Trends in kidney transplantation and living donor nephrectomy in Germany: a total population analysis from 2006 to 2021.

PURPOSE: To analyze recent trends of surgical access routes, length of hospital stay (LOS), and mortality in kidney transplantation (KT) and living donor nephrectomy (LDN) in Germany. MATERIALS AND METHODS: We studied the nationwide German hospital billing database and the German hospital quality reports from 2006 to 2021. RESULTS: There were a total of 35.898 KTs. In total, 9044 (25%) were living donor transplantations, while 26.854 (75%) were transplantations after donation after brain death (DBD). The share of open LDN decreased from 82% in 2006 to 22% in 2020 (- 4%/year; p < 0.001). The share of laparoscopic LDN increased from 18% in 2006 to 70% in 2020 (+ 3%/year; p < 0.001). The share of robotic LDN increased from 0% in 2006 to 8% in 2020 (+ 0.6%/year; p < 0.001). Robotic-assisted KT increased from 5 cases in 2016 to 13 procedures in 2019 (p = 0.2). LOS was shorter after living donor KT, i.e., 18 ± 12.1 days versus 21 ± 19.6 days for DBD renal transplantation (p < 0.001). Moreover, LOS differed for open versus laparoscopic versus robotic LDN (9 ± 3.1 vs. 8 ± 2.9 vs. 6 ± 2.6; p = 0.031). The overall in-hospital mortality was 0.16% (n = 5) after LDN, 0.47% (n = 42) after living donor KT and 1.8% (n = 475) after DBD KT. CONCLUSIONS: There is an increasing trend toward minimal-invasive LDN in recent years. Overall, in-hospital mortality was low after KT. However, 5 deceased healthy donors after LKD caution that the risks of this procedure should also be taken very seriously.

Trends in the use of testicular prostheses in Germany: a total population analysis from 2006-2021.

INTRODUCTION: Testicular tumors are the most common malignancies in young adults and their incidence is growing. The implantation of a testicular prosthesis, for example, during orchiectomy is a standard procedure but its frequency in Germany is unknown. This study aims to analyze trends of testicular prosthesis implantation in recent years in Germany. MATERIAL AND METHODS: The nationwide German hospital billing database and the German hospital quality reports from 2006 to 2021 were studied. RESULTS: A total of 12,753 surgical procedures with implantation of testicular prosthesis and 1,244 procedures with testicular prosthesis explantation were included. Testicular prosthesis implantation increased in total from 699 cases in 2006 to 870 cases in 2020 (+11.4 cases/year; p < 0.001). The share of implantation of testicular prosthesis due to testicular tumor decreased from 72.6% in 2006 to 67.5% in 2020 (p < 0.001). The share of implantation due to gender affirming surgery increased from 6.8% in 2006 to 23.3% in 2020 (p < 0.001). The share of implantation due to testicular atrophy decreased from 11.4% in 2006 to 3.4% in 2020 (p < 0.001). Simultaneous implantation of testicular prosthesis during orchiectomy for testicular cancer increased from 7.8% in 2006 to 11.4% in 2020 (p < 0.001). In 2006, 146 hospitals (85%) performed < 5 testicular prosthesis implantation, while 20 hospitals (12%) performed 5-15 implantation procedures and 6 hospitals (3%) performed > 15 testicular implantation surgeries. In 2021, 115 hospitals (72%) performed < 5 testicular prosthesis implantation, while 39 hospitals (25%) performed 5-15 implantation procedures and 5 hospitals (3%) performed > 15 testicular implantation surgeries. CONCLUSION: This study shows that implantation of testicular prostheses is steadily increasing. Explantation rates are low. Besides testicular cancer transgender surgeries were the main driver for increasing case numbers in recent years.

Trends in Selective Internal Radiation Therapy (SIRT) for Treating Hepatocellular Carcinoma, Cholangiocarcinoma, and Liver Metastasis: A Total Population Analysis from 2006 to 2021 in Germany.

The aim of this study was to investigate trends in selective internal radiation therapy (SIRT) for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCC), and liver metastasis in Germany. We analyzed the nationwide German hospital billing database from 2006 to 2019 for the diagnosis of HCC, CCC or liver metastasis in combination with SIRT. For analyses of SIRT on the hospital level, we used the reimbursement.INFO tool based on German hospitals' quality reports from 2008 to 2021. Linear regression analysis was performed to detect changes over time. We included a total of 14,165 SIRT procedures. The annual numbers increased from 99 in 2006 to 1605 in 2015 (p < 0.001; increase by 1521%), decreasing to 1175 cases in 2019 (p < 0.001). In 2008, 6 of 21 hospitals (28.6%) performed more than 20 SIRTs per year, which increased to 19 of 53 (35.8%) in 2021. The share of SIRT for HCC increased from 29.8% in 2006 to 44.7% in 2019 (p < 0.001) and for CCC from 0% in 2006 to 9.5% in 2019 (p < 0.001), while the share of SIRT for liver metastasis decreased from 70.2% in 2006 to 45.7% in 2019 (p < 0.001). In-hospital mortality was 0.2% after the SIRT procedure. Gastritis (2.7%), liver failure (0.4%), and sepsis (0.3%) were the most common in-hospital complications reported. We observed an increase in SIRT procedures in Germany, with the number of hospitals offering the procedure going up from 21 in 2008 to 53 in 2021. While the treatment of liver metastasis remains the most common indication, SIRT for HCC and CCC increased significantly over the last few years. The mortality and complication rates show that SIRT is a relatively safe procedure.

