Publications by authors named "Luis A Kluth"

110 Publications

Racial/Ethnic Disparities in Tumor Characteristics and Treatments in Favorable and Unfavorable Intermediate Risk Prostate Cancer.

J Urol 2021 Mar 8:101097JU0000000000001695. Epub 2021 Mar 8.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Background: We hypothesized that differences in active treatment rates may exist according race/ethnicity in favorable, as well as unfavorable intermediate risk (IR) prostate cancer (PCa).

Material And Methods: We relied on the Surveillance, Epidemiology and End Results (SEER) 18 database 2010-2015. We stratified according to three racial/ethnic groups (Caucasian vs. African American vs. Hispanic) and PCa baseline characteristics (PSA, clinical T stage, Gleason group grading [GGG], percentage of biopsy cores). We tabulated active treatment rates (radical prostatectomy [RP], external beam radiotherapy [EBRT]), without and with adjustment for baseline age and PCa characteristics.

Results: Baseline PSA, cT-stage, Gleason grade and percentage of positive biopsy cores differed according to racial/ethnic groups in both favorable and unfavorable IR PCa patients (all p <0.05). Similarly, RP and EBRT rates differed according to race/ethnicity in both favorable and unfavorable IR PCA patients. RP and EBRT rates respectively ranged from 31.7-41.8% and 26.3-31.0% in favorable IR and from 33.4-43.9% and 30.9-35.5% in unfavorable IR PCa, across the three race/ethnicity groups (both p <0.05). The above heterogeneity in active treatment rates disappeared and marginal differences remained after adjustment for baseline age and PCa characteristics.

Conclusion: Interpretation of active treatment rates in favorable and unfavorable IR PCa may be severely biased, unless detailed and systematic consideration or adjustment for baseline age and PCa characteristic is enforced.
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http://dx.doi.org/10.1097/JU.0000000000001695DOI Listing
March 2021

The effect of lymph node dissection on cancer-specific survival in salvage radical prostatectomy patients.

Prostate 2021 Mar 5. Epub 2021 Mar 5.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Background: We hypothesized that lymph node dissection (LND) at salvage radical prostatectomy may be associated with lower cancer-specific mortality (CSM) and we tested this hypothesis.

Methods: We relied on surveillance, epidemiology, and end results (2004-2016) to identify all salvage radical prostatectomy patients. Categorical, as well as univariate and multivariate Cox regression models tested the effect of LND (LND performed vs. not), as well as at its extent (log-transformed lymph node count) on CSM.

Results: Of 427 salvage radical prostatectomy patients, 120 (28.1%) underwent LND with a median lymph node count of 6 (interquartile range [IQR], 3-11). According to LND status, no significant or clinically meaningful differences were recorded in PSA at diagnosis, stage and biopsy Gleason score at diagnosis, except for age at prostate cancer diagnosis (LND performed 63 vs. 68 years LND not performed, p < .001). LND status (performed) was an independent predictor of lower CSM (hazard ratio [HR] 0.47; p = .03). Similarly, lymph node count (log transformed) also independently predicted lower CSM (HR: 0.60; p = .01). After the 7th removed lymph node, the effect of CSM became marginal. The effect of N-stage on CSM could not be tested due to insufficient number of observations.

Conclusions: Salvage radical prostatectomy is rarely performed and LND at salvage radical prostatectomy is performed in a minority of patients. However, LND at salvage radical prostatectomy is associated with lower CSM. Moreover, LND extent also exerts a protective effect on CSM. These observations should be considered in salvage radical prostatectomy candidates.
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http://dx.doi.org/10.1002/pros.24112DOI Listing
March 2021

Effect of prostatic apex shape (Lee types) and urethral sphincter length in preoperative MRI on very early continence rates after radical prostatectomy.

Int Urol Nephrol 2021 Feb 19. Epub 2021 Feb 19.

Department of Urology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.

Purpose: To test the effect of anatomic variants of the prostatic apex overlapping the membranous urethra (Lee type classification), as well as median urethral sphincter length (USL) in preoperative multiparametric magnetic resonance imaging (mpMRI) on the very early continence in open (ORP) and robotic-assisted radical prostatectomy (RARP) patients.

Methods: In 128 consecutive patients (01/2018-12/2019), USL and the prostatic apex classified according to Lee types A-D in mpMRI prior to ORP or RARP were retrospectively analyzed. Uni- and multivariable logistic regression models were used to identify anatomic characteristics for very early continence rates, defined as urine loss of ≤ 1 g in the PAD-test.

Results: Of 128 patients with mpMRI prior to surgery, 76 (59.4%) underwent RARP vs. 52 (40.6%) ORP. In total, median USL was 15, 15 and 10 mm in the sagittal, coronal and axial dimensions. After stratification according to very early continence in the PAD-test (≤ 1 g vs. > 1 g), continent patients had significantly more frequently Lee type D (71.4 vs. 54.4%) and C (14.3 vs. 7.6%, p = 0.03). In multivariable logistic regression models, the sagittal median USL (odds ratio [OR] 1.03) and Lee type C (OR: 7.0) and D (OR: 4.9) were independent predictors for achieving very early continence in the PAD-test.

Conclusion: Patients' individual anatomical characteristics in mpMRI prior to radical prostatectomy can be used to predict very early continence. Lee type C and D suggest being the most favorable anatomical characteristics. Moreover, longer sagittal median USL in mpMRI seems to improve very early continence rates.
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http://dx.doi.org/10.1007/s11255-021-02809-7DOI Listing
February 2021

Comparison Between Urothelial and Non-Urothelial Urethral Cancer.

Front Oncol 2020 29;10:629692. Epub 2021 Jan 29.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada.

Background: To test the effect of variant histology relative to urothelial histology on stage at presentation, cancer specific mortality (CSM), and overall mortality (OM) after chemotherapy use, in urethral cancer.

Materials And Methods: Within the Surveillance, Epidemiology and End Results (2004-2016) database, we identified 1,907 primary variant histology urethral cancer patients. Kaplan-Meier plots, Cox regression analyses, cumulative incidence-plots, multivariable competing-risks regression models and propensity score matching for patient and tumor characteristics were used.

Results: Of 1,907 eligible urethral cancer patients, urothelial histology affected 1,009 (52.9%) vs. squamous cell carcinoma (SCC) 455 (23.6%) vs. adenocarcinoma 278 (14.6%) vs. other histology 165 (8.7%) patients. Urothelial histological patients exhibited lower stages at presentation than SCC, adenocarcinoma or other histology patients. In urothelial histology patients, five-year CSM was 23.5% vs. 34.4% in SCC [Hazard Ratio (HR) 1.57] vs. 40.7% in adenocarcinoma (HR 1.69) vs. 43.4% in other histology (HR 1.99, p < 0.001). After matching in multivariate competing-risks regression models, variant histology exhibited 1.35-fold higher CSM than urothelial. Finally, in metastatic urethral cancer, lower OM was recorded after chemotherapy in general, including metastatic adenocarcinoma and other variant histology subtypes, except metastatic SCC.

