Urologie最新文献

Type 2 diabetes mellitus is a well-known metabolic disease with increasing prevalence. Diabetic-related complications lead to different types of organ damage, some of which some of which are less well-known. In the lower urinary tract, a complex interplay of neuronal, myogenic, and urothelial dysfunction leads to functional disorders of the lower urinary tract, with disorders of bladder storage and bladder emptying being in the forefront. In Germany, the number of patients with diabetes mellitus is estimated at over 8 million, with up to 2 million undiagnosed cases. Exact figures on diabetes-related dysfunction of the lower urinary tract are not available, partly because the early phase is often asymptomatic. Symptomatic patients often initially report symptoms of urgency, but later reduced sensitivity and ultimately a feeling of residual urine and urinary retention. Treatment options are limited, not always evidence-based, and often only evaluated in patients without diabetes. Behavioral therapy measures, drug therapy, peripheral neuromodulation, and catheter use such as single-use catheterization or permanent catheter diversion are used. In order to ensure optimal diagnosis and therapy, an understanding of the underlying pathologies and functional diagnostics is necessary.

The superiority of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) over conventional staging methods such as computed tomography (CT) and bone scintigraphy has now been demonstrated for almost all clinical stages of prostate cancer. In primary diagnostics, PSMA-PET/CT is therefore the new standard for risk-adapted whole-body staging. At the same time, PSMA-PET/CT provides a new risk-based classification for predicting overall survival across all early and late stages of the disease. However, the clinical implications of this information are not yet fully understood, particularly as data on systemic therapy for metastatic prostate cancer are still based on conventional imaging. For this reason, clinical follow-up is usually still carried out using conventional imaging. The Prostate Cancer Working Group 4 criteria will represent an initial consensus on therapy monitoring using PSMA-PET/CT. To monitor treatment response using PSMA PET/CT in metastatic castration resistant prostate cancer, there is already a framework (RECIP 1.0) in place. There is no doubt that PSMA PET/CT should be performed prior to PSMA radioligand therapy to optimize patient selection.

Introduction: Prostate cancer guidelines recommend molecular analysis of biomaterial following resistance to first-line systemic therapy in order to identify druggable mutations. We report on our results of molecular analysis of tissue specimens via next generation sequencing (NGS) in men with metastatic castration resistant prostate cancer (mCRPC).

Patients and methods: In all, 311 mCRPC patients underwent NGS analysis from biopsy samples of progressive metastatic lesions or archival radical prostatectomy specimens. NGS analysis was either performed using a panel of 18 prostate cancer-specific amplicons or via the TS0500 panel.

Results: Of the 311 biopsies, 299 (96%) revealed sufficient DNA content for NGS analysis independent on the specimen origin. Biopsies were taken from prostate (31%), lymph nodes (26%), visceral (17%) or osseous (18%) metastases. In 223 (75%) and 76 (25%) patients activating/inhibiting and no mutations were identified, respectively. Most frequently, mutations of HRD genes including a positive HRD score and p53 were identified in 22% of patients each. About 50% of HRD gene mutations were pathogenic and treatment with PARP inhibitors was initiated. Although the majority of p53 alterations were inactivating mutations, 3 patients demonstrated gain-of-function mutations resulting in an inactivation of ATM. Activating androgen receptor mutations and inactivating PTEN mutations were identified in 42 (14%) and 24 (8%) patients, respectively. Specific AR mutations resulted in a switch of hormonal therapy. Mutations of mismatch repair deficiency genes/MSI high were identified in 5 patients resulting in the administration of pembrolizumab. Addition of the TSO 500 panel identified additional mutations in 4.5% of patients and only 2% of the total cohort would have benefitted from this large panel with the identification of druggable mutations.

Conclusion: Druggable mutations were identified in one third of mCRPC patients using an 18 amplicon-panel analyzed via NGS. Based on our data, molecular analysis of AR mutations or mutations of the HRD genes should be performed following progression after first-line hormonal therapy. A more extensive molecular analysis seems to be useful following progression to the standard sequential hormonal, cytotoxicand radioligand therapies. Use of the expensive TSO 500 panel seems to be of additional therapeutic value in only a minority of patients.

