Treatment trends for muscle-invasive bladder cancer in Germany from 2006 to 2019.

PURPOSE: To examine national treatment trends of muscle-invasive bladder cancer (MIBC) in Germany with a special focus on radical cystectomy (RC). PATIENTS AND METHODS: Population-based data were derived from the nationwide hospital billing database of the German Federal Statistical Office and institution-related information from the reimbursement.INFO tool based on hospitals' quality reports from 2006 to 2019. Additionally, we used the German National Center for Cancer Registry data to analyze all cases of bladder cancer with stage ≥ T2 who received RC, chemotherapy, radiation therapy or a combination from 2006 to 2017. RESULTS: The annual number of RC cases in Germany increased by 28% from 5627 cases in 2006 to 7292 cases in 2019 (p = 0.001). The proportion of patients undergoing RC remained constant at about 75% in all age groups between 2006 and 2017 (p = 0.3). Relative to all performed RC, the proportion of patients > 75 years increased from 25% in 2006 to 38% in 2019 (p = 0.03). The proportion of patients receiving a combination of RC and chemotherapy increased from 9% in 2006 to 13% in 2017 (p = 0.005). In 2006, 8 of 299 urology departments (2.7%) performed more than 50 RCs per year, which increased to 17 of 360 (4.7%) in 2019. In 2019, 107 departments (29%) performed 25-49 RCs and 236 (66%) departments performed < 25 RCs. CONCLUSION: In Germany, three out of four patients with MIBC receive RC and the proportion of patients > 75 years is increasing. The combination of surgery and chemotherapy is increasingly used. With overall increasing case numbers, there is a slight tendency towards centralization.

The Treatment Decision-making Preferences of Patients with Prostate Cancer Should Be Recorded in Research and Clinical Routine: a Pooled Analysis of Four Survey Studies with 7169 Patients.

Different patients want to take different roles in the treatment decision-making process; these roles can be classified as passive, collaborative, and active. The aim of this study was to investigate the correlation between decision-making preferences among patients with prostate cancer and personal, disease-related, and structural factors. In four survey studies, we asked 7169 prostate cancer patients about their decision-making preferences using the Control Preferences Scale (CPS) and collected clinical, psychological, and quality-of-life measures. Most patients (62.2%) preferred collaborative decision-making, while 2322 (32.4%) preferred an active role, and only 391 (5.5%) preferred a passive role. Age (p < 0.001), data collection mode (p < 0.001), peer-to-peer support (p = 0.018), treatment status (p < 0.001), performed or planned radical prostatectomy (p < 0.001), metastatic disease (p = 0.001), and quality of life (p < 0.001) showed significant associations with patients' preferred decision-making roles. Oncologic risk group, anxiety, and depression were not significant in the model. In particular, younger prostate cancer patients with higher quality of life completing an online survey want to play a more active role in treatment decision-making. Before treatment has started, patients tend to prefer collaborative decision-making. Few prostate cancer patients in Germany prefer a passive role. These patients are mostly older patients, patients with a metastatic disease, and patients who have opted for prostatectomy. Whether this finding reflects a generational effect or a tendency by age group and disease phase should be investigated. Further research is also needed to describe the causalities of these relationships. The CPS offers valuable information for personal counselling and should be applied in clinical routine. In a large group of patients with prostate cancer, we found that there is a strong desire for joint decision-making with the physician before the actual treatment. Especially younger men, men with active online behaviour, and men with a high quality of life want to be actively involved in therapy decision-making processes.

[Trends in uro-oncological surgery in Germany-comparative analyses from population-based data]. / Entwicklung der operativen Uroonkologie in Deutschland ­ vergleichende Analysen aus populationsbasierten Daten.

Although urologic cancer represents a relevant health economic burden with about 100,000 new cases per year, hardly any knowledge exists about the structure and development of the corresponding uro-oncological interventions at the more than 400 urological surgical hospitals in Germany. Thus, we identified all cases of 5 major tumor surgery procedures in Germany from the DRG (diagnosis-related group) database of the Federal Statistical Office (prostatectomy, cystectomy, renal tumor surgery, retroperitoneal lymphadenectomy, penis surgery) from 2006-2013 (or 2016) by database query and investigated the influences of technical innovations, as well as guideline changes on the developments of case numbers. In addition, we analyzed the correlations between annual case numbers and perioperative outcomes. The results showed a clear correlation between case volume (and thus expertise) of a hospital and an improved perioperative outcome. Nevertheless, there is hardly any tendency towards centralization in these uro-oncological interventions. The development in the number of cases seems to depend more on the effect of advertising by means of technical innovations or the regional relation of the patients to a certain clinic. In the past, centrally controlled attempts to introduce minimum case numbers or voluntary certification of centers had little influence on the distribution of case numbers.

