European Urology Research Articles

Learning Curve in Robot-assisted Kidney Transplantation: Results from the European Robotic Urological Society Working Group

BackgroundRecently, robot-assisted kidney transplantation (RAKT) was recently introduced as renal replacement mini-invasive surgery. ObjectiveTo report surgical technique, including tips and tricks, and the learning curve for RAKT. Design, setting, and participantsAll consecutive RAKTs performed in the five highest-volume centers of the European Robotic Urological Society RAKT group were reviewed, and a step-by-step description of the technique was compiled. Surgical procedureSurgeries were performed with Da Vinci Si/Xi. The patient was placed in the lithotomy position. The Trendelenburg position was set at 20–30° and the robot was docked between the legs. MeasurementsShewhart control charts and cumulative summation (CUSUM) graphs and trifecta were generated to assess the learning curve according to rewarming time (RWT), intra/postoperative complications, and renal graft function (glomerular filtration rate) on days 7 and 30, and at 1 yr. Linear regressions were performed to compare the learning curves of each surgeon. Results and limitationsArterial anastomosis time was below the alarm/alert line in 93.3%/88.9% of RAKTs, while venous anastomosis time was below the alarm/alert line in 88.9%/73.9%. The nonanastomotic RWT exceeded +3 standard deviation (SD) in 24.7% of procedures and +2SD in 37.1%. In only 46% cases, the RWT was below the alert line. The ureteroneocystostomy time was below +2SD and +3SD in 87.9% and 90.2% of cases, respectively. CUSUM showed that the learning curve for arterial anastomosis required up to 35 (mean = 16) cases. Complications and delayed graft function rates decreased significantly and reached a plateau after the first 20 cases. Trifecta was achieved in 75% (24/32) of the cases after the first 34 RAKTs in each center. ConclusionsA minimum of 35 cases are necessary to reach reproducibility in terms of RWT, complications, and functional results. Patient summaryRobot-assisted kidney transplantation requires a learning curve of 35 cases to achieve reproducibility in terms of timing, complications, and functional results. Synergy between the surgeon and the assistant is crucial to reduce rewarming time. High-grade complications and delayed graft function are rare after ten surgeries. Hands-on training and proctorship are highly recommended.

Does chronic hyperglycaemia increase the risk of kidney stone disease? results from a systematic review and meta-analysis

DesignSystematic review and meta-analysis of observational studies was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies reporting on diabetes mellitus (DM) or metabolic syndrome (MetS)...

318 Retrospective Review of Improvement of Erectile Function after Low Intensity Shockwave Treatment with Urogold 100™

Erectile dysfunction (ED) can result from insufficient arterial blood inflow and/or from veno-occlusive dysfunction from reduced erectile tissue expandability secondary to erectile tissue fibrosis. Non-surgical strategies to manage ED in the United States (US) are primarily symptomatic-based, such as PDE5 inhibitors and/or intracavernosal injections. In Europe, disease modification strategies such as Low Intensity Shockwave Treatment (LiSWT) using energy levels 0.09 – 0.12 mJ/mm2 have shown, in multiple sham-controlled prospective studies, significant improvement in both ED outcome measures and blood inflow. The European Urological Association lists Li-SWT as a recognized ED treatment. The Urogold 100™ is an electrohydraulic shockwave device that generates energy levels such as 0.09 – 0.12 mJ/mm2 with a unique parabolic reflector. It is FDA-cleared for improved blood flow and connective tissue activation as non-significant risk in humans. The objective was to perform a single site retrospective chart review of the outcome of ED treatment with the Urogold 100™ shockwave device.

Simulator Availability Index: a novel easy indicator to track training trends. Is Europe currently at a urological training recession risk?

IntroductionTo evaluate the European trend regarding the availability of surgical simulators and to propose a novel index to easily track this trend.Material and methodsDuring European Urology Residents Education Program, from 2014 to 2018, residents were asked through an anonymous survey about the availability of specific simulator training boxes at their department. The Simulator Availability Index (SAI) was made by the ratio between the number of departments with at least one box trainer and the total number of departments evaluated.ResultsThe SAI decreased in five years from 0.47 to 0.41 for laparoscopic trainers, while the already low initial SAI (0.17) decreased by up to 0.05 in four years for both ureteroscopy (URS) and transurethral resection (TUR) trainers.ConclusionsA self-analysis may be advisable in order to improve the spread of information and investigate whether any specific reasons may be responsible for this trend. The SAI might be a simple but useful tool to monitor and evaluate this trend in the context of national training plans.

