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Objectives: To determine the safety and oncological advantages of en bloc resection of bladder tumour (ERBT) vs conventional transurethral resection of bladder tumour (cTURBT) in terms of resection quality, staging quality, and safety., Patients and Methods: We conducted a single-blinded randomised controlled trial at seven European hospitals with the following inclusion criteria: first diagnosis of non-muscle-invasive bladder cancer, no singular carcinoma in situ, and tumour size >4.3 mm. Patients were randomised intraoperatively in a 1:1 ratio to either the ERBT or cTURBT group. Outcome analysis was performed using the chi-square test, t-test, and multivariate regression analysis., Results: A total of 97 patients were randomised into the study (cTURBT = 40, ERBT = 57). A switch to cTURBT was necessary in two patients (3.5%) and 11.5% of the screened patients were preoperatively excluded for ERBT. There was no difference in the specimen presence of detrusor muscle with 73.7% in cTURBT and 67.3% in ERBT specimens (P = 0.69). There were no significant differences in mean operative time (ERBT 27.6 vs cTURBT 25.4 min, P = 0.450) or mean resection time (ERBT 16.3 vs cTURBT 15.5 min, P = 0.732). Overall the complication rate did not differ significantly (ERBT 18.2% vs cTURBT 7.5%, P = 0.142). Bladder perforations occurred significantly more often in the ERBT group (ERBT seven vs cTURBT none, P = 0.020). R0 status was reported more often after ERBT, whilst a second resection was significantly less frequent after ERBT (P = 0.018). Recurrence rates were comparable for both techniques after 6 months of follow-up., Conclusion: The feasibility of ERBT is higher than previously reported. Whereas other perioperative and safety parameters are comparable to cTURBT, bladder perforations occurred significantly more often in the ERBT group and raised safety concerns. This is why this trial was terminated., (© 2024 The Author(s). BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Urothelial bladder cancer (UC) has a wide tumor biological spectrum with challenging prognostic stratification and relevant therapy-associated morbidity. Most molecular classifications relate only indirectly to the therapeutically relevant protein level. We improve the pre-analytics of clinical samples for proteome analyses and characterize a cohort of 434 samples with 242 tumors and 192 paired normal mucosae covering the full range of UC. We evaluate sample-wise tumor specificity and rank biomarkers by target relevance. We identify robust proteomic subtypes with prognostic information independent from histopathological groups. In silico drug prediction suggests efficacy of several compounds hitherto not in clinical use. Both in silico and in vitro data indicate predictive value of the proteomic clusters for these drugs. We underline that proteomics is relevant for personalized oncology and provide abundance and tumor specificity data for a large part of the UC proteome ( www.cancerproteins.org )., (© 2024. The Author(s).)

Background: YouTube is the second most popular website worldwide. It features numerous videos about radical prostatectomy. The aim of this study was to assess the quality of these videos and screen their benefit for patients and doctors., Methods: All videos on YouTube about radical prostatectomy were analysed using a specially developed software (python 2.7, numpy). According to a predefined selection process most relevant videos were analyzed for quality and reliability using Suitability Assessment of Materials (SAM)-Score, Global Quality Score and others., Results: Out of 3520 search results, 179 videos were selected and analysed. Videos were watched a median of 5836 times (interquartile range (IQR): 11945.5; 18-721546). The median duration was 7.2 minutes (min). 125 of the videos were about robotic prostatectomy. 69 videos each were directly addressed to patients and doctors. Medical content generally was of low quality, while technical quality and total quality were at a high level. Reliability was good., Conclusions: Videos on radical prostatectomy on YouTube allow for patient information. While technical quality and reliability are classified as acceptable, medical content was low and warranted preselection. In contrast to Loeb et al. we did not observe a negative correlation between number of views and scientific quality in different scores. Our findings support the need for preselection of videos on YouTube as the potential benefit may vary between videos with the significant risk of low medical quality., Competing Interests: The authors declare no conflict of interest., (© 2023 The Author(s).)

Our aim was to review the current literature regarding the effect of antioxidant supplementation (AS) on male fertility parameters, as AS is commonly used to treat male infertility due to the availability and affordability of antioxidants in many parts of the world., Materials and Methods: PubMed, Medline, and Cochrane electronic bibliographies were searched using the modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines to evaluate studies on the benefit of antioxidant therapy on infertile men. Results were analyzed regarding the following aspects: (a) ingredient and dose; (b) potential mechanism of action and rationale for use; and (c) effect on various reported outcomes., Results: Thus, 29 studies found a substantial positive effect of AS on outcomes of assisted reproductive therapy (ART), WHO semen parameters, and live-birth rate. Carnitines, Vitamin E and C, N-acetyl cysteine, coenzyme Q10, selenium, zinc, folic acid, and lycopene were beneficial ingredients. Nevertheless, some studies did not show a substantial change in one or more factors., Conclusion: AS seems to have a positive effect on male fertility. Environmental factors may play an increasing role in fertility. Further studies are needed to determine the optimal AS combination and the influence of environmental factors.

Introduction: Urine cytology (UC) is a recommended tool for the diagnosis of urothelial malignancies. Thus far, no specific recommendations regarding the role of washing cytology (WC) have been included in the guidelines. The goal of our study was to analyse the relationship between the histology of transurethrally (transurethral resection of the bladder [TURBT]) resected bladder tumours (BCa) and intraoperative UC or WC findings., Materials and Methods: Five hundred consecutive primary TURBT cases conducted between November 2010 and 2015 at our department of the University Hospital Luebeck were retrospectively analysed. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of UC and WC were evaluated to detect BCa. Multivariate logistic regression models were fit to further examine associations between patient- and tumour-related factors and a bladder UC or WC positive for BCa., Results: UC was performed in 297 patients, WC in 294 patients, and both in 261 patients. Sensitivity was 50.7% in UC, 58.1% in WC, and 62.1% for both tests combined. Specificity was 97.8% for UC, 98.0% for WC, and 96.4% for the combined tests. PPV was 98.0% for UC, 98.1% for WC, and 97.2% for combined tests. NPV was 47.8% for UC, 54.5% for WC, and 55.9% for the combined tests. The multivariate analyses revealed no association between positive UC or WC results and subsequent radical cystectomy (UC OR 1.35, 95% CI: 0.3-5.7; WC OR 2.0, 95% CI: 0.4-11.4). Neither UC nor WC was significantly correlated with local recurrence., Conclusions: Cytologic testing is an important diagnostic tool in BCa detection, showing acceptable sensitivity of around 60% and excellent specificity of over 90%. UC and WC present similar sensitivity. Our results advocate, however, against cytologic testing during primary TURBT, especially with regard to the lack of value in assessing the risk of recurrence. The clinical benefit of taking both types of samples at once is minimal. Furthermore, intraoperative WC collection does not reliably predict subsequent cystectomies., (© 2023 S. Karger AG, Basel.)