[Empowerment for our patients : Innovation in everyday urology]. / Empowerment für unsere Patienten : Gelebte Innovation im urologischen Alltag.

Patient empowerment includes measures that promote their autonomy and self-determination in the physician-patient relationship. In addition to successful medical treatment, goals include long-term treatment satisfaction and the best possible quality of life for the patients and their social environment. Various initiatives and projects from German urology are already used to empower our patients. Entscheidungshilfe Prostatakrebs (decision aid for prostate cancer) and the German language decision aid for advanced bladder cancer and for the choice of urinary diversion are implemented under the umbrella of the PatientenAkademie (patient academy) of German Urologists. With more than 12,000 users, Entscheidungshilfe Prostatakrebs is very well established in urological care in Germany. The randomized evaluation study with planned 1200 participants is close to the successful completion of recruitment. Another project from the German urology sector is the project "antiCoagulation Help App for SurgERy" (CHASER). The aim is to develop a smartphone-based decision aid for the perioperative management of patients undergoing antithrombotic therapy. Online support groups can also contribute to empowerment and have been analyzed systematically for prostate cancer patients. A large randomized study on this topic is currently in preparation. Continuing advances in digitalization can thus provide us with useful support in order to provide individual information to our patients. The German Urological Association and its PatientenAkademie have been committed to this for many years.

International multicentre review of perioperative management and outcome for catecholamine-producing tumours.

BACKGROUND: Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. METHODS: Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. RESULTS: Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. CONCLUSION: There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

ANTECEDENTES: La cirugía de los tumores productores de catecolaminas puede complicarse por la inestabilidad hemodinámica intraoperatoria y postoperatoria. Se han propuesto distintas estrategias de manejo perioperatorio, pero ninguna ha sido evaluada en ensayos aleatorizados. Para evaluar este tema, se han recogido los datos de los resultados y del manejo perioperatorio contemporáneo de 21 centros. MÉTODOS: Veintiún centros aportaron datos de los resultados de los pacientes operados por feocromocitoma y paraganglioma entre 2000-2017. Los datos incluyeron el número de pacientes con y sin bloqueo del receptor α, las técnicas quirúrgicas y anestésicas, las complicaciones y la mortalidad perioperatoria. RESULTADOS: Los centros en su conjunto aportaron datos de 1.860 pacientes con feocromocitoma y paraganglioma, de los cuales 343 pacientes fueron intervenidos sin bloqueo del receptor α. La gran mayoría (79%) de las cirugías se realizaron utilizando técnicas mínimamente invasivas, incluido un 17% de procedimientos con preservación de la corteza suprarrenal. La tasa de complicaciones cardiovasculares fue de 5,0% en total; 5,9% (90/1517) en pacientes con bloqueo preoperatorio de los receptores α y 0,9% (3/343) en pacientes no pretratados. La mortalidad global fue del 0,5% (9/1860); 0,5% (8/1517) en pacientes pretratados y 0,3% (1/343) en pacientes no tratados previamente. CONCLUSIÓN: Existe una variabilidad sustancial en el manejo perioperatorio de los tumores productores de catecolaminas, aunque la tasa global de complicaciones es baja. Este estudio brinda la oportunidad para efectuar comparaciones sistemáticas entre estrategias de prácticas terapéuticas variables. Se necesitan más estudios para definir mejor el enfoque de manejo óptimo y parece conveniente volver a evaluar las guías internacionales perioperatorias.

Andrology on the Internet: Most wanted, controversial and often primary source of information for patients.

