Prospective multicentre randomized double-blind placebo-controlled parallel group study on the efficacy and tolerability of StroVac® in patients with recurrent symptomatic uncomplicated bacterial urinary tract infections

PURPOSE

To evaluate efficacy and safety of vaccination with StroVac compared to placebo in patients with recurrent urinary tract infections (rUTI).

MATERIAL AND METHODS

We performed a prospective, double-blinded, placebo-controlled study in patients with uncomplicated rUTI. Patients received three single intramuscular injections with StroVac every two weeks. Primary endpoint was the number of bacterial urinary tract infections (UTI) over 13.5 months after randomization and adjusted by the respective "baseline" value when comparing verum and placebo group. Secondary endpoints were the number of patients with non-recurrence, time to first recurrence, frequency of recurrences, and patients' self-assessment of quality of life using a validated questionnaire.

RESULTS

376 patients were randomized to both groups between January 2012 and March 2015. Mean age was 44.4 years. Patients were mainly female (98.4%). In the StroVac group (n = 188), the number of UTIs was reduced from 5.5 to 1.2, in the placebo group (n = 188) from 5.4 to 1.3 (p = 0.63). In patients with ≥ 7 UTIs prior to study inclusion, StroVac was statistically significantly superior to placebo (p = 0.048). However, in all other secondary endpoints, no statistical differences between the two groups could be seen (all p > 0.3).

CONCLUSION

StroVac reduced the number of clinically relevant UTIs like in former studies but did not show statistically significant better results than the chosen placebo. Most likely, that was due to a, since confirmed, prophylactic effect of the chosen placebo itself. Therefore, placebo-controlled and double-blinded studies using a different ineffective placebo preparation are needed to determine the importance of StroVac in prophylaxis of rUTI.

Treatment outcomes of bladder stones in children with intact bladders in developing countries: A systematic review of >1000 cases on behalf of the European Association of Urology Bladder Stones Guideline panel

INTRODUCTION

Bladder stones (BS) are still endemic in children in developing nations and account for a high volume of paediatric urology workload in these areas. The aim of this systematic review is to comparatively assess the benefits and risks of minimally invasive and open surgical interventions for the treatment of bladder stones in children.

METHODS

This systematic review was conducted in accordance with Cochrane Guidance. Database searches (January 1970- March 2021) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and non-randomised studies (NRSs) with >10 patients per group. Open cystolithotomy (CL), transurethral cystolithotripsy (TUCL), percutaneous cystolithotripsy (PCCL), extracorporeal shock wave lithotripsy (ESWL) and laparoscopic cystolithotomy (LapCL) were evaluated.

RESULTS

In total, 3040 abstracts were screened, and 8 studies were included. There were 7 retrospective non-randomised studies (NRS's) and 1 quasi-RCT with 1034 eligible patients (CL: n=637, TUCL: n=196, PCCL: n=138, ESWL: n=63, LapCL n=0). Stone free rate (SFR) was given in 7 studies and measured 100%, 86.6%-100%, and 100% for CL, TUCL and PCCL respectively. CL was associated with a longer duration of inpatient stay than PCCL and TUCL (p<0.05). One NRS showed that SFR was significantly lower after 1 session with outpatient ESWL (47.6%) compared to TUCL (93.5%) and CL (100%) (p<0.01 and p<0.01 respectively). One RCT compared TUCL with laser versus TUCL with pneumatic lithotripsy and found that procedure duration was shorter with laser for stones <1.5cm (n=25, p=0.04).

CONCLUSION

In conclusion, CL, TUCL and PCCL have comparable SFRs but ESWL is less effective for treating stones in paediatric patients. CL has the longest duration of inpatient stay. Information gathered from this systematic review will enable paediatric urologists to comparatively assess the risks and benefits of all urological modalities when considering surgical intervention for bladder stones.

Trend analysis and regional tumor incidence in Germany for testicular cancer between 2003 and 2014

BACKGROUND

Testicular germ cell tumor (TGCT) is one the most common solid tumors in men between the age of 15 and 35 with an overall incidence rate of 1-1.5 %. Epidemiologic studies have demonstrated different incidence patterns in western civilized countries with overall rising incidence trends.

OBJECTIVE

To analyze differences in regional tumor incidence rates for TGCT and perform a trend analysis for TGCT between 2003 and 2014 in Germany.