Conclusion: Adenocarcinoma, SCC and other histology subtypes affect fewer patients than urothelial histology. Presence of variant histology results in higher CSM. Finally, chemotherapy for metastatic urethral cancer improves survival in adenocarcinoma and other variant histology subtypes, but not in SCC.
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http://dx.doi.org/10.3389/fonc.2020.629692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880052PMC
January 2021

Sex- and Age-Related Differences in the Distribution of Metastases in Patients With Upper Urinary Tract Urothelial Carcinoma.

J Natl Compr Canc Netw 2021 Feb 11:1-7. Epub 2021 Feb 11.

1Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: The distribution of metastatic sites in upper tract urothelial carcinoma (UTUC) is not well-known. Consequently, the effects of sex and age on the location of metastases is also unknown. This study sought to investigate age- and sex-related differences in the distribution of metastases in patients with UTUC.

Materials And Methods: Within the Nationwide Inpatient Sample database (2000-2015), we identified 1,340 patients with metastatic UTUC. Sites of metastasis were assessed according to age (≤63, 64-72, 73-79, and ≥80 years) and sex. Comparison was performed with trend and chi-square tests.

Results: Of 1,340 patients with metastatic UTUC, 790 (59.0%) were men (median age, 71 years) and 550 (41.0%) were women (median age, 74 years). The lung was the most common site of metastases in men and women (28.2% and 26.4%, respectively), followed by bone in men (22.3% vs 18.0% of women) and liver in women (24.4% vs 20.5% of men). Increasing age was associated with decreasing rates of brain metastasis in men (from 6.5% to 2.9%; P=.03) and women (from 5.9% to 0.7%; P=.01). Moreover, increasing age in women, but not in men, was associated with decreasing rates of lung (from 33.3% to 24.3%; P=.02), lymph node (from 28.9% to 15.8%; P=.01), and bone metastases (from 22.2% to 10.5%; P=.02). Finally, rates of metastases in multiple organs did not vary with age or sex (65.2% in men vs 66.5% in women).

Conclusions: Lung, bone, and liver metastases are the most common metastatic sites in both sexes. However, the distribution of metastases varies according to sex and age. These observations apply to everyday clinical practice and may be used, for example, to advocate for universal bone imaging in patients with UTUC. Moreover, our findings may also be used for design considerations of randomized trials.
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http://dx.doi.org/10.6004/jnccn.2020.7637DOI Listing
February 2021

Sex-Related Differences Include Stage, Histology, and Survival in Urethral Cancer Patients.

Clin Genitourin Cancer 2021 Jan 6. Epub 2021 Jan 6.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Purpose: To test the effect of sex on histologic subtype, stage at presentation, treatment, and cancer-specific mortality (CSM) in urethral cancer.

Patients And Methods: We identified urethral cancer patients within the Surveillance, Epidemiology, and End Results (SEER) registry (2004-2016). After matching for tumor and patient characteristics, cumulative incidence plots and multivariable competing risks regression models, adjusted for other-cause mortality, tested CSM according to sex.

Results: Of 1645 eligible urethral cancer patients, 1073 (65%) were male. Urothelial histologic subtype was most frequent in male (59%) but not female (27%) subjects. Adenocarcinoma, squamous cell carcinoma, and other histologies were more frequent in female patients. Most male subjects harbored T1N0M0 (32%) stage disease, whereas most female subjects harbored T3-4N0M0 (29%) stage disease. In urothelial and adenocarcinoma histologic subtypes, African American female subjects were most prevalent (31 and 78%) versus whites (16 and 52%) versus Hispanics (27 and 74%). In T1N0M0 stage, single-mode surgical treatment was more frequent in male than female patients (respectively, 73% vs 59%). In T3-4 and/or N1-2 stage disease, multimodal therapy was more frequent in female than male (42% vs 37%) patients. In nonmetastatic urethral cancer (T1-4N0-2M0), after propensity score matching for stage, race, treatment, and age, cumulative incidence plots showed 5-year CSM of 36% and 25% in female and male patients, respectively, and after further multivariable adjustment resulted in 1.3-fold higher CSM in female as opposed to male patients (P = .07).

Conclusion: Female patients with urethral cancer present with higher disease stage. Despite higher rates of multimodal therapy, and despite matching for stage disadvantage, female subjects with urethral cancer exhibited higher CSM.
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http://dx.doi.org/10.1016/j.clgc.2020.12.001DOI Listing
January 2021

Is Standardization Transferable? Initial Experience of Urethral Surgery at the University Hospital Frankfurt.

Front Surg 2020 14;7:600090. Epub 2020 Dec 14.

Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.

Since January 2018 performance of urethroplasties is done on regular basis at the University Hospital Frankfurt (UKF). We aimed to implement and transfer an institutional standardized perioperative algorithm for urethral surgery (established at the University Hospital Hamburg-Eppendorf-UKE) using a validated Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) in patients undergoing urethroplasty at UKF. We retrospectively analyzed all patients who underwent urethroplasty for urethral stricture disease between January 2018 and January 2020 at UKF. All patients were offered to revisit for clinical follow-up (FU) and completion of USS-PROM. Primary end point was stricture recurrence-free survival (RFS). Secondary endpoints were functional outcomes, quality of life (QoL), and patient satisfaction. In total, 50 patients underwent urethroplasty and 74 and 24% had a history of previous urethrotomy or urethroplasty, respectively. A buccal mucosal graft urethroplasty was performed in 86% ( = 43). After patient's exclusion due to lost of FU, FU <3 months, and/or a pending second stage procedure, 40 patients were eligible for final analysis. At median FU of 10 months (interquartile-range 5.0-18.0), RFS was 83%. After successful voiding trial, the postoperative median Qmax significantly improved (24.0 vs. 7.0 mL/s; < 0.01). Conversely, median residual urine decreased significantly (78 vs. 10 mL; < 0.01). Overall, 95% of patients stated that QoL improved and 90% were satisfied by the surgical outcome. We demonstrated a successful implementation and transfer of an institutional standardized perioperative algorithm for urethral surgery from one location (UKE) to another (UKF). In our short-term FU, urethroplasty showed excellent RFS, low complication rates, good functional results, improvement of QoL and high patient satisfaction. PROMs allow an objective comparison between different centers.
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http://dx.doi.org/10.3389/fsurg.2020.600090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767926PMC
December 2020

Comparison of Complication Rates with Antibiotic Prophylaxis with Cefpodoxime Versus Fluoroquinolones After Transrectal Prostate Biopsy.

Eur Urol Focus 2020 Dec 24. Epub 2020 Dec 24.

Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany.

Background: After recommended restriction of the use of fluoroquinolones, the optimal antibiotic prophylaxis for transrectal prostate biopsy is still under debate.

Objective: To test the effectiveness of cefpodoxime as oral antibiotic prophylaxis for transrectal prostate biopsies and the complication rates relative to fluoroquinolones.

Design, Setting, And Participants: Antibiotic prophylaxis for transrectal prostate biopsies at the Department of Urology at University Hospital Frankfurt was fluoroquinolones for 342 consecutive patients in January 2018 and December 2019 and cefpodoxime for 100 patients from January 2020 to July 2020. Data were prospectively evaluated and retrospectively analyzed. Patients were followed up according to clinical routine at 6 wk after biopsy at the earliest. Patients without follow-up (n = 98) and those receiving antibiotic prophylaxis other than cefpodoxime or fluoroquinolones (n = 15) were excluded.

