The effect of hospital caseload on perioperative morbidity and treatment-related costs in patients undergoing radical cystectomy

The European guideline recommendations on bladder cancer suggest that hospitals should perform at least ten, and preferably more than twenty RC per year, to achieve acceptable perioperative outcomes. Still, the optimal annual caseload volume for RC remains unknown. Thus, the present dissertation aimed to determine an evidence-based optimal annual RC hospital volume threshold and to evaluate its clinical significance based on major perioperative outcomes (mortality, morbidity, length of hospital stay, and hospital revenues). Based on the DRG dataset provided by the Research Data Center of the Fed-eral Bureau of Statistics from 2005 to 2020 (agreement: LMU - 4710-2022), an optimal annual hospital volume threshold was defined through ROC analyses. The DRG dataset contains all reimbursed inpatient cases in Germany apart from psychiatric, forensic, and military cases. All data are available and stored anonymized at the Research Data Center of Federal Bureau of Statistics. All hospitals are required to code and transfer to the Institute for the Hospital Re-muneration System patient data on inpatient diagnoses, coexisting conditions, as well as on perioperative outcomes, and surgical procedures. These data are mandatory for all German hospitals to receive their corresponding remu-neration. These diagnoses and perioperative outcomes are coded according to the ICD-10-GM, whereas surgical procedures are coded according to the German OPS. Based on these ROC analyses, the optimal annual hospital vol-ume threshold for RC that reduces mortality, ileus, sepsis, transfusion, hospital stay, and costs was determined by 54, 50, 44, 44, 71, and 76 RCs/year, re-spectively. Thus, both the annual threshold of 50 and 70 cases/year and the annual threshold of 20 cases/year as proposed by the European recommen-dations on bladder cancer were used to perform multiple analyses on a patient level. Overall, 95,841 patients were included. Of them, 28,291 (30%) under-went RC in low- (<20 cases/year), 49,616 (52%) in intermediate- (20-49 cas-es/year), and 17,934 (19%) in high-volume (≥50 cases/year) hospitals in Ger-many. After adjusting for major determinants, patients undergoing surgery in high-volume hospitals were associated with statistically significant lower risk for mortality (OR: 0.72, 95% CI: 0.64 to 0.8, p < 0.001) compared to patients undergoing surgery in low-volume hospitals. Moreover, the costs were re-duced by 457 euros (95% CI: 207 to 707, p < 0.001) and the length of hospital stay by 2.7 days (95% CI: 2.4 to 2.9, p < 0.001) after RC in high-volume hospi-tals. It should be highlighted that patients that underwent surgery in low-volume hospitals developed more perioperative complications (transfusion, ileus, and sepsis). Furthermore, the threshold of 70 cases/year was also asso-ciated with improved perioperative outcomes (mortality, morbidity, hospital stay, and costs). The centralization of aggressive bladder cancer care seems to not only improve morbidity and mortality but also to reduce both the length of hospital stay and hospital revenues. Based on the present analyses, hospi-tals that perform at least 50 RCs/year should be considered referral centers, hospitals that perform at least 70 RCs/year should be considered excellence centers and hospitals that perform less than 10 RCs/year should refer patients to other centers

