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Background: Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival. Methods: We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0–2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m 2 intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544). Findings: Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86–107) in the abiraterone trial and 72 months (61–74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8–86·9) in the abiraterone group versus 45·7 months (41·6–52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53–0·73]; pinteraction=0·71) or between-trial heterogeneity (I 2 p=0·70). In the first 5 years of treatment, grade 3–5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (

Zusammenfassung: Die operative Behandlung grosser Prostataadenome (> 80g) bei Männern mit symptomatischer Prostatahyperplasie und Therapieversagen mit einem Alphablocker ist eine Herausforderung im klinisch urologischen Alltag. Der operative Goldstandard, die transurethrale Elektroresektion der Prostata (TUR-P) ist aufgrund verlängerter Resektionszeiten bei grossen Adenomen und der damit vergesellschafteten erhöhten Komplikationsraten zur Behandlung ungeeignet. Über Jahrzehnte hinweg wurden grosse Adenome mittels offener Prostataadenomenukleation behandelt. Die Technik ist zum Teil nach wie vor noch etabliert, jedoch mit erheblichen Morbiditäts- und Komplikationsraten behaftet. Vor diesem Hintergrund wurden in den letzten Jahren zahlreiche minimal invasive Techniken entwickelt. Diese beinhalten transurethrale Interventionen, hauptsächlich mit Anwendung von Lasertechnologien, wie die Holmium-Laser-Enukleation (HoLEP) oder die KTP-Laser-Vaporisation (Greenlight™-Laser). Zudem wurden die sehr früh beschriebenen offenen Enukleationstechniken konventionell laparoskopisch und schliesslich auch laparoskopisch roboterassistiert angewandt, evaluiert und weiterentwickelt. Mittlerweile ist die laparoskopisch roboterassistierte Adenomenukleation der Prostata (RASP) und insbesondere die Modifikation mittels extraperitonealem extravesikalem Zugang und intraprostatischer Rekonstruktion der Urethra (EE-RASP) zur Ausschaltung des offenliegenden Wundbettes aus dem Harntrakt mit konsekutiv deutlicher Reduktion der perioperativen Komplikationen, eine etablierte Methode und eine Alternative der neueren transurethralen Methoden.

Background: Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation “Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer” was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available. Objective: To assess current ADT use before prostate cancer surgery in Europe. Design, setting, and participants: This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres. Outcome measurements and statistical analysis: Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence. Results and limitations: We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0–32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0–43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated. Conclusions: EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued. Patient summary: Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.

Background: Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction. Objective: To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes. Design, setting, and participants: We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer. Surgical procedure: The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article. Measurements: The outcomes measured were UC and EF at 12 mo. Results and limitations: A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58–70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88–7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55–11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91–0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25–0.89; p < 0.02) were inversely associated with EF. Conclusions: RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities. Patient summary: We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery.

Vesikovaginale Fisteln (VVF) treten in der westlichen Welt insbesondere als Komplikation nach operativen Eingriffen im weiblichen Becken oder nach pelviner Radiotherapie auf und stellen eine hohe Einschrankung der Lebensqualitat fur die betroffenen Patientinnen dar. In diesem Artikel prasentieren wir unsere minimal-invasive Technik und das Outcome bezuglich der Rekonstruktion vesikovaginaler Fisteln mit Peritoneallappeninterponat.

Diese Ubersichtsarbeit zeigt den derzeitigen Stand der diagnostischen und therapeutischen Moglichkeiten in der Behandlung der uberaktiven Blase (OAB) beim Mann. Grundsatzlich muss die idiopathische OAB (OAB im engeren Sinn) abgegrenzt werden zur OAB, welcher eine auslosende Ursache zugrundeliegt (OAB im erweiterten Sinn). Insbesondere beim Mann kommt hier eine Vielzahl von Differenzialdiagnosen in Frage. Grundvoraussetzung einer korrekten Abklarung ist eine grundliche Anamnese, bei welcher wegweisende Informationen gesammelt und erste Differenzialdiagnosen gestellt werden. Nebst der klinischen Untersuchung, einem Basisblutbild (inklusive PSA, Nierenwerte) und einer Urinanalyse soll die Diagnostik durch Spezialuntersuchungen durch den Facharzt fur Urologie erweitert werden (Zystoskopie/Video-Urodynamik). Die Therapie richtet sich nach der zugrundeliegenden Erkrankung im Falle einer OAB im erweiterten Sinn und sofern behandelbar. Ansonsten erfolgt eine symptomorientierte Therapie im Falle einer idiopathischen OAB. Konservative Therapieansatze umfassen die Beckenboden-Physiotherapie, nichtinvasive Elektrostimulationstherapien oder Lifestyle-Modifikationen, aber auch Medikamente wie Antimuskarinika oder Beta-Sympathomimetika. Invasivere Therapiemoglichkeiten wie Botox-Injektionen in die Harnblase oder die sakrale Neuromodulation sind je nach Ursache als sekundare Therapien zu sehen. Operative Ansatze wie die Blasenaugmentation oder Zystektomie sind bei Therapieversagen in Erwagung zu ziehen. Neben diesen Therapieansatzen nimmt die Patientenberatung eine zentrale Bedeutung ein, da ein Therapieerfolg oft erst nach langerer Zeit und nach mehreren frustranen Therapieversuchen verzeichnet werden kann.