Introduction: Guideline recommendations are meant to help minimize morbidity and to improve the care of nonmuscle invasive bladder cancer (NMIBC) patients but studies have suggested an underuse of guideline-recommended care. The aim of this study was to evaluate the level of adherence of German and Austrian urologists to German guideline recommendations., Methods: A survey of 27 items evaluating diagnostic and therapeutic recommendations (15 cases of strong consensus and 6 cases of consensus) for NMIBC was administered among 14 urologic training courses. Survey construction and realization followed the checklist for reporting results of internet e-surveys and was approved by an internal review board., Results: Between January 2018 and June 2019, a total of 307 urologists responded to the questionnaire, with a mean response rate of 71%. The data showed a weak role of urine cytology (54%) for initial diagnostics although it is strongly recommended by the guideline. The most frequently used supporting diagnostic tool during transurethral resection of the bladder was hexaminolevulinate (95%). Contrary to the guideline recommendation, 38% of the participants performed a second resection in the case of pTa low-grade NMIBC. Correct monitoring of Bacille Calmette-Guérin (BCG) response with cystoscopy and cytology was performed by only 34% of the urologists., Conclusions: We found a discrepancy between certain guideline recommendations and daily routine practice concerning the use of urine cytology for initial diagnostics, instillation therapy with a low monitoring rate of BCG response, and follow-up care with unnecessary second resection after pTa low-grade NMIBC in particular. Our survey showed a moderate overall adherence rate of 73%. These results demonstrate the need for sharpening awareness of German guideline recommendations by promoting more intense education of urologists to optimize NMIBC care thus decreasing morbidity and mortality rates., (© 2021 S. Karger AG, Basel.)

Background: CRP-based scoring systems were found to correlate with survival in patients with urooncologic diseases. Our retrospective single-centre study aimed to confirm CRP as a prognostic parameter in patients with bladder cancer (BCa) undergoing radical cystectomy (RC) and, based on the findings, to develop our own outcome score for muscle-invasive bladder cancer (MIBC) patients undergoing RC in order to identify patients with a high risk of mortality., Material and Methods: A total of 254 patients who underwent RC at Hanover Medical School between 1996 and 2007 were reviewed with a follow-up until autumn 2013. The clinicopathologic parameters assessed included age, co-morbidities, pre-/postoperative serum levels of CRP, leukocytes, haemoglobin, creatinine, urinary diversion, tumour grading, staging, lymph node status, lymph node density (LND), lymphovascular invasion (LVI), metastases, and resection margin status. The Chi-square test was used for univariate analyses. Kaplan-Meier estimates and the log-rank test were used for survival analyses. Regarding outcome, overall survival (OS) was assessed., Results: The multivariate analysis excluding lymph node (LN)-positive and metastatic patients at time of RC showed a significant association of R status (R; p < 0.001), LVI (L; p = 0.021) and preoperative CRP level > 5 mg/l (C; p = 0.008) with OS. Based on these parameters, the RLC score was developed. The median OS in the intermediate, high-risk and very high-risk groups according to the RLC score was 62, 22, and 6.5 months, respectively. The score had a high predictive accuracy of 0.752., Conclusion: The RLC score identifies BCa patients at a higher risk of overall mortality after RC. Overall, our study supports the role of CRP in prognostic score models for BCa., Competing Interests: Hupe MC: Vorträge für und Honorare/Reisekosten von Ipsen, Novartis, Sanofi, Solution Akademie.Struck JP: Vorträge für und Berater/Advisor für Bayer, BMS, Eusai, Ipsen, Janssen, Merck, MSD, Novartis, Pfizer, Roche.Merseburger AS: Vorträge und Berater/Advisor für Amgen, Apogepha, Astellas, Bayer, BMS, Clovis, Ferring, Hexal, Ipsen, Janssen, Merck, MSD, Novartis, Roche, Sanofi, Takeda, TEV., (Thieme. All rights reserved.)

