Urologie最新文献

The diagnosis "urothelial carcinoma with divergent histology (UC-DH)" subsumes urothelial carcinomas that have additional histological features beyond conventional UC (not-otherwise specified, NOS). These include UCs with additional squamous, glandular, trophoblastic, or Müllerian differentiation. Histological subtypes (STs) of UC, such as micropapillary, nested, plasmacytoid, sarcomatoid, lymphoepithelial, and others, must be distinguished from these. Histogenetically, both UCs with divergent histology and the histological UC STs arise from preexisting urothelium. In general, detection of UC-DH/ST is associated with unfavorable and aggressive biology, and the majority of patients are directed to early radical cystectomy. In the case of muscle-invasive UC-DH/ST there is uncertainty as to whether and which neoadjuvant therapy should be performed. The available data on organ-preserving intravesical therapy in patients with non-muscle-invasive UC-DH/ST are still limited and poorly validated. Sarcomatoid, plasmacytoid, and micropapillary UC-DH/STs seem to have less favorable oncological outcomes. In any case, clean, deep resection and sufficient imaging of local staging using multiparametric MRI is required in all patients with UC-DH/ST for individual and risk-adapted treatment planning. Muscle-invasive UC-DH/ST should be treated in the same manner as pure UC, i.e., with neoadjuvant chemotherapy followed by radical cystectomy. Only micropapillary UC seems to respond worse to chemotherapy than pure UC. Also in metastatic UC-DH/ST do the same treatment algorithms apply as in pure UC. In order to recognize UC-DH/ST clinically, a comprehensive histopathological evaluation with reporting of the percentage of each histological component is necessary. Early immunohistochemical or molecular pathological evaluation is also recommended, as particularly the micropapillary variant shows targetable alterations.

Background: Non-muscle-invasive bladder cancer (NMIBC) is characterized by high rates of recurrence and progression, particularly in high-risk disease. Despite transurethral resection and adjuvant intravesical Bacillus Calmette-Guérin (BCG) therapy, a need for more effective bladder-preserving treatment strategies remains.

Objective: The aim of this review is to describe the current therapeutic landscape of NMIBC and to critically evaluate the evidence for novel treatment approaches, particularly in BCG-naïve high-risk NMIBC and in BCG-refractory tumors, as several novel intravesical and systemic therapies have been approved for these entities in the United States.

Methods: This review summarizes current guideline recommendations, phase III trials investigating combinations of PD-1/PD-L1 immune checkpoint inhibitors with BCG in BCG-naïve patients, and emerging treatment strategies for BCG-refractory NMIBC.

Results: In BCG-naïve high-risk NMIBC, phase III trials evaluating durvalumab or sasanlimab in combination with BCG have demonstrated a significant improvement in disease- or event-free survival compared to BCG monotherapy. Regulatory approval in Europe is anticipated. For patients with BCG-refractory disease, several novel intravesical and systemic therapies have been approved in the United States, enabling bladder-preserving treatment approaches. However, approval in Europe appears unlikely, and radical cystectomy is therefore expected to remain the standard of care in this disease setting. In parallel, innovative therapeutic approaches, including gene therapies, oncolytic viruses, and novel drug-delivery systems, are currently under clinical investigation.

Conclusion: The therapeutic landscape of NMIBC is undergoing rapid evolution. Combination strategies and novel intravesical therapies have the potential to expand the role of BCG to reduce recurrence and progression rates and further establish bladder-preserving treatment paradigms.

Radical cystectomy (RC) with pelvic lymphadenectomy followed by urinary diversion is the standard treatment for muscle-invasive bladder cancer (MIBC). Perioperative systemic therapy can improve the oncological outcome of RC. Despite the use of modern surgical techniques, RC is still associated with a high rate of perioperative complications and reduced quality of life. As an alternative to RC, organ preserving trimodal therapy can be performed in selected patients. In light of newer and more effective systemic therapies and the associated higher response rates to neoadjuvant systemic therapy, interest in novel organ-preserving concepts for appropriate patients with MIBC has increased. These approaches aim to better preserve quality of life while achieving oncological outcomes that are at least comparable to those of RC. Clinical re-evaluation after initial systemic therapy requires establishment of robust surrogate parameters for complete pathological and systemic response. To this end, existing combined restaging methods (transurethral resection of bladder tumor [TUR-BT], urinary diagnostics, imaging techniques, liquid biopsies) need to be further developed and validated. This narrative review outlines current developments and challenges that must be considered for the successful implementation of organ-preserving approaches in MIBC and defines the prerequisites under which organ preservation may be feasible.