Penile fractures: the price of a merry Christmas

Objectives To explore whether Christmas might be a risk factor for penile fractures due to the Christmas spirit related to the intimacy and euphoria of these holly jolly days. Patients and methods We evaluated the incidence of penile fractures during Christmas and New Year's Eve through the GeRmAn Nationwide inpatient Data (GRAND) from the Research Data Center of the Federal Bureau of Statistics (Wiesbaden, Germany). Furthermore, we assessed the impact of COVID-19 on penile fractures and their seasonality. Results A total of 3,421 patients with a median, interquartile range (IQR) age of 42 (32–51) years had a penile fracture requiring a hospital stay from 2005 to 2021. In all, 40 (1.2%) penile fractures occurred in 51 days of Christmas (from 24/12 to 26/12 in each year). The daily incidence of penile fractures during Christmas was 0.78 with an incidence rate ratio (IRR) of 1.43 (95% confidence interval [CI] 1.05–1.95, P = 0.02). If every day was like Christmas, 43% more penile fractures would have occurred in Germany from 2005 on. Interestingly, only 28 (0.82%) penile fractures occurred during the New Year's Eve period (31/12 to 02/01 from 2005 to 2021). This resulted in an IRR of 0.98 (95% CI 0.69–1.5, P = 0.98) in the New Year's Eve period. Most patients with penile fractures were admitted to hospital at the weekend (n = 1,322; IRR 1.58, 95% CI 1.48–1.69; P < 0.001). Summer was also associated with more penile fractures (n = 929; IRR 1.11, 95% CI 1.03–1.19; P = 0.008). Both the COVID-19 pandemic (n = 385; IRR 1.06, 95% CI 0.95–1.18, P = 0.29) and its lockdown period (n = 93; IRR 1, 95% CI 0.82–1.23; P = 0.96) did not affect the incidence of penile fractures. Conclusion The incidence of penile fractures displays a seasonality. Last Christmas penile fractures occurred more often. This year to save us from tears, we will NOT do something special (the new Christmas hit of the year)

Efficacy and Safety of Platelet-Rich Plasma Injections for the Treatment of Female Sexual Dysfunction and Stress Urinary Incontinence: A Systematic Review

Introduction: There is no clear evidence in the literature that platelet-rich plasma (PRP) injections improve female sexual dysfunction (FSD) and female stress urinary incontinence (SUI). Objectives: A systematic review was performed to study the efficacy and safety of PRP injections in women with the above pathologies, as well as to explore the optimal dosing, frequency and area of injections, and duration of treatment. Methods: A systematic search on PubMed, Embase and the Cochrane Library database was performed, as well as sources of grey literature from the date of database or source creation to January 2023. After title/abstract and full-text screening, clinical studies on humans evaluating the efficacy of PRP in gynecological disorders using standardized tools were included. Risk of bias was undertaken with RoB-2 for randomized-controlled trials (RCT) and the Newcastle-Ottawa Scale (NOS) for observational studies. Results: Four prospective and one retrospective study explored FSD, while six prospective and one RCT evaluated female SUI. A total of 327 women with a mean age of 51 ± 12 years were included. For FSD, PRP significantly improved the Female Sexual Function Index (FSFI), the Vaginal Health Index (VHI) and the Female Sexual Distress score (FSDS). For SUI, PRP led to a significant improvement in the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF) and the Urogenital Distress Inventory (UDI-6). The identified RCT reported a significantly higher mean score of ICIQ-SF (p < 0.05) and UDI-6 (p < 0.01) in the midurethral sling group compared to the PRP injections group. Regarding the risk of bias, the RCT was characterized by high risk, whereas the observational studies were of moderate risk. The protocol for PRP injections for FSD is the injection of 2 mL of PRP into the distal anterior vaginal wall once a month for 3 months. For female SUI, 5–6 mL of PRP should be injected into the periurethral area once a month for 3 months. Conclusions: Despite the promising initial results of PRP injections, the level of current evidence is low due to methodological issues in the available studies. It becomes clear that there is an emerging need for high-quality research examining PRP injections for the treatment of FSD and female SUI

Oncological impact of perioperative blood transfusion in bladder cancer patients undergoing radical cystectomy: Do we need to consider storage time of blood units, donor age, or gender matching?

Background The oncological impact of perioperative blood transfusions (PBTs) of patients undergoing radical cystectomy (RC) because of bladder cancer (BCa) has been a controversial topic discussed in recent years. The main cause for the contradictory findings of existing studies might be the missing consideration of the storage time of red blood cell units (BUs), donor age, and gender matching. Study Design and Methods We retrospectively analyzed BCa patients who underwent RC in our department between 2004 and 2021. We excluded patients receiving BUs before RC, >10 BUs, or RC in a palliative setting. We assessed the effect of blood donor characteristics and storage time on overall survival (OS) and cancer-specific survival (CSS) through univariate and multivariable Cox regression analysis. We also performed a propensity score matching with patients who received BUs and patients who did not on a 1:1 ratio. Results We screened 1692 patients and included 676 patients for the propensity score matching. In the multivariable analysis, PBT was independently associated with worse OS and CSS (p < .001). Postoperative transfusions were associated with better OS (p = .004) and CSS (p = .008) compared to intraoperative or mixed transfusions. However, there was no influence of blood donor age, storage time, or gender matching on prognosis. Discussion In our study of BCa patients undergoing RC, we demonstrate that PBT, especially if administered intraoperatively, is an independent risk factor for a worse prognosis. However, storage time, donor age, or gender matching did not negatively affect oncological outcomes. Therefore, the specific selection of blood products does not promise any benefits

