Discrepancy between German S3 Guideline Recommendations and Daily Urologic Practice in the Management of Nonmuscle Invasive Bladder Cancer: Results of a Binational Survey

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-Guerin (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

Untersuchungen zur Rolle von Platelet-Derived Growth Factor (PDGF)-C in einem Modell des akuten Nierenversagens, der renalen Ischämie, Reperfusion

Inspite of a growing success in the investigation of causes and the development of acute kidney injury it remains an important medical and economic problem. Especially the high mortality rate after AKI could hardly be reduced within the last four decades. In our study of the potentially protective role of PDGF-C in the model of murine ischemia/reperfusion (IR) we compared its pathology between PDGF-C+/+- and PDGF-C-/--mice for a period of three weeks. All four PDGF-isoforms were – at the latest from day 5 onward – overexpressed in the kidney, PDGF-C instead had a twofold higher mRNA-expression during the complete period of observation which showed rather a moderate increase compared to control animals. At all three time points there was no differential mRNA-expression between PDGF-C+/+- and PDGF-C-/--mice of all PDGF-isoforms and PDGF-receptors. On day 1 after IR we could show, in comparison with sham-operated animals, a stronger tubular damage, more apoptosis, an upregulated renal infiltration by F4/80-positive and ER-HR3-positive macrophages as well as Ly6G-positive neutrophil granulocytes and an upregulated mRNA-expression of the proinflammatory mediators MCP-1, RANTES and CCR2 as well as the biomarkers NGal and KIM-1. We could not find any differences between the two genotypes. On day 5 we found a downregulation of F4/80-positive macrophages and T-lymphocytes as well as a reduced mRNA-expression of the chemokines MCP-1 in PDGF-C-/--mice. The other examined parameters, like tubular damage, ER-HR3-positive macrophages, Ly6G-positive neutrophil granulocytes, proinflammatory mediators, apoptosis, proliferation and the biomarkers NGal and KIM-1 showed no difference between PDGF-C+/+- and PDGF-C-/--mice, but were upregulated compared to sham animals. 21 days after IR we discovered significantly less tubulointerstitial fibrosis in PDGF-C-/--mice in comparison with wildtype mice. We observed reduced levels of collagen I and IV in immunohistochemistry, but no differences in the mRNA-expression of alpha-SMA and the fibrosis parameters collagen I, III, IV and fibronectin between both genotypes. PDGF-C-/--mice had a reduced infiltration by ER-HR3-positive macrophages as well as T-lymphocytes. Furthermore, there was also no difference in the renal infiltration by F4/80-positive macrophages, the expression of the proinflammatory cytokines MCP-1, RANTES and the chemokine receptor CCR2 as well as the biomarkers NGal and KIM-1. All analysed parameters were upregulated compared to sham-operated animals. In contrast to our original hypothesis we could not find a protective, but rather a proinflammatory influence of PDGF-C in the acute phase of renal IR on the days 1 and 5, which led to a significantly increased tubulointerstitial fibrosis in the late phase (day 21). Therefore we concluded that the inhibition of PDGF-C could be a useful treatment of acute and chronic kidney diseases

Complication management for TUR of the bladder

Transurethral resection of bladder cancer is a standard procedure in urology which requires complete resection. Knowledge of the possible complications and their management is essential for practicing urologists. The most common complications are catheter related bladder symptoms, bleeding, infections and perforation of the bladder. Resection of the orifice and positional damage are seldom but severe complications which need immediate treatment. In this review, we summarise the above mentioned complications as well as their management

Modern surgical strategies in the management of complex ureteral strictures

Purpose of review The purpose of this article is to outline the various therapeutic options of ureteral strictures. Recent findings Ureteral strictures with consecutive hydronephrosis can be due to endourological and surgical procedures, inflammatory processes, radiation therapy as well as spontaneous passage of ureteral calculi. When planning surgical correction, stricture length, anatomical location as well as patients' characteristics like age, comorbidities and previous treatment in the peritoneal cavity, retroperitoneum or pelvis should be taken into consideration. Treatment options include not only surgical reconstruction techniques like simple stricture excision, end-to-end anastomosis, ureterolysis with omental wrapping, ureteroneoimplantation, renal autotransplantation and ureter-ileum replacement, but also minimally invasive procedures such as self-expandable thermostents and pyelovesical bypass prosthesis. Various therapeutic options can be offered in the treatment of ureteral strictures, potentially leading to long-term success rate of more than 90% and a rate of significant complications < 5%

Testis-preserving strategies in testicular germ cell tumors and germ cell neoplasia in situ

Testicular germ cell tumors (TGCT) are rare malignancies which affect young adults and adolescents between the ages of 15 and 40 years. In suspected malignant TGCT, the treatment of choice is radical orchiectomy. However, in specific cases this routine surgical approach has been challenged in favor of an organ-preserving approach with comparable oncological outcome. Thus, testis-preserving strategies should be considered in unilateral or bilateral synchronous or metachronous TGCT as well as incidentally found small testicular masses, which are mostly benign lesions including Sertoli cell tumors, Leydig cell tumors, adenomatoid tumors or epidermoid cysts. In case of a testis-preserving surgery, adjuvant postoperative radiation therapy (20 Gy) is recommended. The rational for this approach is that the remaining parenchyma harbors germ cell neoplasia in situ (GCNIS), which might lead to locally recurrent TGCT in 50% in the next following 5 years. However, testicular radiotherapy might result in infertility and 'Sertoli-cell only' syndrome because of radiation-induced destruction of germ cells as well as Leydig cell insufficiency in 20% of all patients leading to life-long androgen substitution. Therefore, radiation therapy should be delay or sperm banking be should performed in fertile patients wish to have children. This review provides an overview on literature regarding testis-preserving strategies in TGCT as well as GCNIS

