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Zusammenfassung Hintergrund und Zielsetzung Die radikale Zystektomie (RCX) ist die kurative Standardbehandlung für muskelinvasive Harnblasenkarzinome. Aufgrund des operativen Ausmaßes und der damit verbundenen komplexen stationären Betreuung ist die RCX mit hoher Morbidität und Mortalität verbunden. Ziel war es, Daten aus dem klinischen Alltag zur gegenwärtigen Praxis des perioperativen Managements zu erfassen. Methoden Mitglieder der DGU und der German Society of Residents in Urology beantworteten anonym einen 24 Fragen umfassenden Online-Fragebogen. Gegenstand waren sowohl klinisch relevante Aspekte der gegenwärtigen EAU/DGU-Leitlinien als auch kontrovers diskutierte klinische Fragen. Ergebnisse Durch die Teilnehmer konnten mindestens 19 % aller infrage kommenden deutschen Zentren erfasst werden. Mehrheitlich wird das präoperative Staging mittels CT-Urografie und CT-Thorax durchgeführt. Die meistgenutzte Antibiotikaprophylaxe umfasst ein Drittgenerations-Cephalosporin plus Metronidazol (46 %), welche im Median für 5 Tage verabreicht werden. Harnleiterschienen (HS) werden im Mittel beim Ileumconduit am 11. und bei der Neoblase am 12. Tag nach RCX entfernt. Gemessen an Surrogatparametern wie oraler Darmvorbereitung, Beginn des Kostaufbaus und Einsatz einer Magensonde sind aktuelle Fast-Track-Konzepte noch nicht allgemein verbreitet ( Schlussfolgerungen Die meisten Aspekte des perioperativen Managements werden leitliniengerecht durchgeführt, so z. B. Staging-Untersuchungen, Einsatz von Antibiotika und Entfernung der HS. Andere klinische Fragestellungen wie Durchführung einer Bildgebung vor Entfernung der HS und Fast-Track-Konzepte werden unterschiedlich gehandhabt, obwohl zunehmende Evidenz in diesen Bereichen existiert. Leitlinienadhärenz war nicht mit Zentrumsgröße oder Anzahl der Eingriffe assoziiert.

Introduction High-resolution micro-ultrasound has the capability of imaging prostate cancer based on detecting alterations in ductal anatomy, analogous to multiparametric magnetic resonance imaging (mpMRI). This technology has the potential advantages of relatively low cost, simplicity, and accessibility compared to mpMRI. This multicenter, prospective registry aims to compare the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mpMRI with high-resolution micro-ultrasound imaging for the detection of clinically significant prostate cancer. Methods We included 1040 subjects at 11 sites in seven countries who had prior mpMRI and underwent ExactVu micro-ultrasound-guided biopsy. Biopsies were taken from both mpMRI targets (Prostate Imaging-Reporting and Data System [PI-RADS] >3 and micro-ultrasound targets (Prostate Risk Identification using Micro-ultrasound [PRIMUS] >3). Systematic biopsies (up to 14 cores) were also performed. Various strategies were used for mpMRI target sampling, including cognitive fusion with micro-ultrasound, separate software-fusion systems, and software-fusion using the micro-ultrasound FusionVu system. Clinically significant cancer was those with Gleason grade group ≥2. Results Overall, 39.5% were positive for clinically significant prostate cancer. Micro-ultrasound and mpMRI sensitivity was 94% vs. 90%, respectively (p=0.03), and NPV was 85% vs. 77%, respectively. Specificities of micro-ultrasound and MRI were both 22%, with similar PPV (44% vs. 43%). This represents the initial experience with the technology at most of the participating sites and, therefore, incorporates a learning curve. Number of cores, diagnostic strategy, blinding to MRI results, and experience varied between sites. Conclusions In this initial multicenter registry, micro-ultrasound had comparable or higher sensitivity for clinically significant prostate cancer compared to mpMRI, with similar specificity. Micro-ultrasound is a low-cost, single-session option for prostate screening and targeted biopsy. Further larger-scale studies are required for validation of these findings.

