Clemens Rosenbaum

Initial Experience of 68Ga-PSMA PET/CT Imaging in High-risk Prostate Cancer Patients Prior to Radical Prostatectomy

UNLABELLED Prostate-specific membrane antigen (PSMA) overexpression theoretically enables targeting of prostate cancer (PCa) metastases using gallium Ga 68 ((68)Ga)-labeled PSMA ligands for positron emission tomography/computed tomography (PET/CT) imaging. Promising detection rates have been reported when using this approach for functional imaging of recurrent PCa; however, until now, the diagnostic accuracy of (68)Ga-PSMA PET/CT for preoperatively identifying lymph node metastases (LNMs) had not been assessed. We retrospectively compared preoperative (68)Ga-PSMA PET/CT lymph node (LN) findings with histologic work-up after radical prostatectomy (RP). Overall, 608 LNs containing 53 LNMs were detected during RP. LNMs were present in 12 of 30 patients (40%). The (68)Ga-PSMA PET/CT scans identified 4 patients (33.3%) as LN true positive and 8 patients (66.7%) as false negative. Median size of (68)Ga-PSMA-PET/CT-detected versus undetected LNMs was 13.6 versus 4.3 mm (p<0.05). Overall sensitivity, specificity, positive predictive value, and negative predictive value of (68)Ga-PSMA PET/CT for LNM detection were 33.3%, 100%, 100%, and 69.2%, respectively. Per-side analyses revealed corresponding values of 27.3%, 100%, 100%, and 52.9%. Conversely, (68)Ga-PSMA PET/CT enabled tumor visualization in the prostate. In 92.9% of patients, the intraprostatic tumor foci were correctly predicted. Overall, (68)Ga-PSMA PET/CT is a promising tool for functional imaging; however, our initial experience revealed substantial influence of LNM size on the diagnostic accuracy of (68)Ga-PSMA PET/CT. PATIENT SUMMARY We assessed the diagnostic accuracy of (68)Ga-PSMA PET/CT in high-risk prostate cancer patients prior to radical prostatectomy. We found that lymph node metastasis detection rates were substantially influenced by lymph node metastasis size.

Redo buccal mucosa graft urethroplasty: success rate, oral morbidity and functional outcomes

To determine the success rate, oral morbidity and functional outcomes of redo buccal mucosa graft urethroplasty (BMGU) for treatment of stricture recurrence after previous BMGU.

Outcomes of single- vs double-cuff artificial urinary sphincter insertion in low- and high-risk profile male patients with severe stress urinary incontinence

To evaluate continence and complication rates of bulbar single‐cuff (SC) and distal bulbar double‐cuff (DC) insertion in male patients with severe stress urinary incontinence (SUI) according to whether the men were considered low or high risk for unfavourable artificial urinary sphincter (AUS) outcomes.

Direct Vision Internal Urethrotomy for Short Anterior Urethral Strictures and Beyond: Success Rates, Predictors of Treatment Failure, and Recurrence Management

OBJECTIVE To determine success rates, predictors of recurrence, and recurrence management of patients treated for short anterior urethral strictures by direct vision internal urethrotomy (DVIU). MATERIALS AND METHODS We identified 128 patients who underwent DVIU of the anterior urethra between December 2009 and March 2016. Follow-up was conducted by telephone interviews. Success rates were assessed by Kaplan-Meier estimators. Predictors of stricture recurrence and different further therapy strategies were identified by uni- and multivariable Cox regression analyses. RESULTS The mean age was 63.8 years (standard deviation: 16.3) and the overall success rate was 51.6% (N = 66) at a median follow-up of 16 months (interquartile range: 6-43). Median time to stricture recurrence was six months (interquartile range: 2-12). In uni- and multivariable analyses, only repeat DVIU (hazard ratio [HR] = 1.87, 95% confidence interval (CI) = 1.13-3.11, P= .015; and HR=1.78, 95% CI = 1.05-3.03, P = .032, respectively) was a risk factor for recurrence. Of 62 patients with recurrence, 35.5% underwent urethroplasty, 29% underwent further endoscopic treatment, and 33.9% did not undergo further interventional therapy. Age (HR = 1.05, 95% CI = 1.01-1.09, P = .019) and diabetes (HR = 2.90, 95% CI = 1.02-8.26, P = .047) were predictors of no further interventional therapy. CONCLUSION DVIU seems justifiable in short urethral strictures as a primary treatment. Prior DVIU was a risk factor for recurrence. In case of recurrence, about one-third of the patients did not undergo any further therapy. Higher age and diabetes predicted the denial of any further treatment.

