Systematic Review and Meta-Analysis Provide no Guidance on Management of Asymptomatic Bacteriuria within the First Year after Kidney Transplantation

(1) Background: Urinary tract infections (UTIs) are among the most frequent complications in kidney transplant (KT) recipients. Asymptomatic bacteriuria (ASB) may be a risk factor for UTIs and graft rejection. We aimed to evaluate available evidence regarding the benefit of screening and treatment of ASB within the first year after KT. (2) Evidence acquisition: A systematic literature search was conducted in MEDLINE, the Cochrane Library CENTRAL and Embase. Inclusion criteria were manuscripts in English addressing the management of ASB after KT. The PICO questions concerned Patients (adults receiving a KT), Intervention (screening, diagnosis and treatment of ASB), Control (screening and no antibiotic treatment) and Outcome (UTIs, sepsis, kidney failure and death). (3) Evidence synthesis: The systematic review identified 151 studies, and 16 full-text articles were evaluated. Seven were excluded because they did not evaluate the effect of treatment of ASB. There was no evidence for a higher incidence of lower UTIs, acute pyelonephritis, graft loss, or mortality in patients not treated with antibiotics for ASB. Analysis of comparative non-randomized and observational studies did not provide supplementary evidence to guide clinical recommendations. We believe this lack of evidence is due to confounding risk factors that are not being considered in the stratification of study patients.

[Urosepsis: pathophysiology, diagnosis, and management-an update]

Urinary tract infections vary widely in their clinical spectrum, ranging from uncomplicated cystitis to septic shock. Urosepsis accounts for 9-31% of all cases of septicemia and is often associated with nosocomial infections. A major risk factor for urosepsis is the presence of obstructive uropathy, caused by conditions such as urolithiasis, tumors, or strictures. The severity and course of urosepsis depend on both the virulence of the pathogen and the patient's specific immune response. Prompt therapy, including antimicrobial treatment and eradication of the infection source, along with supportive measures for circulatory and respiratory stabilization, and adjunctive therapies such as hemodialysis and glucocorticoid therapy, is crucial. Due to demographic changes, an increase in cases of urosepsis is expected-thus, it is of utmost importance for urologists to be familiar with targeted diagnostics and effective treatment.

Prospective evaluation of sexual health following radical cystectomy due to bladder cancer

Background

There is a lack of data concerning sexual health following open radical cystectomy (RC), especially in elderly patients and women.

Aim

To describe sexual health and its impact on general health as well as survival in patients undergoing standard open RC for the treatment of bladder cancer (BC). Due to limited data, subgroup analysis for elderly patients and women was performed.

Methods

A prospective noninterventional clinical study was performed evaluating sexual health in RC with any kind of urinary diversion due to BC with a follow-up of 12 months after RC. The study was approved by the local ethics review board (A 2021-0175) and was registered at the German Clinical Trial Register (DRKS00026255). Assessment of sexual health was done with the following validated questionnaires: EORTC QLQ-C30 (for quality of life; European Organisation for Research and Treatment of Cancer), EORTC SH22 (for sexual health), and IIEF-5 (5-item International Index of Erectile Function).

Outcomes

The standard measurements of EORTC QLQ-C30, EORTC SH22, and IIEF-5 as well as overall survival.

Results

Thirty-two patients participated in the study with a mean age of 71.5 years (SD, 9.7): 25 (78.1%) were male and 7 (21.9%) were female. Overall there is a heterogenic picture for sexual health in the study population, but sexual satisfaction is significantly higher prior to surgery while the importance of a sex life stays high and stable. Interestingly, the general health score is significantly correlated to sexual satisfaction (Pearson's correlation; r = 0.522, P = .002) preoperatively but not following surgery: r = 0.103 (P = .665) after 3 months, r = 0.478 (P = .052) after 6 months, r = 0.276 (P = .302) after 9 months, and r = 0.337 (P = .202) after 12 months. The importance of a sex life is still essential for the patients, especially when recovering from RC; nearly the same can be reported for elderly patients. Unfortunately, the data for women are too limited to report robust results.

Clinical Implications

Evaluation, advice, and monitoring of sexual health must be integrated into clinical practice, particularly in women.

Strengths and Limitations

At least to our knowledge, this is the first systematic prospective evaluation of sexual health in patients with BC receiving RC. Due to the small sample size, there is a risk of selection bias.

Conclusion

Sexual health is important for patients with BC receiving RC, and it is an essential part of quality of life, especially in elderly patients.

Enhancing Human Papillomavirus Vaccination Rates through Better Knowledge? Insights from a Survey among German Medical Students

INTRODUCTION

Vaccination against human papillomavirus (HPV) significantly reduces the risk for malignant diseases like cervix, anal, or penile cancer. However, although vaccination rates are rising, they are still too low mirroring a lack of disease awareness in the community. This study aims to evaluate knowledge about HPV vaccination as well as the vaccination rate among German medical students.

MATERIAL AND METHODS

Medical students were surveyed during a German medical students' sports event. The self-designed survey on HPV vaccination consisted of 24 items. The data collection was anonymous.

RESULTS

Among 974 participating medical students 64.9% (632) were women, 335 (34.4%) were male and 7 (0.7%) were nonbinary. Mean age was 23.1 ± 2.7 (± standard deviation; range 18-35) years. Respondents had studied mean 6.6 ± 3.3 (1-16) semesters and 39.4% (383) had completed medical education in urology. 613 (64%) respondents reported that HPV had been discussed during their studies. 7.6% (74) had never heard of HPV. In a multivariate model female gender, the knowledge about HPV, and having worked on the topic were significantly associated with being HPV-vaccinated. Older students were vaccinated less likely.

CONCLUSIONS

Better knowledge and having worked on the topic of HPV were associated with a higher vaccination rate. However, even in this highly selected group the knowledge about HPV vaccination was low. Consequently, more information and awareness campaigns on HPV vaccination are needed in Germany to increase vaccination rates.