Background Although multiparametric magnetic resonance imaging (mpMRI) revolutionized the implementation of prostate biopsies, a considerable amount of clinically significant prostate cancer (csPCa) is missed when performing mpMRI-targeted biopsies only. Microultrasound (micro-US) is a new modality that allows real-time targeting of suspicious regions. Objective To evaluate micro-US of the prostate with real-time targeting of suspicious regions in patients suspected to have prostate cancer (PCa). Design, setting, and participants We examined 159 patients with prior mpMRI and suspicion of PCa with micro-US in the period from February to December 2018. Micro-US lesions were documented according to the prostate risk identification for micro-US (PRI-MUS) protocol, and were blinded to the mpMRI results and targeted independently of the mpMRI lesions. Outcome measurements and statistical analysis The main outcomes were cancer detection rate, additional detection of csPCa, and International Society of Urological Pathology (ISUP) grade group upgrading via micro-US. Results and limitations PCa was found in 113/159 (71%) men, with 49% (78/159) having clinically significant cancer (csPCa; ISUP ≥ 2). Micro-US–targeted biopsies resulted in a higher ISUP grade group than the nontargeted biopsies in 26% (42/159), compared with both nontargeted and MRI-targeted biopsies in 16% (26/159). In 17% (27/159) of patients, targeted mpMRI–guided biopsy was negative with cancer identified in the micro-US–guided biopsy, of whom 20 had csPCa. The comparison with only MRI-positive patients is the main limitation of this analysis. Conclusions Our data show an added benefit of micro-US in addition to mpMRI-targeted biopsies in a population of men at risk of PCa. A novel biopsy protocol with solely targeted biopsy with micro-US and mpMRI seems possible, replacing conventional ultrasound and omitting standard systematic biopsies. Patient summary In this report, we looked at the performance of microultrasound in the setting of diagnosing prostate cancer. We found that microultrasound is a good addition to magnetic resonance imaging (MRI) of the prostate and presents an alternative for men who may not undergo MRI.

The second version of the PI-RADS™ (Prostate Imaging Reporting and Data System) was introduced in 2015 to standardize the interpretation and reporting of prostate multiparametric magnetic resonance imaging. Recently low cancer detection rates were reported for PI-RADS version 2 category 4 lesions. Therefore the aim of the study was to evaluate the cancer detection rate of PI-RADS version 2 in a large prospective cohort.The study included 704 consecutive men with primary or prior negative biopsies who underwent magnetic resonance imaging/ultrasound fusion guided targeted biopsy and 10-core systematic prostate biopsy between September 2015 and May 2017. All lesions were rated according to PI-RADS version 2 and lesions with PI-RADS version 2 category 3 or greater were biopsied. An ISUP (International Society of Urological Pathology) score of 2 or greater (ie Gleason 3 + 4 or greater) was defined as clinically significant prostate cancer.The overall cancer detection rate of PI-RADS version 2 categories 3, 4 and 5 was 39%, 72% and 91% for all prostate cancer, and 23%, 49% and 77% for all clinically significant prostate cancer, respectively. If only targeted biopsy had been performed, 59 clinically significant tumors (16%) would have been missed. The PI-RADS version 2 score was significantly associated with the presence of prostate cancer (p0.001), the presence of clinically significant prostate cancer (p0.001) and the ISUP grade (p0.001).PI-RADS version 2 is significantly associated with the presence of clinically significant prostate cancer. The cancer detection rate of PI-RADS version 2 category 4 lesions was considerably higher than previously reported. When performing targeted biopsy, the combination with systematic biopsy still provides the highest detection of clinically significant prostate cancer.

