European Association Of Urology Guidelines Research Articles

Interview: Bhaskar Somani

Interview: Bhaskar Somani

Prostate biopsy-infection prophylaxis and patient preparation

Prostate biopsy has been at the center of controversy in recent years due to high infection complications associated with the transrectal route and the withdrawal of authorization for fluoroquinolones and fosfomycin trometemol as prophylaxis. The Urological Infections Guideline Group of the European Association of Urology (EAU) recently published ameta-analysis in two parts based on randomized controlled trials (RCTs) and annually updates the data for the EAU guidelines. The meta-analyses show that transperineal prostate biopsy is associated with significantly fewer infectious complications than transrectal biopsy and should therefore be preferred. If transrectal biopsy is still used, then intrarectal cleansing with povidone-iodine and antibiotic prophylaxis should be used. Antibiotic prophylaxis strategies include targeted prophylaxis after sensitivity testing of the rectal flora, augmented prophylaxis with several antibiotics and empirical monoprophylaxis. Data from RCTs are available for aminoglycosides and third-generation cephalosporins.

Are Prostate Cancer Screenings Performed in Compliance with Cancer Guidelines?

Objective: This study aims to examine whether our region's Prostate Cancer (PCa) screening programs comply with the European Association of Urology (EAU) Guidelines. Method: This study was conducted as a retrospective, cross-sectional study between April 2014 and July 2022. Two hundred seventy patients who applied to our clinic for various reasons and were diagnosed with PCa were included in the study. Characteristics of the patients, such as age at diagnosis, comorbidities, age at first PSA examination, and PSA values, were recorded. Results: The mean age of the patients at the time of cancer diagnosis was 67.42±8.64 (43-91) years. PSA value (median±IQR) at the diagnosis was 9.58±19.43 (1.83-3437) ng/ml. When the distribution of cancer according to different decades of life was examined, there were 5 (%1.8) patients in the 40-50 age range, 44 (16.1%) in the 50-60 age range, 111 (40.7%) in the 60-70 age range, 86 (31.5%) in the 70-80 age range, and 24 (8.8%) after the age of 80. While 138 patients (51.1%) had local and benign tumor features, 59 (21.9%) patients were diagnosed with metastatic findings. Only 31.3% (61/195) of the patients were under regular follow-up by a specific urology doctor. Conclusion: It was found that the screening of prostate cancer, the most common type of cancer in men, was not performed by the guidelines, and as a result, diagnosis and treatment were delayed. It was determined that many patients lost the chance of curative treatment. In this disease, where early diagnosis is vital for effective treatment and preservation of quality of life, it is essential to follow up with aging men in accordance with the guidelines. It may be beneficial to periodically train and follow up with all health professionals interested in this issue.

Ileal Conduit Versus Orthotopic Neobladder Urinary Diversion in Robot-assisted Radical Cystectomy: Results from a Multi-institutional Series