Antimicrobial Prophylaxis in Robot-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review

It remains unclear whether antibiotic prophylaxis (AP) should be recommended or discouraged in robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer (PCa). The development of microbial resistance and side effects are risks of antibiotic use. This systematic review (SR) investigates the evidence base for AP in RALP. A systematic literature search was conducted until 12 January 2023, using Embase, MEDLINE, Cochrane CENTRAL, Cochrane CDSR (via Ovid) and CINAHL for studies reporting the effect of AP on postoperative infectious complications in RALP. Of 436 screened publications, 8 studies comprising 6378 RALP procedures met the inclusion criteria. There was no evidence of a difference in the rate and severity of infective complications within 30 days after RALP surgery between different AP protocols. No studies omitted AP. For patients who received AP, the overall occurrence of postoperative infectious complications varied between 0.6% and 6.6%. The reported urinary tract infection (UTI) rates varied from 0.16% (4/2500) to 8.9% (15/169). Wound infections were reported in 0.46% (4/865) to 1.12% (1/89). Sepsis/bacteraemia and hyperpyrexia were registered in 0.1% (1/1084) and 1.6% (5/317), respectively. Infected lymphoceles (iLC) rates were 0.9% (3 of 317) in a RALP cohort that included 88.6% pelvic lymph node dissections (PLND), and 3% (26 of 865) in a RALP cohort where all patients underwent PLND. Our findings underscore that AP is being administered in RALP procedures without scientifically proven evidence. Prospective studies that apply consistent and uniform criteria for measuring infectious complications and antibiotic-related side effects are needed to ensure the comparability of results and guidance on AP in RALP.

Do or Don't: Results of a Multinational Survey on Antibiotic Prophylaxis in Urodynamics

Antibiotic prophylaxis contributes substantially to the increase in antibiotic resistance rates worldwide. This investigation aims to assess the current standard of practice in using antibiotic prophylaxis for urodynamics (UDS) and identify barriers to guideline adherence. An online survey using a 22-item questionnaire designed according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was circulated among urologists and gynecologists in Austria, Germany, and Switzerland between September 2021 and March 2022. A total of 105 questionnaires were eligible for analysis. Out of 105 completed surveys, most responders (n = 99, 94%) regularly perform dipstick urine analysis prior to urodynamics, but do not perform a urine culture (n = 68, 65%). Ninety-eight (93%) participants refrain from using antibiotic prophylaxis, and sixty-eight (65%) use prophylaxis if complicating factors exist. If asymptomatic bacteriuria is present, approximately 54 (52%) participants omit UDS and reschedule the procedure until antimicrobial susceptibility testing is available. Seventy-eight (78%) participants do not have a standard procedure for antibiotic prophylaxis in their department. Part of the strategy against the development of bacterial resistance is the optimized use of antibiotics, including antibiotic prophylaxis in urodynamics. Establishing a standard procedure is necessary and purposeful to harmonize both aspects in the field of urological diagnostics.

Digital health information on surgical treatment options for overactive bladder is underrepresented

PURPOSE

Digital health information gains growing importance in the medical landscape. Despite its opportunities, there is a risk of patient misinformation which may adversely influence the patient-physician relationship. This investigation aimed to identify and compare differences in the content and quality of online health information on overactive bladder (OAB) between different digital platforms.

METHODS

The platforms Google search, Facebook, Instagram, LinkedIn, and YouTube were searched for the keyword OAB. The search result links were classified as useful or misleading, advertisement and personal experience. Information regarding the organization of the source and available content on treatment modalities was collected. Descriptive analysis was applied. Univariate and multivariate analyses were performed to evaluate heterogeneity regarding the distribution of information depending on the source. A p value < 0.05 was considered statistically significant.

RESULTS

The source with the highest quantity of useful content was YouTube (100%) and Google (100%), whereas LinkedIn included mostly misleading content (73%). YouTube and Google provided the greatest variety of health information and were dominated by professional associations. Surgical procedures for treating OAB were only described in 32% and 48% of Google and YouTube results, respectively. On Google, sacral neuromodulation and OnabotulinumtoxinA were described in 26% and bladder augmentation in only 16% of the search results. In contrast, alternative medicine was present in 76%.

CONCLUSIONS

A large gap in the information on surgical treatments of OAB could be identified independently from the utilized source. In contrast, conservative treatments and alternative medicine dominate the current informational sources.

Non-Antibiotic Prophylaxis for Recurrent UTIs in Neurogenic Lower Urinary Tract Dysfunction (NAPRUN): Study Protocol for a Prospective, Longitudinal Multi-Arm Observational Study

INTRODUCTION

Patients with neurogenic lower urinary tract dysfunction (NLUTD) reliant on intermittent self-catheterization for bladder emptying are at an increased risk of recurrent urinary tract infections (rUTI). So far, the most common practice in the prevention of rUTIs is long-term low-dose antibiotic prophylaxis, phytotherapy, and immunomodulation, whereby antibiotic prophylaxis inevitably leads to the emergence of drug-resistant pathogens and difficulty in treating infections. Therefore, non-antibiotic alternatives in the prevention of rUTIs are urgently required. We aim to identify the comparative clinical effectiveness of a non-antibiotic prophylaxis regimen in the prevention of recurrent urinary tract infections in patients with neurogenic bladder dysfunction who practice intermittent self-catheterization.

METHODS AND ANALYSIS

In this multi-centre, prospective longitudinal multi-arm observational study, a total of 785 patients practising intermittent self-catheterisation due to NLUTD will be included. After inclusion, non-antibiotic prophylaxis regimens will be instilled with either UroVaxom^® (OM-89) standard regimen, StroVac^® (bacterial lysate vaccine) standard regimen, Angocin^®, D-mannose (oral dose 2 g), bladder irrigation with saline (once per day). The management protocols will be pre-defined, but the selection of the protocol will be at the clinicians' discretion. Patients will be followed for 12 months from the onset of the prophylaxis protocol. The primary outcome is to identify the incidence of breakthrough infections. The secondary outcomes are adverse events associated with the prophylaxis regimens and the severity of breakthrough infections. Other outcomes include the exploration of change in susceptibility pattern via the optional rectal and perineal swab, as well as health-related quality of life over time (HRQoL), which will be measured in a random subgroup of 30 patients.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the ethical review board of the University Medical Centre Rostock (A 2021-0238 from 28 October 2021). The results will be published in a peer-reviewed journal and presented at relevant meetings.

