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Purpose To test the value of preoperative and postoperative cystatin C (CysC) as a predictor on kidney function after partial (PN) or radical nephrectomy (RN) in renal cell carcinoma (RCC) patients with normal preoperative renal function. Methods From 01/2011 to 12/2014, 195 consecutive RCC patients with a preoperative estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73m2 underwent surgical RCC treatment with either PN or RN. Logistic and linear regression models tested for the effect of CysC as a predictor of new-onset chronic kidney disease in follow-up (eGFR 2). Moreover, postoperative CysC and creatinine values were compared for kidney function estimation. Results Of 195 patients, 129 (66.2%) underwent PN. In postoperative and in follow-up setting (median 14 months, IQR 10–20), rates of eGFR 2 were 55.9 and 30.2%. In multivariable logistic regression models, preoperative CysC [odds ratio (OR): 18.3] and RN (OR: 13.5) were independent predictors for a reduced eGFR 2 in follow-up (both p 2. Finally, we observed a plateau of postoperative creatinine values in the range of 1.2–1.3 mg/dl, when graphically depicted vs. postoperative CysC values (‘creatinine blind area’). Conclusion Preoperative CysC predicts renal function impairment following RCC surgery. Furthermore, CysC might be superior to creatinine for renal function monitoring in the early postoperative setting.

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.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.The study was conducted in "Olympus Training and Education Center Hamburg West" and "Endo Club Academy" at the University Medical Center Hamburg-Eppendorf.Participants were eligible if they were medical students with no experience in laparoscopy. 24 participants were recruited and finished the study.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 p0.01) 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 (p0.001 and p = 0.005, respectively).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.

ZusammenfassungHarnröhrenstrikturen der Frau sind ein seltenes Krankheitsbild mit individueller Symptomatik. Vor diesem Hintergrund mangelt es an klinischen Leitfäden, die sich mit Diagnostik und Therapie dieser Erkrankung befassen. Mittlerweile liegen einige Ergebnisse zu verschiedenen Operationstechniken vor, ein direkter inter-institutioneller Vergleich wird jedoch durch heterogene Patientenkohorten und kleine Fallzahlen erschwert. Die vorliegende Arbeit befasst sich mit einer aktuellen narrativen Literaturübersicht relevanter Artikel zur klinischen Diagnostik und zu den Therapiemöglichkeiten bei weiblicher Harnröhrenstriktur.Iatrogene Ursachen wie eine vorangegangene Katheterisierung oder ein urogenitaler operativer Eingriff sind die häufigsten Gründe für die Entstehung einer Harnröhrenstriktur bei der Frau. Im klinischen Alltag stellt die körperliche Untersuchung einen wichtigen Grundstein in der Differentialdiagnostik dar, um bei Verdacht auf eine anatomisch-morphologische Ursache der Harnblasenentleerungsstörung weitere diagnostische Maßnahmen (Urethrozystoskopie, Urethrographie, MRT) einzuleiten. Therapeutisch sind minimal-invasive Eingriffe wie Harnröhrenbougierungen oder Urethrotomien oftmals nur mit kurzfristigem Erfolg assoziiert, sodass die offene Harnröhrenrekonstruktion mit langfristigeren Therapieerfolgen hier eine Sonderstellung einnimmt. Zur Verfügung stehen neben offenen Harnröhrenplastiken mit gestielten Lappen aus Vaginal- oder Labialschleimhaut auch die Verwendung freier Transplantate, vor allem dem Mundschleimhaut-Autotransplantat. Aufgrund der genannten Seltenheit der Erkrankung mit nur kleinen publizierten Fallserien ist jedoch eine Beurteilung der vergleichenden Wirksamkeit der verschiedenen Techniken nur schwer möglich. Wie bei allen seltenen Erkrankungen bedarf es hier der Etablierung von multizentrischen, großen Serien, um die Standards im perioperativen Vorgehen zu verbessern.

Purpose To evaluate the interplay of stricture recurrence, sexual function, and treatment satisfaction after substitution urethroplasty. Methods Observational study of men undergoing 1-stage buccal mucosal graft urethroplasty for anterior urethral stricture between 2009 and 2016. Patients were dichotomized by self-reported treatment satisfaction. Sexual function was assessed by validated and non-validated patient-reported outcome measures. Functional recurrence was defined as symptomatic need of re-intervention. Bivariate analyses, Kaplan–Meier estimates, qualitative and quantitative analyses by uni- and multivariable regression were employed to evaluate the interplay of sexual function, functional recurrence, and treatment satisfaction. Results Of 534 men with bulbar (82%), penobulbar (11%), and penile strictures (7.3%), 451 (84%) were satisfied with the surgery. There were no differences in stricture location, previous treatment, graft length, or surgical technique between satisfied and unsatisfied patients (all p ≥ 0.2). Recurrence-free survival was 85% at a median follow-up of 33 mo and decreased significantly with each Likert item towards increasing dissatisfaction (p < 0.001). Dissatisfied patients more often reported postoperative loss of rigidity, tumescence, reduced ejaculatory volume, ejaculatory pain, and reduced penile length (all p ≤ 0.042). In 83 dissatisfied men, functional recurrence (28%) and oral morbidity (20%) were the main drivers of dissatisfaction in qualitative analysis. Multivariable analyses revealed functional recurrence and impaired postoperative ejaculatory function as independent predictors of treatment dissatisfaction (all p ≤ 0.029) after adjusting for confounders. Conclusion We found an association of both functional success and sexual function with patient-reported treatment satisfaction after substitution urethroplasty. Such findings validate the clinical significance of defining the symptomatic need for re-intervention as an endpoint and underline the importance of further research evaluating sexual function before and after open urethral reconstruction.