Intervention: Use of cefpodoxime or fluoroquinolones as antibiotic prophylaxis for transrectal prostate biopsies.

Outcome Measurements And Statistical Analysis: Logistic regression models were used to predict biopsy-related complications according to antibiotic prophylaxis.

Results And Limitations: Of 442 patients, 100 (22.6%) received cefpodoxime as antibiotic prophylaxis. Patient baseline and biopsy characteristics were comparable between the cefpodoxime and fluoroquinolone groups. Moreover, there were no differences in the number of prior prostate biopsies or the proportions of systematic vs. fusion biopsies (p > 0.05). There were no differences between the groups in infectious complications such as epididymitis and prostatitis after biopsy. Infectious complication rates were very low, at 2.0% in the cefpodoxime and0.9%fluoroquinolone group. Moreover, there were no differences between the groups in patient-reported complications, such as gross hematuria occurring at more than 5 d after biopsy, hematospermia, or rectal bleeding. In multivariable analyses, after adjustment for patient and prostate biopsy characteristics, cefpodoxime was not associated with higher complication rates than fluoroquinolones (p > 0.05).

Conclusions: Complications after transrectal prostate biopsies are rare and cefpodoxime might be a sufficient choice as oral antibiotic prophylaxis and noninferior compared to fluoroquinolones.

Patient Summary: Cefpodoxime might be a sufficient choice as an easily applicable oral antibiotic prophylaxis for transrectal prostate biopsy. The safety profile of cefpodoxime is comparable to the safety profile of fluoroquinolones.
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http://dx.doi.org/10.1016/j.euf.2020.11.006DOI Listing
December 2020

Upper Urinary Tract Tumors: Variant Histology Versus Urothelial Carcinoma.

Clin Genitourin Cancer 2020 Dec 2. Epub 2020 Dec 2.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Purpose: To evaluate stage at presentation and cancer-specific mortality (CSM) in upper urinary tract tumors according to histologic subtype.

Methods: Within the Surveillance, Epidemiology, and End Results registry (SEER, 2004-2016), we identified patients with upper urinary tract tumors with pure variant histology (UTVH) and pure upper urinary tract urothelial carcinoma (UTUC). Cumulative incidence plots, after propensity score matching for tumor and patient characteristics, addressed CSM. Subgroup analyses addressed efficacy of radical nephroureterectomy (RNU) in stage T1-2 and of chemotherapy in metastatic UTVH patients.

Results: Of all 11,809 upper urinary tract tumor patients, 154 (1.3%) harbored squamous cell carcinoma (SCC), 86 (0.7%) adenocarcinoma, 39 (0.3%) neuroendocrine carcinoma, 38 (0.3%) other UTVH, and 11,492 (97.3%) UTUC. UTVH patients were more likely to exhibit metastatic stage disease at diagnosis than UTUC (odds ratio, 1.9; 95% confidence interval, 1.3-2.8; P < .01). After detailed matching for performance status, only SCC showed significantly higher CSM than UTUC (multivariate HR = 1.71; P < .01). Subgroup analyses in stage T1-2 RNU patients showed, relative to UTUC patients, no CSM differences for SCC or adenocarcinoma patients. No significant survival benefit for chemotherapy administration was identified in patients with metastatic SCC or metastatic adenocarcinoma. This study is limited by its sample size and the missing centralized pathologic review.

Conclusions: Disease stage at diagnosis is more advanced in UTVH patients than UTUC. Across all stages, CSM is higher for SCC than for UTUC. However, in T1-2 stage disease, RNU results in similar survival in SCC or adenocarcinoma versus UTUC.
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http://dx.doi.org/10.1016/j.clgc.2020.11.004DOI Listing
December 2020

Catheter Management and Risk Stratification of Patients With in Inpatient Treatment Due to Acute Epididymitis.

Front Surg 2020 3;7:609661. Epub 2020 Dec 3.

Department of Urology, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany.

This study aims to evaluate catheter management in acute epididymitis (AE) patients requiring inpatient treatment and risk factors predicting severity of disease. Patients with diagnosed AE and inpatient treatment between 2004 and 2019 at the University Hospital Frankfurt were analyzed. A risk score, rating severity of AE, including residual urine > 100 ml, fever > 38.0°C, C-reactive protein (CRP) > 5 mg/dl, and white blood count (WBC) > 10/nl was introduced. Of 334 patients, 107 (32%) received a catheter (transurethral (TC): = 53, 16%, suprapubic (SPC): = 54, 16%). Catheter patients were older, exhibited more comorbidities, and had higher CRP and WBC compared with the non-catheter group (NC). Median length of stay (LOS) was longer in the catheter group (7 vs. 6 days, < 0.001), whereas necessity of abscess surgery and recurrent epididymitis did not differ. No differences in those parameters were recorded between TC and SPC. According to our established risk score, 147 (44%) patients exhibited 0-1 () and 187 (56%) 2-4 risk factors (). In the high-risk group, patients received a catheter significantly more often than with low-risk (TC: 22 vs. 9%; SPC: 19 vs. 12%, both ≤ 0.01). Catheter or high-risk patients exhibited positive urine cultures more frequently than NC or low-risk patients. LOS was comparable between high-risk patients with catheter and low-risk NC patients. Patients with AE who received a catheter at admission were older, multimorbid, and exhibited more severe symptoms of disease compared with the NC patients. A protective effect of catheters might be attributable to patients with adverse risk constellations or high burden of comorbidities. The introduced risk score indicates a possibility for risk stratification.
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http://dx.doi.org/10.3389/fsurg.2020.609661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744346PMC
December 2020

Recovery from minimally invasive vs. open surgery in kidney cancer patients: Opioid use and workplace absenteeism.

Investig Clin Urol 2021 Jan 13;62(1):56-64. Epub 2020 Nov 13.

Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Purpose: Does surgical approach (minimally invasive vs. open) and type (radical vs. partial nephrectomy) affects opioid use and workplace absenteeism.

Materials And Methods: Retrospective multivariable regression analysis of 2,646 opioid-naïve patients between 18 and 64 undergoing radical or partial nephrectomy via either a minimally invasive vs. open approach for kidney cancer in the United States between 2012 and 2017 drawn from the IBM Watson Health Database was performed. Outcomes included: (1) opioid use in opioid-naïve patients as measured by opioid prescriptions in the post-operative setting at early, intermediate and prolonged time periods and (2) workplace absenteeism after surgery.

Results: Patients undergoing minimally invasive surgery had a lower odds of opioid use in the early and intermediate post-operative periods (early: odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62-0.97; p=0.02, intermediate: OR, 0.60; 95% CI, 0.48-0.75; p<0.01), but not in the prolonged setting (prolonged: OR, 1.00; 95% CI, 0.75-1.34; p=0.98) and had earlier return to work (minimally invasive vs. open: -10.53 days; 95% CI, -17.79 to -3.26; p<0.01). Controlling for approach, patient undergoing partial nephrectomy had lower rates of opioid use across all time periods examined and returned to work earlier than patients undergoing radical nephrectomy (partial vs. radical: -14.41 days; 95% CI, -21.22 to -7.60; p<0.01).