STUDY REGISTRATION NUMBER

German Clinical Trials Register: Number DRKS00029142.

Gender-specific outcomes in immune checkpoint inhibitor therapy for advanced or metastatic urothelial cancer: a systematic review and meta-analysis

PURPOSE

To analyze gender-specific differences in survival parameters in advanced or metastatic urothelial cancer patients undergoing immune checkpoint inhibition.

METHODS

The primary aim of this systematic review and meta-analysis was to evaluate gender-specific differences in disease-free (DFS), progression-free (PFS), cancer-specific survival (CSS), event-free survival (EFS), overall survival (OS) and objective response rate (ORR). The sources MEDLINE, Embase and Cochrane Library were systematically searched from January 2010 to June 2022. No restrictions were made concerning language, study region or publication type. A comparison of gender-specific differences in survival parameters was performed using a random-effects meta-analysis. A risk of bias assessment was done using the ROBINS-I tool.

RESULTS

Five studies were included. In a random-effect meta-analysis of the studies, PCD4989g and IMvigor 211 with both using atezolizumab, females were more likely to have better objective response rate (ORR) than men (OR 2.24; 95% CI 1.20-4.16; p = 0.0110). In addition, females had a comparable median OS to men (MD 1.16; 95% CI - 3.15-5.46; p = 0.598). In summary, comparing all results, a tendency was seen toward better response rates and survival parameters in female patients. The risk of bias assessment yielded an overall low risk of bias.

CONCLUSIONS

There is a tendency toward better outcomes in women for immunotherapy in advanced or metastatic urothelial cancer, but only for the antibody atezolizumab women have a significantly better ORR. Unfortunately, many studies fail to report gender-specific outcomes. Therefore, further research is essential when aiming for individualized medicine. This research should address immunological confounders.

[Do we need to treat asymptomatic bacteriuria in immunocompromised patients? : A rapid review]

BACKGROUND

Antimicrobial resistance (AMR), especially multidrug resistant Escherichia coli strains, is a problem even in Europe. That is why inadequate usage of antibiotic therapy should be avoided, especially in the treatment of asymptomatic bacteriuria (ASB).

OBJECTIVES

Should ASB be treated with antibiotics in immunocompromized patients, namely solid organ transplant, especially kidney transplant or stem cell transplant recipients?

MATERIALS AND METHODS

A rapid review based on a systematic literature search in MEDLINE between 1980 and 2022 was performed. For evidence synthesis, only randomized controlled trials (RCTs) or quasi-RCTs were considered.

RESULTS

No studies were identified for the search term solid organ and stem cell transplantation. Three RCTs (antibiotic therapy versus no therapy) were included for adult kidney transplantation. None of the studies showed a benefit for antibiotic therapy of ASB in reduction of symptomatic urinary tract infections, especially in the late transplantation phase two months after kidney transplantation; furthermore, this therapy may promote AMR development. In addition, there are numerous gaps of evidence, e.g., in pediatric transplantation or regarding the influence of special immunosuppressants.

CONCLUSION

There is no evidence for antibiotic therapy of ASB in adult kidney transplantation two months after the surgery. Further studies addressing the identified evidence gaps are essential for the prevention of further AMR development.

Thirty-Year-Old Male Patient with Non-Seminoma and Coincidental Rectal Cancer

We present the case of a 31-year-old male patient with non-seminoma (90% embryonal carcinoma, 10% teratoma) pT1b L1 V0 Pn0 R0 cN2 cM0, Clinical Stage IIb and "good prognosis group" according to IGCCCG of the left testis. According to EAU guidelines, he received three cycles of BEP. After the second cycle, he developed recurrent, clinically not significant rectal bleeding, which we associated with deep thrombocytopenia. Following chemotherapy, there was one lymph node in the CT scan left, with a diameter of 0.9 cm at the inferior mesenteric arteria and the rectal bleeding did not stop; so coloscopy and staging revealed rectal cancer (adenocarcinoma) with peritoneal carcinosis. The patient was scheduled for radio-chemotherapy. Next-generation sequencing of the adenocarcinoma showed two mutations in KRAS and TP53 genes. To our knowledge, this is the first case of non-seminoma and coincidental rectal cancer. Furthermore, this case underlines the significance of molecular biological studies for the development of individualized targeted therapies, especially in younger patients and in chemo- and/or platin-resistance.

Prospective Evaluation of Health-Related Quality of Life in Patients with Metastatic Urothelial Carcinoma Undergoing Immunotherapy with Pembrolizumab: Symptom Burden Can Predict Survival

INTRODUCTION

Despite the fact that guidelines recommend monitoring of quality of life during all phases of treatment in urothelial carcinoma, prospective data about health-related quality of life (HRQoL) in metastatic urothelial carcinoma undergoing immunotherapy are sparse. Consequently, we performed a prospective clinical pilot study about HRQoL using the Functional Assessment of Cancer Therapy - Immune Checkpoint Modulator (FACT-ICM) questionnaire.

MATERIALS AND METHODS

Formally, this study is a prospective uni-centric noninterventional observation from January 2021 to December 2021.

RESULTS

Fourteen patients with a mean age of 73.9 years (SD 8.8) participated in the study. The physical well-being subscale of FACT-G is most impaired during therapy with mean scores of 7.5, 6.2, and 4.0 followed by the emotional well-being. The FACT-G total score is stable during therapy with mean scores of 51.1, 50.4, and 48.0 and it is not significantly decreasing during therapy (p = 0.317). Furthermore, the symptom burden of these patients is low and not significantly changing over time (p = 0.500), but survival decreases significantly if symptom burden is high (FACT-ICM score over 40; p < 0.001).