Standard radical cystectomy (RC) in women includes the removal of the bladder, urethra, uterus with the adnexa, and the anterior vaginal wall, thereby severely affecting the urinary, sexual, and reproductive system. To limit these detrimental effects, organ-sparing, including nerve-sparing approaches, have been developed. Health-related quality of life (HRQOL) and functional outcomes are, indeed, becoming increasingly central to the shared decision-making with the patient. The objectives of this narrative review are: (I) to review the current status of RC in women, including the use of different urinary diversions (UDs); (II) to discuss organ-sparing approaches and their impact on oncological and functional outcomes in women; (III) to discuss the impact of RC on HRQOL and sexual function in women.We performed a non-systematic literature review of the available publications in the PubMed database.Over the past years, gender differences in oncological and functional outcomes after RC have received increased attention. According to the currently available literature, organ-sparing approaches can be safely performed in well-selected women without negatively impacting oncological outcomes. The orthotopic neobladder is feasible and oncologically safe in well-selected and informed women. The choice of the UD should be based on comprehensive counseling and the patient's comorbidities and preferences. There still is a lack of data on sexual recovery after the different surgical approaches aimed to mitigate sexual dysfunction in women undergoing RC.Pre-and post-operative counseling and support of females undergoing RC regarding their expectations and experiences in terms of quality of life and functional and sexual outcomes are currently insufficient. Well-designed studies in this field are necessary to further improve outcomes of women treated with RC with an overarching aim to close the gender gap in managing women with bladder cancer.

The transcription factor GATA binding protein 3 (GATA3) is commonly used in surgical pathology as a diagnostic marker to distinguish urothelial carcinomas from other cancer entities. However, the clinical relevance of GATA3 expression in urothelial bladder cancer is not completely clarified. In this study, we investigated GATA3 immunostaining on 2710 urothelial bladder carcinomas on a tissue microarray platform by using two different antibodies to better understand its impact in relation to pathological parameters of disease progression and patient outcome. Nuclear GATA3 immunostaining was regularly seen in normal urothelium and found in 74%/82% of interpretable urothelial neoplasms depending on the antibody used. Within pTa tumors, the rate of GATA3 positive tumors decreased with advancing grade. GATA3 positivity was seen in 98.6%/99.8% of pTaG2 low-grade, 98.6%/100% of pTaG2 high-grade, and 94.9%/99.2% of pTaG3 high-grade tumors (P = .0002). As compared to pTa tumors, GATA3 positivity was markedly less common in muscle-invasive urothelial carcinoma (59.9%/71.6%; P .0001). Within pT2-4 cancers, high-level GATA3 immunostaining was associated with the presence of lymph node metastasis (P = .0034), and blood vessel (P = .0290) or lymphatic invasion (P = .0005) but unrelated to pT stage. GATA3 immunostaining results for both antibodies were not associated with overall survival in 586 patients treated by cystectomy for pT2-4 urothelial carcinoma. The results of our study identify GATA3 expression as a frequent event in noninvasive urothelial carcinomas with favorable tumor features. Loss of GATA3 immunostaining is linked with muscle-invasive disease but is largely unrelated to pathological parameters and patient prognosis.

Ensuring future urological care at the interface between out- and inpatient care is challenging due to demographic developments with an increasing proportion of urological diseases, the simultaneous threat of a shortage of physicians, and the increasing outpatient treatment of complex urological diseases.The cross-sectoral cooperation model between a university maximum care provider and the urologic joint practice with a hospital affiliation (BAG) presented below can serve as an ideal model for outpatient-inpatient care.Since 2016, there has been close cooperation between the BAG in Winsen/Buchholz and the University Medical Center Hamburg-Eppendorf (UKE). In addition to direct patient transfer and the continuous pre- and posttreatment of patients, two residents from the UKE rotate to the BAG every year.The BAG benefits from this cooperation through planning security and support in everyday patient care, while the UKE benefits from patient transfer as well as surgical and "basic urological" training of residents. By avoiding duplicate examinations and earlier discharge of patients into outpatient follow-up care, resources are spared. Meaningful patient preselection enables minor interventions to be performed close to home via the BAG, whereas complex cases are carried out at a center of excellence.The cooperation is seen positively by all parties without exception and, above all, as a benefit for the patient's wellbeing. The optimal training and further education of young urologists in this expanding field can thus be supported and should be integrated into urological resident training.HINTERGRUND: Die Sicherstellung der zukünftigen urologischen Versorgung über die Schnittstelle ambulant-stationär hinweg stellt durch die demografische Entwicklung mit zunehmendem Anteil an urologischen Krankheitsbildern bei gleichzeitig drohendem Ärzt*innenmangel sowie zunehmender Ambulantisierung auch komplexer urologischer Krankheitsbilder eine Herausforderung dar.Das im Folgenden dargestellte sektorenverbindende Kooperationsmodell zwischen universitärem Maximalversorger und Belegarztwesen kann hier als ideales Bindeglied der ambulant-stationären Patientenversorgung fungieren.Seit 2016 besteht eine enge Kooperation zwischen der urologischen Berufsausübungsgemeinschaft (BAG) in Winsen/Buchholz sowie dem Universitätsklinikum Hamburg-Eppendorf (UKE). Neben direktem Patiententransfer, engmaschiger Vor- und Nachbehandlung von Patienten rotieren zudem jährlich zwei Assistenzärzt*innen des UKE in die BAG.Die BAG profitiert hierbei durch Planungssicherheit und Entlastung im Alltag. Das UKE durch Patiententransfer und operative sowie „basisurologische“ Ausbildung der Assistent*innen. Durch Vermeidung von Doppeluntersuchungen und frühere Entlassung der Patienten in die ambulante Nachbehandlung werden Ressourcen geschont; eine sinnvolle Patientenvorselektion ermöglicht kleinere Eingriffe heimatnah über die BAG, wohingegen komplexe Fälle an einem Zentrum mit großer Expertise erfolgen.Die Zusammenarbeit wird von allen Parteien ausnahmslos positiv und v. a. als ein Gewinn für das Patientenwohl gesehen, da aufgrund der guten Vernetzung eine reibungslose Versorgung gewährleistet werden kann. Eine solche Rotation urologischer Assistenzärzt*innen sollte als möglicher Baustein in die Weiterbildungsordnung der urologischen Facharztausbildung integriert werden.