Penile cancer is a rare but relevant tumor entity. Due to the low case numbers in individual hospitals deviations from treatment standards and delayed treatment repeatedly occur. This is all the more serious as only an early and consistent treatment management can ensure a curative approach. For this reason, in several European countries penile cancer is only treated in a few special centers. This article provides a current overview of the epidemiology and etiology as well as diagnostic recommendations and treatment options for this malignant neoplasm. The early diagnosis is decisive for the subsequent approach. A consistent primary management with an organ-preserving complete resection of the primary tumor and all lymph nodes infested by the tumor whenever possible is a basic prerequisite for a curative treatment of penile cancer. In a metastatic situation a multimodal treatment concept is often necessary. A good psycho-oncological accompaniment of the patient and a consistent follow-up care also appear to be crucial.

Background: Imaging guides the staging of urothelial carcinoma and thus plays a central role in treatment decisions. Current guidelines reflect the increasing importance of multiparametric MRI (mpMRI) of the bladder with standardized reporting according to the Vesical Imaging Reporting and Data System (VI-RADS).

Materials and methods: This work comprises a narrative, guideline-oriented update based on the European Association of Urology (EAU; 2025 update) and German S3 guidelines (long version 3.0, 2025); recent key studies on VI-RADS-/bpMRT- and PET-based methods; and early targeted imaging approaches.

Results: Multiparametric MRI with classification according to VI-RADS shows high accuracy for discriminating between non-muscle-invasive bladder cancer (NMIBC) and MIBC (area under the receiver operating curve ≈ 0.93-0.95) with good interobserver reliability. Regarding the question "muscle-invasive: yes/no," biparametric MRI (bpMRI) without contrast agent is frequently noninferior to mpMRI in selected settings and reduces the imaging time; however, contrast agent can be useful in the case of unclear findings. For distant and nodal staging, fluorodeoxyglucose positron-emission tomography/CT (FDG-PET/CT) shows an incremental advantage over CT in selected situations. While hybrid PET/MRI implementation is already promising but not yet nationwide, NECTIN-4-targetted PET imaging is still in its infancy and also limited by heterogeneous target expression.

Conclusion: For local staging of urothelial carcinoma, mpMRI-or, in selected cases, bpMRI-should preferably be performed prior to transurethral resection of the bladder tumor (TUR-B) according to VI-RADS standards. Only in selected cases is FDG-PET/CT to be used for N/M staging and restaging. Targeted imaging (e.g., NECTIN-4) and artificial intelligence (AI) are still in the research phase, whereby prospective trials with decision-impact outcomes and standardized implementation and quality processes have priority.

Background: Artificial intelligence (AI) in surgical disciplines has the potential to support all areas of patient care, with the goal of improving treatment quality and patient safety. A group of multidisciplinary experts discussed the current situation as well as steps required to successfully integrate AI into surgical disciplines in the context of a consensus conference at the second Digital Health Summit (Brandenburg an der Havel, Germany) in August 2024.

Methods: A modified Delphi procedure was performed with 16 multidisciplinary physicians and scientists on the topic of AI in surgical disciplines and beyond. In two online meetings with subsequent Delphi survey rounds (LimeSurvey) and a final hybrid meeting, individual statements were contributed, discussed, and consented by all 16 participants based on current national clinical guidelines.

Results: From a total of 103 submitted statements, 36 statements on reality (n = 12), utopia (n = 13), and opportunities for digital transformation (n = 11) were consented after discussion and modification. We achieved a consensus of at least 75% for all the statements presented, with six of the statements achieving a strong consensus of 100% agreement.

Conclusion: The consensus statements show the great potential of AI for improving patient care in surgical disciplines. Challenges such as the lack of digitalization structures and legal frameworks were identified, and practice-oriented proposals for implementation were developed. The need for multidisciplinary cooperation between medical professionals, politics, and industry was emphasized in order to facilitate the German healthcare system remaining competitive for the future, both nationally and internationally.

For many decades, the treatment of metastatic urothelial carcinoma (mUC) was dominated by platinum-based chemotherapy. However, the introduction of immune checkpoint inhibitors in combination with modern antibody-drug conjugates (ADCs) and FGFR3 inhibitors has replaced this "old" standard due to significantly better efficacy. Although these therapies are targeted therapies, biomarker-driven therapy decisions are rarely used to date. The currently available biomarkers are also only helpful in isolated therapy situations. However, this could change fundamentally for ADCs in view of the pronounced expression variability of potential target structures such as NECTIN4, HER2, EGFR, and TROP2. The presence of activating FGFR3 mutations or fusions already defines a clearly delineated, albeit still small, therapeutic niche that could also gain importance in localized stages of urothelial carcinoma in the future. In order to be able to use these therapeutic innovations in a targeted and precise manner in the future, biomarker-based stratification of urothelial carcinomas is likely to play a greater role. Current developments thus open up considerable potential for true precision oncology.