MATERIAL AND METHODS

TGCT cases in Germany which were diagnosed between 2003 and 2014 were provided by the Robert-Koch-Institute, Berlin. For statistical analysis, cluster and spatial scan tests according to Kulldorff were used for cases with seminoma and non-seminoma. Results are presented in administrative districts and graphically illustrated. We performed a trend-analysis in order to evaluate age-adjusted incidence trends in Germany. Tests were two-sided with a level of significance of α=0.05.

RESULTS

In total we included 35,066 patients. Overall, 22,634 cases had newly diagnosed seminoma and 12,432 were diagnosed as non-seminoma. Maximum incidence of seminoma and non-seminoma was observed for age-group 38-40 years and 26-28 years, respectively. No second peak for the incidences of seminoma and non-seminoma with respect to age were observed. Cluster analysis revealed areas with high and low incidence rates as well as slightly different spatial distribution in Germany between seminoma and nonseminoma. Furthermore, there was no significant increase in age-adjusted incidence rates over the reviewed time period in both cohorts.

DISCUSSION

In this study differences in reginal tumor incidence rates for seminoma and non-seminoma are reported with both tumor entities revealing distinct clusters. Furthermore, tumor incidence trends for seminoma and nonseminoma between 2003 and 2014 were stable which might indicate the beginning of a plateau phase for TGCT incidence rates in Germany.

CONCLUSION

In this analysis we were able to identify regions with significantly higher tumor incidence rates for both seminoma and non-seminoma which were specific for these two subtypes. Furthermore, trend analysis revealed a steady incidence rate for testicular cancer in Germany.

Aktualisierung der S2k-Leitlinie zur Diagnostik, Therapie und Metaphylaxe der Urolithiasis (AWMF Registernummer 043-025)

Die Zunahme des medizinischen Wissens, technische Neuerungen gemeinsam mit demographischem Wandel stellen eine Herausforderung an die Neukonzeption von Leitlinien und klinischen Studien dar. Die vorliegende S2k-Leitlinie, die sich ausschließlich mit Nieren- und Harnleitersteinen beschäftigt, soll die Behandlung von Harnsteinpatienten in Klinik und Praxis unterstützen, aber auch Patienteninformationen zur Urolithiasis geben. Die zunehmende interdisziplinäre Zusammenarbeit in der Steintherapie zeigt sich auch an der Anzahl beteiligter Fachgruppen und Arbeitsgemeinschaften in der Erstellung des neuen Leitlinienupdates. Die vorliegende, aus einem interdisziplinären Konsensusprozess hervorgegangene S2k-Leitlinie stellt die aktuellen Empfehlungen praxisnah dar und gibt Entscheidungshilfen für Diagnostik‑, Therapie- und Metaphylaxemaßnahmen auf Basis von Expertenmeinungen und verfügbaren Evidenzgrundlagen aus der Literatur.

Surgical treatment of large volume prostates: a matched pair analysis comparing the open, endoscopic (ThuVEP) and robotic approach

OBJECTIVE

To compare open simple prostatectomy, endoscopic enucleation and laparoscopic, robot-assisted enucleation of high-volume prostate in terms of operation time, blood loss, transfusion and complication rates and early continence rates.

MATERIAL AND METHODS

Patients with BPH treated endoscopically (ThuVEP, Hamburg and Hannover) or robotically (Mainz) were evaluated prospectively for prostate size, free flow and validated questionnaires (IPSS, QoL). 35 patients were matched to patients after open prostatectomy (Mainz) for age, prostate size, IPSS and QoL scores. Operation time was noted from the first cut to the last suture; blood loss was estimated by the drop of haemoglobin preoperatively and one day after surgery. Transfusion rates were documented. Early continence was estimated by pad use over the first 24 h after catheter removal. Statistical analysis was performed with SPSS 22.0.

RESULTS

No significant differences in prostate size, age and preoperative questionnaires were found (p > 0.3). Postoperative flow and the results of the questionnaires were significantly improved (all p < 0.05), without difference between the approaches (p > 0.8). Endoscopic surgery showed superiority in operation time (both p < 0.05); blood loss and transfusion rates were significantly lower compared to open surgery (both p < 0.01) and lower than in robotic surgery without reaching significance (p = 0.18, p = 0.36). Similar results were seen in early continence rates.