The aim of the present study was to analyze copy number variations (CNV) of multiple oncogenes and tumor suppressor genes in genomic DNA from primary tumor tissue, lymph node metastasis and cell-free DNA (cfDNA) from serum of 72 urothelial carcinoma of bladder (UCB) patients treated with radical cystectomy (RC), using multiplex ligation-dependent probe amplification (MLPA). We hypothesized that primary tumor and lymph node metastasis show similar CNV profiles, and CNV are more present in lymph node metastasis compared to primary tumor tissue. Samples from 43 (59.7%) patients could be analyzed. In total, 35 (83%), 26 (68%) and 8 (42%) patients had CNV in primary tumor, serum and lymph node metastasis, respectively. MYC, CCND1, ERBB2 and CCNE1 displayed the most frequent amplifications. In particular, CNV in ERBB2 was associated with aggressive tumor characteristics. CNV in both ERBB2 and TOP2A were risk factors for disease recurrence. The current findings show that CNV are present in various oncogenes and tumor suppressor genes in genomic DNA from primary tumor, lymph node metastasis and cfDNA from serum. CNV were more present in genomic DNA from primary tumor tissue compared to cfDNA from serum and genomic DNA from lymph node metastasis. Patients with CNV in ERBB2 and TOP2A are at increased risk for disease recurrence following RC. Further studies are necessary to validate, whether these genes may represent promising candidates for targeted-therapy.

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 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.

Objective We conducted a systematic review and meta-analysis to assess the available literature regarding the surgical and oncologic outcomes of patients undergoing salvage radical cystectomy (SV-RC) for recurrence or failure of bladder sparing therapy (BST) for muscle-invasive bladder cancer (MIBC). Methods We searched MEDLINE (PubMed), EMBASE and Google Scholar databases in May 2020. We included all studies of patients with ≥ cT2N0/xM0 bladder cancer that were eligible for all treatment modalities at the time of treatment decision who underwent BST including radiotherapy (RTX). A meta-analysis was conducted to calculate the pooled rate of several variables associated with an increased need for SV-RC. Study quality and risk of bias were assessed using MINORS criteria. Results 73 studies comprising 9110 patients were eligible for the meta-analysis. Weighted mean follow-up time was 61.1 months (range 12–144). The pooled rate of non-response to BST and local recurrence after BST, the two primary reasons for SV-RC, was 15.5% and 28.7%, respectively. The pooled rate of SV-RC was 19.2% for studies with a follow-up longer than 5 years. Only three studies provided a thorough report of complication rates after SV-RC. The overall complication rate ranged between 67 and 72% with a 30-day mortality rate of 0–8.8%. The pooled rates of 5 and 10-year disease-free survival after SV-RC were 54.3% and 45.6%, respectively. Conclusion Approximately one-fifth of patients treated with BST with a curative intent eventually require SV-RC. This procedure carries a proportionally high rate of complications and is usually accompanied by an incontinent urinary diversion.

Background Deletions of 17p13 recurrently occur in renal cell carcinoma (RCC) but their prognostic role seems to be uncertain. Methods To determine prevalence, relationship with tumor phenotype, and patient prognosis, a tissue microarray containing samples from 1809 RCCs was evaluated using dual labeling fluorescence in situ hybridization (FISH) with 17p13 and chromosome 17 centromere probes. Results A 17p13 deletion was found in 72 of 1429 interpretable tumors. The frequency of 17p13 deletions varied greatly between RCC subtypes and was highest in chromophobe RCC (24/72; 33.3%). 17p13 deletions were also found in 35 (3.7%) of 946 clear cell RCC, 9 (4.3%) of 208 papillary RCC, 1 of 121 oncocytomas (0.8%), as well as in several rare cases of comprising 1 of 7 Xp11.2 translocation cancers, 1 of 3 collecting duct carcinomas, and 1 of 20 not otherwise specified (NOS) carcinomas. In clear cell carcinomas, 17p13 deletions revealed a strong and consistent association with higher Fuhrman, ISUP, and Thoenes grade (p < 0.0001 each), and linked to advanced tumor stage (p = 0.0168), large tumor diameter (p = 0.0004), distant metastases (p = 0.0077), cancer-specific survival (p = 0.0391), and recurrence-free survival (p = 0.0072). In multivariate analysis, 17p13 deletions showed in clear cell RCC a dependent prognostic role for established clinical-pathological parameters. Conclusion 17p13 deletions have a dual role in RCC. They are associated with disease progression in clear cell RCC and possibly other subtypes and they are linked to the development of chromophobe RCC—a subtype with a particularly favorable prognosis.

Purpose DNA ploidy measurement has earlier been suggested as a potentially powerful prognostic tool in many cancer types, but the role in renal tumors is still unclear. Methods To clarify its prognostic impact, we analyzed the DNA content of 1320 kidney tumors, including clear cell, papillary and chromophobe renal cell carcinoma (RCC) as well as renal oncocytoma and compared these data with clinico-pathological parameters and patient prognosis. Results A non-diploid DNA content was seen in 37% of 1276 analyzable renal tumors with a striking predominance in chromophobe carcinoma (74.3% of 70 cases). In clear cell carcinoma, a non-diploid DNA content was significantly linked to high-grade (ISUP, Fuhrman, Thoenes; p p = 0.0011), distant metastasis (p p = 0.0010), and earlier recurrence (p p = 0.0063), distant metastasis (p = 0.0138), shortened overall survival (p = 0.0010), and earlier recurrence (p = 0.0003). Conclusion In summary, the results of our study identify a non-diploid DNA content as a predictor of an unfavorable prognosis in clear cell and papillary carcinoma.