BackgroundHead-to-head comparisons between ileal conduit (IC) and orthotopic neobladder (ONB) in terms of peri- and postoperative outcomes and complications, in the specific setting of robot-assisted radical cystectomy (RARC), are not available. ObjectiveTo address the impact of the type of urinary diversion (UD, IC vs ONB) on RARC morbidity, as well as operative time (OT), length of stay (LOS), and readmissions. Design, setting, and participantsUrothelial bladder cancer patients treated with RARC at nine high-volume European institutions between 2008 and 2020 were identified. InterventionRARC with either IC or ONB. Outcome measurements and statistical analysisIntra- and postoperative complications were collected and reported according to the Intraoperative Complications Assessment and Reporting with Universal Standards recommendations and European Association of Urology guidelines, respectively. Multivariable logistic regression models tested the impact of UD on outcomes, after adjustment for clustering at single hospital level. Results and limitationsOverall, 555 nonmetastatic RARC patients were identified. In 280 (51%) and 275 (49%) patients, an IC and an ONB were performed, respectively. Eighteen intraoperative complications were recorded. The rates of intraoperative complications were 4% in IC patients and 3% in ONB patients (p = 0.4). The median LOS and readmission rates were 10 versus 12 d (p < 0.001) and 20% versus 21% (p = 0.8) in IC versus ONB patients, respectively. At a multivariable logistic regression analyses, the type of UD (IC vs ONB) reached the independent predictor status for prolonged OT (odds ratio [OR]: 0.61, p = 0.03) and prolonged LOS (OR: 0.34, p < 0.001), but not for readmission (OR: 0.92, p = 0.7). Overall, 513 postoperative complications were experienced by 324 patients (58%). At least one postoperative complication was experienced by 160 (57%) IC patients versus 164 (60%) ONB patients (p = 0.6). The type of UD reached the status of an independent predictor of UD-related complications (OR: 0.64, p = 0.03). ConclusionsCompared with RARC with ONB, RARC with IC is less prone to UD-related postoperative complications, prolonged OT, and prolonged LOS. Patient summaryTo date, the impact of the type of urinary diversion, namely, ileal conduit versus orthotopic neobladder, on peri- and postoperative outcomes of robot-assisted radical cystectomy is unknown. Based on a rigorous data accrual, which relied on established complication reporting systems (Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology recommended systems), we reported intra- and postoperative complications according to urinary diversion type. Moreover, we found that ileal conduit was associated with lower operative time and length of stay, and yielded a protective effect in terms of urinary diversion–related complications.

Impact of an optimized surveillance protocol based on the European Association of Urology substratification on surveillance costs in patients with primary high-risk non-muscle-invasive bladder cancer.

The optimal frequency and duration of surveillance in patients with high-risk non-muscle-invasive bladder cancer (NMIBC) remain unclear. The aim of the present study is to develop an optimal surveillance protocol based on the European Association of Urology (EAU) substratification in order to improve surveillance costs after transurethral resection of bladder tumor (TURBT) in patients with primary high-risk NMIBC. We retrospectively evaluated 428 patients with primary high-risk NMIBC who underwent TURBT from November 1993 to April 2019. Patients were substratified into the highest-risk and high-risk without highest-risk groups based on the EAU guidelines. An optimized surveillance protocol that enhances cost-effectiveness was then developed using real incidences of recurrence after TURBT. A recurrence detection rate ([number of patients with recurrence / number of patients with surveillance] × 100) of ≥ 1% during a certain period indicated that routine surveillance was necessary in this period. The 10-year total surveillance cost was compared between the EAU guidelines-based protocol and the optimized surveillance protocol developed herein. Among the 428 patients with primary high-risk NMIBC, 97 (23%) were substratified into the highest-risk group. Patients in the highest-risk group had a significantly shorter recurrence-free survival than those in the high-risk without highest-risk group. The optimized surveillance protocol promoted a 40% reduction ($394,990) in the 10-year total surveillance cost compared to the EAU guidelines-based surveillance protocol. The optimized surveillance protocol based on the EAU substratification could potentially reduce over investigation during follow-up and improve surveillance costs after TURBT in patients with primary high-risk NMIBC.

Prognosis of Primary Papillary Ta Grade 3 Bladder Cancer in the Non–muscle-invasive Spectrum