Background: Several international medical societies reported a negative impact on urology residency training programs due to the COVID-19 pandemic., Objectives: The aim of this study was to investigate the impact of the pandemic on urological residency in Germany., Materials and Methods: From the 20 th of May 2020 until the 20 th of June 2020, a Germany-wide online survey on the continuing residency training was distributed via the members of the working group, social media (Facebook, Twitter, Instagram) and the German Society of Residents in Urology (GeSRU e.V.) newsletter. The survey covered 3 topics: 1) basic characteristics of the participants, 2) general and 3) subjective influence of the COVID-19 pandemic on clinics and further residency training., Results: A total of 50 residents took part in the survey; 54% were women. The median age was 31 years. Most of the participants were in their 2nd (22%) and 5th (26%) year of training and worked in a university hospital (44%) or in a clinic of maximum care (30%). 38% of the respondents stated that they only served urological emergencies during the COVID-19 pandemic. For 28% this meant a very large delay (80-100%) in the specialisation, while 28% stated only a minor impact. 66% documented training impairments caused by fewer operations, low patient numbers in the outpatient department (50%), congress (50%) and workshop (44%) cancellations. 46% of residents reported direct contact with COVID-19 patients while 10% were deployed on interdisciplinary IMC units. Numerous physical distancing and hygiene measures have been implemented by the clinics., Conclusion: On average, around 50% of the urology residents indicated significant restrictions in training due to the COVID-19 pandemic in Germany. The delay in training cannot currently be measured in units of time, but it can be assumed that training for residents during the pandemic is likely to be of a lower quality compared to previous generations., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The insertion of a ureteral access sheath (UAS) is a frequent procedure during flexible ureteroscopy (fURS) to facilitate kidney stone treatment. The aim of this study was to investigate the influence of 12/14 French (F) UAS on fURS outcomes., Methods: We performed a retrospective monocentric analysis of fURS procedures conducted at the Department of Urology (University Hospital Schleswig-Holstein, Lübeck, Germany) for kidney stone treatment via lithotripsy or basket stone retrieval between September 2013 and June 2017. Uni- and multivariate analyses were done with the help of RStudio (Version 1.0.136) software., Results: In total, 283 consecutive fURS were analyzed. UAS was applied in 98 cases (34.63%). The insertion of UAS was preferred in cases with multiple kidney stones and larger median maximal stone diameter (p < 0.05). UAS usage correlated with elevated radiation exposure in seconds (94 vs. 61; p < 0.0001), prolonged operation time in minutes (99 vs. 66, p < 0.0001), length of hospital stay over 48 h (LOS, 22.49% vs. 10.81%; p = 0.015), more frequent postoperative systemic inflammatory response syndrome (SIRS, 13.27% vs. 4.32%; p = 0.013) and lower postoperative stone-free rates (60.20% vs. 78.92%; p = 0.0013). Moreover, we conducted uni- and multivariate subgroup analysis for cases with multiple kidney stones (≥ 2) and comparable stone burden; UAS was inserted in 48.3% of these cases (71/147). On multivariate logistic regression, UAS insertion was statistically associated with prolonged operation time in minutes (101 vs. 77; p = 0.004). No statistical differences regarding radiation exposure, stone-free rates, postoperative SIRS rates or LOS were noted between UAS and non-UAS patients with multiple kidney stones of similar size (p > 0.05)., Conclusions: 12/14F UAS does not seem to improve overall outcomes in fURS for kidney stones. In patients with multiple kidney stones it may be associated with elevated operation time without a clear benefit in terms of improved stone-free status or reduced perioperative complication rate. Further prospective randomized studies to specify the indications for UAS usage are urgently needed., (© 2022. The Author(s).)

Against the background of the changes in the collective bargaining agreement-for municipal hospitals in the version of January 1, 2021, and for university hospitals in the version of March 7, 2020-this article deals with the legal consequences of chronic violations of the German Working Hours Act in medicine, but especially in surgical specialties such as urology. It includes an overview of current law and sanctions for violations and highlights responsibilities as well as exceptions. It is important to clarify the distribution of responsibilities with regard to working hours in the institution concerned in order to avoid fines and, in the worst case, imprisonment. It should also be clear who is liable in specific cases for persistent working time violations. When changing duty models, it is important to bear in mind that this can lead to a considerable deterioration in the opportunities for further training and education of physicians, meaning that in the long term the compatibility of further training in line with working hours can only be achieved with sufficient staffing of the hospitals. In some cases, this is diametrically opposed to economic interests in the health care system and thus presents an almost insoluble dilemma. In the view of the working group, structural changes in the diagnosis-related group (DRG)-based inpatient sector are needed in the near future., (© 2022. The Author(s).)

The amendment to the collective agreement is intended to significantly improve the working conditions of physicians and includes longer-term duty scheduling, work on a maximum of two weekends per month, less overtime. Smaller hospitals often have problems implementing these requirements and have to make compromises. At least the overtime is now better paid-overall, an improvement in working conditions can only be achieved by increasing the number of staff, then better and more intensive training is also possible., (© 2021. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: To date, over 4.2 million Germans and over 235 million people worldwide have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Uro-oncology (UO) patients are particularly vulnerable but in urgent need of life-saving systemic treatments. Our multicentric study examined the impact of the COVID-19 crisis on the medical care of UO patients in German university hospitals receiving ongoing systemic anti-cancer treatment and to detect the delay of medical care, defined as deferred medical treatment or deviation of the pre-defined follow-up assessment., Methods: Data of 162 UO patients with metastatic disease undergoing systemic cancer treatment at five university hospitals in Germany were included in our analyses. The focus of interest was any delay or change in treatment between February 2020 and May 2020 (first wave of the COVID-19 crisis in Germany). Statistical analysis of contingency tables were performed using Pearson's chi-squared and Fisher's exact tests, respectively. Effect size was determined using Cramér's V (V)., Results: Twenty-four of the 162 patients (14.8%) experienced a delay in systemic treatment of more than 2 weeks. Most of these received immuno-oncologic (IO) treatments (13/24, 54.2%, p = 0.746). Blood tests were delayed or canceled significantly more often in IO patients but with a small effect size (21.1%, p = 0.042, V = 0.230). Treatment of patients with renal cell carcinoma (12/73, 16.4%) and urothelial carcinoma (7/32, 21.9%) was affected the most., Conclusions: Our data show that the COVID-19 pandemic impacted the medical care of UO patients, but deferment remained modest. There was a tendency towards delays in IO and ADT treatments in particular., (© 2021. The Author(s).)