Nebennierentumoren uber 4 cm Grosse und mit kleiner Dichte in der nativen Computertomographie unter 10 Hounsfield-Einheiten bedurfen einer eingehenden klinischen und endokrinologischen Abklarung. Hyperkortisolismus, primarer Hyperaldosteronismus, Phaochromozytome und Nebennierenmetastasen sind mogliche Operationsindikationen. Die laparoskopische Adrenalektomie ist heute Therapiestandard. Die roboterunterstutzte Laparoskopie wird zunehmend entsprechend ihrer Verfugbarkeit dank verbesserter Sicht, Vergrosserung und Instrumentenbeweglichkeit in Anspruch genommen und auch bei grossen Tumoren, Phaochromozytomen, Nierenrindenkarzinomen, partiellen Adrenalektomien oder Metastasektomien sinnvoll eingesetzt. Die laparoskopisch-roboterassistierte Adrenalektomie wird bereits heute in vielen Zentren mit etablierter urologischer Robotik in der Routine bevorzugt.

Inflammatory myofibroblastic tumors are rare tumors with an ALK (anaplastic lymphoma kinase) gene rearrangement in up to 65% of all cases. In our patient, the tumor was not primary resectable due to its extension. Under neoadjuvant treatment with the first generation ALK inhibitor crizotinib no tumor response was seen, but the following therapy with the next generation ALK inhibitor lorlatinib led to a rapid and deep response, enabling a complete tumor resection by partial cystectomy. Our case indicates that ALK positive inflammatory myofibroblastic tumors which do not respond to ALK inhibition with crizotinib can be successfully treated with newer agents.

In der Schweiz erkranken rund 1000 Patienten pro Jahr an einem Nierenzellkarzinom, was gut 3 % aller Krebserkrankungen ausmacht. Aufgrund haufiger durchgefuhrter Bildgebungen sowie besserer Qualitat derselben werden Nierentumoren heute oft als Zufallsbefund entdeckt. Die Nierenteilresektion loste in den letzten Jahren die radikale Nephrektomie als Therapie der Wahl bei Nierentumoren bis 7 cm ab. Hierbei steht der Erhalt der Nierenfunktion im Vordergrund, wobei im Vergleich zur radikalen Nephrektomie moglichst viele Nephronen erhalten werden. Die roboterassistierte Nierenteilresektion als minimal-invasive Variante zeigt hierbei gegenuber der offenen Nierenteilresektion ebenburtige onkologische und funktionelle Resultate mit den Vorteilen der minimal-invasiven Chirurgie. Alternative Behandlungsformen wie Kryoablation oder Radiofrequenzablation sind nichtoperablen Patienten vorbehalten. Die Rezidivrate nach Nierenteilresektion bei Nierenzellkarzinom ist tief, auch bei mikroskopisch nachweisbaren Tumoranteilen im Resektionsrand (R1-Resektion). Die Nachsorge mittels Computertomographie soll individuell gemass Risikostratifizierung erfolgen.

Context Surgical repair of a vesicovaginal fistula (VVF) has been described extensively in the literature for several decades. Advances in robotic repair have been adopted since 2005. Objective A consensus review of existing data based on published case series, expert opinion, and a survey monkey. Evidence acquisition This document summarizes the consensus group meeting and survey monkey results convened by the European Association of Urology Robotic Urology Section (ERUS) relating to the robotic management of VVF. Evidence synthesis Current data underline the successful robotic repair of supratrigonal nonobstetric VVF. The panel recommends preoperative marking of the fistula by a guidewire or ureteral catheter, and placement of a protective ureteral JJ stent. An extravesical robotic approach usually provides a good anatomic view for adequate and wide dissection of the vesicovaginal space, as well as bladder and vaginal mobilization. Careful sharp dissection of fistula edges should be performed. Tension-free closure of the bladder is of utmost importance. Tissue interposition seems to be beneficial. The success rate of published series often reaches near 100%. An indwelling bladder catheter should be placed for about 10 d postoperatively. Conclusions When considering robotic repair for VVF, it is essential to establish the size, number, location, and etiology of the VVF. Robotic assistance facilitates dissection of the vesicovaginal space, harvesting of a well-vascularized tissue flap, and a tension-free closure of the bladder with low morbidity for the patient being operated in the deep pelvis with delicate anatomical structures. Patient summary Robotic repair of a vesicovaginal fistula can be applied safely with an excellent success rate and very low morbidity. This confirms the use of robotic surgery for vesicovaginal fistula repair, which is recommended in a consensus by the European Association of Urology Robotic Section Scientific Working Group for reconstructive urology.

Die medikamentose Therapie hat einen grossen Stellenwert in der Behandlung von Patienten mit Symptomen des unteren Harntrakts („lower urinary tract symptoms“, LUTS) bei Prostatavergrosserung. Neben synthetischen Praparaten stehen zahlreiche Phytotherapeutika zur Verfugung. Die Datenlage zu Phytotherapeutika in der Therapie von LUTS zeigt eine grosse Varianz und ist teils sogar widerspruchlich. Grundsatzlich muss jedes Praparat isoliert betrachtet werden, da sich Extraktionsverfahren und Zusammensetzung unterscheiden. Einzelne Praparate wie der hexanische Extrakt der Sagepalmfrucht (HESr) und das Kombinationspraparat aus Sagepalmfruchtextrakt und Brennnesselwurzelextrakt (PRO 160/120) konnten im Vergleich zu Plazebo eine signifikante Verbesserung sowie eine vergleichbare Wirkung wie synthetisch-medikamentose Standardtherapien auf LUTS erzielen. Phytotherapeutika zeichnen sich durch eine gute Vertraglichkeit, geringe Nebenwirkungen und eine unbeeinflusste Sexualfunktion aus. Phytotherapeutika, welche uber suffiziente Daten aus randomisierten Studien verfugen, kommen fur Patienten mit geringer bis moderater Symptomatik in Betracht, insbesondere wenn synthetische Praparate abgelehnt werden oder aufgrund ihres Nebenwirkungsspektrums fur den Patienten nicht tolerabel sind.