BackgroundTa grade 3 (G3) non–muscle-invasive bladder cancer (NMIBC) is a relatively rare diagnosis with an ambiguous character owing to the presence of an aggressive G3 component together with the lower malignant potential of the Ta component. The European Association of Urology (EAU) NMIBC guidelines recently changed the risk stratification for Ta G3 from high risk to intermediate, high, or very high risk. However, prognostic studies on Ta G3 carcinomas are limited and inconclusive. ObjectiveTo evaluate the prognostic value of categorizing Ta G3 compared to Ta G2 and T1 G3 carcinomas. Design, setting, and participantsIndividual patient data for 5170 primary Ta–T1 bladder tumors from 17 hospitals were analyzed. Transurethral resection of the tumor was performed between 1990 and 2018. Outcome measurements and statistical analysisTime to recurrence and time to progression were analyzed using cumulative incidence functions, log-rank tests, and multivariable Cox-regression models with interaction terms stratified by institution. Results and limitationsTa G3 represented 7.5% (387/5170) of Ta–T1 carcinomas of which 42% were classified as intermediate risk. Time to recurrence did not differ between Ta G3 and Ta G2 (p = 0.9) or T1 G3 (p = 0.4). Progression at 5 yr occurred for 3.6% (95% confidence interval [CI] 2.7–4.8%) of Ta G2, 13% (95% CI 9.3–17%) of Ta G3, and 20% (95% CI 17–23%) of T1 G3 carcinomas. Time to progression for Ta G3 was shorter than for Ta G2 (p < 0.001) and longer than for T1 G3 (p = 0.002). Patients with Ta G3 NMIBC with concomitant carcinoma in situ (CIS) had worse prognosis and a similar time to progression as for patients with T1 G3 NMIBC with CIS (p = 0.5). Multivariable analyses for recurrence and progression showed similar results. ConclusionsThe prognosis of Ta G3 tumors in terms of progression appears to be in between that of Ta G2 and T1 G3. However, patients with Ta G3 NMIBC with concomitant CIS have worse prognosis that is comparable to that of T1 G3 with CIS. Our results support the recent EAU NMIBC guideline changes for more refined risk stratification of Ta G3 tumors because many of these patients have better prognosis than previously thought. Patient summaryWe used data from 17 centers in Europe and Canada to assess the prognosis for patients with stage Ta grade 3 (G3) non–muscle-invasive bladder cancer (NMIBC). Time to cancer progression for Ta G3 cancer differed from both Ta G2 and T1 G3 tumors. Our results support the recent change in the European Association of Urology guidelines for more refined risk stratification of Ta G3 NMIBC because many patients with this tumor have better prognosis than previously thought.

Clinical parameters associated with altered sperm DNA fragmentation index among primary infertile men: Findings from a real-life cross-sectional study.

Recurrent pregnancy loss and unexplained infertility are the current indications to test sperm DNA fragmentation according to the European Association of Urology Guidelines on sexual and reproductive health. To identify a novel and better performing model to diagnose primary infertile men presenting with altered sperm DNA fragmentation and to outline its predictive ability in respect to current European Association of Urology Guidelines' recommendations. Data from the latest 515 consecutive primary infertile men as for World Health Organization criteria were analyzed. Semen analysis, sperm DNA fragmentation (according to sperm chromatin structure assay), and serum hormones were considered in every patient. Altered sperm DNA fragmentation was defined with levels greater than 30%. Descriptive statistics was applied to compare patients with normal versus SDF>30%. The new predicting model was identified through logistic regression analysis exploring potential predictors of SDF>30% at first clinical presentation. Diagnostic accuracy between the two predictive models (European Association of Urology Guidelines vs. new) was assessed, and decision curve analyses tested their clinical benefit. Of 515, 268 (51.9%) patients had SDF>30% at clinical presentation. Patients with SDF>30% were older (median [interquartile range] 39 [35-43] vs. 37 [34-41]years), had lower mean testicular volume (Prader 15 [12-20] vs. 17.5 [13.5-20] and lower total motile sperm count (1.80 [0.7-13.2] vs. 11.82 [4.2-44.5] × 106 ), all p<0.001. No other clinical differences were depicted. The two groups showed similar rates of history of recurrent pregnancy loss and unexplained infertility. At multivariable logistic regression analysis, age more than 38years (odds ratio: 2.43) and baseline total motile sperm count less than 20×106 (odds ratio: 3.72) were associated with SDF>30%, after adjusting for Prader<15, history of miscarriages and unexplained infertility, all p<0.0001. The newly identified model (unexplained infertility + history of poli-abortions + Prader<15 + age ≥38years + total motile sperm count <20×106 ) showed higher accuracy to identify SDF>30% at baseline in respect to European Association of Urology Guidelines (area under the curve: 72.1 vs. 52.7), with superior clinical net benefit use. The application of the European Association of Urology sexual and reproductive health guidelines does not ensure proper identification of primary infertile men with pathological sperm DNA fragmentation. We propose a novel and better performing predictive model to identify the infertile men with altered sperm DNA fragmentation at first clinical assessment. As altered sperm DNA fragmentation has been widely linked with the inability to conceive, this second-level test could be further implemented over the diagnostic workup of a broader subset of patients presenting for male factor infertility. We propose a better performing model to identify this specific category of patients.

Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries

BackgroundEvidence-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. ObjectiveTo assess current ADT use before prostate cancer surgery in Europe. Design, setting, and participantsThis 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 analysisOur 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 limitationsWe 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. ConclusionsEAU 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 summaryAndrogen 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.

Nephrometry and cumulative morbidity after partial nephrectomy: A standardized assessment of complications in the context of PADUA and R.E.N.A.L. scores.

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.

Selection for antimicrobial prophylaxis in emergency and elective transurethral procedures: Susceptibility pattern in Türkiye.

In this study, we aimed to determine the most appropriate antimicrobial agents for prophylactic antibiotic use during emergency and elective transurethral procedures. The study was conducted in five hospitals located in five different geographical regions of Türkiye. The microorganism cultured in urine before emergency and elective transurethral procedures in these centers between March 2021 and March 2022 were reviewed retrospectively from the hospital records. Demographic data (age and gender) of the patients, comorbid disorders, previous urological procedures, anomalies of the urogenital tract, use of urethral catheters (permanent or clean intermittent catheterization), cultured microorganisms, and antibiotic susceptibilities were noted. The patients hospitalized or had antibiotics for any reason in the previous 1 month were excluded from the study. A total of 1450 patients, 742 men (51.2%) and 708 women (48.8%), were included in the study. The mean age of the patients was 55.3±19.36 (1-98) years. Diabetes mellitus was evident in 271 (18.7%) patients. The five most common microorgan-isms cultured in urine, in order of frequency, were: ESBL (-) Escherichia coli in 418 (28.8%), ESBL (+) E. coli in 309 (21.3%), Klebsiella pneumonia in 183 (12.6%), Enterococcus faecalis in 124 (8.6%), and Pseudomonas aeruginosa in 89 (6.1%). The susceptibility rates to antimicrobial agents recommended for prophylaxis by the American Urology Association and the European Association of Urology guidelines were found as follows: cefepime 87.1%, ampicillin+sulbactam 84%, TMP-SMX 71.6%, amoxicillin+clavulanate 63.5%, cefoxitin 59%, ceftazidime 58.6%, cefuroxime 43.5%, ceftriaxone 43%, and cefixime 38.4%. We found that currently recommended antimicrobials provide poor coverage for the most common pathogens isolated. Urologists should consider patient-based antibiotic prophylaxis in endoscopic urethral procedures, follow appropriate proto-cols, and consider local antibiotic resistance.

Contemporary Management of Large and Complex Renal Calculi: Have we found the Perfect Solution Yet?

Abstract This review provides a thorough overview of contemporary treatment strategies for complex renal calculi, including large-volume stones, stones with increased hardness and greater number, or stones with abnormal anatomy. The development of tailored treatment plans for stone removal is essential for treatment success. A literature search was conducted on PubMed using the Keyword “complex renal calculi” along with “percutaneous nephrolithotomy (PCNL),” “retrograde intrarenal surgery (RIRS),” “endoscopic combined intrarenal surgery (ECIRS),” “stone free rate,” and “complications.” Based on the findings, the use of “minimally invasive PCNL,” “multiple-tract PCNL,” “staged RIRS,” and “ECIRS” is proposed in addition to the traditional PCNL suggested using the European Association of Urology guidelines. Renal calculi in patients with solitary kidneys or who underwent kidney transplants are considered to be complex, and treatment options that allow preservation of their remaining renal function should be considered.