The Internet is an important source of health information with relevant impact on the physician-patient relationship. The German urological associations host one of the most comprehensive platforms for patient information on urological diseases. The aim of the study was to characterise its users and their specific needs. We invited users of the website www.urologenportal.de via pop-up to complete a 26-item online survey to evaluate health-related behaviour, distress and decision-making preferences. We received n = 551 complete responses. The most frequently requested topics were from the field of andrology (45.4%, n = 250). Of these, the most popular topics were circumcision (28.9%, n = 159) and erectile dysfunction (18.1%; n = 100). Overall, 216 users (39.2%) searched for information prior to their first doctor's appointment, and 89.3% (n = 492) preferred autonomous or shared decision-making. Users seeking information on circumcision were less frequently under urological treatment (p < .001), and more self-determined regarding healthcare decisions (p = .01). Circumcision was the only information on the website, which received relevant critical comments. Andrology was the most frequently requested urological topic. The vast majority of patients wanted to take self-determined healthcare decisions and searched for information prior to a doctor's appointment. This might have an impact on the physician-patient relationship and causes a high demand for good-quality health information websites.

[Evaluation of the decision aid "Entscheidungshilfe Prostatakrebs" from the patients' view : Results from the first three months]. / Evaluation der Entscheidungshilfe Prostatakrebs aus Patientensicht : Ergebnisse der ersten 3 Monate.

BACKGROUND: The decision aid "Entscheidungshilfe Prostatakrebs" is available online free of charge since June 2016. It is designed to support patients with their treatment decision-making and to lighten the burden on their treating urologists. This study evaluates usage data from the first 3 months. MATERIALS AND METHODS: The ICHOM standard set was applied to allow a personalised presentation and to collect relevant data for subsequent counselling. Additionally, personal preferences and psychological burden were assessed amongst others. We collected anonymous data. A multivariate model evaluated predictors for high user satisfaction. RESULTS: From June through August 2016 a total of 319 patients used the decision aid, showing a continuous monthly increase in the number of users. There were n = 219 (68.7%) complete questionnaires. Median age was 66.1 ± 8.0 years. The oncological risk was low in 30.3%, intermediate in 43.6% and high in 26.1%. A majority of 57.5% used the decision aid together with their partner, 35.1% alone and 5.5% with their children. In all, 54.8% were "very satisfied" and 32.0% were "satisfied" with the decision aid for a total satisfaction rate of about 87%. The only predictors of total satisfaction were the usage mode and reported distress level. CONCLUSIONS: As shown by the continuously increasing number of users this decision aid is becoming well established in German urology. Patients' overall ratings are very positive. The majority of patients use the decision aid with their partner. This represents a significant advantage of a multimedia approach compared to print media.

Robots drive the German radical prostatectomy market: a total population analysis from 2006 to 2013.

BACKGROUND: To assess trends in the distribution of patients for radical prostatectomy in Germany from 2006 to 2013 and the impact of robotic surgery on annual caseloads. We hypothesized that the advent of robotics and the establishment of certified prostate cancer centers caused centralization in the German radical prostatectomy market. METHODS: Using remote data processing we analyzed the nationwide German billing data from 2006 to 2013. We supplemented this database with additional hospital characteristics like the prostate cancer center certification status. Inclusion criteria were a prostate cancer diagnosis combined with radical prostatectomy. Hospitals with certification or a surgical robot in 2009 were defined as 'early' group. Linear covariant-analytic models were applied to describe trends over time. RESULTS: Annual radical prostatectomy numbers declined from 28 374 (2006) to 21 850 (2013). High-volume hospitals (⩾100 cases) decreased from 87 (22.0%) in 2006 to 43 (10.4%) in 2013. Low-volume hospitals (<50 cases) increased from 193 (48.7%) to 280 (67.4%). Mean radical prostatectomy caseloads of hospitals with early vs without certification declined from 155 to 130 vs 77 to 39 (P=0.021 for trend comparison). Early robotic hospitals maintained their volume >200 cases per year contrary to the overall trend (P<0.001 for trend comparison). A multivariate model for caseload numbers of 2013 indicated a robotic system to be the most important factor for higher caseloads (multiplication factor 7.3; 95% confidence interval: 6.6-8.0). A prostate cancer center certification (multiplication factor 1.6; 95% confidence interval: 1.50-1.59) had a much smaller impact. CONCLUSIONS: We found decentralization of radical prostatectomy in Germany. The driving force for this development might consist in the overall decline of radical prostatectomy numbers. The most important factor for achieving higher caseloads was the presence of a robotic system. In order to optimize outcomes of radical prostatectomy additional health policy measures might be necessary.