Based on unfavorable oncological and functional outcomes of non-organ-confined (NOC) prostate cancer (PCa), defined as ≥ pT3, pN1 or both, we aimed to develop a NOC prediction tool based on multiparametric MRI-guided targeted fusion biopsy (TBx). Analyses were restricted to 594 patients with simultaneous PCa detection at systematic biopsy (SBx), TBx and subsequent radical prostatectomy (RP) at our institution. Development (n = 396; cohort 1) and validation cohorts (n = 198; cohort 2) were used to develop and validate the NOC nomogram. A head-to-head comparison was performed between stand-alone TBx model and combined TBx/SBx model. Second validation was performed in patients with positive TBx, but negative SBx (n = 193; cohort 3). The most parsimonious TBx model included three independent predictors of NOC: pretreatment PSA (OR 1.05 95% CI: 1.01–1.08), highest TBx-detected Gleason pattern (3 + 3 [REF] vs. ≥ 4 + 5; OR 9.3 95% CI 3.8–22) and presence of TBx-detected perineural invasion (OR 2.2 95% CI: 1.3–3.6). The combined TBx/SBx model had the same predictors. For the stand-alone TBx and combined TBx/SBx model, external validation yielded accuracy of 76.5% (95% CI: 69.3–83.1) and 76.6% (95% CI: 69.4–83.6) within cohort 2. The external validation of the stand-alone TBx model yielded 72.4% (95% CI: 65.0–79.6) accuracy within cohort 3. Our stand-alone TBx-based nomogram can identify PCa patients at the risk of NOC, using three simple variables, with the similar accuracy as the TBx/SBx-based model. It is non-inferior to combined TBx/SBx-based model and performs with sufficient accuracy in specific patients with positive TBx, but negative SBx.

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.

ZusammenfassungDer Hodenhochstand stellt eine der häufigsten Erkrankungen im Kindesalter dar und wird bei 3 – 8 % der männlichen Patienten diagnostiziert. Das Ziel der Therapie des Hodenhochstandes ist der Deszensus in den Hodensack innerhalb des ersten Lebensjahres, um anhaltende degenerative Veränderungen des Hodens zu vermeiden. Oft ist dazu eine operative Behandlung notwendig.Die chirurgische Therapie des tastbaren Hodens im Bereich der Leiste ist die Orchidopexie und bei nicht tastbaren Hoden ein laparoskopischer Ansatz mit ggf. inguinaler Freilegung. Die Orchidopexie für einen tastbaren Hoden kann durch einen traditionellen Leistenschnitt (inguinal) oder transskrotal behandelt werden. Der inguinale Zugangsweg gilt für die Orchidopexie als operative Methode der Wahl.

Posterior urethral injuries in men usually result from polytrauma with pelvic fractures and severe associated injuries. If left untreated, posterior urethral injury can lead to severe complications and even death, so precise diagnosis should be made when urethral injury is suspected. The cardinal symptom of urethral injury is blood leakage from the meatus. Retrograde urethrography is the diagnostic tool of choice. In the case of complete urethral avulsion, the formation of a urethral stricture due to pronounced scarring fibrosis is inevitable. In principle, various therapeutic approaches are available. Often, urinary diversion by means of a transurethral or suprapubic catheter is performed first. However, there is also the possibility of direct endoscopic or open urethral realignment with subsequent temporary catheterization. Immediate surgical reconstruction is useful only in exceptional cases of simultaneous bladder neck or rectal injury. In cases of complete urethral avulsion, secondary transperineal bulboprostatic reanastomosis at the interval after three months of suprapubic continuous drainage with excellent success rate is the gold standard and can be supplemented with ancillary maneuvers if necessary to ensure a tension-free anastomosis.Posteriore Harnröhrenverletzungen beim Mann gehen meist auf Polytraumata mit Beckenfrakturen und schweren Begleitverletzungen zurück. Unbehandelt kann eine posteriore Harnröhrenverletzung zu schweren Komplikationen bis hin zum Tod führen, so dass bei Verdacht auf Harnröhrenverletzung eine präzise Diagnostik erfolgen sollte. Das Kardinalsymptom einer Harnröhrenverletzung stellt Blutaustritt aus dem Meatus dar. Diagnostisches Mittel der Wahl ist die retrograde Urethrographie. Bei komplettem Harnröhrenabriss ist die Ausbildung einer Harnröhrenstriktur durch ausgeprägte, narbige Fibrosierung unvermeidbar. Grundsätzlich stehen verschiedene therapeutische Ansätze zur Verfügung. Häufig erfolgt zunächst eine Harnableitung mittels transurethralem oder suprapubischem Katheter. Es gibt jedoch auch die Möglichkeit einer direkten endoskopischen oder offenen Kontinuitätswiederherstellung mit anschließender passagerer Katheterableitung. Eine sofortige operative Rekonstruktion ist nur in Ausnahmefällen bei simultaner Blasenhals- oder Rektumverletzung sinnvoll. Bei vollständigen Harnröhrenabriss stellt die sekundäre transperineale, bulboprostatische Reanastomose im Intervall nach dreimonatiger suprapubischer Dauerableitung mit exzellenter Erfolgsrate den Goldstandard dar und kann bei Bedarf um Zusatzmanöver ergänzt werden, um eine spannungsfreie Anastomose zu gewährleisten.

Cadherin-16 (CDH16) is a member of the cadherin superfamily which is also termed kidney specific cadherin (ksp-cadherin) because of its preferred expression in the normal kidney where it plays a pivotal role in tubulus formation during embryonal development. However, little is known about the prognostic role of CDH16 in renal cell carcinomas.CDH16 protein was analyzed by immunohistochemistry in more than 1,300 renal cell carcinomas (RCCs) in a tissue microarray format.A CDH16 positivity was found in 81% of 1,115 interpretable tumors. Staining was weak in 34%, moderate in 32% and strong in 15% of tumors. CDH16 positivity was more common in oncocytomas (99% positive) and chromophobe carcinomas (94%) than in papillary (73%) and clear cell RCCs (82%; P0.0001). In clear cell RCC, reduced CDH16 staining was significantly linked to high-grade (P0.0001), advanced pT stage (P = 0.0452), distant metastasis (P = 0.0003) as well as to shortened recurrence free (P0.0001), overall (P = 0.0002), and tumor specific survival (P = 0.0092). In a multivariate analysis including pT, pN, ISUP grade, and M status, CDH16 expression loss was an independent prognostic parameter for overall (P = 0.0016) and tumor specific survival (P = 0.0218) in clear cell RCC. Unequivocal associations with tumor phenotype and prognosis were not seen in papillary RCC.Our data demonstrate that reduction of CDH16 expression is a strong and potentially clinically useful independent predictor of poor prognosis in clear cell RCC.