Objective: Osteoprotective medications are a key element not only in the management of bone metastases of castration-resistant prostate cancer (mCRPC) but also of hormone-sensitive prostate cancer (mHSPC). Additionally, osteoprotective drugs can prevent androgen deprivation-induced bone loss. The aim of this study was to illustrate the practice pattern of osteoprotection for prostate cancer patients in Germany., Material and Methods: We designed an online survey consisting of 16 questions. The survey was sent to the nation-wide working groups "Oncology" and "Uro-Oncology" as well as to colleagues from the departments of urology of University Hospital Schleswig-Holstein (Campus Lübeck), Academic Hospital Brunswick and Technical University of Munich. Furthermore, we developed flow charts for decision guidance for osteoprotection within the different stages of prostate cancer., Results: Our analysis demonstrates a routine use of osteoprotection in the management of bone metastases of mCRPC. In contrast, osteoprotective medications are less often used for the treatment of bone metastases of mHSPC and for the prevention of androgen deprivation-induced bone loss. Our flow charts depict the different dosages and intervals for the administration of osteoprotective drugs in the different stages of prostate cancer., Conclusions: Osteoprotection is not only confined to mCRPC with bone metastases. It plays a crucial role in the management of all stages of metastatic prostate cancer., Competing Interests: Hupe MC: Vorträge für und Honorare/Reisekosten von Ipsen, Novartis, Sanofi, Solution Akademie. Müller M: keine. Struck JP: Vorträge für und Berater von Novartis, Roche und Solution Akademie. Wießmeyer JR: keine. Ozimek T: keine. Steuber T: Honorare von und Berater/Advisor für Amgen, Astra Zeneca, Astellas, Bayer, Janssen, ProteoMedix, Sanofi, GSK. Gschwend JE: Vorträge für und Berater/Advisor für Amgen, Astra-Zeneca, Bayer, BMS, Janssen, Merck, MSD, Pfizer, Roche. Hammerer P: Berater/Advisor für Amgen, Apogepha, Astellas, Bayer, BMS, Ferring, Ipsen, Janssen, Merck, MSD, Roche, Sanofi, Takeda. Kramer MW: Honorare/Reisekosten von und Berater/Advisor für Bayer, BMS, Eusai, Ipsen, Janssen, Merck, MSD, Novartis, Pfizer, Roche. Merseburger AS: Vorträge und Berater/Advisor für Amgen, Apogepha, Astellas, Bayer, BMS, Clovis, Ferring, Hexal, Ipsen, Janssen, Merck, MSD, Novartis, Roche, Sanofi, Takeda, TEVA., (Thieme. All rights reserved.)

Background: The range of medical apps is broad and diverse. The previous evaluations are inconsistent and limited to the respective areas of application., Objectives: The main objective of this work is to comprehensively present, organize, and evaluate the current range of urological apps with the help of a semi-automatic retrospective app store analysis (SARASA)., Methods: Application of an adaptable method based on filter processes according to predefined criteria by means of SARASA to characterize urological apps from various subject areas in the Apple App Store with subsequent manual filtering and evaluation., Results: From the original list of 34,830 apps in the "Medicine" category of the Apple App Store on 27 September 2021, 3556 apps remained after apps without a German-language store description were removed. 43 subject-specific apps remained for further analysis and description. The number of reviews, rating, topicality, urological issues, technical support and richness of content were taken into account. The two most relevant apps for each topic are presented in detail., Conclusion: SARASA offers an easy-to-use method for applying filter processes to identify apps in app stores that meet predefined, formal criteria. The highest number of apps can be classified in categories of patient information and further education and training. An app officially listed by the German Federal Institute for Drugs and Medical Products (BfArM) in the sense of a digital health application (DiGA), the costs of which are reimbursed by the health insurance companies, is available for urology in only one single case. The authors see great potential for future developments in this regard., (© 2021. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Oral chemolitholysis is a noninvasive therapy for uric acid (UA) stones. Proper patient selection is crucial for success of the therapy., Objective: To develop a nomogram for prediction of UA stones using parameters gathered during emergency work-up for flank pain., Design, Setting, and Participants: A single-center cohort (459 patients) with singular ureteral stones and available stone analysis was retrospectively reviewed for radiological, urinary, and serological findings indicating UA stones., Outcome Measurements and Statistical Analysis: A Mann-Whitney U test or Kruskal-Wallis test was applied for univariate analysis. Categorical variables were compared using a χ 2 test. Binary logistic regression of significant parameters was performed to design the nomogram., Results and Limitations: Univariate analysis revealed statistically significant differences in parameters between predominantly UA and non-UA groups, including median age (60 yr, interquartile range [IQR] 51.5-70.5 vs 51 yr, IQR 39-62; p < 0.001), body mass index (30.0 kg/m 2 , IQR 27.25-35.0 vs 26.6 kg/m 2 , IQR 24.0-30.467; p < 0.001), stone density (435.0 HU, IQR 329.0-528.0 vs 750.0 HU, IQR 548.0-995.0; p < 0.001), serum UA (437.5 μmol/l, IQR 374.25-478.0 vs 321.0 μmol/l, IQR 273.0-377.0; p < 0.001), and urine pH (5.5, IQR 5.0-5.5 vs 6.0, IQR 5.5-6.5; p < 0.001). Radiolucency was more frequent in the predominantly UA group (88.60% vs 32.70%; p < 0.001). Multivariate binary logistic regression confirmed age, body mass index, stone density, serum UA, urine pH, and radiolucency as independent predictors of UA stones and these parameters were used to design the nomogram., Conclusions: We present a nomogram for the prediction of uric acid stones., Patient Summary: We developed a nomogram as a simple tool with potential to be useful in patient counseling regarding chemolitholysis as a tailored stone treatment for uric acid urinary stones., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Radiological parameters predicting a postoperative stone-free status (SFS) or a complicated perioperative course of mini-PNL, are scarce. Our aim was to identify such factors for prone 17.5F mini-PNL., Methods: A monocentric cohort of 103 cases was retrospectively analysed for factors predicting SFS and relevant complications, i.e. Clavien-Dindo (CD) ≥ 2. Parameters measured on preoperative supine CT included maximal stone diameter, skin-to-stone distance (SSD), ideal tract length (ITL), access angle, minimal T12-Lower Kidney Pole distance (T12LP) and minimal Iliac Crest-Lower Kidney Pole distance (ICLP). Infundibulopelvic angle (IPA) was measured on intraoperative pyelography., Results: The median maximal stone diameter was lower in cases with postoperative SFS [16 mm (Min. 10; Max. 35) vs. 20 mm (Min. 6; Max. 85), p = 0.0052]. CD ≥ 2 was more frequent in cases with a bigger stone burden [19 mm (Min. 13; Max. 85) vs. 16 mm (Min. 6; Max. 49), p = 0.0056] and with the ribs in the access angle [7/23 (30.43%) vs. 8/76 (10.53%); p = 0.0454]. T12LP significantly differed in cases with and without CD ≥ 2 [80.48 mm (± 21.31) vs. 90.43 mm (± 19.42), p = 0.0397]; however, it had no influence on SFS (p > 0.05). SSD, ITL, IPA and ICLP were significant regarding neither SFS nor CD ≥ 2 prevalence (p > 0.05). Using multivariate logistic regression, T12LP was confirmed as an independent predictor on CD ≥ 2 prevalence., Conclusions: Preoperative computed tomographic factors indicating elevated kidney position influence perioperative course of mini-PNL. T12LP and the presence of ribs in the access angle are, apart from stone diameter, the most useful indicators for cases at risk of CD ≥ 2.