Conclusions: Patients undergoing various forms of surgery for kidney cancer had lower rates of peri-operative opioid use, fewer days of workplace absenteeism, but no difference in long-term rates of opioid use in patients undergoing minimally invasive as compared to open surgery.
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http://dx.doi.org/10.4111/icu.20200194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801161PMC
January 2021

The effect of race/ethnicity on histological subtype distribution, stage at presentation and cancer specific survival in urethral cancer.

Urol Oncol 2020 Dec 10. Epub 2020 Dec 10.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Objective: To test the effect of race/ethnicity on histological subtype, stage at presentation, and cancer specific mortality (CSM) in urethral cancer patients.

Material And Methods: Stratified analyses (Surveillance, Epidemiology and End Results [2004-2016]) tested the effect of race/ethnicity on histology and stage. Cumulative incidence-plots and multivariable competing-risks regression models (CRR), addressed CSM, after matching for TNM-stage, histology, age, and gender.

Results: Of 1,904 urethral cancer patients, 71% were Caucasian, 16% African American, 7% Hispanic and 5% other. African Americans were younger (66 years) than Caucasians (73 years) and Hispanics (74 years). In African Americans, adenocarcinoma (25%) and squamous cell carcinoma (SCC; 29%) were more frequent than in Caucasians (12% and 23%) or Hispanics (15% and 20%). African Americans with adenocarcinoma exhibited higher stage than other adenocarcinoma patients. In CRR, African Americans (35%) and Hispanics (29%) exhibited highest and second highest 3-year CSM, even after matching. After further multivariable adjustment of matched CRRs, CSM was higher in Hispanics (HR: 1.93, P= 0.03) and in African Americans (Hazard ratio 1.35, P= 0.07), relative to Caucasians.

Conclusion: Race/ethnicity impacts important differences on urethral cancer patients. African American race/ethnicity predisposes to higher rate of SCC and adenocarcinoma. Moreover, African Americans are younger and present with higher stage at diagnoses. Finally, even after most detailed matching for stage, age, gender, and adjustment for treatment and systemic therapy and socioeconomic status, African Americans and Hispanics exhibit higher CSM than Caucasians.
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http://dx.doi.org/10.1016/j.urolonc.2020.11.031DOI Listing
December 2020

AUTHOR REPLY.

Urology 2020 Dec;146:258-259

Department of Urology, University Medical Center Frankfurt, Frankfurt (Main), Germany.

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http://dx.doi.org/10.1016/j.urology.2020.07.076DOI Listing
December 2020

Long-Term Effects of Mental Training on Manual and Cognitive Skills in Surgical Education - A Prospective Study.

J Surg Educ 2020 Nov 27. Epub 2020 Nov 27.

Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Objectives: Limited training opportunities and expanding requirements are challenging surgical education, calling for alternative training methods like simulation or mental training. The aim of this study is to evaluate short- and long-term effects of a structured mental training on surgical performance.

Design: Medical students without laparoscopic experience were randomly assigned to 3 groups: (1) control (2) video training, and (3) video plus mental training performing 2 E-BLUS (European Training in Basic Laparoscopic Urological Skills) exercises, "peg transfer" (PT) and "cutting a circle" (CC). Group 3 performed a structured mental training course (identification of procedural key steps, relaxation, mental vocalization, and imaging). Longitudinal assessment including binominal checklists, global rating scales (GRS), procedural times, and Test of Performance Strategies (TOPS) were performed at baseline, day 2, 14, and after 16 months. Statistical analysis included ANOVA and general linear models with repeated measures.

Setting: The study was conducted in "Olympus Training and Education Center Hamburg West" and "Endo Club Academy" at the University Medical Center Hamburg-Eppendorf.

Participants: Participants were eligible if they were medical students with no experience in laparoscopy. 24 participants were recruited and finished the study.

Results: The mental training group maintained significantly better GRS scores at 16 months for PT (mean score 24.6 [95% CI: 21-28.25]) and CC (mean score 22.5 [18.4-26.6]) (both p < 0.01) and performed faster in the latter (261 seconds [Std. Dev 116] vs. 427 seconds [SD 132] vs. 368 seconds [SD 78]) compared to the other groups (p = 0.004). Longitudinally, mental training had a significant effect on TOPS scores and procedural times (p < 0.001 and p = 0.005, respectively).

Conclusion: In addition to short time efficacy, our study is the first to ascertain a positive long-term effect of mental training on manual and cognitive skills and might be a useful and cost-effective tool in surgical education.
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http://dx.doi.org/10.1016/j.jsurg.2020.11.005DOI Listing
November 2020

The Effect of Adverse Patient Characteristics on Perioperative Outcomes in Open and Robot-Assisted Radical Prostatectomy.

Front Surg 2020 10;7:584897. Epub 2020 Nov 10.

Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.

To analyze the effect of adverse preoperative patient and tumor characteristics on perioperative outcomes of open (ORP) and robot-assisted radical prostatectomy (RARP). We retrospectively analyzed 656 patients who underwent ORP or RARP according to intraoperative blood loss (BL), operation time (OR time), neurovascular bundle preservation (NVBP) and positive surgical margins (PSM). Univariable and multivariable logistic regression models were used to identify risk factors for impaired perioperative outcomes. Of all included 619 patients, median age was 66 years. BMI (<25 vs. 25-30 vs. ≥30) had no influence on blood loss. Prostate size >40cc recorded increased BL compared to prostate size ≤ 40cc in patients undergoing ORP (800 vs. 1200 ml, < 0.001), but not in patients undergoing RARP (300 vs. 300 ml, = 0.2). Similarly, longer OR time was observed for ORP in prostates >40cc, but not for RARP. Overweight (BMI 25-30) and obese ORP patients (BMI ≥30) showed longer OR time compared to normal weight (BMI <25). Only obese patients, who underwent RARP showed longer OR time compared to normal weight. NVBP was less frequent in obese patients, who underwent ORP, relative to normal weight (25.8% vs. 14.0%, < 0.01). BMI did not affect NVPB at RARP. No differences in PSM were recorded according to prostate volume or BMI in ORP or RARP. In multivariable analyses, patient characteristics such as prostate volume and BMI was an independent predictor for prolonged OR time. Moreover, tumor characteristics (stage and grade) predicted worse perioperative outcome. Patients with larger prostates and obese patients undergoing ORP are at risk of higher BL, OR time or non-nervesparing procedure. Conversely, in patients undergoing RARP only obesity is associated with increased OR time. Patients with larger prostates or increased BMI might benefit most from RARP compared to ORP.
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http://dx.doi.org/10.3389/fsurg.2020.584897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683519PMC
November 2020

Bladder cancer stage and mortality: urban vs. rural residency.

Cancer Causes Control 2021 Feb 23;32(2):139-145. Epub 2020 Nov 23.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Objective: Relative to urban populations, rural patients may have more limited access to care, which may undermine timely bladder cancer (BCa) diagnosis and even survival.