Male infertility, what Mobile Health Applications "know": quality analysis and adherence to European Association of Urology Guidelines.

Male infertility (MI) is one of the most important worrying topics for the fertile age population. Nowadays, several mobile health applications (MHAs) have been developed to help and assist patients suffering from male infertility (MI), but their quality and adherence to the guidelines is not solved issue yet. On 2nd July 2022, an observational cross-sectional descriptive study of all MHAs on male infertility was conducted: a search on both the iTunes App Store and Google Play Store was performed. Our group reviewed all MHAs, evaluating the quality, using Mobile Application Rating Scale (MARS), and the adherence to European Association of Urology guidelines, with a special tool created for this manuscript. In the final analysis we included 10 MHAs: 20% (n = 2) from the iTunes App Store and 80% (n = 8) from the Google Play Store. Across the sample, 80% (n = 8) of the apps provided general information on MI, 60% (n = 6) focused on diagnosis and 50% (n = 5) focused on treatment options, respectively. According to MARS tool, the mean score was 2.18 (0.78), 3.78 (0.36), 3.0 (0.53), 3.19 (0.45), 2.18 (0.54) for Engagement, Functionality, Aesthetic, Information and Subjective quality, respectively. According to EAU Adherence Score, the highest score was reported by "Infertilità" with 12/15 points while the lowest score was reported by "Fertility Diet Guide", 0/15 points. Nowadays, MHAs present in the market are not a reliable source of information on MI. An ideal MHAs should be based on scientific evidence, user friendly, respecting privacy and security laws, making patients feel capable and confident to change personal behavior or attitudes.

Растворение мочекислых камней мочеточника

Uric acid stones (UA), consisting of uric acid/uric acid dihydrate, occur in 6.1-15.1% of all cases of urolithiasis in industrialized countries. At the same time, the frequency of these stones is directly dependent on age. Thus, the incidence of UA reaches 40% in men over 80 years of age and 27.3% in women over 90 years of age. UA are the only stones that are amenable to dissolution therapy with the use of citrate salts that alkalinize urine pH. A number of authors and European Association of Urology guidelines consider stone dissolution as a first-line therapy in the treatment of patients with UA, both as monotherapy and in combination with surgical procedures.The results of conservative treatment of 86 patients aged 28 to 78 years with radiolucent ureteral stones ranging in size from 3 to 25 mm and a density of 133 to 728 HU, who underwent 89 courses of stone dissolution therapy from 2011 to 2018, are presented in the article. They had no obstruction or were prestented. There were 52 men (n=55 courses) and 34 women (n=34 courses).In 78 out of 89 clinical cases (87.6%), stone-free status was obtained within 14 to 181 days. Most often the duration of therapy was 30 days. In 11 (12.4%) cases the treatment was considered ineffective. However, only in 4 (4.5%) patients the stone size did not change, while in 7 (7.9%) cases it decreased. The results of the study suggest the high efficiency of citrate therapy in patients with ureteral stones in case of unobstructed urine outflow (including those with stents), which is comparable to surgical treatment.

Preoperative CT features to predict risk stratification of non-muscle invasive bladder cancer.

To investigate whether preoperative CT features can be used to predict risk stratification of non-muscle invasive bladder cancer (NMIBC). The 168 patients with pathologically confirmed NMIBC who underwent preoperative CT urography were retrospectively analyzed and were divided into training (n = 117) and testing (n = 51) sets. According to the European Association of Urology Guidelines, patients were classified into low-risk (n = 50), medium-risk (n = 23), and high-risk (n = 95) groups. A random over-sample was performed to handle the offset caused by the unbalanced groups. We measured some CT features that may help stratify which for modeling were determined using an F-test-based feature selection with a tenfold cross-validation procedure, and the Gaussian Naive Bayes model was trained on the entire training set. In the testing set, the performance of the model was evaluated. The selected CT features were the maximum and the minimum diameter of the largest tumor, whether the largest tumor is located at the trigone, and tumor number. In the testing set, the model reached a macro- and micro- AUC of 0.783 and 0.745 with an accuracy of 0.529. As for the one-vs-rest problem, the model was most effective in identifying low-risk individuals, with an AUC, accuracy, sensitivity, and specificity of 0.870, 0.647, 1.000, and 0.438, respectively; the medium-risk group reached 0.814, 0.882, 0.250, and 0.936, respectively; the identification of the high-risk group was harder, going 0.665, 0.529, 0.250, and 0.870, respectively. It is feasible to predict the risk stratification of NMIBC using preoperative CT features.