[Evaluation of the joint information platform : Information offered by German urologists]. / Evaluation des Urologenportals : Das gemeinsame Informationsangebot der deutschen Urologen.

BACKGROUND: The Internet is an important source for health issues and especially professional associations should offer reliable information. Since 2001 the professional German urological associations (DGU and BDU) have hosted a joint platform to inform patients. Because a complete relaunch is currently ongoing, we evaluated the users' needs and wishes. MATERIALS AND METHODS: Using a pop-up on the website www.urologenportal.de , users were invited to complete a 26-item online survey. We used a validated questionnaire for evaluation of the website. Data acquisition was performed in an anonymised manner. RESULTS: We received n = 200 complete responses from February through September 2015. Respondents' median age was 57 years (range 17-89 years); 79 % were male. Users rated relevance and comprehensibility of information as very good and superior compared to layout and structure of the website. Of the users 73 % were affected themselves, but only half of them reported to have consulted a urologist. At the time of the survey, 54 % of the respondents had to make a health-related decision. The website helped 54 % of these respondents in their decision-making and 20 % reported to have changed their mind due to the information obtained. The three most frequently requested urological topics were circumcision/phimosis (33 %), prostatic enlargement (19 %), and erectile dysfunction (18 %). CONCLUSIONS: Currently the Urologenportal as the joint information platform hosted by German urologists is perceived as a comprehensible source of relevant information. The ongoing relaunch should focus particularly on the website's structure and layout.

[Decision aids for patients are widely accepted by German urologists : A survey among members of the German Society of Urology (DGU) and the Federation of German Urologists (BDU)]. / Entscheidungshilfen für Patienten finden bei deutschen Urologen breite Akzeptanz : Umfrage unter Mitgliedern von DGU und BDU.

BACKGROUND: Treatment decision making remains a complex task for localized prostate cancer. Decision aids for patients can support the medical consultation. However, it is not known if German urologists accept decision aids for patients. Comparative data exist from a current survey among american urologists and radio oncologists. MATERIALS AND METHODS: From October through November 2014 we conducted an online survey consisting of 11 multiple-choice questions and an optional free text commentary among the members of DGU and BDU. All data was processed anonymously. We received 464 complete responses for a 6.6 % return rate. For group comparison we applied the Chi2-test. RESULTS: Respondents' median age was 50 (range 26-87) years and 15 % were female. 7 % were residents, 31 % employed at a clinic, and 57 % in private practice. Due to the low response rate of younger colleagues the results were not representative for the basic population. Regardless of age (p = 0.2) and professional environment (p = 1) shared decision making was preferred by 89 %. When counseling their patients with localized prostate cancer 20 % relied exclusively on conversation. To support their conversation 63 % used print media, 49 % decision aids, 33 % contact offers to support groups, 24 % Internet resources and 13 % video material. From using decision aids 86 % expected positive effects for patients and 78 % for physicians (p = 0.017). 15 % expected a change of the treatment decision. 77 % would motivate their patients to use a decision aid. CONCLUSIONS: In comparison to the opinion of american urologists and radio oncologists the acceptance of decision aids for patients among German urologists is significantly higher.

[Minimum caseload requirements in urologic oncology: not without evidence from health services research]. / Mindestmengen in der Uroonkologie : Nicht ohne Evidenz aus der Versorgungsforschung.

BACKGROUND: Minimum caseload requirements can be an appropriate tool to optimize and stabilize the quality of treatment with complex surgical procedures. For several procedures there is sufficient evidence for a positive correlation between high case numbers and lower morbidity and mortality rates. In urologic oncology there is also an effect of moderate strength for radical prostatectomy, radical cystectomy, and radical nephrectomy. Therefore, several healthcare systems have introduced minimal numbers per hospital to centralize certain procedures. DISCUSSION: Since 2004 minimal caseload requirements have been introduced in Germany for selected operations. However, urooncologic procedures have not been included yet. Due to the high incidence of urologic malignancies and sufficient evidence, a centralization of these procedures seems to be favorable. CONCLUSION: However, prior to the introduction of minimum caseload requirements for these major urooncologic procedures, exact evaluation of the available evidence for the German healthcare system will be necessary. If a minimal caseload for these procedures is introduced, the process should be monitored closely and evaluated continuously.