Methods: We tested the effect of residency status (rural areas [RA < 2500 inhabitants] vs. urban clusters [UC ≥ 2500 inhabitants] vs. urbanized areas [UA, ≥50,000 inhabitants]) on BCa stage at presentation, as well as on cancer-specific mortality (CSM) and other cause mortality (OCM), according to the US Census Bureau definition. Multivariate competing risks regression (CRR) models were fitted after matching of RA or UC with UA in stage-stratified analyses.

Results: Of 222,330 patients, 3496 (1.6%) resided in RA, 25,462 (11.5%) in UC and 193,372 (87%) in UA. Age, tumor stage, radical cystectomy rates or chemotherapy use were comparable between RA, UC and UA (all p > 0.05). At 10 years, RA was associated with highest OCM followed by UC and UA (30.9% vs. 27.7% vs. 25.6%, p < 0.01). Similarly, CSM was also marginally higher in RA or UC vs. UA (20.0% vs. 20.1% vs. 18.8%, p = 0.01). In stage-stratified, fully matched CRR analyses, increased OCM and CSM only applied to stage T1 BCa patients.

Conclusion: We did not observe meaningful differences in access to treatment or stage distribution, according to residency status. However, RA and to a lesser extent UC residency status, were associated with higher OCM and marginally higher CSM in T1N0M0 patients. This observation should be further validated or refuted in additional epidemiological investigations.
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http://dx.doi.org/10.1007/s10552-020-01366-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810614PMC
February 2021

Impact of "Time-From-Biopsy-to-Prostatectomy" on Adverse Oncological Results in Patients With Intermediate and High-Risk Prostate Cancer.

Front Surg 2020 25;7:561853. Epub 2020 Sep 25.

Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany.

Many patients with localized prostate cancer (PCa) do not immediately undergo radical prostatectomy (RP) after biopsy confirmation. The aim of this study was to investigate the influence of "time-from-biopsy-to- prostatectomy" on adverse pathological outcomes. Between January 2014 and December 2019, 437 patients with intermediate- and high risk PCa who underwent RP were retrospectively identified within our prospective institutional database. For the aim of our study, we focused on patients with intermediate- ( = 285) and high-risk ( = 151) PCa using D'Amico risk stratification. Endpoints were adverse pathological outcomes and proportion of nerve-sparing procedures after RP stratified by "time-from-biopsy-to-prostatectomy": ≤3 months vs. >3 and < 6 months. Medians and interquartile ranges (IQR) were reported for continuously coded variables. The chi-square test examined the statistical significance of the differences in proportions while the Kruskal-Wallis test was used to examine differences in medians. Multivariable (ordered) logistic regressions, analyzing the impact of time between diagnosis and prostatectomy, were separately run for all relevant outcome variables (ISUP specimen, margin status, pathological stage, pathological nodal status, LVI, perineural invasion, nerve-sparing). We observed no difference between patients undergoing RP ≤3 months vs. >3 and <6 months after diagnosis for the following oncological endpoints: pT-stage, ISUP grading, probability of a positive surgical margin, probability of lymph node invasion (LNI), lymphovascular invasion (LVI), and perineural invasion (pn) in patients with intermediate- and high-risk PCa. Likewise, the rates of nerve sparing procedures were 84.3 vs. 87.4% ( = 0.778) and 61.0% vs. 78.8% ( = 0.211), for intermediate- and high-risk PCa patients undergoing surgery after ≤3 months vs. >3 and <6 months, respectively. In multivariable adjusted analyses, a time to surgery >3 months did not significantly worsen any of the outcome variables in patients with intermediate- or high-risk PCa (all > 0.05). A "time-from-biopsy-to-prostatectomy" of >3 and <6 months is neither associated with adverse pathological outcomes nor poorer chances of nerve sparing RP in intermediate- and high-risk PCa patients.
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http://dx.doi.org/10.3389/fsurg.2020.561853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545071PMC
September 2020

Association of surgical approach and prolonged opioid prescriptions in patients undergoing major pelvic cancer procedures.

BMC Surg 2020 Oct 14;20(1):235. Epub 2020 Oct 14.

Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA.

Background: The rise in deaths attributed to opioid drugs has become a major public health problem in the United States and in the world. Minimally invasive surgery (MIS) is associated with a faster postoperative recovery and our aim was to investigate if the use of MIS was associated with lower odds of prolonged opioid prescriptions after major procedures.

Methods: Retrospective study using the IBM Watson Health Marketscan® Commerical Claims and Encounters Database investigating opioid-naïve cancer patients aged 18-64 who underwent open versus MIS radical prostatectomy (RP), partial colectomy (PC) or hysterectomy (HYS) from 2012 to 2017. Propensity weighted logistic regression analyses were used to estimate the independent effect of surgical approach on prolonged opioid prescriptions, defined as prescriptions within 91-180 days of surgery.

Results: Overall, 6838 patients underwent RP (MIS 85.5%), 4480 patients underwent PC (MIS 61.6%) and 1620 patients underwent HYS (MIS 41.8%). Approximately 70-80% of all patients had perioperative opioid prescriptions. In the weighted model, patients undergoing MIS were significantly less likely to have prolonged opioid prescriptions in all three surgery types (Odds Ratio [OR] 0.737, 95% Confidence Interval [CI] 0.595-0.914, p = 0.006; OR 0.728, 95% CI 0.600-0.882, p = 0.001; OR 0.655, 95% CI 0.466-0.920, p = 0.015, respectively).

Conclusion: The use of the MIS was associated with lower odds of prolonged opioid prescription in all procedures examined. While additional studies such as clinical trials are needed for further confirmation, our findings need to be considered for patient counseling as postoperative differences between approaches do exist.
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http://dx.doi.org/10.1186/s12893-020-00879-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557098PMC
October 2020

Micropapillary Versus Urothelial Carcinoma of the Urinary Bladder: Stage at Presentation and Efficacy of Chemotherapy Across All Stages-A SEER-based Study.

Eur Urol Focus 2020 Sep 19. Epub 2020 Sep 19.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Background: Stage-specific guideline recommendations are lacking for chemotherapy in micropapillary carcinoma of the urinary bladder (MCUB).

Objective: To test the efficacy of stage-specific chemotherapy for MCUB.

Design, Setting, And Participants: Within the Surveillance, Epidemiology and End Results (SEER) registry (2001-2016), we identified patients with MCUB and pure urothelial carcinoma of the urinary bladder (UCUB) of all stages.

Outcome Measurements And Statistical Analysis: Kaplan-Meier survival analyses and multivariate Cox regression models were used to determine cancer-specific mortality (CSM) in addition to power analyses.

Results And Limitations: Of 210 491 patients of all stages, 518 (0.2%) harboured MCUB versus 209 973 (99.8%) UCUB. Stage at presentation was invariably higher in MCUB than in UCUB patients. Of the MCUB patients, 223 (43.1%) received chemotherapy versus 42 921 (20.4%) of the UCUB patients. In MCUB patients, chemotherapy improved CSM-free survival significantly in metastatic stage (hazard ratio [HR] 0.36, p = 0.04). Longer median CSM-free survival was also associated with chemotherapy use in addition to radical cystectomy (RC) versus RC alone in non-organ-confined MCUB (HR 0.69, p = 0.2). Additional power analyses revealed an underpowered comparison. Finally, no CSM difference was recorded in organ-confined MCUB according to the use of chemotherapy in addition to RC versus RC alone (HR 0.98, p = 1).