Clinical manifestation, diagnosis and treatment of bladder pain syndrome: literature review

Augustina Zaveriuchaitė1, Geistė Tubutytė1 1 Vilnius University, Faculty of Medicine, Vilnius, Lithuania Abstract Background. Bladder pain syndrome (BPS) is a chronic disorder with unknown aetiology characterized by bladder pain and associated with urination frequency of more than 10 times per day. The treatment of this disease is complicated and requires a multi-disciplinary approach. Aim. To review and summarize the clinical, diagnostic and treatment features of bladder pain syndrome. Materials and methods. The search of literature was conducted in the international database PubMed. Keywords such as ,,bladder pain syndrome“, ,,interstitial cystitis“, ,,treatment“, ,,diagnostics‘‘ and their combinations were used. 756 articles were ruled out due to their title and abstract non-compliance to our subject. 90 articles were fully read and 70 of them, published in English language in the period of 2000-2021 were included to this review. Results. According to the International Society for the Study of Bladder Pain Syndrome (ESSIC), to diagnose this syndrome the duration of symptoms should be no less than 6 months and without other possible explanation. In 2021 the guidelines of BPS treatment were introduced by the European Association of Urology (EAU). Conclusions. Symptoms such as pelvic pain, pressure, discomfort, nocturia, dyspareunia, bladder spasms are characteristic for this disease. The EAU guidelines suggest making the diagnosis of BPS based on pain, pressure or discomfort perceived in the bladder region, accompanied by at least one other symptom and without any other possible explanation. There is currently no treatment to ensure a permanent improvement; hence the goal is to ameliorate patients‘ quality of life and decrease the manifestation of symptoms. Keywords: bladder pain syndrome, interstitial cystitis, treatment of bladder pain syndrome.

Penile Autophotography Underestimates the Degree of Penile Curvature in Peyronie’s Disease

BackgroundPenile curvature is the most debilitating symptom of Peyronie’s disease (PD); the evaluation of the degree of angulation is essential for planning treatment strategy. However, the most used method of penile at-home autophotography (AHP) is associated with some potential pitfalls and discrepancies compared with different assessment methods. ObjectiveTo compare the degree of penile curvature quantified by AHP and in-office intracavernosal alprostadil injection (ICI) prior to therapy. Design, setting, and participantsData from 55 PD patients of a single tertiary referral center were analyzed. All patients provided standardized AHP of the erect phallus. Clinic-based assessment included ICI with curvature measurement and completion of the International Index of Erectile Function (IIEF-15). Outcome measurements and statistical analysisThe Wilcoxon and/or chi-square test was used to compare the degree of curvature obtained using AHP and ICI, and to evaluate whether erectile dysfunction was a predictor of a relevant difference of >10° in curvature assessment between AHP and ICI. Results and limitationsOur study showed a significant (p < 0.001) difference in the degree of penile curvature between AHP (48° [38°; 55°]) and ICI (50° [40°; 65°]). Patients suffering from erectile dysfunction tend to have a higher difference in the degree of penile curvature between AHP and ICI than patients with good erectile function (p < 0.001). Our study is not devoid of limitations. First, we did not use Peyronie's Disease Questionnaire, as suggested by the European Association of Urology guidelines. Second, we did not evaluate inter- and intraobserver variations in the measurements. ConclusionsAHP tends to underestimate the extent of penile curvature compared to ICI. Erectile dysfunction is an independent predictor of measurement differences of >10° between AHP and ICI. Patient summaryIt is necessary to evaluate the degree of penile curvature in Peyronie’s disease prior to therapy decision. The at-home self-photography underestimates the real degree of penile curvature compared with an erection by in-office penile drug injection. Especially men suffering from erectile dysfunction carry the risk of a high difference in the measured degree of penile curvature, with a potential impact on the further treatment.