[Treatment of nonmetastatic prostate cancer: a systematic review of interactive, personalized patient decision aids]. / Therapie des nichtmetastasierten Prostatakarzinoms : Eine systematische Übersicht interaktiv personalisierter patientenorientierter Entscheidungshilfen.

BACKGROUND: Patients with nonmetastatic prostate cancer face a complex treatment decision. To support them with personalized information, a variety of interactive computerized decision aids have been developed in Anglo-Saxon countries. Our goal was to identify relevant decision aids and investigate their didactic strengths and limitations. MATERIALS AND METHODS: We included decision aids that derived individualized content from personal and clinical data provided by the patient. By conducting a systematic literature and internet research through November 2013 supplemented by expert interviews, we identified 10 decision aids of which 6 had been investigated scientifically. We compared their individual characteristics as well as the design and results of the evaluation studies. RESULTS: The decision aids present two to seven therapy choices, whereby radical prostatectomy and percutaneous radiotherapy are always included. Number and type of parameters provided by the patient also vary considerably. Two decision aids derive a therapeutic recommendation from the patient's input. Evaluation studies showed higher disease-related knowledge and greater confidence in the treatment decision after using one of six decision aids. Satisfaction with the decision aid was predominantly high. CONCLUSIONS: Currently personalized patient decision aids for treatment of nonmetastatic prostate cancer are only available in English. These tools can facilitate the shared decision making process for patients and physicians. Therefore, comparable decision aids should be developed in German.

[Removal of the primary tumor in hematogenous metastatic tumor disease: reasons against]. / Entfernung des Primärtumors bei hämatogen metastasierter Tumorerkrankung : Gründe dagegen.

Primarily treating metastatic malignancies systemically was an untouchable dogma for decades. Accordingly local therapy was reserved for localized disease only. However, in some oncological entities this apodictic principle could be disproved. In metastatic renal cell carcinoma cytoreductive nephrectomy is the current standard of care for appropriately selected patients but there is a lack of robust data for radical prostatectomy in patients with hematogenous spread from prostate cancer. Therefore, surgical treatment is not recommended outside clinical trials for the latter indication.

[Eye symptoms in hypophyseal adenomas, craniopharyngiomas and meningiomas of the anterior and middle cranial fossa]. / Augensymptome bei Hypophysenadenomen, Kraniopharyngeomen und Meningeomen der vorderen und mittleren Schädelgrube.

Among 181 inpatients suffering from pituitary adenoma, craniopharyngioma, or meningioma of the anterior or middle cranial fossa, 112 had ocular symptoms initially or during the course of the disease. Patients' histories were analyzed with regard to ophthalmological, neurological, and radiological diagnostic procedures carried out, and the conclusions drawn from these. Initial symptoms and signs were often misinterpreted and appropriate investigations consequently delayed. The mean duration of the history was 2.67 years (0-13 years) for the pituitary adenomas, 1.44 years (3 months-6 years) for the craniopharyngiomas and 3.73 years (1 month-24 years) for the meningiomas. Typical initial eye symptoms were progressive loss of vision with or without optic nerve atrophy, visual field defects, extraocular nerve palsies, and exophthalmus, the last two occurring if parasellar extension of the tumor was present. Plain skull X-rays were abnormal in nearly all cases of pituitary adenomas, but the incidence of abnormalities was less frequent with cases of craniopharyngiomas and meningiomas. The tumor was demonstrated by computerized tomography in all cases of pituitary adenomas, in 5 out of 6 cases with craniopharyngiomas and, where the examination was performed before and after administration of contrast medium, in all cases of meningiomas. Introduction of CT, however, shortened the duration of the history only in the meningioma group; the mean dropped from 4.38 years to 3.04 years. The chance of achieving a cure by surgical intervention lessened with both increasing length of history and tumor size. Out of 90 patients (15.6%) operated on, 14 died in the postoperative period. Vision improved postoperatively in only 26 patients whereas it remained unchanged or decreased further in 40 patients. In 10 cases there were no postoperative data available. These results emphasize the necessity of making an early diagnosis. This can nearly always be achieved if a careful clinical examination and adequate additional diagnostic procedures are carried out.