CONCLUSION

Physical and emotional needs have a strong impact on HRQoL and should be dealt with during treatment. If symptom burden is high, survival decreases. This needs further evaluation.

Comparison of inpatient and outpatient palliative sedation practice - A prospective observational study

INTRODUCTION

Palliative sedation (PS) is an intrusive measure to relieve patients at the end of their life from otherwise untreatable symptoms. Intensive discussion of the advantages and limitations of palliative care with the patients and their relatives should precede the initiation of PS since PS is terminated by the patient's death in most cases. Drugs for PS are usually administered intravenously. Midazolam is widely used, either alone or in combination with other substances. PS can be conducted in both inpatient and outpatient settings; however, a quality analysis comparing both modalities was missing so far.

PATIENTS AND METHODS

This prospective observational study collected data from patients undergoing PS inpatient at the palliative care unit (PCU, n = 26) or outpatient at a hospice (n = 2) or at home (specialized outpatient palliative care [SAPV], n = 31) between July 2017 and June 2018. Demographical data, indications for PS, and drug protocols were analyzed. The depth of sedation according to the Richmond Agitation Sedation Scale (RASS) and the degree of satisfaction of staff members and patient's relatives were included as parameters for quality assessment.

RESULTS

Patients undergoing PS at the PCU were slightly younger compared to outpatients (hospice and SAPV combined). Most patients suffered from malignant diseases, and midazolam was the backbone of sedation for inpatients and outpatients. The median depth of sedation was between +1 and -3 according to the RASS with a trend to deeper sedation prior to death. The median degree of satisfaction was "good," scored by staff members and by patient's relatives. Significant differences between inpatients and outpatients were not seen in protocols, depth of sedation, and degree of satisfaction.

CONCLUSION

The data support the thesis that PS is possible for inpatients and outpatients with comparable results. For choosing the best place for PS, other aspects such as patient's and relative's wishes, stress, and medical reasons should be considered.

[What is the proportion of infectiology in the specialization urology? : A pilot study to underline the significance of Antibiotic Stewardship in urology]

BACKGROUND

Urinary tract infections account for one of the most bacterial infectious diseases worldwide.

OBJECTIVES

The primary aim of this pilot project was to identify the relative percentage of antibiotic use in comparison to all patients in a university medical center for the better establishment of antibiotic stewardship (ABS) programs.

MATERIAL AND METHODS

This is an epidemiological pilot project. In the time period of three months it was evaluated which relative percentage of the patients was treated with antibiotics for bacterial urinary tract infection in comparison to all patients.

RESULTS

In summary, about 40% of all urological patients received an antibiotic treatment against urinary tract infections or as perioperative prophylaxis against bacterial infection in the operating room (OR). The antibiotic use at the urological ward is highest in comparison to ambulance or OR.

CONCLUSION

Infectious diseases, especially bacterial infections, account for a significant part of urology. This knowledge is essential to establish ABS programs and to tackle the progression of antibiotic resistance. Detailed studies are necessary to understand antibiotic prescription practice in urology to develop targeted ABS interventions.

Comparative Analysis of Guideline Adherence between Germany and Austria by Using the Example of Uncomplicated Urinary Tract Infections

<b><i>Background:</i></b> Medical guidelines represent the evidence-based state of the art of their scientific field. They aim to guide decisions for physicians and patients about appropriate health care for specific clinical circumstances. However, guideline recommendations are often not adhered to in clinical practice. In particular, a large discrepancy exists regarding the treatment of uncomplicated urinary tract infections. To date, just a few studies addressed the potential reasons for these guideline violations. <b><i>Objectives:</i></b> This investigation aimed to identify and complement reasons for the nonadherence to guideline recommendations. <b><i>Methods:</i></b> A survey amongst a total of 563 German and Austrian urologists identified physician- and patient-related factors contributing to this current state. <b><i>Results:</i></b> The physician’s personal experience, the lack of applicability to individual patients, and shortage of time were identified as crucial barriers for the physician. Patient-related barriers were poor experience with the antibiotic, fear of collateral damage, and inadequate information about the disease and its therapy. <b><i>Conclusions:</i></b> We suggest modifying guideline designs by including abstracts and flowcharts appropriate for daily use and separate patient instructions to improve guideline compliance. Furthermore, guideline authors should communicate updates in a timely and accessible manner. Presentations at scientific congresses increase visibility and enhance the dialogue with colleagues.

[Urinary bladder microbiome analysis and probiotic treatment options for women with recurrent urinary tract infections]

Novel preventive measures and therapeutic approaches are needed to reduce the frequency of recurrent urinary tract infections (rUTI) and the associated emergence of multidrug-resistant uropathogens. The aim of this review is to systematically present the available evidence on the urinary bladder microbiome of healthy women and those with rUTIs. In addition, relevant studies on the efficacy of probiotics in rUTIs are presented in a structured manner. This will provide an overview on the current state of research and an outlook on treatment strategies beyond the usual antimicrobial options.

Reduction of Perioperative Antibiotic Prophylaxis in Open Radical Cystectomy with Ileal Conduit Is Feasible: Results of a Prospective Clinical Trial

Introduction

The aim of this study is to perform a prospective clinical trial in antibiotic prophylaxis, infectious complication, and colonization of ileal conduit (IC) following radical cystectomy (RC) since urinary tract infections (UTIs) and surgical site infections (SSIs) contribute significantly to the morbidity associated with RC and IC. Moreover, an optimal regimen of antibiotic prophylaxis has not been established, yet.