The 2022 Updated European Association of Urology Guidelines on the Use of Adjuvant Immune Checkpoint Inhibitor Therapy for Renal Cell Carcinoma

In KEYNOTE-564, adjuvant pembrolizumab, a PD-1 antibody, significantly improved disease-free survival (DFS) in localised clear-cell renal cell carcinoma (ccRCC) with a high risk of relapse. In 2021, the European Association of Urology RCC Guidelines Panel issued a weak recommendation for adjuvant pembrolizumab for high-risk ccRCC as defined by the trial until final overall survival data and results from other trials were available. Meanwhile, the primary DFS endpoints were not met for adjuvant atezolizumab (PD-L1 inhibitor; IMmotion010), adjuvant nivolumab plus ipilimumab (CheckMate 914), or perioperative nivolumab (PROSPER). Owing to heterogeneity, a meta-analysis is not recommended. Pembrolizumab remains the only immune checkpoint inhibitor currently recommended in this setting. Overall survival data are immature and biomarkers to predict outcome are lacking. Uncertainty exists and overtreatment is occurring. Treatment decisions should be made with caution and with the involvement of each patient. Patient summaryNew results from three trials of immunotherapy after surgery for kidney cancer to reduce the risk of recurrence showed no improvement with these treatments. These results are in contrast to an earlier study that showed that the antibody pembrolizumab did extend the time before kidney cancer recurrence, even though it is not yet clear if overall survival is longer. Thus, we cautiously recommend pembrolizumab as additional treatment in high-risk kidney cancer after surgery, but patient preference should be carefully considered and the risk of overtreatment should be discussed.

Disease-Free Survival of Patients with Muscle Invasive Bladder Cancer Treated by Radical Cystectomy vs. Bladder-Sparing Therapy at a Nationwide Level

<h3>Purpose/Objective(s)</h3> Organ-sparing treatment has become the standard of curative cancer treatment for many tumor types. For patients with muscle invasive bladder cancer (MIBC), radical cystectomy (RC) is still the recommended treatment according to both the American Urological Association and the European Association of Urology guidelines. An attempted RCT between RC and bladder sparing therapy (BST) failed due to low accrual and noncompliance. A large prospective comparative study is the best alternative to compare outcomes between modalities. We hypothesized that the two-year disease-free survival (DFS) with BST is equal to the DFS with RC in selected patients with non-metastasized MIBC. <h3>Materials/Methods</h3> All patients diagnosed with MIBC between November 2017 and November 2019 were identified via the population-based Netherlands Cancer Registry. Detailed clinical data was retrieved by consulting medical files. Only patients treated with BST or RC were included. BST was defined as patients treated with concurrent chemoradiation (CRT) or external beam radiation followed by brachytherapy (BT). The primary endpoint was DFS, defined as free from muscle invasive locoregional recurrence, distant metastasis or death. Secondary endpoint was overall survival (OS). Two-year follow-up (FU) data were collected Survival was analyzed with a Cox proportional hazards model, we present the crude results in this abstract. Time was defined from treatment start to first event. Patients were censored at end of FU if alive or at last contact if lost to follow-up. <h3>Results</h3> A total of 1429 patients were included, 1100 underwent RC, 283 concurrent CRT and 44 BT. Median follow-up was 22 months (range: 1-43 months). Patients treated by RC and BST had similar DFS with a crude HR 0.96 (95%CI 0.78-1.16). The 2-year DFS for patients treated by RC, concurrent CRT or BT was 56% (95%CI 53-60%), 56% (95%CI 50-63%) and 67% (95%CI 52-82%) respectively. After a median time of 15.8 months, salvage cystectomy was performed in 21 patients (6,4%) of which 17 in the CRT and 4 in the BT group. The 2-year OS for patients treated with RC, concurrent CRT or BT was 63.8% (95%CI 61-67%), 68.3% (95%CI 62-74%) and 85.9% (95%CI 75-96%) respectively. The crude HR for OS was 0.84, 95%CI 0.66-1.05, (p=0.14) for RC vs CRT and 0.40 95%CI 0.17-0.77(p=0.015) for RC vs BT. Our study is limited by the inherent biases of observational data. <h3>Conclusion</h3> At two years, DFS did not significantly differ between patients treated with BST and RC. We conclude that after appropriate selection BST leads to similar DFS rates compared to RC. Nevertheless, these results should be interpreted with care, as the treatment groups were not yet matched for case-mix variables. The results of this study can be used to aid patients and physicians to choose the modality best tailored to their individual preferences.