Management of Anterior Urethral Strictures in Adults: A Survey of Contemporary Practice in Germany

Introduction: Treatment methods of anterior urethral strictures in adults have undergone considerable changes in the recent past. Our goal was to determine national practice patterns among German urologists and to compare results with the results of prior international surveys. Methods: We conducted a survey on the management of urethral strictures among German urologists. Results: Eight hundred forty-five urologists, representing about 14.6% of German urologists, answered the survey. Most common procedures were direct vision internal urethrotomy (DVIU; 87.2%), blind internal urethrotomy (57.5%), dilatation (56.3%), ventral buccal mucosa graft urethroplasty (31.6%) and excision and primary anastomosis (28.9%). In case of a 3.5-cm bulbar stricture and in the case of a 1-cm bulbar stricture after 2 failed DVIUs, a consecutive urethroplasty was significantly more often favoured compared to transurethral treatment options (44.9 vs. 21.3% and 59.4 vs. 8.3%, both p < 0.001). Conclusion: Open urethral reconstruction reveals to be a more common method in practice nowadays. Adherence to recommended treatment algorithms improved in comparison to prior surveys.

Incidence, Risk Factors, Management, and Complications of Rectal Injuries During Radical Prostatectomy

Rectal injury (RI) during radical prostatectomy (RP) is a severe complication. So far, only limited data describing the incidence, risk factors, management, and complications of RI are available. In an analysis of data for 24178 patients, we identified 113/24076 patients (0.47%) undergoing open or robotic RP and 7/102 patients (6.86%) after salvage RP who experienced an RI. Besides salvage RP, local tumor stage, Gleason grade, lymph node status, and surgical experience, but not surgical approach (robotic vs open), could be identified as risk factors for RI in univariate and multivariate analysis. Intraoperative management of RI comprised closure with two to three layers. In 13/109 patients (11.9%), a diverting colostomy/ileostomy was carried out. Some 12% of men with closure of an RI developed a recto-anastomosis fistula, and 57% of those who had an additional diverting enterostomy. Thus, the overall incidence of recto-anastomosis fistula after RP was <0.1%. The extent of rectal laceration, prior radiation, and intraoperative signs of rectal infiltration were associated with the development of a subsequent recto-anastomosis fistula. Some 83% of patients with a recto-anastomosis fistula needed further intervention. PATIENT SUMMARY: We analyzed the incidence, risk factors, management, and complications of rectal injury during radical prostatectomy. Overall, the incidence of rectal injury and subsequent development of recto-anastomosis fistulas is low unless the patient has significant risk factors.

Impact of preoperative risk on metastatic progression and cancer-specific mortality in patients with adverse pathology at radical prostatectomy

To evaluate the impact of preoperative risk category on metastatic disease and prostate cancer‐specific mortality (CSM) in patients with prostate cancer (PCa) with adverse pathology at radical prostatectomy (RP).

Effect of repeat prostate biopsies on functional outcomes after radical prostatectomy

PURPOSE Growing acceptance of active surveillance (AS) results in a relevant number of patients who will undergo radical prostatectomy (RP) after multiple biopsy sessions (Bx) due to cancer progression. The effect of repeat Bx on functional outcomes after RP remains controversial. METHODS Overall, 11,140 patients who underwent RP from 2007 to 2015 were analyzed. Number of Bx sessions (1 vs. 2 vs. ≥3) before RP was examined. Association between number of Bx sessions and erectile dysfunction (ED) and urinary incontinence (UI) was assessed by univariable and multivariable logistic regressions. RESULTS A total of 9,797 (87.9%) had 1 Bx, 937 (8.4%) had 2 Bx, and 406 (3.6%) had 3 or more Bx. Median age was 65 years (IQR: 59-69). Increasing Bx sessions were associated with advanced age at surgery (1, 2, and ≥3 Bx: 65, 65, and 67 years, P<0.001); 982 (45.9%), 906 (57.9%), and 597 (60.9%) patients achieved potency at 1, 2, and 3 years after RP, respectively. On adjusted analysis repeat Bx compared to initial Bx had no influence on ED at 1, 2, and 3 years. At 1, 2, and 3 years after RP, 6,107 (87.9%), 4,825 (90.9%), and 3,696 (91.6%) patients achieved continence. Number of Bx session had no influence on UI at follow up. CONCLUSION Our findings demonstrate that ED and UI rates are comparable among patients undergoing RP after initial and repeat Bx sessions. This is of importance when counseling AS patients. No adverse functional outcomes are expected if AS has to be discontinued and RP as curative option is contemplated.