Introduction: For risk stratification of non-muscle invasive bladder cancer (NMIBC), the depth of stromal invasion can be further classified, where the lamina muscularis mucosae (MM) serves as a reference structure. While the overall identifiability of MM in standard transurethral specimens is low, en bloc resection may help in identification and overall orientation. The aims of this study were to report the detection rate of MM in en bloc resected bladder tumors (ERBT) and to provide real-world information on tissue stability and preservation of en bloc architecture during recovery and processing for histopathologic evaluation., Methods: Thirty-four ERBT specimens were histologically re-evaluated with regard to MM detectability and structure as well as the presence of en bloc architecture and further histologic features. Associations with tumor size and energy source and within histologic parameters were assessed by standard Pearson's chi-squared analyses and Cramér's V effect size testing (V)., Results: The first parameter assessed was MM detection rate. In 19 out of 34 samples (56%) MM was detectable: scattered in 9 cases (26%), interrupted in 8 cases (24%) and continuous in 2 cases (6%). The second parameter assessed was preservation of en bloc architecture. In 11 out of 34 samples (32%), en bloc architecture could not be confirmed, and these samples served as a reference group for the detection of MM. Preservation of en bloc architecture was associated with an increased MM detection rate (MM in en bloc preserved 16/23, 70% vs. non-preserved 3/11, 27%; p = 0.020; V = 0.398) and with tumor size (p = 0.005; V = 0.595). Medium-sized tumors (1.1-2 cm) were best preserved. The choice of energy source did not show relevant association with en bloc architecture (p = n.s.)., Conclusions: In line with recent publications, ERBT increases the MM detection rate considerably. However, a third of the ERBT specimens lost en bloc architecture during sample recovery and processing. Tumor size is a relevant factor, with optimal architecture preservation between 1 and 2 cm. Optimizing resection techniques, recovery, transport, and diagnostic processing of ERBT samples is warranted to verify the diagnostic value of MM-based substaging.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic is disrupting urology health-care worldwide. Reduced emergency room visits resulting in adverse outcomes have most recently been reported in pediatrics and cardiology. We aimed to compare patients with emergency room visits for pyelonephritis in 2019 (pre-COVID-19 era) and within the first wave of pandemic in 2020 (COVID-19 era) with regard to the number of visits and severe adverse disease outcomes., Methods: We performed a retrospective multicentre study comparing characteristics and outcomes of patients with pyelonephritis, excluding patients with hydronephrosis due to stone disease, in 10 urology departments in Germany during a 1-month time frame in March and April in each 2019 and 2020., Results: The number of emergency room visits for pyelonephritis in the COVID-19 era was lower (44 patients, 37.0%) than in the pre-COVID-19 era (76 patients, 63.0%), reduction rate: 42.1% (p = 0.003). Severe adverse disease outcome was more frequent in the COVID-19 era (9/44 patients, 20.5%) than in the pre-COVID-19 era (5/76 patients, 6.6%, p = 0.046). In detail, 7 versus 3 patients needed monitoring (15.9 vs. 3.9%), 2 versus no patients needed intensive-care treatment (4.5 vs. 0%), 2 versus no patients needed drain placement (4.5 vs. 0%), 2 versus no patients had a nephrectomy (4.5 vs. 0%), and 2 versus 1 patient died (4.5 vs. 1.3%)., Conclusion: This report of collateral damage during CO-VID-19 showed that emergency room visits were decreased, and severe adverse disease outcomes were increased for patients with pyelonephritis in the COVID-19 era. Health authorities should set up information campaign programs actively encouraging patients to utilize emergency room services in case of severe symptoms specifically during the actual second wave of pandemic., (© 2021 S. Karger AG, Basel.)

Introduction: The goal was to determine risk factors for Clavien-Dindo (CD) grade ≥2 complications, with special focus on early postoperative systemic inflammatory response syndrome (SIRS), for flexible ureteroscopy (fURS)., Materials and Methods: A retrospective monocentric statistical analysis relating to 32 factors was performed with the χ2 test, Mann-Whitney U tests, and multivariate logistic regression., Results: In total, 416 consecutive fURS performed between September 2013 and June 2017 were analyzed; 283 (68.03%) of these were for stone surgery and 133 (31.97%) for diagnostic purposes. In 43 cases (10.34%), CD ≥2 occurred; 31 cases (72.09%) of these were SIRS. On multivariate logistic regression, positive preoperative urine culture and steep pyelographic and CT-based infundibulopelvic angle (IPA) have been confirmed as independent risk factors for both CD ≥2 and SIRS. Greater maximal median stone diameter and female gender were significantly associated only with a higher CD ≥2 prevalence, but not with SIRS. The influence of ureteral access sheath (UAS) on CD ≥ 2 or SIRS occurrence could not be confirmed on multivariate analysis. Perioperative antibiotic prophylaxis for patients with negative urine culture showed no difference regarding SIRS prevalence., Conclusion: Steep CT-based IPA can be considered as a new radiologic predictor of complicated postoperative course and SIRS. The role of UAS as well as indications for perioperative antibiotic prophylaxis should be determined in prospective studies., (© 2021 S. Karger AG, Basel.)