Neurogenic Lower Urinary Tract Dysfunction in the First Year After Spinal Cord Injury: A Descriptive Study of Urodynamic Findings.

We aimed to provide a real-world description of neurogenic lower urinary tract dysfunction within the first year after spinal cord injury with a focus on unfavorable urodynamic parameters that are associated with urological morbidity. Urodynamic investigations from 97 patients with traumatic or ischemic acute spinal cord injury and managed according to the European Association of Urology Guidelines on Neuro-Urology were analyzed at a single university spinal cord injury center at 1 month, 3 months, 6 months, and 12 months after injury. Unfavorable urodynamic parameters were defined as detrusor overactivity in combination with detrusor sphincter dyssynergia, maximum storage detrusor pressure of 40 cm H2O or higher, bladder compliance less than 20 mL/cm H2O, and vesicoureteral reflux of any grade. One or more unfavorable urodynamic parameter was observed in 87 out of 97 patients (90%) within the first year after spinal cord injury. Eighty-eight percent of the patients showed detrusor overactivity with detrusor sphincter dyssynergia, 39% a maximum storage detrusor pressure of 40 cm H2O or higher, and 7% vesicoureteral reflux. No patient developed a low-compliance bladder. Using a standardized urodynamic follow-up schedule, we found unfavorable urodynamic parameters in a majority of the population within the first year after spinal cord injury. As early treatment based on urodynamic findings might reduce the risk of deterioration of upper and lower urinary tract function, thereby improving long-term outcomes, there is need for further research regarding recommendations for a urodynamic follow-up schedule during the first year after spinal cord injury.

The comprehensive complication index is more sensitive than the Clavien-Dindo classification for grading complications in elderly patients after radical cystectomy and pelvic lymph node dissection: Implementing the European Association of Urology guideline.

Lack of assessment of 90-d perioperative morbidity in elderly patients after radical cystectomy and pelvic lymph node dissection (PLND) using a standard reporting methodology, and the Clavien-Dindo classification (CDC) does not accurately reflect the burden of complications. We aim to report the 90-d complications of elderly patients after radical cystectomy, and to compare the validity of the Comprehensive Complication Index (CCI) and CDC. Retrospective review of 280 patients aged ≥75 years who received radical cystectomy between 2006 and 2021. The 90-d complications of elderly patients after radical cystectomy were reported by implementing the EAU criteria. The CDC and CCI were both used for grading complications. The Spearman rank correlation coefficient was used to estimate the correlation between postoperative stay and CDC/CCI. Logistic regression was used to identify the risk factors for major complications. The sample size for a fictive superiority trial was calculated for different endpoints. A total of 225 (80.36%) patients suffered from 528 complications. The cumulative CCI had a more accurate prediction of postoperative stay than the CDC (r = 0.378, p < 0.001 vs. r = 0.349, p < 0.001). The need for sample size could decrease when CCI was used for the primary endpoint. More risk factors for major complications were identified when CCI ≥33.7 was defined as the endpoint of major complications. CCI is better than CDC for grading the severity of complications in elderly patients after radical cystectomy and PLND.