Material and Methods

After a positive vote of ethical review committee and the registration at the German Clinical Trials Register (DKRS 00020406), we started a prospective clinical unicentric not interventional study. The urine samples were collected by sterile catheterization of the IC. All patients received an antibiotic prophylaxis with 3 × 500 mg metronidazole and 3 × 1.5 g cefuroxime intravenously for 3 days starting on the day before RC. Ureteral stents got removed on days 9 and 10 after surgery without prior antibiotic administration. The student t test and the χ² test or the Fisher exact test were used. For risk factor assessment, the univariate Cox regression method was applied.

Results

Nineteen male (63.3%) and 11 female patients (36.7%) with a median age of 70.5 years were included. Three patients developed complicated UTI (10%) on day 12 after RC with E. faecium and needed antibiotic treatment with meropenem (Clavien-Dindo II). Two patients (6.7%) developed SSI with E. faecium and needed surgery (Clavien-Dindo IIIb). Palliative RC (p < 0.0001), prior radiation therapy (p < 0.0001), and timeframe >3 months from diagnosis to RC (p = 0.036) are significantly associated with the development of complicated UTI. Interestingly, the IC got colonized with Staph. haemolyticus at day 12 after RC (n = 12; 40.0%). We must assume that our data have some limitations like a unicentric study population.

Conclusion

Further evaluation of reduction to single-shot antibiotic prophylaxis in nonpalliative RC with IC could be feasible.

[New aspects in Fournier's gangrene - a rapid review]

Fournier's gangrene (FG) is a sporadic, life-threatening, necrotising infection affecting the perineum, perineal region and genitals. Published literature provides hints that the outcome of this disease has failed to improve in recent years. We have therefore performed a rapid evidence synthesis by searching the database MEDLINE. The literature from 2020 was studied to identify new aspects to improve the care of FG patients and plan further therapeutic research. 18 publications were chosen for this review, 15 of these were original research and three systematic reviews. 12 were retrospective case series, 2 epidemiological studies, with one prospective clinical study, one systematic review and 2 systematic reviews, together with a meta-analysis. Most of the authors of the studies concluded that FG is still a severe disease with unacceptable mortality rates, so that there is urgent need for therapy improvement. New risk factors for higher mortality in FG have been identified in these studies, namely dyslipoproteinemia, diabetes mellitus, heart disease, as well as both acute and chronic kidney failure. Furthermore, 4 of the included studies investigated the association of SGLT2- and DDP4-inhibitors, which are drugs used in diabetes mellitus, and the incidence of FG. No studies reported a significant association between these drugs and FG, especially not a meta-analysis with 84 included studies. New promising concepts for wound conditioning are hyperbaric oxygenation (HBO), vacuum-assisted wound closure (VAC) and Maggot therapy (blowfly larvae). In summary, FG is still a severe disease, the prognosis has not improved in recent years and so there is an urgent need for improved therapy. This could only be achieved with further research in FG. In our opinion and due to the rarity of FG, this would be possible with a national registry study. For example, it might be possible to calculate risk stratification from this registry to identify patients who would benefit from treatment in a centre or with special wound conditioning.

Permanent Flank Bulge after Flank Incision: Patient- and Physician-Reported Outcome

INTRODUCTION

The aim of this study was to determine the incidence and risk factors for postoperative flank bulging and associated physiologic/psychologic consequences as well as to establish a clinical flank bulge classification system after open retroperitoneal surgery.

METHODS

In this retrospective study, a postal patient survey was sent to 240 patients who underwent open retroperitoneal surgery between 2007 and 2017. Patients, who reported a flank bulge, were invited for further evaluation, which included a clinical examination and standardized photo documentation.

RESULTS

Forty-three of 120 patients (35.8%) reported a flank bulging after retroperitoneal surgery. During clinical examination, a flank bulge could be confirmed in 25 patients, whereas in 18 patients, no bulging could be detected, leading to a corrected rate of flank bulge-positive patients of 20.8%. The corresponding relaxation values ranged from 1 to 1.44 and correlated with the clinical degree of bulging. A body mass index of ≥25 was identified as a risk factor. No correlation was found regarding age, gender, surgery side, access to the retroperitoneum, surgical procedure, and pathology. Thirty-seven patients complained about chronic pain or suffered from the cosmetic impact of bulging. Thirteen of those patients had shown a flank bulge during clinical examination, resulting in a symptomatic bulge rate of 10.8% (13/120 patients).

CONCLUSION

Chronic pain and postoperative flank bulging are 2 of the most common long-term complications after open retroperitoneal access. If an open retroperitoneal approach is required, particularly obese patients should be thoroughly informed about the risk of flank bulging and chronic pain.

Rising significance of antibiotic stewardship in urology and urinary tract infections - a rapid review

PURPOSE OF REVIEW

To give an overview of the significance as well as recent developments in antibiotic stewardship (ABS) in urology and for the treatment of urinary tract infections (UTI). This rapid review is focused on recent publications during the past 18 months.

RECENT FINDINGS

Despite the evidence to support the use of ABS interventions in the treatment of UTIs, there remains considerable inappropriate use of antibiotics, up to 68%, especially concerning the treatment of asymptomatic bacteriuria and the overuse of fluoroquinolones. Emerging evidence indicate that ABS programs can improve patient outcome and reduce multidrug-resistant pathogens.Interestingly, in this past 18 months new targets for ABS have been developed, e.g. involvement of a pharmacist, strict adherence to guidelines, improvement of the guidelines itself and understanding the prescription process in the emergency room as well as the analysis of own surveillance data.

SUMMARY

ABS programs in urology are essential and their significance has become more apparent than ever before. New targets for ABS interventions should be evaluated in prospective controlled clinical trials of their effectiveness to reduce further inappropriate antibiotic use without hindering the treatment of UTIs.