ObjectiveTo explore feasibility in terms of delivering and evaluating a combination of physiotherapy and psychotherapy for patients with chronic pelvic pain syndrome (CPPS).DesignProspective non-randomised controlled pilot study.SettingTertiary care facility with a specialised interdisciplinary outpatient clinic for patients with CPPS.ParticipantsA total of 311 patients was approached; 60 participated. 36 patients were included in the intervention group (mean age ±SD 48.6 years±14.8; 52.8% female) and 24 in the control group (mean age ±SD 50.6 years±14.5; 58.3% female). Fourteen participants were lost to follow-up.InterventionsParticipants were non-randomly allocated to the intervention group with two consecutive treatment modules (physiotherapy and cognitive behavioural therapy) with a duration of 9 weeks each or to the control group (treatment as usual).Main outcome measuresFeasibility was operationalised in terms of delivering and evaluating the therapeutic combination. Regarding eligibility as the first aspect of feasibility, willingness to participate, dropout and satisfaction were assessed; for the second aspect, standardised self-report questionnaires measuring health-related quality of life, depression severity and pain were applied.ResultsAlthough eligibility and willingness-to-participate rates were low, satisfaction of the participants in the intervention group was high and dropout rates were low. Results indicated a small and non-significant intervention effect in health-related quality of life and significant effects regarding depression severity and pain.ConclusionsThe combination of physiotherapy and psychotherapy for patients with CPPS seems to be feasible and potentially promising with regard to effect. However, a subsequent fully powered randomised controlled trial is needed.Trial registration numberGerman Clinical Trials Register (DRKS00009976) and ISRCTN (ISRCTN43221600).

Nephrometry scores aid in clinical decision-making, yet evidence is scarce regarding their impact on cumulative morbidity following partial nephrectomy (PN).Retrospective, monocentric study of 122 patients with suspicious renal masses undergoing open or robot-assisted PN between January 2019 and August 2020. Morbidity assessment followed European Association of Urology guidelines on complication reporting. 30-d complications were extracted using a PN-specific catalog, were graded by the Clavien-Dindo classification (CDC), and Comprehensive Complication Index (CCI®) values were calculated. The impact of nephrometry on cumulative morbidity was evaluated by (1) comparing morbidity estimates between Preoperative Aspects and Dimensions Used for an Anatomical (PADUA)/R.E.N.A.L. complexity groups, (2) by Pearson's correlation between nephrometry scores and CCI®, and (3) by multivariable regression models using any 30-d complication and 30-d CCI® as endpoints.Of 122 patients, 101 (83%) underwent open and 21 (17%) robot-assisted PN. Median PADUA and R.E.N.A.L. scores were 9 (interquartile range, IQR 8-10) and 8 (IQR 6-9), respectively. Of 218 complications in 92 patients (75%), the majority was classified as minor (CDC grade ≤IIIa). Median 30-d CCI® was 8.7 (IQR 0.50-15). There was a small positive correlation between PADUA or R.E.N.A.L. score with CCI® (all P ≤ 0.026), explaining 4.7% and 4.1% of the variation in CCI®, respectively. After adjustment, nephrometry scores were associated with any 30-d complication and the CCI® (all P ≤ 0.011). PADUA and R.E.N.A.L. high complexity tumors were positively associated with both morbidity endpoints compared to low complexity tumors (all P ≤ 0.041).At a referral center, PN may be safely performed, even if morbidity assessment follows a strict protocol. Nephrometry risk classification does only marginally translate into clinical relevant differences regarding short-term complications. Thus, nephron-sparing surgery should not be withheld from patients with high complexity renal masses.

INTRODUCTION AND OBJECTIVE:There is a non-negligible proportion of men with recalcitrant bladder neck stenoses following treatment for benign prostatic hyperplasia (BPH) refractory to transurethral...

INTRODUCTION AND OBJECTIVE:For short and obliterative bulbar strictures, non-transecting excision and primary anastomosis (EPA) has come of age to avoid disrupting spongiosal blood flow. Longer obl...

INTRODUCTION AND OBJECTIVE:There are only few reconstructive options in men with recurrent, panurethral strictures, and diversion, perineostomy or suprapubic catheter are frequently inevitable. We ...

INTRODUCTION AND OBJECTIVE:Recently, pentafecta criteria (PC) have been proposed by an international expert panel to objectively assess quality of care after open radical cystectomy (ORC) in bladde...

Background To test for the impact of patient comorbidities and medical risk factors on kidney function after partial (PN) or radical nephrectomy (RN) in renal cell carcinoma (RCC) patients with normal preoperative renal function. Materials and methods From January 2011 to December 2014, 195 consecutive RCC patients with a preoperative estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73 m2 underwent PN or RN. Stratification was performed according to postoperative acute kidney injury (AKI) vs. no AKI. Moreover, logistic regression models tested for risk factors predicting postoperative AKI and subsequent new-onset chronic kidney disease (eGFR Results Of all eligible patients, 127 (65.1%) exhibited AKI. AKI patients underwent more frequently RN (44.9 vs. 13.2% PN) and harbored more often preoperative diabetes (17.3 vs. 5.9% no diabetes), hypertension (46.5 vs. 23.5% no hypertension) and larger median tumor size (4.5 vs. 2.5 cm, all p 60 years and RN as well as preoperative diabetes were risk factors for postoperative eGFR Conclusions Postoperative AKI is a non-negligible event especially after RN that can be further triggered by comorbidities such as diabetes and hypertension. Comorbidities should be considered in clinical decision-making for RCC surgery and patients need to be counseled about the increased risk of consecutive renal function impairment.