Testis-Sparing Surgery in Patients with Germ Cell Cancer: Indications and Clinical Outcome

Testicular cancer affects mainly young men between 20 and 30 years of age. Due to the availability of effective chemotherapy, the majority of patients are cured. Despite an increased risk of metachronous testicular cancer, it should be carefully considered whether immediate orchiectomy is indicated. This mini review gives an account of the available literature on testis-sparing surgery in patients with unilateral or bilateral synchronous or metachronous testicular cancer. (c) 2018 S. Karger GmbH, Freibur

Salvage management of patients with relapsing testicular germ cell tumors

Purpose of review This review aims to summarize the latest evidence of medical and surgical treatment options for patients with relapsing testicular germ cell tumors. Recent findings Depending on International Germ Cell Cancer Classification Group risk classification 10-50% of patients with metastatic TGCT develop relapse which needs further multimodality treatment. With regard to therapy, early relapses are stratified according to their prognostic risk profile which results in a 3-year overall survival between 6% in the very high to 77% in the very low risk group. Prognostic risk score dictates systemic therapy which might be second line chemotherapy (TIP, PEI) or high dose chemotherapy. Any residual masses following salvage chemotherapy need to be completely resected due the presence of viable cancer and/or teratoma in more than 50% of cases. Targeted therapy in men with druggable mutations is for individualized cases only. Patients with late relapses developing more than 2 years after first-line chemotherapy are best managed by surgery. Desperation surgery is reserved for those patients with rising markers during or immediately after chemotherapy and good risk factors such as rising alpha-fetoprotein, <3 metastatic sites and complete resectability. Multimodality treatment will result in long-term cure of 25% to 60%. Due to the complexity of treatment, chemotherapy as well as surgery should be performed in highly experienced centres only. Multimodality treatment to salvage relapsing patients with metastatic testis cancer requires extensive experience for both systemic therapy and surgery. If done properly, it will result in moderate to high cure rates. Personalized therapeutic options are currently evaluated in clinical trials

Nonguideline concordant treatment of testicular cancer.

407 Background: The management of testicular cancer requires a complex multimodal therapeutic approach. Despite the availability of regularly updated national and international guidelines on testicular cancer, treatment still differs between the institutions probably affecting the patients’ outcome. Our study aims to investigate frequently occurring errors regarding the diagnosis and therapy of testicular cancer in consideration of the current EAU guidelines. Methods: We performed a retrospective analysis including 129 patients diagnosed with testicular cancer that were referred to our department between 09/2015 and 10/2016. Patients’ age, histology, clinical stage, IGCCCG risk classification, treatment (surveillance, chemotherapy, radiotherapy, surgery) and follow-up were investigated and compared to the EAU guidelines’ recommendations. Results: Of the eligible 129 patients, 34 (26%) patients displayed a non-guideline concordant care. The most common error was undertreatment (47%), mostly due to missing chemotherapy cycles. Modified treatment and overtreatment occurred in 20% and 16% respectively, while inappropriate treatment (9%) and misdiagnosis (6%) were rarely seen. In secondary treated patients, non-guideline concordant therapy was observed more frequently compared to those patients receiving primary therapy (59% vs. 41 %). Almost all patients (93%) receiving a non-guideline concordant therapy suffered a relapse in contrast to 67% of patients that were treated according to the EAU guidelines. Conclusions: Non-adherence to the current EAU guidelines on testicular cancer appears to be a major problem in various testicular cancer treating institutions. In our study, the most frequent error was undertreatment, followed by modified treatment and overtreatment. Inappropriate therapy leads to a higher relapse rate and morbidity associated with a worse curative outcome. </jats:p

Diagnosis and management of the growing teratoma syndrome: A single-center experience and review of the literature

Objectives: To evaluate the diagnostic, surgical as well as ontological outcome of patients with a growing teratoma syndrome. Material and methods: We performed a retrospective analysis including 680 patients with advanced nonseminomatous germ cell tumors who underwent a postchemotherapy retroperitoneal lymph node dissection. The peri- and postoperative outcome of 22 patients (3%) that fulfilled the criteria of a growing teratoma syndrome were analyzed: nonseminomatous germ cell tumors with increasing tumor size during or after chemotherapy despite normalized or decreasing tumor markers. Results: The median tumor diameter at time of surgery was 6 cm (4-12.2). For a complete resection of the residual masses, adjunctive surgery had to be performed in 4 (18%) patients: resection of the abdominal aorta, inferior vena cava or renal vein with graft replacement, nephrectomy and resection of parts of the intestine. Eight postoperative complications occurred in 5 (23%) patients, with 4/8 of these complications affecting only one patient. Fifty percent of all complications were classified as Clavien-Dindo grade III or IV. After a median follow-up of 25 months, relapse occurred in 2 patients (9%); all but one patient is alive resulting in an overall survival of 95.5%. Conclusions: The growing teratoma syndrome is a rare phenomenon among patients with advanced nonseminomatous germ cell tumors and necessitates complete surgical resection of the masses with curative intention. Due to its complexity and potential adjunctive surgery, the treatment should be performed in tertiary referral centers only. (C) 2018 Elsevier Inc. All rights reserved