CONCLUSION

Due to our results, endoscopic surgery should be considered as first-line therapy unless there are comorbidities like diverticula and/or bladder calculi that can be easily treated simultaneously by robotic surgery. Against the background of these findings, indications favouring open surgery are getting sparse.

[What is the current status of shock wave lithotripsy?]

BACKGROUND

Shock wave lithotripsy (SWL) became the therapy of choice for the majority of patients with urolithiasis early after its introduction in the early 1980s. Since then, SWL remains the only noninvasive therapy modality for the treatment of urinary stones. Although lithotripters became more versatile and affordable-making them available worldwide-indications for SWL have shifted as well. In most western countries, endoscopic techniques took the lead in stone therapy due to high (early) stone-free and better reimbursement rates. Notwithstanding SWL remains the first-line therapy for most intrarenal and many ureteral stones.

PURPOSE

This contemporary review illuminates technical aspects and improvements of lithotripsy over recent years in context with the current guideline recommendations.

RESULTS

Technical advances in lithotripsy such as shock wave generation, focusing, coupling, stone localization and modifications in therapy regimens are reviewed and presented.

CONCLUSIONS

Urologists are recommended to carefully select the appropriate therapy modality for a patient with urolithiasis. A more comprehensive understanding of the physics of shock waves could lead to much better results, thus, endorsing SWL as first-line therapy for urolithiasis instead of contemporary endourology treatment options.

[S2k guidelines on diagnostics, therapy and metaphylaxis of urolithiasis (AWMF 043/025) : Compendium]

Every tenth German citizen will suffer from at least one urinary calculus during the lifetime. The diagnostics, treatment and follow-up treatment of urolithiasis are, therefore, part of the daily routine practice for all urologists in hospitals and private practices as well as in many other disciplines, such as general practitioners, internists, nephrologists and pediatricians. Although the diagnostics and therapy have experienced substantial alterations over the last 10 years, the possibilities of metabolic diagnostics and secondary prevention for patients at risk are, unfortunately and unjustly, in many places very poorly represented. The present S2k guidelines, which for the first time were established in an interdisciplinary consensus process, represent the current practical recommendations and, whenever possible, use tables and algorithms in order to facilitate easy reference in the routine daily work. Last but not least, this greatly simplifies the measures for metaphylaxis.

[Gap between postulated and real outcome quality of radical prostatectomy]

BACKGROUND

Certified Prostate Centers proclaim congruent process and outcome quality results for treatment of prostate carcinoma. Therapy in accordance with the guidelines after presentation of the patient in an interdisciplinary conference and regular documented follow up are not in themselves a guarantee for good quality results (complication free, continence, erectile function, negative surgical margins, biochemical recurrence free), and are significantly influenced by factors not contained within the certification framework.

DISCUSSION

An association between exceeding the minimum number of operations and quality assurance exists, if at all, only vaguely and on no account justifies the absolute numbers necessary for certification. Although good measuring instruments for a Pentafecta analysis are available, the gathering of quality results for a center are limited to questionnaires for functional quality results and in the non-differentiated request for a pT2R1 rate of under 10 % for oncological quality results.

CONCLUSIONS

The reasons for this systematic ignoring of the for the patient so important quality results with a simultaneous excessive regard for standardizing organizational procedure processes are manifold. They comprise valid verifiability of process quality, the unclear effects of standardized treatment pathways on actual operation quality and the capitulation to statistical and patient determined problems with sufficient acquisition of comparable functional OP results. Whereas the outcome quality is more important than the process quality for patients with prostate carcinoma, the certified centers conduct themselves in exactly the opposite manner, thus creating a virtually insoluble dilemma.

[Perioperative Outcomes in Correlation to the Learning Curve for Robotic Assisted Partial Nephrectomy: The First 109 Cases of our Clinic]

BACKGROUND

In contrast to conventional laparoscopic partial nephrectomy, the approach of robot-assisted partial nephrectomy (RAPN) shows a steep learning curve with shorter warm ischaemia times (WIT) and comparable postoperative outcomes. Therefore RAPN is considered a good minimally-invasive surgical procedure for patients presenting with a renal cell carcinoma in clinical stage cT1a. The aim of the presented study was to evaluate the perioperative outcomes of our patients after RAPN and to illustrate the learning curve based on characteristic perioperative parameters such as WIT.