Background No procedure-specific definitions in complication reporting have been universally accepted in urological surgery, and conventional classification systems do not reflect cumulative morbidity. Objective To conduct a rigorous assessment of 30-d complications after radical cystectomy and improve morbidity estimates by introducing the novel Comprehensive Complication Index (CCI). Design, setting, and participants A retrospective proof-of-concept study of 506 patients with bladder cancer between 2009 and 2017. Intervention Radical cystectomy with pelvic lymph node dissection. Outcome measurements and statistical analyses Thirty-day complications were extracted from digital charts based on a procedure-specific catalog. Each complication was graded by the Clavien-Dindo classification (CDC), and each individual CCI was calculated. We evaluated traditional morbidity endpoints and tested the ability of both classification tools to mirror cumulative morbidity. Multivariable regression analyses were employed for risk modeling using conventional and novel endpoints. The study fulfilled all the European Association of Urology (EAU) criteria of standardized reporting. Limitations include restricted follow-up of 30 d. Results and limitations Of 506 patients, 503 (99%) experienced a total of 2485 complications, of which the majority was classified as “minor” (CDC grade ≤ IIIa; 89%). Overall, 29 (5.7%), 20 (4.0%), and 12 (2.4%) patients were reoperated, readmitted, and died within 30 d, respectively. When using the CCI to capture cumulative morbidity, the proportion of patients with most severe complication burden (CDC grade ≥ IIIb or corresponding CCI > 33.7) increased to 31% as compared with 11% when considering only the highest-grade complication according to the CDC. Age-adjusted comorbidity and delta hemoglobin were the main drivers of perioperative complications for all outcomes in multivariable models. Conclusions The assessment of short-term morbidity after radical cystectomy may be refined and optimized by employing the EAU criteria of standardized reporting and using the CCI to capture cumulative morbidity. These are the cornerstones of urgently needed procedure-tailored benchmarking to improve comparability and quality control. Patient summary Characterization of short-term morbidity after radical cystectomy was improved by using several validated assessment tools and adhering to existing guidelines for reporting surgical complications.

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. 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. 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%. 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.

Objective To analyze functional outcomes and complication rates of distal double cuffs (DC) or transcorporal cuffs (TC) as salvage approaches in high-risk patients, since there is an ongoing debate about optimal cuff-placement in a salvage setting (SV). Existing studies analyzing DC or TC are controversial with respect to functional outcomes and complication rates. Studies directly comparing both approaches in SV are scarce. Methods and Patients Prospective data collection was performed since 2009. DC/TC were applied according to a standardized protocol in SV. Salvage DC was chosen in case of a membranous single cuff explantation due to erosion or infection. TC were implanted after bulbar urethroplasty or DC explantation. Activation was performed 6 weeks postoperatively. Further follow-up was scheduled 6/24 months postoperatively and every 2 years thereafter. Primary/secondary endpoints were continence/complication rates. Results In total, 71 high-risk patients were available for analysis (58 DC, 13 TC). Median age was 70 years. Median follow-up was 24 months. Objective/social continence were 88%/94% in the DC and 72%/100% in the TC cohort, respectively (P = .37/P = 1). Overall, there were no significant differences with respect to infections, erosions, mechanical failure, and explantation rates. The times of explantation-free survival were similar in Kaplan-Meier analysis (Log-rank 0.399). Conclusion Complication and continence rates were not significantly different between both cohorts. Hence, a DC in SV can be considered as equally safe and effective. A sequential implantation (first DC, second TC) may be a viable approach to extend overall AUS incontinence therapy.

Objectives To analyse functional outcomes and complication rates of artificial urinary sphincter (AUS) implantation with a distal bulbar double cuff (DC) for the treatment of stress urinary incontinence (SUI) in men with and without a history of external beam radiotherapy (RT). Patients and methods Data of all patients undergoing AUS implantation with a distal bulbar DC (DC-AUS) were collected prospectively from 2009 to 2015. Indications for DC implantation were based on urethral risk factors in terms of RT and previous proximal bulbar urethral interventions including, endoscopic or open surgery for urethral stricture or SUI. Implantation was carried out to a standardised protocol. Activation of the AUS was performed 6 weeks after implantation. Further follow-up (FU) included pad test, uroflowmetry, post-void residual urine measurements, radiography, and a standardised questionnaire. Continence and complication rates were compared between patients with a history of RT and non-RT patients. Explantation-free survival was estimated using Kaplan-Meier curves and the log-rank test. Firth's penalized Cox-regression analyses were performed to analyse proportional hazard ratios for explantation. Results In all, 150 men (median age 70 years, interquartile range [IQR] 66-74) after DC-AUS implantation were available for analysis. Overall, 73 men (48.7%) had a history of RT. The median (IQR) FU was 24 (7.25-36) months. Baseline clinical characteristics only differed regarding previous open SUI surgery (P = 0.016). Social and objective continence was achieved in 94.8% and 84.3% of all patients treated by implantation of a DC-AUS, respectively. Between the RT and non-RT patients there were no statistically significant differences in continence rates [social continence: 100% vs 90.2% (P = 0.194); objective continence: 87% vs 82% (P = 0.877)]. For complications rates there were no significant differences between RT and non-RT patients after DC-AUS implantation [infection (P = 0.09), erosion (P = 0.31), mechanical failures (P = 0.14)]. According to Kaplan-Meier analysis explantation rates in patients with a history of RT (26.0%) vs non-RT patients (20.8%), estimated explantation-free survival, and AUS durability, did not differ significantly (log-rank P = 0.219). Conclusion Our data from a large institutional series indicate DC-AUS implantation to be an effective and safe treatment strategy in men with SUI and a history of RT.

Context Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. Objective To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. Evidence acquisition A collaborative narrative review of the literature from 2010 to present was conducted. Evidence synthesis Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3–9% and 0–4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4–14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. Conclusions There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. Patient summary In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.