Conclusions: Stage at presentation was invariably higher in MCUB than in UCUB patients. Very important CSM reduction was associated with chemotherapy use in metastatic MCUB. A promising protective effect of perioperative chemotherapy might also be applicable to non-organ-confined MCUB, but without sufficient statistical power. Conversely, no association was recorded in organ-confined MCUB.

Patient Summary: Patients with micropapillary carcinoma of the urinary bladder (MCUB) present in higher tumour stages than those with urothelial carcinoma of the urinary bladder. Chemotherapy for MCUB is effective in metastatic stages, but of no beneficial effect in organ-confined stage. In not-yet-metastatic but already non-organ-confined stages, we did not have enough observations to show a statistically significant protective effect of chemotherapy.
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http://dx.doi.org/10.1016/j.euf.2020.08.010DOI Listing
September 2020

Impact of Cardiovascular and Metabolic Risk Factors on Stricture Recurrence After Anterior One-stage Buccal Mucosal Graft Urethroplasty.

Urology 2020 Dec 18;146:253-259. Epub 2020 Sep 18.

Department of Urology, University Medical Center Frankfurt, Frankfurt (Main), Germany.

Objectives: To evaluate the impact of cardiovascular, metabolic and smoking related risk factors on recurrence in patients with buccal mucosal graft urethroplasty for anterior urethral strictures.

Patients And Methods: Retrospective single-center analysis between 2009 and 2016. Covariates included American Society of Anesthesiology (ASA) score, body mass index, and smoking status (never vs ever), coronary artery disease, arterial hypertension, diabetes mellitus, change in hemoglobin, creatinine, c-reactive protein, and leucocyte count. Descriptive and survival analyses evaluated the association with stricture recurrence.

Results: Overall, 1039 patients had buccal mucosal graft urethroplasty of which 517 remained for final analysis. Patients with stricture recurrence (n = 76) were significantly older (P < .001), had a higher American Society of Anesthesiology score (P = .006), higher proportion coronary artery disease (P = .011), and hypertension (P = .003) compared to those patients without stricture recurrence. Patients without stricture recurrence had a significantly larger drop in hemoglobin (1.5 [0.9, 2.1] vs 1.2 [0.7, 1.8]) mg/dl ( = .005).Overall stricture-free recurrence rate was 86%, with a median follow-up of 32 (95% confidence interval: 26-30) months. In multivariable analysis, a larger drop of hemoglobin remained the only independent, statistically significant negative predictor of stricture recurrence (Hazard ratio, 95% confidence interval: 0.74, 0.57-0.97, P = .03).

Conclusion: A larger drop of hemoglobin is independently associated with recurrence free survival. This may be considered as a surrogate marker for good microvascular circulation of the corpus spongiosum and therefore neovascularization of the graft. Contrary to the existing and mostly heterogenous previous studies, our findings suggest that stricture recurrence is largely independent of cardiovascular and metabolic risk factors.
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http://dx.doi.org/10.1016/j.urology.2020.07.073DOI Listing
December 2020

Impact of tumor size on the oncological outcome of high-grade nonmuscle invasive bladder cancer - examining the utility of classifying Ta bladder cancer based on size.

Urol Oncol 2020 Nov 29;38(11):851.e19-851.e25. Epub 2020 Jul 29.

Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany. Electronic address:

Purpose: To examine survival rates and to calculate the risk of disease recurrence, progression, overall, and cancer-specific mortality in patients diagnosed with high-risk NMIBC using a multi-institutional dataset to evaluate differences between the guidelines of the European Association of Urology and the guidelines of the National Comprehensive Cancer Network (NCCN) with regard to tumor size in risk stratification.

Methods And Material: In total 1,116 individuals diagnosed with high-risk NMIBC between 2001 and 2013 were included in the analysis. Patients were stratified to NCCN guideline recommendations (high-grade T1, high-grade Ta ≤ 3 cm, and high-grade Ta > 3 cm). Recurrence and progression rates were calculated. Kaplan-Meier curves were fitted to examine differences in recurrence-free (RFS) and progression-free survival (PFS). Multivariable Cox proportional hazards regression models were employed to calculate differences in the RFS, PFS, overall, and cancer-specific survival (CSS).

Results: The majority of patients were diagnosed with high-grade T1 disease (N = 576, 51.6%), while 34.2% and 14.2% of patients were diagnosed with high-grade Ta ≤ 3 cm and Ta > 3 cm NMIBC, respectively. The 1- and 5-year RFS (1-year: 80.5% vs. 64.9%; 5-year: 58.6% vs. 48.3%, P = 0.048) and PFS (1-year: 99.1% vs. 98.6%; 5-year: 97.7% vs. 92.4%, P = 0.054) rates were higher in patients with Ta ≤ 3 cm. Patients diagnosed with high-grade Ta > 3 cm experienced unfavorable progression-free, and cancer-specific survival compared to high-grade Ta ≤ 3 cm, respectively (PFS: 2.41, 95% confidence interval [CI] 1.05-5.56, P = 0.038; CSS: hazard ratios [HR] 2.22, 95% CI 1.02-4.89, P = 0.048).

Conclusion: Patients diagnosed with high-grade Ta NMIBC ≤3 cm demonstrated a favorable progression-free, and cancer-specific survival compared to patients diagnosed with high-grade Ta > 3 cm and high-grade T1 NMIBC.
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http://dx.doi.org/10.1016/j.urolonc.2020.06.034DOI Listing
November 2020

Obesity is associated with adverse short-term perioperative outcomes in patients treated with open and robot-assisted radical cystectomy for bladder cancer.

Urol Oncol 2021 Jan 17;39(1):75.e17-75.e25. Epub 2020 Jul 17.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

Background: Obese patients may be predisposed to adverse perioperative outcomes and it is uncertain whether robot-assisted radical cystectomy (RARC) benefits obese patients in comparison to open radical cystectomy (ORC). Thus, we tested the effect of obesity and surgical approach on perioperative outcomes and total hospital charges.

Methods: Within the National Inpatient Sample database (2008-2015), we identified obese (body mass index ≥30 kg/m2) vs. non-obese patients with non-metastatic bladder cancer treated with RARC or ORC. Estimated annual percent changes and weighted multivariable logistic and linear regression models adjusted for clustering as well as age, comorbidities, hospital volume, and respectively surgical approach, lengths of stay, and/or complications were used.

Results: Of all 11,594 patients (unweighted patient count), 1,119 (9.7%) were obese vs. 10,475 (90.3%) were not-obese. Obesity rate increased significantly over time (5.5%-13.3%, annual change: 11%, P = 0.001). RARC, as well as treatment in high volume hospitals was more prevalent in obese vs. non-obese patients (18.3 vs. 14.5% and 40.9 vs. 37.0%, both P < 0.01). In multivariable regression models, obesity independently predicted overall complications (odds ratio [OR] 1.23, confidence interval [CI]: 1.09-1.42), major complications (OR 1.63, CI: 1.41-1.87), longer hospital stay (OR 1.17, CI: 1.02-1.34) and higher total hospital charges ($+8,260, CI: 3951-12,570), all P < 0.01). In subgroup analyses in obese patients, RARC was not associated with overall (OR 1.15, P = 0.4) and major complications (OR 1.10, P = 0.6) or length of stay (OR 0.78, P = 0.1) compared with ORC but with higher hospital charges (+$16,794, P = 0.005).