Characterizing the Benign Prostatic Hyperplasia Literature: A Bibliometric Analysis

To characterize the current landscape and future directions of academic benign prostatic hyperplasia (BPH) by using bibliometric analysis. We used the Web of Science Core Collection to conduct a bibliometric analysis of leading BPH articles. Bibliometric analyses are quantitative approaches examining the impact of academic literature. We used the following search terms and Boolean logic "("benign prostat*") AND (hyperplasia OR enlarg*)" and characterized the 100 most-cited BPH articles through 2018 including citations, journal, author, year, and country. The top 100 BPH articles were published between 1978 and 2012. Citations ranged from 153 to 2171 across 27 different journals, including 10 urology-specific journals. The Journal of Urology was the most published journal (n=25), followed by European Urology (n=17), and Urology (n=15). In general, the oldest 10 articles focused on BPH etiology/pathogenesis, while the newest 10 focused on treatment. The 1990's was the most productive decade with nearly half of the top 100 articles (n=44). Twenty-six different countries contributed to the top 100 articles, with the US (n=74), Italy (n=19), and Canada (n=12) being the most common. This study represents the first bibliometric analysis of the leading BPH articles impacting the academic literature. The focus has evolved from BPH pathogenesis to treatment, perhaps reflecting a shift in research funding and capacity. These findings may guide research priorities for this increasingly common condition.

Condition-specific surveillance in health care-associated urinary tract infections as a strategy to improve empirical antibiotic treatment: an epidemiological modelling study

BackgroundHealth care-associated urinary tract infection (HAUTI) consists of unique conditions (cystitis, pyelonephritis and urosepsis). These conditions could have different pathogen diversity and antibiotic resistance impacting on the empirical antibiotic choices. The aim of this study is to compare the estimated chances of coverage of empirical antibiotics between conditions (cystitis, pyelonephritis and urosepsis) in urology departments from Europe.MethodsA mathematical modelling based on antibiotic susceptibility data from a point prevalence study was carried. Data were obtained for HAUTI patients from multiple urology departments in Europe from 2006 to 2017. The primary outcome of the study is the Bayesian weighted incidence syndromic antibiogram (WISCA) and Bayesian factor. Bayesian WISCA is the estimated chance of an antibiotic to cover the causative pathogens when used for first-line empirical treatment. Bayesian factor is used to compare if HAUTI conditions did or did not impact on empirical antibiotic choices.ResultsBayesian WISCA of antibiotics in European urology departments from 2006 to 2017 ranged between 0.07 (cystitis, 2006, Amoxicillin) to 0.89 (pyelonephritis, 2009, Imipenem). Bayesian WISCA estimates were lowest in urosepsis. Clinical infective conditions had an impact on the Bayesian WISCA estimates (Bayesian factor > 3 in 81% of studied antibiotics). The main limitation of the study is the lack of local data.ConclusionsOur estimates illustrate that antibiotic choices can be different between HAUTI conditions. Findings can improve empirical antibiotic selection towards a personalized approach but should be validated in local surveillance studies.

Infrequent use of clinical trials registries in published systematic reviews in urology.