OBJECTIVE To examine the performance of a primary magnetic resonance imaging (MRI)/ultrasonography (US) fusion-guided targeted biopsy (TB), and in combination with an added systematic biopsy (SB). PATIENTS AND METHODS Analysis of 318 consecutive biopsy-naive men with suspicious multiparametric MRI (mpMRI; Prostate Imaging Reporting and Data System [PI-RADS] score ≥3) undergoing transrectal TB and 10-core SB between January 2012 and December 2016. The indication for performing mpMRI was based on clinical parameters and decided by the treating urologist before admission. TB was performed with a sensor-based MRI/US fusion-guided platform. Clinically significant prostate cancer was defined as Gleason score ≥4 + 3 = 7 (International Society of Urological Pathology Grade [ISUP] grade 3) or maximum cancer core length of ≥6 mm. RESULTS A median (interquartile range) of 14 (13-14) biopsies per case were taken. The overall cancer detection rate (CDR) was 77% (245/318). The TB alone detected 67% of prostate cancers and the SB alone detected 70%. The PI-RADS dependent CDR for the combination of TB/SB were 38% (21/55), 78% (120/154) and 95% (104/109) for PI-RADS scores of 3/4/5, respectively. Clinically significant prostate cancer was diagnosed by the combination of TB and SB in 195 men (61%) and by TB alone in 163 cases (51%). The number of missed or underestimated prostate cancers with a Gleason score ≥8 for TB alone was 31 (10%, P < 0.001) and 21 (7%, P < 0.001) for SB alone in comparison with the results of the combination of TB and SB. The rate of insignificant prostate cancer was comparable for the combination of TB and SB and TB alone (50/318, 16% vs 50/318, 16%). CONCLUSIONS Pre-biopsy mpMRI is of incremental value in increasing the detection of clinically significant prostate cancer in biopsy-naive patients with suspicion of prostate cancer. Combining TB with SB further improved the diagnostic accuracy without increasing the rate of insignificant prostate cancer.

The aim of this paper was to compare the perioperative and postoperative results of photoselective vaporization of the prostate with the GreenLight-XPS 180 Watt System (PVP) and transurethral resection of the prostate (TURP). This retrospective study included 140 men who underwent PVP and 114 men who underwent TURP for symptomatic benign prostate enlargement (BPE) between June 2010 and February 2015. The primary outcome measures were the patient reported outcome, operative results, International Prostate Symptom Score-Quality of Life (IPSS-QoL), complication rates, catheterization time, and length of hospital stay. The median follow-up times were 27 months (range 14&ndash, 44) for the PVP group and 36 months (range 25&ndash, 47) for the TURP group. The patient characteristics were well balanced in both groups with a median age of 71 years (PVP group) vs. 70 years (TURP group) and a comparable prostate volume (median 50 mL in the PVP group vs. 45 mL in the TURP group). The IPSS-QoL was significantly higher in the PVP group than in the TURP group (median 22 + 4, range 16&ndash, 27 + 3&minus, 5 vs. median 19 + 3, range 15&minus, 23 + 3&minus, 4, p = 0.02). Men undergoing PVP were more likely to be on anticoagulants (PVP group n = 23, 16% vs. TURP group n = 2, 2%, p &lt, 0.001). The median operation time (OT, min) for both procedures was comparable with 68 min (PVP group, range 53&ndash, 91) vs. 67 min (TURP group, range 46&ndash, 85). The rate of severe intraoperative bleeding was significantly lower in the PVP group than in the TURP group (n = 7, 5% vs. n = 16, 14%, p = 0.01). The postoperative catheterization time and length of hospital stay was significantly lower in the PVP group (median 1&ndash, 2 days, range 1&ndash, 4) vs. the TURP group (median 2&ndash, 4 days, range 2&ndash, 5, both p &lt, 0.001). Complication rates (Clavien-Dindo classification &ge, III) based on the follow-up data showed no statistically significant difference between the PVP group and the TURP group (n = 6, 4% vs. n = 6, 5%, p = 0.28). The IPSS on follow-up showed an equivalent reduction in symptoms for both treatment modalities (IPSS-QoL of 5 + 1, 11 + 0&minus, 2 for both). There were no differences concerning urge (PVP group n = 3, 2% vs. TURP group n = 3, 3%, p = 0.90) and men were similarly satisfied with the postoperative outcome (PVP group 92% vs. TURP group 87%, p = 0.43). The PVP group was associated with a shorter hospitalization time and showed a reduced risk of bleeding, despite patients remaining on anticoagulants, without increasing the overall operative time. There was no difference in the patient reported outcome for both procedures.