Conclusion: Obesity predisposes to higher rates of adverse perioperative outcomes at radical cystectomy. The benefit of RARC could not be validated in obese patients.
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http://dx.doi.org/10.1016/j.urolonc.2020.06.020DOI Listing
January 2021

Holmium laser enucleation of the prostate: efficacy, safety and preoperative management in patients presenting with anticoagulation therapy.

World J Urol 2020 Jun 2. Epub 2020 Jun 2.

Department of Urology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.

Purpose: We evaluated efficacy and safety profile of patients with anticoagulation therapy (AT) undergoing holmium laser enucleation of the prostate (HoLEP).

Methods: Within our prospective institutional database (11/2017 to 11/2019), we analyzed functional outcomes and 30-day complication rates of HoLEP patients according to Clavien-Dindo classification (CLD), stratified according to specific AT vs. no AT. Further analyses consisted of uni- and multivariate logistic regression models (LRM) predicting complications.

Results: Of 268 patients undergoing HoLEP, 104 (38.8%) received AT: 25.7% were treated with platelet aggregation inhibitors (PAI), 8.2% with new oral anticoagulants (NOAC) and 4.9% with AT-combinations or coumarins bridged with low molecular weight heparins (LMWH/combination). Patients receiving AT were significantly more comorbid (p < 0.01). Pre- and postoperative maximal flow rates, residual void urine and IPSS at 3 months after surgery were invariably improved after HoLEP for patients with/ without AT. Overall complication rate was 19.5% in patients with no AT vs. 26.1% vs. 27.3 vs. 46.2%, respectively, in patients with PAI, NOAC and LMWH/combination (p < 0.01). Major complications (CLD ≥ 3b) occurred in 6.1% of no AT patients vs. 4.3% vs. 4.5 vs. 0% in patients with PAI, NOAC and LMWH/combination, respectively (p < 0.01). In multivariate LRM, AT was not significantly associated with higher complication rates, whereas high ASA status (OR 2.2, p = 0.04), age (OR 1.04, p = 0.02) and bioptical or incidental prostate cancer (OR 2.5, p = 0.01) represented independent risk factors.

Conclusion: Despite higher overall complication rates in AT patients, major complications were not more frequent in AT patients. HoLEP is safe and effective in anticoagulated patients.
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http://dx.doi.org/10.1007/s00345-020-03272-2DOI Listing
June 2020

Complication Rates After TRUS Guided Transrectal Systematic and MRI-Targeted Prostate Biopsies in a High-Risk Region for Antibiotic Resistances.

Front Surg 2020 28;7. Epub 2020 Feb 28.

Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.

There is still an ongoing debate whether a transrectal ultrasound (TRUS) approach for prostate biopsies is associated with higher (infectious) complications rates compared to transperineal biopsies. This is especially of great interests in settings with elevated frequencies of multidrug resistant organisms (MDRO). Between 01/2018 and 05/2019 230 patients underwent a TRUS-guided prostate biopsy at the department of Urology at University Hospital Frankfurt. Patients were followed up within the clinical routine that was not conducted earlier than 6 weeks after the biopsy. Among 230 biopsies, 180 patients took part in the follow-up. No patients were excluded. Patients were analyzed retrospectively regarding complications, infections and underlying infectious agents or needed interventions. Of all patients with follow up, 84 patients underwent a systematic biopsy (SB) and 96 a targeted biopsy (TB) after MRI of the prostate with additional SB. 74.8% of the patients were biopsy-naïve. The most frequent objective complications (classified by Clavien-Dindo) lasting longer than one day after biopsy were hematuria (17.9%, = 32), hematospermia (13.9%, = 25), rectal bleeding (2.8%, = 5), and pain (2.2%, = 4). Besides a known high MDRO prevalence in the Rhine-Main region, only one patient (0.6%) developed fever after biopsy. One patient each (0.6%) consulted a physician due to urinary retention, rectal bleeding or gross hematuria. There were no significant differences in complications seen between SB and SB + TB patients. The rate of patients who consulted a physician was significantly higher for patients with one or more prior biopsies compared to biopsy-naïve patients. Complications after transrectal prostate biopsies are rare and often self-limiting. Infections were seen in <1% of all patients, regardless of an elevated local prevalence of MDROs. Severe complications (Clavien-Dindo ≥ IIIa) were only seen in 3 (1.7%) of the patients. Repeated biopsy is associated with higher complication rates in general.
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http://dx.doi.org/10.3389/fsurg.2020.00007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059219PMC
February 2020

Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM).

World J Urol 2020 Nov 18;38(11):2863-2872. Epub 2020 Feb 18.

Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

Objectives: To evaluate objective treatment success and subjective patient-reported outcomes in patients with radiation-induced urethral strictures undergoing single-stage urethroplasty.

Patients And Methods: Monocentric study of patients who underwent single-stage ventral onlay buccal mucosal graft urethroplasty for a radiation-induced stricture between January 2009 and December 2016. Patients were characterized by descriptive analyses. Kaplan-Meier estimates were employed to plot recurrence-free survival. Recurrence was defined as any subsequent urethral instrumentation (dilation, urethrotomy, urethroplasty). Patient-reported functional outcomes were evaluated using the validated German extension of the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM).

Results: Overall, 47 patients were available for final analyses. Median age was 70 (IQR 65-74). Except for two, all patients had undergone pelvic radiation therapy for prostate cancer. Predominant modality was external beam radiation therapy in 70% of patients. Stricture recurrence rate was 33% at a median follow-up of 44 months (IQR 28-68). In 37 patients with available USS PROM data, mean six-item LUTS score was 7.2 (SD 4.3). Mean ICIQ sum score was 9.8 (SD 5.4). Overall, 53% of patients reported daily leaking and of all, 26% patients underwent subsequent artificial urinary sphincter implantation. Mean IIEF-EF score was 4.4 (SD 7.1), indicating severe erectile dysfunction. In 38 patients with data regarding the generic health status and treatment satisfaction, mean EQ-5D index score and EQ VAS score was 0.91 (SD 0.15) and 65 (SD 21), respectively. Overall, 71% of patients were satisfied with the outcome.

Conclusion: The success rate and functional outcome after BMGU for radiation-induced strictures were reasonable. However, compared to existing long-term data on non-irradiated patients, the outcome is impaired and patients should be counseled accordingly.
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http://dx.doi.org/10.1007/s00345-020-03102-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644515PMC
November 2020

Minimally invasive cancer surgery is associated with a lower risk of venous thromboembolic events.

J Surg Oncol 2020 Mar 8;121(3):578-583. Epub 2020 Jan 8.

Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Venous thromboembolism (VTE) is a significant source of postoperative morbidity and mortality in patients undergoing common oncologic procedures. We sought to estimate the effect of surgical approach on the risk of developing a VTE.