Validity of systematic reviews may be affected by non-publication of statistically non-significant or unfavorable clinical trial results. One function of clinical trial registries is to make these non-published studies available and thereby reduce potential publication bias. We aim to assess the use of clinical trial registries in published systematic reviews in urology. We identified all systematic reviews published in the five highest-impact general urology journals that publish original research between January 1 and December 31, 2017. Full-text analysis was performed to determine if protocols included searching clinical trial registries meeting WHO Registry Network criteria. Of a total of 204 search results, 92 were included in the analysis as systematic reviews. The majority searched the MEDLINE (91, 98%), EMBASE (69, 75%), and Cochrane (49, 53%) databases. Based on published methods, only 16 (17%) systematic reviews searched any clinical trial registries: 14 (15%) ClinicalTrials.gov, 6 (6%) WHO International Clinical Trials Registry Platform, and 2 (2%) ISRCTN registry. Rates of searching clinical trial registries were low regardless of the journal: 8 of 34 (24%) in European Urology; 2 of 10 (20%) in BJU International; 3 of 17 (18%) in Urology; 2 of 18 (11%) in The Journal of Urology; and 1 of 13 (8%) in World Journal of Urology. The majority of recently published systematic reviews in urology do not routinely search clinical trial registries. Inclusion of these registries can help identify unpublished trial data, which may improve the quality of systematic reviews by reducing publication bias.

Multicenter Analysis of Postoperative Complications in Octogenarians After Radical Cystectomy and Ureterocutaneostomy: The Role of the Frailty Index.

The purpose of this study was to assess patient frailty as a risk factor for radical cystectomy (RC) complications. We performed an analysis of prospectively collected data of consecutive patients 80 years of age or older who underwent RC and ureterocutaneostomy in 6 primary care European urology centers. Frailty was measured using a simplified frailty index (sFI) with a 5-item score including: (1) diabetes mellitus; (2) functional status; (3) chronic obstructive pulmonary disease; (4) congestive cardiac failure; and (5) hypertension, with a maximum 5-item score meaning high level of frailty. Within 90 days surgical complications were scored according to the Clavien Classification System (CCS). sFI≥3 was considered as poor frailty status. Clinical and pathological variables were analyzed as predictors of severe complications (CCS≥3). One hundred seventeen patients were enrolled. Most patients reported an sFI score of 2 and 3, respectively, 31/117 (26.5%) and 45/117 patients (38.5%). CCS≥3 occurred in 17/117 patients (14.5%). Patients with sFI≥3 were significantly older than patients with sFI<3 (median age, 85 years [interquartile range (IQR), 82-86] versus 82 years [IQR, 80-84]; P= .001). Most CCS≥3 scores occurred in patients with sFI≥3: 13 (11.1%) versus 4 (3.4%; P= .02). No significative differences were detected in terms of length of hospital stay, pathological stage, and postoperative bowel canalization when related to sFI. sFI≥3 was an independent risk factor of CCS≥3 in univariate and multivariate analysis (respectively, odds ratio [OR], 3.81 [95% confidence interval (CI), 1.16-12.5; P= .02] and OR, 3.1 [95% CI, 0.7-13.7; P= .01]). Body mass index, age, American Society of Anesthesiologists score≥3, and pathological stage were not related to CCS≥3. RC appears feasible in elderly patients with an sFI<3. In cases of sFI≥3, this choice should be carefully valued, discussed, and possibly avoided because of a higher risk of complications.

Comparative Study between Retrograde Intrarenal Surgery and Percutaneous Nephrolithotomy for the Treatment of Renal Stones

Background: The prevalence of urolithiasis has increased during the last decades and now affects approximately 9% of the adult population specially in developed countries. European Urology Guidelines recommend PCNL in stones larger than 2 cm in size and ESWL in stones smaller than 2 cm in size as the first treatment option. With advances in technology, new generation flexible ureteroscopes with safe and effective lithotripters such as holmium laser have been developed and RIRS became an important alternative in the treatment of large urinary stones.&#x0D; Objective: To evaluate the safety and efficacy of retrograde intrarenal surgery (RIRS) in the treatment of kidney stones and to compare its results with those of percutaneous nephrolithotomy (PCNL).&#x0D; Materials and Methods: We retrospectively analyzed a total of 50 patients ─ 27 patients (20 males and 7 females) who underwent PCNL and 23 patients (17 males and 6 females) who underwent RIRS between January 2015 and December 2017.&#x0D; Results: The mean duration of operation was 60.65 ± 23.56 minutes in the RIRS group and 50.55 ± 12.77 minutes in the PCNL group (p&lt;0.047). The hospital stay was significantly shorter in the RIRS group (2.21 ± 0.9 vs 5.29 ± 1.53 days in the RIRS and PCNL groups, respectively; p&lt;0.016). Stone-free rates after one session were 88.6% and 84.8% in the RIRS and PCNL groups respectively. Blood transfusions were required in five patients in the PCNL group. Complication rates were higher in the PCNL group.&#x0D; Conclusion: This study reveals that RIRS can be an alternative to PCNL in the treatment of kidney stone.&#x0D; J Enam Med Col 2019; 9(2): 84-89

Resident burnout in USA and European urology residents: an international concern.