The Impact of Repeat Prostate Biopsies on Oncologic, Pathological and Perioperative Outcomes after Radical Prostatectomy.

Purpose: The impact of repeat biopsy sessions on radical prostatectomy remains controversial regarding perioperative, pathological and oncologic outcome. Materials and Methods: We analyzed the records of 12,624 patients who underwent radical prostatectomy from 2007 to 2013. The association of the number of biopsy sessions (range 1 to 3 or more) with pathological outcomes and perioperative complications was analyzed using the Wilcoxon matched pair test. To test the association between biopsy sessions and biochemical recurrence‐free survival we used Kaplan‐Meier curves and multivariable Cox regression analysis. Results: Of the patients 89.2% had 1 biopsy session, 7.4% had 2 sessions and 3.4% had 3 or more sessions. Median followup was 36.6 months. In patients with 1, 2 and 3 or more biopsy sessions prostate volume (38, 44 and 45 ml) and prostate specific antigen (6.7, 7.6 and 10.1 ng/ml, respectively) were greater (each p <0.001). The perioperative outcome was more favorable. Patients with 1, 2 and 3 or more biopsy sessions more often had organ confined tumors (67.6%, 72.1% and 72.9%, p = 0.003) and higher tumor volume (3.1, 3.0 and 3.6 ml, p <0.001) but a lower tumor percent (7.5%, 3.7% and 2.4%, respectively, p <0.001). More biopsy sessions were associated with fewer lymph node metastases (1, 2 and 3 sessions 0.23, 0.13 and 0.17, respectively, p <0.001). Gleason score and surgical margin status did not differ. The overall biochemical recurrence rate was 18.9% and it was comparable among the biopsy groups. No association was found between the number of biopsies and biochemical recurrence. Conclusions: Patients with multiple biopsy sessions experience a slightly more favorable pathological outcome without an impact on the oncologic outcome. The perioperative outcome was more favorable in patients with multiple biopsies.

Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis

Objectives The objective of this study was to compare the recurrence rate and de novo incontinence after endoscopic treatment of vesicourethral stenosis (VUS) after radical prostatectomy (RP) and for bladder neck stenosis (BNS) after transurethral resection of the prostate (TURP). Methods Retrospective analysis of patients treated endoscopically for VUS after RP or for BNS after TURP at three German tertiary care centers between March 2009 and June 2016. Investigated endpoints were recurrence rate and de novo incontinence. Chi-squared tests and t-tests were used to model the differences between groups. Results A total of 147 patients underwent endoscopic therapy for VUS (59.2%) or BNS (40.8%). Mean age was 68.3 years (range 44–86), mean follow-up 27.1 months (1–98). Mean time to recurrence after initial therapy was 23.9 months (1–156), mean time to recurrence after prior endoscopic therapy for VUS or BNS was 12.0 months (1–159). Patients treated for VUS underwent significantly more often radiotherapy prior to endoscopic treatment (33.3 vs. 13.3%; p = 0.006) and the recurrence rate was significantly higher (59.8 vs. 41.7%; p = 0.031). The overall success rate of TUR for VUS was 40.2%, success rate of TUR for BNS was 58.3%. TUR for BNS is significantly more successful (p = 0.031). The mean number of TUR for BNS vs. TUR for VUS in successful cases was 1.5 vs. 1.8, which was not significantly different. The rate of de novo incontinence was significantly higher in patients treated for VUS (13.8 vs. 1.7%; p = 0.011). After excluding those patients with radiotherapy prior to endoscopic treatment, the recurrence rate did not differ significantly between both groups (60.3% for VUS vs. 44.2% for BNS; p = 0.091), whereas the rate of de novo incontinence (13.8 for VUS vs. 0% for BNS; p = 0.005) stayed significantly higher in patients treated for VUS. Conclusion Most patients with BNS are successfully treated endoscopically. In patients with VUS, the success rate is lower. Both stenoses differ with respect to de novo incontinence. Patients must be counseled regarding the increased risk of de novo incontinence after endoscopic treatment of VUS, independent of prior radiotherapy. Longer follow-up is warranted to address long-term outcomes.