Urologie最新文献

Muscle invasive bladder cancer is generally an aggressive disease. Radical cystectomy (RC) is traditionally the treatment of choice. Due to possible advantages in morbidity, peri-interventional mortality, and quality of life, bladder-preserving treatment strategies are of interest. Here, trimodal therapy (TMT) consisting of maximum transurethral resection and subsequent radiochemotherapy with subsequent cystoscopic follow-up plays an important role. Current cohort analyses indicate equivalent oncological results of TMT to RC in selected patients. However, the use of systemic therapy alone with combined chemo-/immunotherapy or cytotoxic combination therapy also shows promising efficacy both in early surrogate parameters and in oncological endpoints. Overall, studies to date suggest that bladder preservation is possible without compromising oncologic outcomes. Future developments aim to refine patient selection by combining different risk factors and biomarkers to further improve outcomes.

Background: Patients with locally advanced or metastatic urothelial carcinoma face a poor prognosis. Standard first-line treatment involves platinum-based combinations followed by avelumab maintenance therapy. Follow-up therapies include enfortumab vedotin, vinflunine, and taxanes.

Objective: To analyze new drug combinations in first-line and follow-up treatment for metastatic urothelial carcinoma concerning their clinical relevance, toxicities, and novel treatment sequences.

Materials and methods: Analysis of new study data from EV-302/KN-A39 (enfortumab vedotin and pembrolizumab) and CheckMate-901 (nivolumab and gemcitabine-cisplatin) for untreated metastatic patients as well as TROPHY-U-01 (sacituzumab govitecan) and THOR (erdafitinib) for later lines.

Results: The new standard in first-line treatment for metastatic urothelial carcinoma is the combination of enfortumab vedotin and pembrolizumab. For cisplatin-eligible patients with contraindications to enfortumab vedotin, the combination of nivolumab and gemcitabine-cisplatin offers an alternative. Erdafitinib presents a new biomarker-based option in the follow-up treatment of metastatic urothelial carcinoma.

Conclusion: These novel combinations are revolutionizing the treatment standard for metastatic urothelial carcinoma and necessitate a new approach to managing side effects.

Up to the 1970s, a cultural battle raged in Germany and Europe about the question of the sense to inform and educate young people about gender, sex, and sexuality. One physician realized early that it is important to educate adults about their bodies and their genital and genitourinary disorders. Max Hodann (1894-1946), thus, unintentionally flooded urological practices with countless patients.

According to current guidelines, patients with muscle-invasive urothelial carcinoma (pT2-pt4a pN0) should be offered neoadjuvant cisplatin-containing chemotherapy before radical cystectomy. If not used neoadjuvantly, chemotherapy can be administered in the adjuvant setting (for > pT3 or pN+ disease). Both neoadjuvant and adjuvant therapy lead to improved overall survival. In the adjuvant setting, the checkpoint inhibitor nivolumab has also been approved for treatment of PD-L1-positive tumors (tumor proportion score [TPS] ≥ 1%). On the one hand, real-world evidence shows that cisplatin-fit patients often do not receive chemotherapy and, on the other hand, that a relevant proportion of patients are also not suitable for cisplatin-based chemotherapy. Further multimodal therapeutic strategies are hence urgently needed to improve the prognosis of affected patients. In particular, the use of antibody-drug conjugates and combination strategies involving checkpoint inhibitors are currently being intensively researched.

Radical cystectomy is currently the standard of care for muscle-invasive bladder cancer. Different parts of the small and large intestines can be utilized for continent and incontinent urinary diversion. The postoperative follow-up after urinary diversion should consider functional, metabolic and oncological aspects. The functional follow-up of (continent) urinary diversion includes stenosis, emptying disorders or incontinence. The oncological follow-up should focus on the detection of local, urethral and upper tract recurrences as well as distant metastases. As 90% of the tumor recurrences occur during the first 3 years, a close follow-up should be carried out during this period. Metabolic disturbances, such as vitamin B12 and bile acid deficits, acidosis and disorders of calcium metabolism can also occur during long-term follow-up. The metabolic follow-up should consider the metabolic consequences of the parts of the intestines utilized for the urinary diversion.

Bacillus Calmette-Guérin (BCG) therapy is the standard of care in the treatment of high-risk non-muscle invasive bladder cancer (NMIBC). In the absence of a response to BCG and persistent high-grade disease, cystectomy is recommended depending on the clinical risk. A variety of targeted therapy approaches, which aim at immune- and gene-based molecular targets, such as PD-(L)1 and FGFR, are currently being investigated in randomized studies for BCG-unresponsive NMIBC. Furthermore, novel forms of application for instillation therapy, such as the TAR device, in combination with gemcitabine or erdafitinib are being investigated in clinical trials in order to extend the duration of action of the active substance on the urothelium. Thus, there are now many developments that could make bladder-preserving therapy with comparable survival data possible as an alternative to BCG or in the event of BCG failure. In the future, it will be necessary to clarify how BCG response can be predicted by using molecular markers and how to define risk groups that should primarily be given an alternative therapy to BCG.

Upper tract urothelial carcinoma (UTUC) is a cancer that is often already in an advanced stage at the time of initial diagnosis. Although urothelial carcinoma of the upper and lower urinary tracts both originate from the urothelium and have similar genetic alterations, there are significant differences in their distribution. In localized high-risk UTUC, radical nephroureterectomy is the gold standard therapy. In metastatic UTUC, major changes are emerging in sequential therapy due to the investigation of new classes of drugs. In addition to platinum-based combination chemotherapy and immunotherapy, new substances such as antibody-drug conjugates (ADCs) and FGFR inhibitors are used.

Background: Radical prostatectomy (RP) is one of the most common therapeutic strategies for treating localized prostate cancer (PCa). Currently, the significance of postoperative functional limitations for affected patients in the long-term course, especially in comparison to age-related comorbidities, is unclear.

Objective: The aim of this study was to quantify the prevalence of subjective health restrictions alongside functional deficits in long-term PCa survivors after RP and their relevance for subjective impairments in everyday life.

Materials and methods: Using the German version of the Self-Administered Comorbidity Questionnaire (SCQ-D), 3173 long-term survivors after RP reported their comorbidities in 13 predefined categories and in 3 free-text fields along the dimensions "problem," "treatment," and "impairment".

Results: The mean age at survey was 79.5 years (standard deviation, SD ± 6.4), with a mean time since RP of 17.4 years (SD ± 3.7). The three most frequently identified comorbidities/percentage of patients who felt impaired were: hypertension (62.2%/8.5%), back pain (44.1%/54.5%), and osteoarthritis (36.1%/54.1%). The most frequently mentioned additional health problems can be subsumed under the umbrella term "urological problems" (6.1%/72.7%): incontinence (4.8%/74.3%), bladder problems (1.1%/61.8%), and erectile dysfunction (0.5%/47.1%).

Conclusion: In summary, non-cancer-related comorbidities in the long-term course after RP are often perceived as "problems" but rarely lead to subjective impairment. In contrast, treatment-related urological problems are rarely reported as "problems", but they very often lead to subjective impairment in everyday life.