Background: The introduction of checkpoint inhibitors is a long-awaited new option for a urothelial cancer with a poor prognosis. Apart from clinical studies, the data on real world experience is scarce. Methods: Patients for monotherapy with either Atezolizumab, Nivolumab or Pembrolizumab after chemotherapy were included. Adverse events and immune related adverse events as well as survival data and imaging analyses were recorded in a prospectively designed multi-center data base. Duration of response, progression free survival (PFS), and overall survival (OS) were estimated with the Kaplan-Meier method. Results: A total of 28 patients were included. The median follow-up was 8.0 (range, 0.7-41.7) months. Median PFS was 5.8 (95% CI, 2.3-NA) months. Median OS for all patients was 10.0 (95% CI, 8.0-NA) months. The overall response rate (ORR) was 21.4% (6 out of 28 patients). Adverse events were recorded in 20 (71.4%) of patients. Higher grade adverse events (≥Grade 3) were present in 11 (39.3%) patients. No therapy related deaths occurred during the observation period. A total of 13 (46.4%) patients had adverse events that were considered to be immune related. The most commonly affected organ was the thyroid gland with 21.4% of events. Conclusion: Our real-world clinical series confirms an objective response for about every fifth patient, promising OS and a low incidence for severe adverse events (≥Grade 3)., (Copyright © 2020 Fuhrmann, Struck, Ivanyi, Kramer, Hupe, Hensen, Fürschke, Peters, Merseburger, Kuczyk and von Klot.)

Background: Whether or not double J (DJ) stenting during transurethral resection of a bladder tumour (TURBT) harms patients with regard to possible metachronous upper urinary tract urothelial cancer (UUTUC) development remains controversial. This study evaluated the impact of DJ compared to nephrostomy placement during TURBT for bladder cancer (BCa) on the incidence of metachronous UUTUCs., Methods: We retrospectively analysed 637 patients who underwent TURBT in our department between 2008 and 2016. BCa, UUTUC and urinary drainage data (retrograde/anterograde DJ and percutaneous nephrostomy) were assessed, along with the prevalence of hydronephrosis, and mortality. Chi-square and Fisher's exact test was performed for univariate analyses. Survival analysis was performed by the Kaplan-Meier method and log-rank tests., Results: UUTUC was noted in 28 out of 637 patients (4.4%), whereas only eight (1.3%) developed it metachronously to BCa. Out of these, four patients received DJ stents, while four patients received no urinary drainage of the upper urinary tract. Placement of urinary drainage significantly correlated with UUTUC (50.0% vs. 17.9%; p = 0.041). DJ stenting significantly correlated with UUTUC (50.0% vs. 11%; p <  0.01), while no patient with a nephrostomy tube developed UUTUC. UUTUC-free survival rates were significantly lower for patients with DJ stents than for all other patients (p = 0.001). Patients with or without DJ stents had similar overall survival (OS) rates (p = 0.73), whereas patients with nephrostomy tubes had significantly lower OS rates than all other patients (p <  0.001)., Conclusions: Patients with DJ stenting during TURBT for BCa might have an increased risk of developing metachronous UUTUC. This study indicated advantages in placing nephrostomy tubes rather than DJ stents; however, confirmation requires investigation of a larger cohort. Even so, the increased mortality rate in the nephrostomy group reflected hydronephrosis as an unfavourable prognostic factor.

Introduction: The aim of this study was to analyze the influence of residents' participation in flexible ureteroscopy (fURS) on intra- and postoperative outcomes., Materials and Methods: Intra- and postoperative parameters were compared in a retrospective monocentric setting between 3 groups: "resident group" (47 cases) for surgeries performed by experienced residents alone, "consultant group" (245 cases) for surgeries performed by consultants alone, "resident plus consultant group" (124 cases) for training surgeries between September 2013 and June 2017., Results: Patients operated by residents alone had a significantly smaller median kidney stone diameter (5.0 vs. 7.0 mm for "consultant group" and 6.0 mm for "resident plus consultant group," p = 0.011), shorter operating time (median 47.0 vs. 63.0 and 77.0 min, p < 0.001) and fluoroscopy time (median 39.0 vs. 69.5 and 89.0 s, p < 0.001), as well as shorter postoperative hospital stay (p = 0.013). The laser application rate was the smallest in the "resident group" (10.64 vs. 31.43 and 29.84%, p = 0.009). Univariate analysis revealed no relevant differences regarding flexible ureteroscope defect rate, postoperative stone-free rate, or ≥2 Clavien-Dindo classification complications between the groups (p > 0.05)., Conclusion: A proper case selection of less complicated cases, especially without laser application, could balance the experience deficit of the residents. fURS can be incorporated as a part of residents' training without an impact on fURS device defect rate or clinical outcomes., (© 2020 S. Karger AG, Basel.)

The Internet has shaped and changed society like no other technology. Culturally, the emergence of the Internet is being described as having the same impact on society as the invention of printing. In 2018, more than 4 billion people had access to the Internet. Among all Internet users, approximately 80 % search the Internet for health-related information, with cancer being the most frequently searched condition. Patients rate the Internet as the second most helpful source of information, outranked only by consultation with a medical doctor. There are more than 2.6 billion active social media users. Among urological residents, 97 % use social media on a regular basis. Digitalisation has the potential to strengthen patients' health literacy and optimise patient care, especially in the oncologic field. In summary, digitalisation bears an enormous potential for the field of urology., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The working and continued training conditions of assistant physicians in urology in Germany have already been analyzed. But what about senior urologists in Germany? Under which conditions do they have to work? As far as we know no published data currently exist which illuminate the conditions of this special urological professional group, therefore, the results of this survey are presented., Objective: To survey and evaluate the current working conditions of certified and senior urologists in Germany as comprehensively as possible., Material and Methods: The working group of employed physicians of the Professional Association of German Urologists (BvDU) carried out a survey within the framework of the urological senior physician forum 2016 and on-line via the e‑mail distributor of the German Society for Urology (DGU). The questions involved the workload, working conditions and satisfaction, overtime performed, working hours and opt out regulations., Results: A total of 176 senior physicians participated in the survey of which 88% were male and 12% female. In Germany there are 1125 senior physicians. The average age of the responders was 44.9 years. In more than 80% of the participants the average weekly working hours were over 50 h and 70% signed an opt out regulation. An association between an increasing job dissatisfaction above a working week over 55 h and an average attendance in on-call service over 4 h could be established. The number of on-call services had no influence on job satisfaction. A total of 43% (70 out of 162) of the participants stated that overtime hours were regularly forfeited and 12% (20 out of 162) that all overtime hours were forfeited. Approximately 30% of senior physicians in German urology were dissatisfied with the current working conditions in the present form., Conclusion: Based on the acquired data, adaptation and improvements in the working conditions of senior urologists are necessary in order to maintain the attractiveness of the occupational image and leading positions in German urology.