Added value of randomised biopsy to multiparametric magnetic resonance imaging‐targeted biopsy of the prostate in a contemporary cohort

Objective To assess the added value of concurrent systematic randomised ultrasonography-guided biopsy (SBx) to multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy and the additional rate of overdiagnosis of clinically insignificant prostate cancer (ciPCa) by SBx in a large contemporary, real-world cohort. Patients and Methods A total of 1552 patients with positive mpMRI and consecutive mpMRI-targeted biopsy and SBx were enrolled. Added value and the rate of overdiagnosis by SBx was evaluated. Primary outcome: added value of SBx, defined as detection rate of clinically significant PCa (csPCa; International Society of Urological Pathology [ISUP] Grade ≥2) by SBx, while mpMRI-targeted biopsy was negative or showed ciPCa (ISUP Grade 1). Secondary outcome: rate of overdiagnosis by SBx, defined as detection of ciPCa in patients with negative mpMRI-targeted biopsy and PSA level of <10 ng/mL. Results Detection rate of csPCa by mpMRI-targeted biopsy and/or SBx was 753/1552 (49%). Added value of SBx was 145/944 (15%). Rate of overdiagnosis by SBx was 146/656 (22%). Added value of SBx did not change when comparing patients with previous prostate biopsy and biopsy naïve patients. In multivariable analysis, a Prostate Imaging-Reporting and Data System (PI-RADS) 4 index lesion (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.66–6.78; P = 0.001), a PI-RADS 5 index lesion (OR 2.89, 95% CI 1.39–6.46; P = 0.006) and age (OR 1.05, 95% CI 1.03–1.08; P < 0.001) were independently associated with added value of SBx. Conclusions In our real-world analysis, we saw a significant impact on added value and added rate of overdiagnosis by SBx. Subgroup analysis showed no significant decrease of added value in any evaluated risk group. Therefore, we do not endorse omitting concurrent SBx to mpMRI-guided biopsy of the prostate

Diagnostic Biopsy for Small Renal Tumours: A Survey of Current European Practice

Background and objective: Renal tumour biopsy (RTB) can help in risk stratification of renal tumours with implications for management, but its utilisation varies. Our objective was to report current practice patterns, experiences, and perceptions of RTB and research gaps regarding RTB for small renal masses (SRMs). Methods: Two web-based surveys, one for health care providers (HCPs) and one for patients, were distributed via the European Association of Urology Young Academic Urologist Renal Cancer Working Group and the European Society of Residents in Urology in January 2023. Key findings and limitations: The HCP survey received 210 responses (response rate 51%) and the patient survey 54 responses (response rate 59%). A minority of HCPs offer RTB to >50% of patients (14%), while 48% offer it in <10% of cases. Most HCPs reported that RTB influences (61.5%) or sometimes influences (37.1%) management decisions. Patients were more likely to favour active treatment if RTB showed highgrade cancer and less likely to favour active treatment for benign histology. HCPs identified situations in which they would not favour RTB, such as cystic tumours and challenging anatomic locations. RTB availability (67%) and concerns about delays to treatment (43%) were barriers to offering RTB. Priority research gaps include a trial demonstrating that RTB leads to better clinical outcomes, and better evidence that benign/indolent tumours do not require active treatment. Conclusions and clinical implications: Utilisation of RTB for SRMs in Europe is low, even though both HCPs and patients reported that RTB results can affect disease management. Improving timely access to RTB and generating evidence on outcomes associated with RTB use are priorities for the kidney cancer community. Patient summary: A biopsy of a kidney mass can help patients and doctors make decisions on treatment, but our survey found that many patients in Europe are not offered this option. Better access to biopsy services is needed, as well as more research on what happens to patients after biopsy