This article provides a comprehensive overview of the current treatment options for patients with metastatic castration-resistant prostate cancer (mCRPC) following the failure of first-line therapy. Although significant progress has been made in the primary treatment of hormone-sensitive prostate cancer, the management of mCRPC remains a clinical challenge. The article outlines the diagnostic criteria for mCRPC, which can be confirmed through biochemical progression and imaging techniques. Various drug classes are available for the treatment of mCRPC after first-line therapy failure, including androgen receptor signaling pathway inhibitors (ARPI), chemotherapeutics such as docetaxel and cabazitaxel, as well as newer agents like poly(ADP-ribose) polymerase (PARP) inhibitors and prostate-specific membrane antigen (PSMA)-based radioligand therapies. These agents are used as monotherapy or in combination, depending on the patient's status and treatment history. Choosing the appropriate follow-up therapy after first-line failure is often difficult because current study results are mostly based on older treatment concepts. Precise, molecular-based treatment planning could play a key role here. Molecular markers such as BRCA 1/2 mutations and imaging techniques like PSMA-PET/CT can help identify the most suitable therapy for individual patients. For example, patients with BRCA 1/2 mutations may benefit from a combination of PARP and ARPI therapy, while those with high PSMA levels may be considered for PSMA radioligand therapy. Thus, therapeutic options for the treatment of mCRPC are now diverse and promising, with the challenge being to determine the right sequences and combinations based on the individual patient profile.

Background: The introduction of hybrid DRGs on 1 January 2024 is intended to create incentives to perform inpatient urology services, e.g., ureterorenoscopy (URS), on an outpatient basis. The effects on the reality of care are currently unclear.

Objectives: The aim of the survey was to gather an opinion on the introduction of hybrid DRGs in urology and to analyze initial practical experiences and future prospects.

Materials and methods: In a Germany-wide online survey conducted between May and July 2024, 32 questions were asked about patient care, further training and other indications, among other things. In addition, an assessment of the outpatient potential for URS for ureteral and kidney stones and hydrocele resections was requested.

Results: A total of 364 urologists responded to the survey: 54.5% were in private practice and 45.5% worked in hospitals. 91.1% were active surgeons. The concept of hybrid DRGs was rated positively by 34% of those working in surgery, but 68% saw no relief in their everyday work. 51% expressed concerns about the negative impact on further training. The proportion of URS performed on an outpatient basis in 2023 was 21% (ureteral stones) and 11% (kidney stones), with a long-term potential increase of up to 33%. Two thirds of hydrocele resections were already performed on an outpatient basis, and 74% of respondents considered these to be billable in a hybrid DRG.

Conclusion: The survey shows a differentiated opinion on hybrid DRGs in urology, but the sample only comprises around 6% of urologists in Germany. It would make sense to repeat the survey at a later date in order to evaluate developments in practical use.

Background: Neurophysiological investigations are infrequently utilized in the diagnostic workup of lower urinary tract symptoms (LUTS).

Objective: To determine the potential contributions of neurophysiological assessments in the diagnostic process of LUTS and their integration into systemic neurological and psychosomatic disorders.

Materials and methods: This study elucidates the role of neurophysiological tests specific to pelvic floor diagnostics, namely pudendal nerve somatosensory-evoked potentials (SEP) and external anal sphincter electromyography (EMG), through the presentation of two clinical case reports.

Results: When combined with clinical history, physical examination, and urodynamic studies, pudendal SEP and external anal sphincter EMG facilitate both diagnostic precision and the topographic localization of LUTS. This allows, particularly in conjunction with supplementary imaging modalities such as magnetic resonance imaging (MRI), for a definitive diagnosis and, consequently, the formulation of individualized, targeted therapeutic strategies.

Conclusion: The increased application of specific neurophysiological methods in the diagnostic evaluation of LUTS is warranted, particularly in complex cases. This approach not only enhances diagnostic accuracy but also aligns with the goal of developing personalized, specific, and resource-efficient therapeutic interventions.