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood. An anonymous 32-question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts. Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work-life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non-medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on-call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047). In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

Robotic Surgery Research in Urology: A Bibliometric Analysis of Field and Top 100 Articles.

Introduction: There has been a surge in robotic surgery research publications over the past 20 years. However, to date, there has been no characterization of urology's contribution to the robotic field, and there is a lack of bibliometric literature to guide future investigation. We conducted this bibliometric analysis to characterize the distributions and characteristics of robotic surgery research in the urologic field, with subanalysis of the top 100 articles. Materials and Methods: The Web of Science Core Collection of the ISI Web of Science was searched and analyzed to determine distributions and characteristics of robotic urologic surgery research. The top 100 articles were categorized by urologic subfield and organ of pathology, with a level of evidence rating system applied (adapted from the Centre of Evidence-Based Medicine). Results: The total number of articles retrieved was 1294 from 1999 to 2018. The number of articles published in the last decade has increased by 845.75%, with 153 articles published in the preceding decade. The United States leads countries in publication with 699 (54.02%) articles across the field, and 71 within the top 100 articles. The Journal of Endourology published most articles (n = 292, 22.57%) within the field, while European Urology published most (n = 36) within the top 100 articles. Top 100 articles where generally associated with cancer (n = 76), with prostate cancer dominating literature (n = 38). The most common level of evidence for top 100 articles was that of a level 3 study (n = 31). Conclusions: This analysis of research activity has the potential to guide future robotic surgery research trends in the field of urology. There has been an explosion in robotic surgery urologic research activity over the last decade, with level 3 evidence dominating the top 100 articles of the field.

Appropriate empiric antibiotic choices in health care associated urinary tract infections in urology departments in Europe from 2006 to 2015: A Bayesian analytical approach applied in a surveillance study.

BackgroundHealth care associated urinary tract infections (HAUTI) is a common complicating factor of urological practice. It is unclear what the appropriate empirical antibiotic choices are and how infection control policies (ICP) influence this. The aim of this study is to use probabilistic approaches towards the problem. That is to determine the chances of coverage of empirical antibiotic choices in HAUTIs and their annual trends in Europe. In addition, the impact of departmental self-reported compliance with catheter management and regulated usage of prophylactic antibiotics policies was tested. The estimated chances of coverage of antibiotics and further probabilistic calculations are carried out using the Global Prevalence of Infections in Urology (GPIU) annual surveillance study European data.MethodsGPIU is a multi-state annual prevalence study conducted in urology departments to detect patients with HAUTIs, using the Center for Disease Control (CDC) definitions and antimicrobial resistance (AMR). In this analysis; the European cohort from 2005 to 2015 was used. The estimated chance of coverage for each antibiotic choice in HAUTIs was calculated using the Bayesian Weighted Incidence Syndromic Antibiogram (WISCA) approach. Annual trend of the overall cohort and number of appropriate antibiotic choices were estimated. Departments were compared according to their self-reported compliance to ICPs to determine if there was an impact on chances of coverage and appropriate antibiotic choices.ResultsWe estimated that in most study years less than half of the single agent antibiotics and all combination options were appropriate for empirical treatment of HAUTIs. Departments with compliance to both ICPs were estimated to have 66%(2006) to 44% (2015) more antibiotic choices compared to departments with complete lack of compliance to the ICPs. In our estimates departments with adherence to a single policy was not superior to departments with complete lack of adherence to ICPs.ConclusionsMost single agent choices had limited coverage for HAUTIs and combination choices had improved chance of coverage. Optimal antibiotic selection decision should be part of decision experiments and tested in local surveillance studies. Departments with self-reported compliance to ICPs have more antibiotic choices and details of the compliance should be evaluated in future studies. The analysis herein showed that over the 10-year course there was no clear time trend in the chances of coverage of antibiotics (Bayesian WISCA) in European urology departments.

Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study.

To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures. A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed. A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working≤ 50h per week, laparoscopic training and having laparoscopic training boxes. Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.

PD43-10 CURRENT CUT-OFF VALUE FOR PEAK SYSTOLIC VELOCITY AND RESISTANCE INDEX UNDER PENILE DOPPLER ULTRASOUND NOT ADEQUATE ENOUGH FOR PATIENT WITH ERECTILE DYSFUNCTION

INTRODUCTION AND OBJECTIVES:Penile Doppler ultrasound is a frequently-utilized tool for diagnosing vasculogenic erectile dysfunction (ED). Current guideline from European Urology suggested a cut-of...

The landscape of urological retractions: the prevalence of reported research misconduct.

To evaluate the landscape of retractions of literature and to determine the prevalence of research misconduct in the field of urology. Three databases (PUBMED, Embase, Retraction Watch) were queried for all retracted studies on urological topics in both urological and non-urological journals from April 1999 to March 2018. Two reviewers screened the records and determined the final list of articles to be included in the analysis. A total of 138 articles met the inclusion criteria. Over 80% of retractions occurred after 2009. Retractions originated from 76 different journals (13 urological journals) and 28 countries. The most common reasons for retraction were plagiarism (28%), fake peer review (20%), error (20%), and falsification of data (13%). Misconduct accounted for two-thirds of the retractions (n = 93). A large watermark, indicating retraction of the article, was present in 75% of the manuscripts. Articles were cited a total of 4454 times, 38% of citations happened after retraction. The majority of retracted articles related to urological oncology (70%). The highest number of retractions for an individual author was five. Rates of retraction among popular urological journals since 2010 have increased but remain a small proportion of all publications: BJUI, 0.189%; World Journal of Urology, 0.132%; European Urology, 0.058%; Urology, 0.047%; and Journal of Urology, 0.024%. Retractions of urological literature, similarly to retractions of other biomedical literature, have been rising over the last decade. The majority of these retractions stem from research misconduct. Despite retractions, flawed articles continued to be cited.

Editorial introductions

Editorial introductions

3104 Characterizing the top 100 articles in benign prostatic hyperplasia literature using bibliometric analysis

OBJECTIVES/SPECIFIC AIMS: The prevalence of BPH, coupled with associated disability ranging from quality of life impairments to hospitalization, has spurred decades of research into its pathophysiology, diagnosis, treatment, and outcomes. For these reasons, we conducted a study to characterize the current landscape of BPH literature, including the most commonly cited articles impacting the field. METHODS/STUDY POPULATION: We used the Web of ScienceTM databases to conduct a bibliometric analysis of the top 100 leading BPH articles. Bibliometric analyses are quantitative approaches examining the impact of academic literature. We used the following search terms: ‘benign prostatic hyperplasia’ and ‘benign prostatic enlargement.’ We identified and characterized the 100 most-cited BPH articles including their citations, journal, author, year, and country through September 2018. RESULTS/ANTICIPATED RESULTS: The top 100 BPH articles were published between 1978 and 2012. The number of citations ranged from 143 to 2,158 across 26 different journals, including 9 urology-specific journals. The Journal of Urology (5-year impact factor: 4.91) was the most published journal with 26 articles, followed by European Urology (5-year impact factor: 15.66) with 16, and Urology (5-year impact factor: 2.39) with 13. The oldest 10 articles in the top 100 mainly focused on BPH etiology/pathogenesis, while the newest 10 articles mainly focused on medical treatment. The 1990’s was the most productive decade accounting for nearly half of the top 100 articles (n=46). Eight authors had two or more first author publications, and 8 institutions had five or more publications in the top 100. Thirteen different countries were represented in the top 100 articles, with the US (n = 64), Italy (n=7), and Germany (n=5) being the most common. The articles were published in the following Web of Science Categories: Urology &amp; Nephrology (n=68), Medicine, General &amp; Internal (n=15), and Endocrinology &amp; Metabolism (n=7). DISCUSSION/SIGNIFICANCE OF IMPACT: This study represents the first bibliometric analysis of the leading 100 BPH articles impacting the academic literature. The literature focus has evolved from BPH pathogenesis/etiology to treatment, and was primarily published in 3 specialty journals. Our findings highlight the most impactful BPH literature, and may be used to guide research and funding priorities for this increasingly common condition.