We sought to characterize a standardized postoperative radiographic and functional voiding trial, and determine its impact on outcomes after substitution urethroplasty.This is an observational, monocenter study of men who underwent 1-stage ventral onlay buccal mucosal graft urethroplasty for bulbar urethral stricture between January 2009 and December 2016. Patients were stratified by voiding trial success vs failure, including radiographic (extravasation or residual narrowness) and functional (post-void residual volume greater than 100 ml) failure, 21 days postoperatively. End points were voiding trial failure and recurrence-free survival. Regression models were created to determine risk factors of voiding trial failure and evaluate the impact of voiding trial failure on recurrence.The voiding trial succeeded and failed in 437 (85.2%) and 76 (14.8%), respectively, of 513 men. Of the latter men 54 (71.1%) showed evidence of extravasation and 22 (28.9%) had residual narrowness or functional failure. On multivariable logistic regression analyses no preoperative predictor of voiding trial failure was found (all p0.05). At a median followup of 32 months Kaplan-Meier analyses (log rank test p = 0.033) and multivariable Cox regression analyses (HR 1.86, p = 0.037) revealed an association of voiding trial failure and stricture recurrence. When further stratifying voiding trial failure, residual narrowness or functional failure (HR 4.60, p0.001) but not extravasation (HR 1.08, p = 0.9) was a risk factor for recurrence. Limitations include the retrospective assessment of investigated end points.Residual narrowness or functional failure at an early voiding trial after buccal mucosal graft urethroplasty may predict stricture recurrence. Identifying intraoperative complexity factors predicting initial voiding trial failure might be a key to identifying those individuals with early recurrence.

The international meeting on reconstructive Urology (IMORU) is a live surgery event (LSE) where expert surgeons perform various reconstructive surgeries. To evaluate patient safety, an extended follow-up of the complications of two subsequent IMORU meetings were gathered. Also, a detailed survey concerning the participant’s assessment of the educational benefit was performed. All patients that were operated during the IMORU V and VI were included. Primary endpoint was the analysis of complications. Outcome was reviewed 36 months postoperatively via telephone survey and clinical database assessment, registrating any complications. At IMORU VII all participants were able to participate in a survey using a standardized, not-validated questionnaire concerning the learning effect and the quality of the surgeries. 57 operations by 32 different surgeons were reviewed. The total number of any complications (peri- or postoperative) was n = 9 (15.8%) with three major complications. Four (7%) perioperative complications and five (8.8%) postoperative complications were noted. The Charlson score proved to be the only significant recorded predictor of the incidence of any complication (p = 0.019; univariate logistic regression analysis). Participant survey showed that the surgeons, surgical technique, and surgical presentation were perceived as excellent. Improvement of knowledge and of the surgical armamentarium both received positive ratings. This is to our knowledge the first follow-up of LSE in the field of reconstructive urology. Rate of complications in general was acceptable. The performed survey showed participants value the quality and the educational benefit. Further studies are needed to improve learning possibilities.

Purpose of review Treatment of penile and distal urethral strictures including the fossa navicularis and the meatus remains challenging due to their adverse etiology and lack of ventral tissue support. In this contemporary review, we summarize the available evidence and recent advancements in reconstructive techniques. Recent findings Over the last years, several refinements of already established techniques have been added to the reconstructive armamentarium in the management of penile urethral strictures. These include the single-stage combination of flap and graft, the additional use of tissue glue, or an optimized single-stage tubularization using a free graft. Summary There is a shift toward an increased use of single-stage procedures even in complex strictures of the penile and distal urethra. This is reflected by advancements and refinements in operative techniques. Nonetheless, staged urethroplasty remains a cornerstone of curative management in such patients with durable success rates. Future research should focus on identifying distinct patient and stricture characteristics to determine the individual therapeutic approach with optimal functional outcomes.

Objectives: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. Material and Methods: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. Results: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3–14) months and differed significantly in those with (6.5 months, IQR 4–10) and those without BNC recurrence (10 months, IQR 6–20, p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months, IQR 6–9) compared to those treated successfully (median 12 months, IQR 9–25, p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months, IQR 2–12) and those without a recurrence (6 months, IQR 6–10, p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%, p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. Conclusions: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts.

Urethral strictures in women are rare and patients may present with varying symptoms. Hence, clinical guidelines regarding diagnostic algorithms and treatment approaches are scarce. Several small case series have presented results for several operative techniques, but patient cohorts are generally heterogeneous and relatively small, which hampers reliable comparability across institutions. The present narrative review aims to provide a contemporary overview of the literature regarding the clinical and therapeutical approach in women with urethral strictures.Iatrogenic reasons such as previous catheterization or genitourinary surgical interventions are the most common cause of female urethral strictures. In daily clinical routine, physical examination is the cornerstone for differential diagnosis and may aid in the decision to expand diagnostic workup by urethrocystoscopy, urethrography, or magnetic resonance imaging in case of suspected anatomic or morphologic cause of voiding disorder. Endoscopic approaches such as dilation or urethrotomy only provide short-term symptomatic relief and open urethroplasty is more commonly associated with durable long-term success. Regarding the surgical approach, there are comparable operative techniques at hand, using vaginal or labial flaps or oral mucosal grafts. Given the relative rarity of female urethral strictures with only small case series published, a statement regarding the superiority of one approach over the other is hardly possible. As for all rare disorders, multi-institutional, large patient series are needed to generate reliable evidence and to improve standards in the perioperative care of women with urethral strictures.Harnröhrenstrikturen der Frau sind ein seltenes Krankheitsbild mit individueller Symptomatik. Vor diesem Hintergrund mangelt es an klinischen Leitfäden, die sich mit Diagnostik und Therapie dieser Erkrankung befassen. Mittlerweile liegen einige Ergebnisse zu verschiedenen Operationstechniken vor, ein direkter inter-institutioneller Vergleich wird jedoch durch heterogene Patientenkohorten und kleine Fallzahlen erschwert. Die vorliegende Arbeit befasst sich mit einer aktuellen narrativen Literaturübersicht relevanter Artikel zur klinischen Diagnostik und zu den Therapiemöglichkeiten bei weiblicher Harnröhrenstriktur.Iatrogene Ursachen wie eine vorangegangene Katheterisierung oder ein urogenitaler operativer Eingriff sind die häufigsten Gründe für die Entstehung einer Harnröhrenstriktur bei der Frau. Im klinischen Alltag stellt die körperliche Untersuchung einen wichtigen Grundstein in der Differentialdiagnostik dar, um bei Verdacht auf eine anatomisch-morphologische Ursache der Harnblasenentleerungsstörung weitere diagnostische Maßnahmen (Urethrozystoskopie, Urethrographie, MRT) einzuleiten. Therapeutisch sind minimal-invasive Eingriffe wie Harnröhrenbougierungen oder Urethrotomien oftmals nur mit kurzfristigem Erfolg assoziiert, sodass die offene Harnröhrenrekonstruktion mit langfristigeren Therapieerfolgen hier eine Sonderstellung einnimmt. Zur Verfügung stehen neben offenen Harnröhrenplastiken mit gestielten Lappen aus Vaginal- oder Labialschleimhaut auch die Verwendung freier Transplantate, vor allem dem Mundschleimhaut-Autotransplantat. Aufgrund der genannten Seltenheit der Erkrankung mit nur kleinen publizierten Fallserien ist jedoch eine Beurteilung der vergleichenden Wirksamkeit der verschiedenen Techniken nur schwer möglich. Wie bei allen seltenen Erkrankungen bedarf es hier der Etablierung von multizentrischen, großen Serien, um die Standards im perioperativen Vorgehen zu verbessern.

