the PLR was assessed using the Mann-Whitney U test. The cutoff levels for leukocytosis, thrombocytosis, and the PLR were defined using receiver operating characteristic curve analysis, with the 5-year CSS as the binary classifier. Results A PLR of ≤ 28 (CSS, P = .033; OS, P = .029) and leukocytosis (CSS, P = .01; OS, P = .001; PFS, P = .003) were significantly associated with adverse oncologic outcomes using the log-rank test. On multivariate regression analysis, the PLR (CSS, P = .022; OS, P = .025) remained a significant prognostic marker among the standard staging variables and hemoglobin level. Advanced BC disease was significantly more prevalent in the patient subgroup with a low PLR (pT2-pT4, 35%; vs. pT ≤ 1, 24%; P = .006) and leukocytosis (pT2-pT4, 46%; vs. pT ≤ 1, 30%; P + , 49%; vs. pN0, 39%; P Conclusion To the best of our knowledge, the present study is the first report of the preoperative PLR as a prognostic factor in patients undergoing RC for UCB. Compared with other inflammatory markers in BC, the PLR can be assessed without additional effort. External validation and its combination with other parameters might improve current prognostication systems for UCB.

We objectively quantified daytime and nocturnal continence rates, and defined predictive features for favorable continence outcomes after radical cystectomy and orthotopic ileal neobladder creation.At 1 institution 1,012 cystectomies were performed between 2004 and 2015. Questionnaires evaluating the continence status were sent to 244 patients. To objectify postoperative urine loss daytime and nocturnal pad tests were performed. Continence was defined as the need for up to 1 safety pad and urine loss 10 gm or less per test. Predefined associative features were tested for an influence on continence outcomes. Statistical analysis was done with the Fisher exact and Mann-Whitney U tests, and linear logistic regression models. Significance was considered at p0.05.A total of 188 patients (77.0%) returned the questionnaires. Median followup was 61 months. Median daytime pad use was 1 pad per day (range 0 to 9). Median daily urine loss based on standardized pad testing was 8 gm (range 0 to 2,400). During the night a median of 1 pad (range 0 to 7) was used and median nocturnal urine loss was 28.5 gm (range 0 to 1,220). The continence rate was 54.3% during the day and 36.3% at night. On multivariate analysis good preoperative ECOG (Eastern Cooperative Oncology Group) status (OR 2.987, p = 0.010), retained sensation of bladder filling (OR 6.462, p = 0.003) and preoperative coronary heart disease (OR 0.036, p = 0.002) were independent predictors of daytime success. Based on preoperative risk factors a simple predictive score for daytime continence was created (AUC 0.725, p0.001).Continence rates after orthotopic ileal neobladder creation are lower than previously described when objective continence definitions are applied. Patients with good performance status, without coronary heart disease and with retained sensation of orthotopic ileal neobladder filling have better daytime continence outcomes.

To analyse the impact of perioperative complications and complex treatment courses on postoperative health-related quality of life (HRQOL) after radical cystectomy (RC) and continent (ONB) or incontinent (IC) urinary diversion at multiple prospective time points. A total of 121 consecutive patients underwent RC with curative intent between 2013 and 2014. HRQOL was prospectively assessed preoperatively, after 3 and 12 months, using the QLQ-C30 questionnaire. The impact of complex perioperative treatment courses including cases requiring surgical re-interventions was retrospectively assessed using Martin criteria and the Clavien–Dindo scale. Urinary continence was determined using the validated ICIQ-SF questionnaire. Statistical analysis included Kruskal–Wallis ANOVA, Spearman’s rank correlation, and ordinal regression models (p

PURPOSE The evaluation of the potential clinical benefit of four-dimensional ultrasound (4D-US) in the assessment of bladder cancer (BC). MATERIAL AND METHODS 20 patients with indication for cystoscopy for suspicion of bladder cancer were prospectively included in this study. All patients underwent two-dimensional ultrasound (2D-US), contrast enhanced ultrasound (CEUS) and real-time four-dimensional ultrasound (4D-US). All acquisitions were compared to each other in regard to image quality. This assessment was done using a 6 point scale (1 = best). All patients underwent subsequently cystoscopy with resection of the tumor (TURB), due a histopathological analysis was possible. RESULTS All examinations were performed successfully and no patient had to be excluded from the study. Patients acceptance of 4D-US was consistently good. No adverse events occurred. Image quality of real time 4D-US (score: 1.27±0.46) was significantly superior (p