[Urological emergency management : Detection and treatment]

As a result of the restructuring of emergency care provided by statutory health insurance companies and demographic change, the number of people presenting to emergency departments in hospitals is continuously increasing. A significant proportion of these emergencies concern the specialist discipline of urology. The clinical manifestations in emergency medical care range from trauma-related injuries to the urogenital tract and urinary transport disorders to hematuria and life-threatening infections. Due to the high incidence of urological tumors and the urogenital tract's affection in other malignant diseases, oncological patients are also frequently affected by urological emergencies. Fast and efficient diagnostic and therapeutic action is crucial in these situations to achieve an optimal treatment result.

[Antibiotic prophylaxis for endourological interventions considering antibiotic stewardship]

Perioperative antibiotic prophylaxis in endourology is used to reduce or avoid postoperative surgical site infections and complicated urinary tract infections. Special attention is paid to antibiotic stewardship strategies to avoid the continuing selection of antibiotics and multidrug-resistant uropathogens as well as collateral damage to the microbiome. The individual risk profile, the local resistance situation, the expected pathogen spectrum, the pharmacokinetics and the approval of each substance are important aspects to be considered in the indications and selection of perioperative antibiotic prophylaxis. Furthermore, applicable hygiene regulations and the surgical care of an intervention must be observed.

Implementation of Palliative Care in Clinical Practice in German Units for Allogeneic Stem Cell Transplantation: A Nationwide Survey

Allogeneic stem cell transplantation (alloSCT) is a curative therapy for otherwise fatal diseases, however it is associated with a considerable morbidity and mortality. In consequence, it can be assumed that a considerable percentage of patients would benefit from high-quality palliative care (PC) during their course of disease. To assess the standard of PC in German transplant centers, a questionnaire was sent out to all German centers recognized from the EBMT membership list and the annually ZKRD report (n = 52). The response rate was not as high as expected with n = 27 (51,9%), even after reminding by phone calls or by e-mails. In brief, palliative care after allogeneic stem cell transplantation shows a wide variation in Germany. This is true for structures, processes and measures. A national standard for SCT-patients has not been established so far and there are no pre-conditions concerning palliative care after alloSCT for a certification by the EBMT according the JACIE standards. There is a considerable need for a crosslinking of alloSCT with PC. Clear standards should be established by the scientific societies concerning personnel, structure and processes.

[Complicated urinary tract infections]

Urinary tract infections (UTIs) are among the most common bacterial infections in Germany, both in outpatient and inpatient settings. The clinical spectrum is heterogeneous and ranges from benign, often self-limiting, uncomplicated infections to complicated urinary tract infections (cUTIs) with life-threatening courses. Complicated urinary tract infections have a higher risk of chronicity, recurrence and/or progression than uncomplicated infections and may be associated with severe disease progression. Stratification of patients with urinary tract infections is, therefore, of utmost importance. Host factors rather than pathogen attributes determine the pathophysiology and therapy of complicated urinary tract infections and pyelonephritis. Complicated UTIs and pyelonephritis are also associated with high rates of antimicrobial resistance in the causative pathogens, so they should be given particular emphasis.

Hyperbaric Oxygenation in the Treatment of Fournier's Gangrene: A Systematic Review

INTRODUCTION

Fournier's gangrene (FG) is a sporadic, life-threatening, necrotizing infection affecting the perineum, perineal region, and genitals. Hyperbaric oxygenation (HBO) improves tissue perfusion and promotes angiogenesis and collagen synthesis. Despite these positive effects of HBO, the indication and the effects on outcome as adjunct therapy in FG remain controversial. Consequently, we decided to perform a systematic review to compare the treatment of FG with or without the use of HBO as an adjunct therapy.

MATERIALS AND METHODS

We performed a systematic review following the recommendations provided in the Cochrane Handbook of systematic Reviews and the PRISMA reporting guidelines. Due to the paucity of data and a suspected lack of randomized controlled trials, we considered all the available information for this systematic review.

RESULTS

The literature search for primary studies yielded 79 results. Finally, 13 studies were considered, which included a total of 376 patients with FG, of whom 202 received HBO therapy. Five of these studies had a retrospective case-control design. However, these 5 studies included a total of 319 patients; 145 of these patients were treated with adjunct HBO therapy. Overall, this leads to a mortality rate of 16.6% in the HBO group and 25.9% in the non-HBO group. Overall, risk of bias was assessed as moderate to high.

CONCLUSIONS

We conclude that despite the risk of bias, HBO has potential as an adjunct in FG treatment, but it is challenging to carry out further studies, mainly due to the rareness of FG and availability of HBO.

Leflunomide in the treatment of BK polyomavirus associated nephropathy in kidney transplanted patients - A systematic review

BK polyomavirus (BKPyV) associated nephropathy (BKVAN) is seen in about 5% of renal transplant patients and can lead to chronic graft failure or graft loss. No effective therapy is available. Leflunomide has shown promising results in BKVAN. We performed a systematic review about the use of leflunomide for the treatment of BKVAN. The recommendations of the Cochrane Handbook of systematic Reviews were followed. Due to different study designs and endpoints no meta-analysis was performed. The literature search for primary studies yielded 274 results. Finally, twelve studies were included with a total of 267 patients. Clearance of BKPyV viremia was reported in 33.3% to 92.3% of cases and 27 graft losses (10.1%). The included studies were very heterogeneous, especially in terms of leflunomide dosing. Pharmacokinetics seem to have an important impact on the efficacy of leflunomide in BKVAN. There was no correlation between leflunomide serum levels and virus reduction. New adverse events of leflunomide have been described, e.g. haemolytic anaemia and thrombotic microangiopathy. Overall, the risk of bias in the studies was assessed as high and the quality of evidence was rated low. The role of leflunomide in BKVAN remains unclear, but further studies seem reasonable and should address pharmacokinetic aspects.