Methods: IBM Watson Health Marketscan Database was used to conduct this retrospective study. In total, 12 938 patients who underwent either a radical prostatectomy, partial colectomy, or hysterectomy via a minimally invasive or open approach. We used a propensity-weighted logistic regression analysis to assess the independent effect of surgical approach on VTE. The primary outcome of interest was the 90-day rate of VTE after surgery.

Results: Patients undergoing minimally invasive surgery across all three surgical procedures were noted to have a lower odds of developing a VTE: (radical prostatectomy, odds ratio [OR]: 0.667, 95% confidence interval [CI]: 0.500-0.891; P = .006 |partial colectomy: OR, 0.620, 95% CI: 0.477-0.805; P < .001| hysterectomy: OR, 0.549 95% CI: 0.353-0.854; P = .008).

Conclusion: We found that a minimally invasive approach was associated with significantly lower odds of VTE compared with undergoing the same open procedure. This study highlights how surgical approach may be an independent risk factor for development of VTE and may elucidate potential risk mitigation strategy.
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http://dx.doi.org/10.1002/jso.25832DOI Listing
March 2020

Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options.

World J Urol 2020 Oct 30;38(10):2609-2620. Epub 2019 Nov 30.

Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

Objectives: To describe the operative technique and report outcomes from the largest series of patients who underwent single-stage dorsal inlay buccal mucosal graft urethroplasty (BMGU) for isolated meatal stenoses and fossa navicularis strictures.

Patients And Methods: First, we evaluated patients who underwent single-stage BMGU for distal urethral strictures (meatus and fossa navicularis) between 2009 and 2016 at our department. Clinical and surgical characteristics were prospectively collected in an institutional database. Recurrence was defined as symptomatic need of any instrumentation during follow-up, was retrospectively assessed by patient interview, and recurrence-free survival was plotted using Kaplan-Meier curves. Second, a systematic literature review was performed through Medline to summarize the available evidence on distal urethroplasty using flaps or grafts.

Results: Of 32 patients, 16 (50%) presented with a hypospadias-associated stricture, followed by seven (22%), five (16%), and four (13%) patients with iatrogenic, inflammatory, and congenital strictures, respectively. At a median follow-up of 42 months (IQR 23-65), single-stage dorsal inlay BMGU was successful in 22 patients (69%), and estimated recurrence-free survival rates were 79% and 74% at 12 and 24 months, respectively. Overall, 62 patients from five studies in the literature review underwent BMGU for isolated distal strictures and success rates ranged from 56 to 100%.

Conclusion: Recurrent meatal stenoses and fossa navicularis strictures represent some of the most complex uro-reconstructive challenges. Inlay BMGU proves to be a valid and efficient last-resort single-stage technique. However, higher recurrence risk must be considered and staged urethroplasty should be discussed individually. Prospective randomized controlled trials are needed to prove the superiority of flaps, grafts or staged approaches over each other in this context.
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http://dx.doi.org/10.1007/s00345-019-03035-8DOI Listing
October 2020

Differences in survival and impact of adjuvant chemotherapy in patients with variant histology of tumors of the renal pelvis.

World J Urol 2020 Sep 20;38(9):2227-2236. Epub 2019 Nov 20.

Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA.

Background: The impact of variant histologies on overall survival (OS), as well as their influence on the response to neoadjuvant and adjuvant chemotherapy (AC) is well studied in patients diagnosed with bladder cancer. However, little is known about tumors with variant histologies of the upper urinary tract. The objective of this study was to assess the survival of the predominant variant histologies of tumors of the renal pelvis (RPT) after surgical intervention, and to examine the influence of AC on the OS of the different variant histologies.

Methods: We identified 21,318 patients with RPT undergoing surgical intervention using the National Cancer Database for the period 2004-2015. We employed multivariable Cox proportional hazards regression models and Kaplan-Meier curves to evaluate the OS according to variant histology. Separate multivariable Cox regression models were used to assess the specific effect of AC on OS of the histological subgroups.

Results: The majority of patients were diagnosed with pure urothelial carcinoma (PUC) (96.1%). Overall, 826 patients were diagnosed with variant histologies (adenocarcinoma N = 298, squamous cell carcinoma N = 291, sarcomatoid N = 137, others N = 100). Compared to PUC, adenocarcinomas showed longer OS (HR 0.76, 95% confidence interval (CI) 0.62-0.94, p = 0.01), while sarcomatoid tumors had shorter OS (HR 1.59, 95% CI 1.12-2.26, p = 0.011). A subgroup analysis of patients undergoing AC showed a survival benefit in patients with PUC (HR 0.81, 95% CI 0.73-0.9, p < 0.001).

Conclusion: We found that variant histologies of upper urinary tract carcinomas exhibit different survival rates and that AC was only associated with an OS benefit in patients with PUC.
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http://dx.doi.org/10.1007/s00345-019-03003-2DOI Listing
September 2020

[Knowledge of German-speaking urologists regarding the association between penile cancer and human papilloma virus: results of a survey of the European PROspective Penile Cancer Study (E-PROPS)].

Aktuelle Urol 2019 Nov 19. Epub 2019 Nov 19.

Urologische Klinik, St. Elisabeth-Klinikum Straubing, Deutschland.

Background:  A recent meta-analysis showed that penile cancer (PeC) is associated with the human papilloma virus (HPV) in 50 % of patients in Europe. It is unknown whether urologists are aware of the impact of viral carcinogenesis.

Methods:  A (German-language) survey comprising 14 items was created and sent to urologists of 45 clinical centres in Germany (n = 34), Austria (n = 8), Switzerland (n = 2) and Italy/South Tyrol (n = 1) once in Q3/2018. According to a predefined quality standard, a total of 557 surveys were eligible for final data analysis (response rate: 85.7 %). Among other questions, urologists were asked to state the frequency of HPV-associated PeC in Europe. 4 potential answers were provided: (A)-"< 25 %", (B)-"25 - 50 %", (C)-"> 50 - 75 %", (D)-"level of association unknown". For the final calculation, a tolerance of ± 50 % was considered acceptable, so B and C were deemed correct answers. Based on a bootstrap-adjusted multivariate logistic regression model, criteria independently predicting a correct answer were identified.

Results:  Categories A-D were selected in 19.2 % (n = 107), 48.8 % (n = 272), 12.9 % (n = 72) and 19 % (n = 106), respectively, representing a rate of 61.8 % of urologists (n = 344) reaching the endpoint (B + C). Autonomous performance of chemotherapy for PeC by urologists within the given centre (OR 1.55, p[Bootstrap] = 0.036) and the centre's number of urological beds (OR 1.02, p[Bootstrap] = 0.025) were the only parameters showing a significant independent impact on the endpoint. In contrast, the status of a university centre (p = 0.143), a leading position of the responding urologist (p = 0.375) and the number of PeC patients treated per year and centre (p = 0.571) did not significantly predict a correct answer.

Conclusions:  Our results demonstrate insufficient knowledge on the association of PeC and HPV among German-speaking urologists.
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http://dx.doi.org/10.1055/a-1032-8086DOI Listing
November 2019