Background PD-L1 expression predicts response to immune checkpoint inhibitors in renal cell carcinomas (RCC), but has also been suggested to be linked to poor patient outcome. Methods We analyzed PD-L1 in > 1400 RCC in a tissue microarray format by immunohistochemistry. Results were compared with histological tumor type, parameters of cancer aggressiveness, and intratumoral CD8+ cytotoxic cells. Result At a cut-off level of 5% PD-L1 positive tumor cells, PD-L1 positivity was seen in 6.3% of 633 clear cell RCC (ccRCC), 18.2% of 165 papillary RCC, 18.8% of 64 chromophobe RCC, and 41.7% of 103 oncocytomas. In ccRCC, PD-L1 positivity was significantly linked to high ISUP (p p p p = 0.0042), short recurrence-free (p p = 0.0002). Intratumoral CD8+ lymphocytes were more frequent in PD-L1 positive (1055 ± 109) than in PD-L1 negative ccRCC (407 ± 28; p + cells (p p p = 0.0027), and Thoenes grade (p p = 0.0280). Conclusions These data suggest that PD-L1 expression in highly immunogenic RCCs facilitates immune evasion and contributes to cancer aggressiveness.

Harnrohrenplastiken sind Verfahren zur Rekonstruktion der Harnrohre bei angeborenen Stenosen oder erworbenen (traumatisch, infektios, iatrogen) Strikturen oder Defekten der Harnrohre. Sie umfassen eine Vielzahl von operativen Eingriffen. Hierbei kommen in Abhangigkeit von ihrer Atiologie, Lokalisation oder Auspragung verschiedene Verfahren zum Einsatz: Endoskopische Verfahren wie z. B. Urethrotomia interna oder Blasenhalsinzision; offene Rekonstruktionen wie z. B. T- bzw. YV-Plastik, perineale oder bulboprostatische Re-Anastomosierung, End-zu-End-Anastomosierung, Rekonstruktionen mit Genitalhautlappen oder die Verwendung von freien Transplantaten der Mundschleimhaut oder von Spalthaut (Mesh-Graft-Plastik). Die einzelnen Verfahren unterscheiden sich in ihrer Komplexitat. Es wird zwischen einzeitigen sowie zwei- oder mehrzeitigen Verfahren unterschieden. Abhangig von der Anzahl der zum Tragen kommenden Faktoren ist mit unterschiedlichen perioperativen und langfristigen Komplikationen zu rechnen. Die Fruhkomplikationen umfassen Infektionen sowie Wundheilungsstorungen. Langfristige Komplikationen beinhalten Fistelbildungen und Rezidiv-Strikturen, das Nachtraufeln nach der Miktion und die erektile Dysfunktion. Insgesamt handelt es sich bei der Harnrohrenplastik um einen Eingriff mit hohen Erfolgsraten. Die Komplikationen korrelieren mit der Komplexitat des Eingriffs und lassen sich durch ein standardisiertes perioperatives Management sowie korrekte Indikationsstellungen und standardisierte OP-Techniken reduzieren. Die spannungsfreien suburethralen alloplastischen Schlingen (SFAS), die Mitte der 90iger Jahre des vergangenen Jahrhunderts von Ulf Ulmsten etabliert wurden, haben die operative Behandlung der weiblichen Belastungsinkontinenz revolutioniert. Exzellente Langzeitergebnisse, eine leichte Erlernbarkeit der Technik aber auch der zunehmende Verlust an Expertise im Umgang mit Alternativverfahren sind Grunde fur die breite Anwendung. Falsche Indikationsstellungen durch eine inadaquate praoperative Diagnostik, Verfahrensmodifikationen und eine mangelnde urogynakologische operative Expertise konnen die postoperativen Resultate jedoch massiv beeintrachtigen. Schwerwiegende Komplikationen im Zusammenhang mit dem urogynakologischen Einsatz von v. a. Polypropylen-Netzen und Bandern haben nun dazu gefuhrt, dass in den USA und seit Juni 2018 in Grosbritannien der Einsatz von artifiziellem Netzmaterial in der Behandlung der weiblichen Belastungsinkontinenz bis auf weiteres untersagt wurde. Die bis dato in Uberarbeitung befindliche S2e-AWMF-Leitlinie (AWMF-Register-Nr. 015/005, Klasse S2e) (AWMF 2013) spiegelt die Problematik noch nicht wider, dennoch sollte diese jedem Anwender bewusst sein.