Targeting IL-11 in the treatment of BK virus-associated haemorrhagic cystitis-A promising new approach

The BK polyomavirus (BKPyV) has pathogenic relevance especially in immunocompromised patients. No causal therapy has been established yet. Therefore, new therapeutic targets need to be identified in experimental studies. A 3D organotypic cell culture model with primary urothelial cells and fibroblasts was used as infection model. The detection of virus replication was performed with quantitative polymerase chain reaction (qPCR), and immunohistochemistry (IHC) was also used for analysis. Interleukin levels were measured by enzyme‐linked immunosorbent assay (ELISA). Interestingly, the signal transducer and activator of transcription 3 (STAT3) pathway seems to be activated during infection with BKPyV, for example phosphorylated STAT3 is significantly (P < 0.0001) elevated on day 6 following infection. Therefore, we performed ELISAs for involved interleukins in STAT3 pathway. Interleukin 11 (IL‐11) was significantly (P = 0.026) elevated at day 9. Subsequently, 3D cultures were treated with IL‐11 neutralizing antibody. At day 9 following infection, the median virus replication rate is 4.4 × 10⁶ copies/ml. The difference to replication rate without treatment was significantly lower at day 6 (P < 0.0001) and at day 9 (P < 0.0001), respectively. STAT3 pathways seem to be involved during BKPyV infection and need further investigation in experimental studies. A very promising target for treatment might be IL‐11.

Can Isoflavones Influence Prostate Specific Antigen Serum Levels in Localized Prostate Cancer? A Systematic Review

Low risk prostate cancer does not always necessitate aggressive or invasive intervention and is best monitored through active surveillance, but in daily practice a majority of men seek a more proactive approach. Therefore, tertiary chemoprevention is an attractive option for men seeking a way to slow disease progression. Several natural anti-carcinogens have been identified in soy beans, especially isoflavones. Case series have been published, demonstrating a positive influence of isoflavones on PSA serum levels in prostate cancer. Consequently, we decided to perform a systematic review about the effect of isoflavones compared to placebo on PSA levels in localized prostate cancer following the recommendations provided in the Cochrane Handbook of systematic Reviews. On the whole, the primary aim of this review is to summarize the evidence for the use of isoflavones in localized prostate cancer in terms of PSA response. As a result, in all randomized controlled trials identified for this review, isoflavones seem to have no influence on PSA levels in localized prostate cancer. The influence of isoflavones on overall survival in localized prostate cancer remains unclear. Furthermore, isoflavones are interesting substances for further research, for example in lipid metabolism and cholesterol.

Catheter-Associated Urinary Tract Infections in Adult Patients

BACKGROUND

Urinary tract infections are among the more common types of nosocomial infection in Germany and are associated with catheters in more than 60% of cases. With increasing rates of antibiotic resistance worldwide, it is essential to distinguish catheter-associated asymptomatic bacteriuria from catheter-associated urinary tract infection (CA-UTI).

METHODS

This review is based on publications from January 2000 to March 2019 that were retrieved by a selective search in Medline. Randomized clinical trials and systematic reviews in which the occurrence of CA-UTI in adult patients was a primary or secondary endpoint were included in the analysis. Two authors of this review, working independently, selected the publications and extracted the data.

RESULTS

508 studies were identified and 69 publications were selected for analysis by the prospectively defined criteria. The studies that were included dealt with the following topics: need for catheterization, duration of catheterization, type of catheter, infection prophylaxis, education programs, and multiple interventions. The duration of catheterization is a determinative risk factor for CA-UTI. The indications for catheterization should be carefully considered in each case, and the catheter should be left in place for the shortest possible time. The available data on antibiotic prophylaxis do not permit any definitive conclusion, but they do show a small benefit from antibiotic-impregnated catheters and from systemic antibiotic prophylaxis.

CONCLUSION

Various measures, including careful consideration of the indication for catheterization, leaving catheters in place for the shortest possible time, and the training of nursing personnel, can effectively lower the incidence of CA-UTI. The eous in some respects, and thus no recommendations can be given on certain questions relevant to CA-UTI.

Novel 3D organotypic urothelial cell culture model for identification of new therapeutic approaches in urological infections

PURPOSE

3D organotypic cell cultures offer the possibility to study cell growth in a more in vivo like situation. To our knowledge no 3D culture of primary urothelial cells has been established yet. BK Polyomavirus (BKPyV), replicating in urothelial cells, may cause haemorrhagic cystitis in immunocompromised patients.

PRIMARY ENDPOINTS OF THIS STUDY

Establishment of a 3D organotypic cell culture of primary urothelial cells and fibroblasts; use of this model as infection model for archetype BKPyV; description of first parts of viral life cycle with identification of therapeutic targets.

METHODS

This is an experimental study. Primary urothelial cells were purchased from CellnTec, Bern, Switzerland; fibroblasts were isolated from the ureter of patients with no urothelial malignancy in their medical history. As main methods we used quantitative real-time PCR and immunohistochemistry. Outcomes were analysed using SPSS 23.0.

RESULTS

We were able to develop a 3D organotypic culture for primary urothelium. An infection with archetype BKPyV was established in this model with virus replication rates up to 6.41 × 108 copies/ml on day 9 following Infection. Interestingly, proliferation rate of the urothelial cells is significantly (p = 0.049 at day 6 following infection) elevated while cells are losing differentiation under infection. Phosphorylated STAT3 is also significantly elevated (p < 0.0001) during infection.

CONCLUSIONS

The established of urothelial 3D cultures is a new method to study several urothelial diseases. The archetype BKPyV infection model is novel and the first method to study archetype viral life cycle. The STAT3 pathway might be an interesting target for the development of a causal therapy.

Is BK Virus-Associated Cystitis a Generalized Epithelial Disease?