825 - Satisfaction with surgical training and confidence in performing surgical procedures among European urology residents

825 - Satisfaction with surgical training and confidence in performing surgical procedures among European urology residents

827 - Academic and scientific activity of European urology residents during their training

827 - Academic and scientific activity of European urology residents during their training

Abstract B151: Exploring the induction of immunogenic cell death (ICD) by high-intensity focused ultrasound (HIFU)

Abstract Immunogenic cell death (ICD) is an intriguing concept within cancer immunotherapy. Indeed, by inducing a specific means of cellular demise, a protective immune response can be triggered against the dying cells. As such, the dying cancer cells are—in a way—turned into a vaccine, attracting immune cells to the site of cell death, and activating them to trigger an anticancer immune response. Since the early discovery of ICD, more mechanistic insights into the hallmarks of ICD have been unraveled and several state-of-the-art cancer therapies have been identified as bona fide ICD inducers (1, 2).One of the cancer therapies which could be a potential candidate to induce ICD is high-intensity focused ultrasound (HIFU) (3). HIFU is currently used as a way of debulking solid tumors in a non-invasive, image-controlled and precise way without the use of ionizing radiation. Depending on the ultrasound parameters, tumor tissue can be ablated either in a mechanical (tissue disruption) or thermal way (heating and coagulative necrosis). Interestingly, there are some indications that HIFU may also affect the immune system: experiments in mice and man have shown attraction/activation of immune cells to/in the tumor site (4, 5). Of note: these immunostimulating effects were reported to be more prominent for mechanical HIFU than thermal HIFU. However, neither the mechanisms behind these observations, nor the possible link to the induction of ICD have been investigated. Therefore, the key aim of work is to investigate the potential of HIFU to induce ICD. Using a custom-designed HIFU set-up, we were able to—in a precise, automated and controlled way—expose B16F0 melanoma cells to HIFU in vitro. The HIFU-exposed tumor cells were subsequently evaluated for the occurrence of apoptosis and ICD hallmarks. More specifically, we evaluated the exposure of calreticulin (CRT) on the cell membrane and release of high mobility group box 1 (HMGB-1) and adenosine triphosphate (ATP). Our data show that application of mechanical HIFU protocols (using short, repeated ultrasound bursts) induce a significant fraction of apoptotic cells (as measured by a loss of mitochondrial membrane potential) within 4h after treatment. Importantly, already within the first hour after HIFU exposure, high levels of the ICD hallmark and Toll-like receptor 4 agonist HMGB-1 were found in the supernatant of the HIFU-treated cells, compared to untreated controls. To determine the effect of HIFU on ATP release, a quinacrine assay was performed to stain intracellular ATP-containing vesicles. Using flow cytometry, we observed that HIFU triggered exocytosis of these vesicles, with 2- to 3-fold reductions in quinacrine fluorescence at 4h and 24h after HIFU exposure, respectively. In addition, at 24h after HIFU exposure, &amp;gt;30% of the cells exposed CRT on the outer leaflet of the cell membrane, which was a drastic increase compared to blanks (&amp;lt;1% CRT exposure). Taken together, these results indicate that 3 key hallmarks of ICD can be detected after treatment of B16F0 melanoma cells with an optimized mechanical HIFU protocol. Currently, vaccination experiments are ongoing to determine whether HIFU-treated cells induce protective immunity in mice. If we could identify mechanical HIFU as a true ICD inducer, this might have important repercussions to how HIFU ablative therapies are applied in the clinic: modified HIFU regimens that not only focus on full ablation, but also trigger ICD could be envisaged to simultaneously tackle primary tumors as well as distant metastasis. Moreover, this could provide a solid basis for the rational combination of HIFU with other immunotherapies to strengthen the evoked immune response.