Objectives: Patients’ oncological outcome after radical cystectomy (RC) due to urothelial carcinoma of the urinary bladder (UCB) is always up for debate. There is accumulating evidence on the influence of routine blood parameters. We aimed to identify reasonable and easy-to-detect biomarkers, such as preoperative C-reactive protein (CRP) and hemoglobin (Hb) levels, as predictors of overall survival (OS) and cancer-specific survival (CSS) in patients undergoing RC for UCB. Materials and Methods: This is a large single-center study in which both preoperative CRP and Hb levels were available in 1,043 patients undergoing RC for UCB from 2004 to 2018 with a median follow-up time of 22 months (mean 38, max. 170). We used the Kaplan-Meier method, log-rank test, and Cox regression models for assessment of OS and CSS. Using our data, we validated an existing outcome prediction score (TNR-C). Results: Median CRP level was 0.5 mg/dL (IQR 0.2–1.4), and median Hb level was 13.4 g/dL (IQR 11.9–14.7). We found that patients with CRP values above the median reached a significantly lower median survival than those with CRP values below the median (23 vs. 83 months, p < 0.001). The TNR-C score was successfully validated, and we discriminated between 3 risk groups (5-year CSS: 76, 40, and 16% for low, intermediate, and high risk, respectively). We observed a similar outcome for patients with a Hb level below the median: CSS was significantly poorer than with Hb levels above the median (median CSS 27 vs. 91 months, p < 0.001). Multivariant analysis showed CRP and Hb levels to be independent prognostic parameters for CSS and OS. Conclusions: We found elevated preoperative CRP levels and decreased Hb levels to be independent prognostic factors indicating an unfavorable outcome in patients undergoing RC for UCB and were able to validate the TNR-C score in a large patient cohort. We propose using these routine biomarkers for individual risk stratification and optimization of therapeutic strategies in patients undergoing RC for UCB.

Introduction: Enhanced recovery after surgery (ERAS) concepts are implemented in various surgical disciplines. For patients undergoing radical cystectomy, prospective data are still rare. In the year 2014, our group could prove significant benefits of ERAS for these patients in a prospective randomized study compared to a conservative regimen. Objective: To evaluate long-term follow-up results of ERAS concepts in patients undergoing radical cystectomy for bladder cancer. Methods: Of the 101 patients who had initially prospectively been randomized to ERAS or a conservative regimen, 35 patients could be included in the study. Median follow-up time was 83 months. Primary end point assessed quality of life. Secondary end points were cancer-specific survival and overall survival. Results: Five to seven years after the initial inclusion to the study, no significant difference regarding quality of life parameters was detected (p values range between 0.112 and 0.970). Continence status in patients with neobladder showed no significant differences between ERAS and conservative regimens (p = 0.785). Cancer-specific survival in the ERAS group did not differ significantly from that in the conservative group (49 vs. 58%, p = 0.725). Conclusions: While ERAS represents an excellent way to improve postoperative reconvalescence and quality of life in the short-term follow-up, our data do not support the idea that there is also a long-term effect in terms of quality of life issues.

INTRODUCTION AND OBJECTIVES:For many solid and malignant tumours thrombocytosis is associated with an impaired onclogical outcome concerning cancer specific survival (CSS).So far there is only limi...

Purpose: Early rehabilitation (ER) after radical cystectomy (RC) seems to be crucial for quality of life, education and prevention of complications after hospital discharge. We investigated an inpatient ER setting for bladder cancer (BC) patients. Methods: In total, 103 BC patients who underwent ileum neobladder reconstruction were included. The major issues from the patients’ point of view, functional outcome parameters and complications during ER were analysed. A Wilcoxon signed rank test was used to compare body mass index (BMI) and diurnal as well as nocturnal use of urinary pads before and after ER. Results: At the beginning of ER, the median Karnovsky performance scale score was 70% (interquartile range [IQR] 70–90%) and the mean BMI was 25.8 kg/m2 (IQR 21.9–27.9). The 4 most common complaints were urinary incontinence (80.6%), general weakness (73.8%), urinary mucus (49.5%) and mental distress (44.7%). During the programme, 28.2% of patients had a urinary tract infection requiring antibiotics and 15.5% presented a symptomatic acidosis. Median diurnal use of urinary pads significantly decreased during ER (4 vs. 3; p < 0.001). At the end of the ER programme, 76.0, 54.8 and 30.8% of the patients indicated an improvement of their physical capacity, incontinence and psychological distress respectively. Conclusions: Our study demonstrates the need for postoperative rehabilitation after RC. Further investigations should compare outcome parameters to ambulatory and outpatient ER models.