Background:  An adequate online presence is essential for any medical practice. Studies have shown that patients increasingly use the internet for medical information, to search for physicians and to use online services. Expert associations and journals use social media to maximise their online reach., Objectives:  This study presents chances and risks of an online presence for urologists., Results:  A professional and visually appealing website is key to modern doctor-patient communication. When developing a professional digital identity, one must consider technical aspects as well as legal requirements. Recommendations and guidelines have been put in place to give guidance, e. g. on social media strategies or the development of a websites content design. Medical professionals need in-depth consultation, especially regarding the complex legal requirements., Conclusion:  Content published online must be handled thoughtfully - no matter what digital medium is used. It is advisable to strictly separate private and professional online presences. Furthermore, the goals regarding an online presence should be regularly reevaluated and, if necessary, adjusted., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Currently, continuing medical evaluation takes place in Germany-but not nationally or regularly, and without national standards. Therefore, comparisons between different clinics and trainers can currently not be drawn. Survey modes, such as those that have existed in Switzerland for decades, could provide a constructive basis in the assessment of the current continuing medical education of urology residents and subsequently facilitate the discussion on improvements. This requires constructive cooperation of all involved, without attributing the responsibility only to the educators. Models of rewarding good continuing education should also be found.

Current surveys show that 45% of German urologic residents do not feel sufficiently prepared for their later urologic work, and 85% lack a structured training curriculum in their home institutions. Furthermore, they report a lack of transparency and evaluations as well as economic constraints. This gives reason to revise and adapt the current urologic training curriculum. In the following article we compare the current urologic curriculum with other disciplines and discuss chances and limits of possible future models. These include better definitions of basic training skills, specialization, a structured evaluation system, standardization of exams and room for research.

Due to demographic changes and aging in the German population combined with the shortage of doctors, new techniques are needed to ensure urological patient care in the future. Telemedicine offers great potential to facilitate patient monitoring in their familiar surroundings and to ameliorate patient's compliance with the suggested therapy concept. Through optimal and reliable transfer of patient data, telemedicine helps to optimise patient satisfaction with urological therapies, binds them to their doctor and raises diagnostic safety. For a successful use of telemedicine, detailed education of participating patients and urologists as well as detailed fault monitoring are required., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To measure the usage rate of social media (SoMe) resources in the prostate cancer community, we performed a comprehensive quantitative and qualitative assessment of SoMe activity on the topic of PCa on the four most frequented platforms., Methods: We scanned the SoMe platforms Facebook, Twitter, YouTube, and Instagram for "prostate cancer" as a cross-sectional analysis or during a defined time period. Sources were included if their communication centered on PCa by title and content. We assessed activity measurements for each SoMe source and classified the sources into six functional categories., Results: We identified 99 PCa-related Facebook groups that amassed 31,262 members and 90 Facebook pages with 283,996 "likes". On YouTube, we found 536 PCa videos accounting for 43,966,634 views, 52,655 likes, 8597 dislikes, and 12,393 comments. During a 1-year time period, 32,537 users generated 110,971 tweets on #ProstateCancer on Twitter, providing over 544 million impressions. During a 1-month time period, 638 contributors posted 1081 posts on Instagram, generating over 22,000 likes and 4,748,159 impressions. Among six functional categories, general information/support dominated the SoMe landscape on all SoMe platforms., Conclusion: SoMe activity on the topic of PCa on the four most frequented platforms is high. Facebook groups, YouTube videos, and Twitter tweets are mainly used for giving general information on PCa and education. High SoMe utilization in the PCa community underlines its future role for communication of PCa.

Background: Modifications in resection techniques may overcome obvious limitations of conventionally performed transurethral resection (e. g., tumor fragmentation) of bladder tumors or provide an easier patient treatment algorithm (e. g., tumor vaporization)., Objectives: The present review article summarizes the current literature in terms of en bloc resection techniques, histopathological quality, complication rates, and oncological outcomes., Materials and Methods: A separate data search was performed for en bloc resection (ERBT, n = 27) and vaporization (n = 15) of bladder tumors., Results: In most cases, ERBT is performed in a circumferential fashion. Alternatively, ERBT may be performed by undermining the tumor base via antegrade application of short energy impulses. Based on high rates of detrusor in specimens of ERBT (90-100%), a better histopathological quality is assumed. Significant differences in perioperative complication rates have not been observed, although obturator-nerve-based bladder perforations are not seen when laser energy is used. There is a nonstatistically significant trend towards lower recurrence rates in ERBT groups. Tumor vaporization may provide a less invasive technique for older patients with recurrences of low-risk bladder cancer. It can be performed in an outpatient setting., Conclusions: ERBT may provide better histopathological quality. Tumor vaporization is performed in health care systems where reimbursement is adequate.