BK polyomavirus-associated haemorrhagic cystitis (BKHC) is a complication after allogeneic stem cell transplantation, which can occur in 5-60% of the cases. BK viruria alone can also occur in up to 100%. BKHC can lead to severe morbidity in stem cell-transplanted patients, but data about this disease is limited. Consequently, we conducted a prospective unicentric non-interventional trial on BKHC as well as BK viruria after first adult allogeneic stem cell transplantation with a follow-up time of 1 year after inpatient treatment. Between November 2013 and December 2015, we were able to include 40 adult patients with a mean age of 52.8 years. Twenty-seven (67.5%) of these patients were male and 13 (32.5%) were female. Acute myeloid leukaemia was the most frequent underlying disease (n = 15; 37.5%). Only 1 patient developed BKHC during inpatient treatment (n = 1; 2.5%), but BK viruria was frequent (n = 11; 27.5%) during inpatient treatment as well as in the follow-up time (n = 14; 35%). Interestingly, BK viruria was significantly associated with mucositis (p = 0.038) and number of transfused platelet concentrates (p = 0.001). This unexpected association will be discussed and needs further investigation.

Current Evidence on Nonantibiotic Prevention of Recurrent Urinary Tract Infections

Clinicians should be aware of the limited evidence on nonantibiotic prophylactic treatment for recurrent urinary tract infections. Owing to the rising antibiotic resistance rates worldwide, nonantibiotic prevention strategies should be considered for patient care. Further research is necessary to evaluate nonantibiotic treatment strategies using a robust randomised controlled trial methodology to contribute to a strong evidence basis.

Desperate need for better management of Fournier's gangrene

Introduction

To compare earlier and later patient groups with Fournier's gangrene, specifically with the incidence of rising antibiotic resistance rates in mind. Primary endpoints were to compare therapy, outcomes, and resistance rates.

Material and methods

A multicentric, retrospective, multi-national study was performed. Two groups with different time frames of treatment were defined: Group 1 (n = 50) and Group 2 (n = 104). Demographics and outcomes were analysed using Student-t test, chi-square test, or Fisher exact test. Survival data were estimated using the Kaplan Meier method and compared by Log rank testing.

Results

There were no significant demographic differences. Nor was there any significant difference in therapy or outcomes in the groups except for the duration of intensive care unit treatment, which lasted a mean 6.3 days in Group 1 and 11.5 days in Group 2 (p = 0.018). Survival time did not improve over the years (p = 0.268). We fortunately did not observe an increased rate of multi-resistant organisms (p = 1.000). This study's limitations are mainly due to its retrospective study design.

Conclusions

Despite increasing antibiotic resistance rates worldwide, it was not apparent in our population. But the situation for these patients is alarming, since final outcome failed to improve over the last ten years despite more intensive critical-care therapy.

Comparison of intravenous or intravesical cidofovir in the treatment of BK polyomavirus-associated hemorrhagic cystitis following adult allogeneic stem cell transplantation-A systematic review

INTRODUCTION

BK polyomavirus can lead to hemorrhagic cystitis (BKPyV-HC) in allogeneic stem cell transplantation and therefore to increased morbidity. No causal therapy has been established yet. Cidofovir (CDV) is a nucleotide analog of cytosine that is active against various DNA viruses and it has been described for therapy of BKPyV-HC using 2 admission routes: intravenous and intravesical.

METHODS

We performed a systematic review regarding the comparison of intravenous or intravesical cidofovir in the treatment of BKPyV-HC following adult allogeneic stem cell transplantation. Since there is a lack of randomized controlled trials, we considered all kinds of studies for this review. Due to heterogeneity of the data, we were not able to perform a meta-analysis, so the results are shown descriptively.

RESULTS

The literature search for primary studies yielded 232 results. Finally, 9 studies where considered which included a total of 189 adult patients with BKPyV-HC after allogeneic stem cell transplantation. We could only identify retrospective studies for this review. A total of 172 patients received intravenous CDV, 17 patients received intravesical CDV, and 2 patients received CDV in both admission routes. In 68.0% of the cases, a complete response for intravenous CDV was documented and in 88.2% for intravesical CDV. Interestingly, no kidney toxicity was mentioned in intravesical CDV. 9.3% of the intravenously treated patients had renal failure.

CONCLUSION

There is only weak evidence for the use of CDV. The intravesical admission route should be further investigated because of a good toxicity profile.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention

BACKGROUND

We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs.

MATERIALS AND METHODS

An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015.

RESULTS

For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection.

CONCLUSION

In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Antibiotic Prophylaxis in Prostate Biopsies: Contemporary Practice Patterns in Germany

Purpose

Prostate biopsy (pbx) is the most common outpatient procedure in urology. Complications are urinary tract infections, including hospitalization and sepsis. Recommendations on antibiotic prophylaxis (apx) are scarce, and healthcare data are not available. The study addressed the following endpoints: the duration and spectrum of antimicrobial prophylaxis in transrectal and transperineal pbx in the hospital and the practice setting.

Methods

A questionnaire compiled data about age, gender, board certification, and place of work. Information about the frequency of pbx, duration and type of apx, usage of disinfecting lubricant, and urine or rectal swab cultures was collected. The study refers to German urologists.

Results

Overall 478 urologists answered the questionnaire. 15.5% (74) of respondents were residents. 50.8% (243) of urologists work in a practice; the rest in a hospital. Only 4.8% do not perform pbx. Transrectal pbx are performed a median of two times a week. The majority (446, 98%) prescribe an apx, mostly fluoroquinolones (407, 89.5%). In total, 10.1% (46) of the participants use a single-shot-apx. apx has a median duration of 4 days. One-third uses a disinfecting lubricant. Urine and rectal swab cultures are analyzed by 45.5% (207) and 24.4% (111), respectively.

Conclusion

Most urologists prescribe an extended apx for both transrectal and transperineal pbx. Perineal pbx is still a deviation from everyday practice and not an established alternative to transrectal pbx. Urologists are aware of the increasing fluoroquinolone-resistance and are adapting with rectal swab and urine cultures. Further studies need to evaluate alternatives to 5-day apx and results should be addressed in our guidelines. This is of importance in light of the increasing resistance rates and fluoroquinolone side effects.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1

OBJECTIVES

We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients.

MATERIALS AND METHODS

An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, -EMBASE, and the Cochrane Library to identify literature published in 2010-2015.

RESULTS

We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed.

CONCLUSION

In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.