MATERIAL AND METHODS

The data of 109 patients treated by RAPN in our clinic between January 2010 and April 2015 were retrospectively analysed regarding perioperative, laboratory and oncological outcomes. Postoperative complications until 30 days after surgery were documented. We analysed the data of the largest patient population treated by a single urologist, comparing WIT, operating time, blood loss and decline of the glomerular filtration rate between the first and the second 30 consecutive cases.

RESULTS

Mean WIT was 18.4 min (SD±10.2), mean operating time was 199 min (SD±20), and mean estimated blood loss was 657 millilitres (SD±715 ml). Mean loss of GFR was reported to be 4.99 mg/dl/1.73 m (2) (SD±15.44). 83 (76%) malignant lesions were removed. 11 patients (10%) had a R1 resection, one patient had a R2 resection and in 2 cases the resection status was Rx. 22% of patients developed postoperative complications. Intraoperative complications were documented in 2 cases. According to the Clavien-Dindo Classification, 6% of patients had grade 1 and 2 complications and 13% developed grade 3 and 4 complications. WIT was significantly lower after 30 consecutive cases treated by one urologist. Regarding operating time, GFR or blood loss no significant correlation was found.

CONCLUSION

Our data is in line with the surgical outcomes described in the literature. RAPN is a safe surgical technique with a steep learning curve. In our experience, 30 surgical cases provide a urologist with sufficient expertise to achieve good perioperative results. Weaknesses of this report include the retrospective design and insufficient documentation in some cases.

[Asymptomatic kidney stones: active surveillance vs. treatment]

The prevalence of kidney stones is increasing worldwide. Asymptomatic non-obstructing kidney stones are increasingly detected as an incidental finding on radiologic imaging, which has been performed more frequently over the last decades. Beside the current interventional treatment modalities such as extracorporeal shockwave lithotripsy (ESWL), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PNL), active surveillance of asymptomatic kidney stones has been a focus of discussion lately, not only for attending physicians, but even more so for patients. The current German and European guidelines recommend active surveillance for patients with asymptomatic kidney stones if no interventional therapy is mandatory because of pain or medical factors. Herein we review the current literature on risks and benefits of active surveillance of asymptomatic non-obstructing kidney stones.

[Robot-assisted laparoscopic partial nephrectomy: functional and oncological outcomes]

BACKGROUND

In recent years, small renal masses (SRM) have been increasingly detected as an incidental finding of radiological or ultrasound studies for other indications. Organ-sparing renal tumor resection as open partial nephrectomy (OPN) is the international standard for renal tumors <7 cm.

RESULTS

Due to technical developments, minimally invasive procedures have emerged as an alternative to OPN. In experienced hands, conventional laparoscopic partial nephrectomy (LPN) has achieved good functional and oncological results comparable to OPN. Robot-assisted laparoscopic partial nephrectomy (RAPN) has been performed since 2004. Compared to LPN, RAPN provides a faster learning curve, better visualization and more versatile instrumentation due to the degrees of freedom of the articulated instruments. After about 30 procedures, a level of experience is reached, which is characterized by good functional results, less blood loss, and shorter warm ischemia time of the kidney as compared to LPN. This can relate to a shorter hospital stay and faster recovery. Complications according to the Clavien classification are mostly grade I and II and are mainly treated conservatively.

CONCLUSION

Oncological long-term results are not available yet; so that RAPN cannot be considered as an equivalent treatment to LPN and OPN. Until long-term evidence is available, decisions regarding the surgical technique for organ-sparing renal tumor resection will be determined by patient's wishes and surgeon's preference.

[Complication management in prolapse and incontinence surgery]

Tension-free alloplastic slings (TFAS) have revolutionized surgery for female stress urinary incontinence for more than 20 years. The procedure is easy to perform, minimally invasive with a short operating time in an outpatient setting and has proven efficacy comparable to retropubic colposuspension. The frequency of surgery for female stress incontinence has tripled within one decade which has to have an impact on the number of complications. In contrast, sacrocolpopexy has remained the gold standard in urological prolapse surgery as none of the new techniques has reached similar efficacy or safety; however, possible complications have to be named and their causes have to be understood to maintain the highest quality of care in the future. Possible complications of TFAS are potentially underestimated with respect to prevalence and manageability. Possible complications of prolapse and incontinence surgery are presented and the underlying causes are identified. Knowledge of the pathophysiology and the cause of complications together with the results of a postoperative diagnostic work-up, allow complication management to be tailored to each individual patient. To prevent complications all conservative treatment options should have been tried preoperatively and a complete evaluation (including urodynamics) should have been carried out for every patient. Postoperative urodynamics may help to document treatment success and to identify and quantify complications.