Objectives: We had previously demonstrated changes in defecation after radical cystectomy (RC). Reports addressing long-term bowel disorders following RC are rare. This cross-sectional study evaluates long-term bowel issues in a large cohort., Material and Methods: A questionnaire assessing changes in bowel function (diarrhea, constipation, urge to defecate, sensation of incomplete defecation, and flatulence) and its effect on quality of life was developed based on the gastrointestinal quality of life index and distributed in collaboration with the German bladder cancer support group. There were 431 evaluable questionnaires. For the analyses, we focused on patients that had the RC>1 year ago (n = 324)., Results: Current bowel problems were reported by 42.6% of patients. The most frequent bowel problems were flatulence (48.8%), diarrhea (29.6%), and sensation of incomplete defecation (22.5%). In cases of bowel problems, 39.7% and 59.8% of the patients indicated life restriction and dissatisfaction, respectively. Prevalence of diarrhea and flatulence were significantly higher>12 (vs. ≤12) months following RC. Both symptoms significantly correlated with younger age at RC, life restriction, lower quality of life, lower health state, and lower energy level. Additionally, diarrhea significantly correlated with pouches as urinary diversion (vs. ileal conduit or ureterocutaneostomy) and higher dissatisfaction level., Conclusions: To our knowledge this is the largest cohort evaluating long-term bowel symptoms after RC. Diarrhea is a prominent symptom after RC with a high impact on daily life that leads to dissatisfaction. A better understanding of long-term bowel symptoms could be translated into optimized surgical procedures, postoperative medication/nutrition, and patient education., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Guidelines support the use of neoadjuvant (NAC) and adjuvant (AC) chemotherapy in muscle-invasive bladder cancer. However, data from North America reported the underutilization of NAC in favor of AC despite the lower level of scientific evidence supporting AC. We aimed to assess current practice patterns of NAC and AC in -Germany., Methods: A 15-question online survey was developed and sent via email newsletters to members of the -German Association of Urology and of the German Society of Residents in Urology in October 2016 to analyze current practice patterns., Results: The survey yielded 141 individual responses from 61 different German urology departments. Eighty-nine (69.0%) and 119 (93.0%) participants were stated to regularly use NAC and AC respectively. The number of participants who were stated to use NAC and AC regularly was not associated with the type of institution (academic vs. nonacademic), number of hospital beds, and number of cystectomies performed annually. Gemcitabine/cisplatin combination chemotherapy was named as the primarily used NAC regimen by 80 (95%) respondents. The median number of administered cycles was 3 for NAC and 4 for AC. In the case of cisplatin ineligibility, combination chemotherapy with gemcitabine/carboplatin was the most common regimen. Respondents stated that chemotherapy was generally administered by urologists (81% for NAC and 85% for AC)., Conclusions: Our survey of current practice shows a high acceptance rate of NAC in Germany, which was independent of the type of institution. Although the scientific level of evidence for AC is lower, it still seems to be more widely accepted than NAC. NAC and AC were generally administered by urologists., (© 2018 S. Karger AG, Basel.)

Context: En-bloc resection of bladder tumors (ERBT) is a promising alternative to conventional transurethral resection of bladder tumor., Objective: To review the current results of ERBT., Evidence Acquisition: A literature search of articles that included the keywords bladder and en bloc was performed on July 15, 2016 using PubMed/Medline. Relevant English-written original articles were considered. Data from the manuscripts were categorized focusing on recent trends on resection techniques, specimens' quality, morbidity, and recurrence., Evidence Synthesis: ERBT provides high rates of detrusor muscle (> 95%) and specimens of high quality for pathological evaluation. It has not been analyzed whether second resections can therefore be avoided. All energy devices (lasers, electric cautery) have been used to perform ERBT with similar perioperative and oncological results. Data show that there is not much difference in respect of perioperative morbidity compared with conventional transurethral resection of bladder tumor; however, only a few publications used a systematic classification system. No conclusions can be drawn regarding the impact of ERBT on recurrence., Conclusions: The major advantage of ERBT is the high rate of detrusor muscle. Based on limited data, no significant differences are observed regarding perioperative morbidity and recurrence rates., Patient Summary: En-bloc resection of bladder tumor is an emerging technique aimed at improving quality of surgical specimens. Available evidences suggest safety and oncologic equivalence compared with the standard transurethral resection of bladder tumor., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: High-quality urologic residency training programs are crucial to secure both the future of our specialty and patient care. However, little is known about the current training and working conditions among German urology residents., Objectives: To comprehensively assess the training- and working conditions among urologic residents in Germany., Materials and Methods: The GeSRU invited all German urologic residents to complete an online survey on training- and work conditions. Furthermore, the model of effort-reward imbalance (ERI) was applied to measure psychosocial strain at work., Results: A total of 476 urologic residents participated in the survey. Workdays are characterized by high pace and workload and economic considerations. This comes at the cost of professional training, research and family time. Due to these circumstances, a relevant part of residents draws or at least considers consequences. Psychosocial strain among participants is high and conveys a risk for physicians' health and patients' quality of care., Conclusion: Our findings call for an adjustment of urologic working and training conditions to preserve high-quality medical treatment and to ensure an attractive working environment.

Limitations inherent in the conventional transurethral resection of bladder tumours, the standard approach for diagnosis and treatment of bladder cancer, are well known: staging errors due to insufficient resection depth as well as intravesical tumour fragmentation, both of which make histopathological evaluation difficult. The purpose of this review is to present recent clinical data on the en-bloc resection of bladder tumours (ERBT), which has been demonstrated to offer a high potential to overcome these limitations. The recent findings show that ERBT provides a good resection quality with varying detection rates for tunica muscularis, which is a surrogate marker for resection quality regarding muscle-invasive tumours. ERBT can be performed using all energy sources. Available data show no relevant difference with regard to perioperative morbidity compared with cTURB. No conclusions can be drawn regarding the impact of ERBT on recurrence as the data are partly controversial. This has to be defined by further studies., Competing Interests: Interessenkonflikt: T.R.W. Herrmann gibt Beratertätigkeiten und Vortragshonorare für Karl Storz GmbH; Boston Scientific; LisaLaser oHG; Asclepion; Ipsen PharmaAG und Janssen-Cilag GmbH an. Die anderen Autoren haben keine Interessenkonflikte., (© Georg Thieme Verlag KG Stuttgart · New York.)