Robot-Assisted Transvesical Enucleation of Benign Prostatic Hyperplasia: Lessons from a Single Surgeon’s Learning Curve

INTRODUCTION

Open simple prostatectomy is a well-established and effective operation for prostate volumes greater than 80 gm but also associated with bleeding and urinary incontinence. To benefit from the advances of laparoscopy, robot-assisted simple prostatectomy was established. We determined the learning curve of this minimally invasive surgery by evaluating the first procedures by an experienced robotic surgeon.

METHODS

Patients presenting for surgical therapy with prostate volumes greater than 80 gm were considered for the study. Evaluation included validated questionnaires preoperatively, and at 6 and 12 weeks postoperatively. Blood loss, transfusions, operation time and pad use after catheter removal were documented. The experience based on the results from 18 cases treated with robot-assisted simple prostatectomy by one of us (JWT) is presented.

RESULTS

Mean age of the 18 patients was 71.2 years, mean enucleated prostate volume was 91 gm and mean preoperative flow was 9.0 ml/second. I-PSS and QoL values improved significantly from 25 to 6.1 (p <0.005) and from 5 to 1.1 (p <0.005), respectively, and flow rate increased to 28.2 ml/second (p <0.005) postoperatively. There were no significant changes in sexual performance based on IIEF (p = 0.73). Of the 18 patients 14 had complete continence immediately after catheter removal, and at 6 weeks postoperatively 17 were completely continent. Decreases in operation time from 250 to 150 minutes and blood loss from 400 to 200 ml were noted after 5 procedures. Only minor complications occurred and 1 patient required transfusion postoperatively (Clavien-Dindo II).

CONCLUSIONS

Robot-assisted simple prostatectomy is a safe and effective operation for benign prostatic hyperplasia, which can be learned with good results in a rather short time.

[European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence]

CONTEXT

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

OBJECTIVE

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

[EAU Guidelines on Urinary Incontinence]

CONTEXT

The first European Association of Urology (EAU) guidelines on incontinence were published in 2001. These guidelines were periodically updated in past years.

OBJECTIVE

The aim of this paper is to present a summary of the 2009 update of the EAU guidelines on urinary incontinence (UI).

EVIDENCE ACQUISITION

The EAU working panel was part of the 4th International Consultation on Incontinence (ICI) and, with permission of the ICI, extracted the relevant data. The methodology of the 4th ICI was a comprehensive literature review by international experts and consensus formation. In addition, level of evidence was rated according to a modified Oxford system and grades of recommendation were given accordingly.

EVIDENCE SUMMARY

A full version of the EAU guidelines on urinary incontinence is available as a printed document (extended and short form) and as a CD-ROM from the EAU office or online from the EAU Web site (http://www.uroweb.org/guidelines/online-guidelines/). The extent and invasiveness of assessment of UI depends on severity and/or complexity of symptoms and clinical signs and is different for men, women, frail older persons, children, and patients with neuropathy. At the level of initial management, basic diagnostic tests are applied to exclude an underlying disease or condition such as urinary tract infection. Treatment is mostly conservative (lifestyle interventions, physiotherapy, physical therapy, pharmacotherapy) and is of an empirical nature. At the level of specialised management (when primary therapy failed, diagnosis is unclear, or symptoms and/or signs are complex/severe),more elaborate assessment is generally required, including imaging, endoscopy, and urodynamics. Treatment options include invasive interventions and surgery.

CONCLUSIONS

Treatment options for UI are rapidly expanding. These EAU guidelines provide ratings of the evidence (guided by evidence-based medicine) and graded recommendations for the appropriate assessment and according treatment options and put them into clinical perspective.

[Ureter triplex with non-functioning upper pole due to ectopic ureterocele and refluxive third ureter bud : case report and review of the literature]

We present the case of an 8-month-old boy with ureter triplication on the left side with non-functional upper pole due to ectopic ureterocele and a refluxive third ureter bud. We performed an upper pole heminephroureterectomy with resection of the ureterocele and of the refluxive third ureter bud and reimplantation of the lower pole ureter using the psoas hitch technique.