Adoption of Lutetium-177 PSMA radioligand therapy for metastatic castration resistant prostate cancer: a total population analysis in Germany from 2016 to 2020.

PURPOSE: This study is to investigate the adoption and current trends of Lutetium-177 PSMA RLT for mCRPC in Germany. METHODS: We analyzed data from the reimbursement.INFO tool based on German hospitals' quality reports for Lutetium-177 PSMA RLT from 2016 to 2020 and from the nationwide German hospital billing database (Destatis) for general therapy with open radionuclides in combination with prostate cancer from 2006 to 2020. For validation of these billing data, we included the 177Lu-PSMA RLT cycles from two participating institutions from 2016 to 2020. For detection of trends over time we applied linear regression models. RESULTS: General therapy with open radionuclides increased from 2006 to 2020. We identified a total of 12,553 177Lu-PSMA RLT cycles. The number of 177Lu-PSMA RLTs steadily increased from a total of 1026 therapies in 2016 to 3328 therapies in 2020 (+ 576 RLT/year; p < 0.005). In 2016, 25 departments of nuclear medicine offered this treatment, which increased to 44 nuclear medicine departments in 2020. In 2016, 16% of nuclear medicine departments (4/25) performed more than 100 177Lu-PSMA RLTs, which increased to 36% (16/44) in 2020 (p < 0.005). In 2016, 88% (22/25) of 177Lu-PSMA RLTs were performed at a university hospital, which decreased to 70% (31/44) in 2020. The proportion of patients older than 65 years receiving 177Lu-PSMA RLT increased from 78% in 2016 to 81% in 2020. CONCLUSION: Treatment of mCRPC with 177Lu-PSMA RLT has been rapidly increasing in Germany in the recent years providing an additional therapy option. This development is remarkable, because of outstanding formal EMA approval.

Focal Therapy for Renal Cancer: Comparative Trends in the USA and Germany from 2006 to 2020 and Analysis of the German Health Care Landscape.

INTRODUCTION: The aim of the study was to investigate trends of FT for in-patient treatment of renal RCC in the USA and Germany. METHODS: We analyzed the SEER database for the USA and the nationwide German hospital billing database each from 2006 to 2019 for a RCC diagnosis in combination with FT, radical nephrectomy, and partial nephrectomy. FT was defined as radiofrequency ablation (RFA) or cryotherapy. Linear regression analysis was performed to detect changes over time. RESULTS: For the USA, we included 7,318 FT cases. The share of FT increased from 2.4% in 2006 to 6.4% in 2019 (p < 0.001). For Germany, we identified 2,920 FT cases. The share of FT increased from 0.7% in 2006 to 2.0% in 2019 (p < 0.001). The number of RFAs in the USA steadily increased by 227% from a total of 93 in 2006 to 304 in 2019 while the number of cryotherapies in the USA steadily increased by 289% from a total of 127 in 2006 to 494 in 2019 (p < 0.001). The number of RFAs in Germany increased by 344% from a total of 59 in 2006 to 262 in 2019 (p < 0.001) while the number of cryotherapies steadily increased by 43% from a total of 54 in 2006 to 77 in 2019 (p < 0.001). In Germany, RFA is significantly more performed than cryotherapy while in the USA cryotherapy is more frequently applied. CONCLUSION: We observed a constant increase of FT in the USA and Germany for RCC in-patient treatment with a higher share in the USA.

Reducing inter-observer variability and interaction time of MR liver volumetry by combining automatic CNN-based liver segmentation and manual corrections.

PURPOSE: To compare manual corrections of liver masks produced by a fully automatic segmentation method based on convolutional neural networks (CNN) with manual routine segmentations in MR images in terms of inter-observer variability and interaction time. METHODS: For testing, patient's precise reference segmentations that fulfill the quality requirements for liver surgery were manually created. One radiologist and two radiology residents were asked to provide manual routine segmentations. We used our automatic segmentation method Liver-Net to produce liver masks for the test cases and asked a radiologist assistant and one further resident to correct the automatic results. All observers were asked to measure their interaction time. Both manual routine and corrected segmentations were compared with the reference annotations. RESULTS: The manual routine segmentations achieved a mean Dice index of 0.95 and a mean relative error (RVE) of 4.7%. The quality of liver masks produced by the Liver-Net was on average 0.95 Dice and 4.5% RVE. Liver masks resulting from manual corrections of automatically generated segmentations compared to routine results led to a significantly lower inter-observer variability (mean per case absolute RVE difference across observers 0.69%) when compared to manual routine ones (2.75%). The mean interaction time was 2 min for manual corrections and 10 min for manual routine segmentations. CONCLUSIONS: The quality of automatic liver segmentations is on par with those from manual routines. Using automatic liver masks in the clinical workflow could lead to a reduction of segmentation time and a more consistent liver volume estimation across different observers.

Multimodal image registration for liver radioembolization planning and patient assessment.

PURPOSE: Multimodal imaging plays a key role in patient assessment and treatment planning in liver radioembolization. It will reach its full potential for convenient use in combination with deformable image registration methods. A registration framework is proposed for multimodal liver image registration of multi-phase CT, contrast-enhanced late-phase T1, T2, and DWI MRI sequences. METHODS: A chain of four pair-wise image registrations based on a variational registration framework using normalized gradient fields as distance measure and curvature regularization is introduced. A total of 103 cases of 35 patients was evaluated based on anatomical landmarks and deformation characteristics. RESULTS: Good anatomical correspondence and physical plausibility of the deformation fields were attained. The global mean landmark errors vary from 3.20 to 5.36 mm, strongly influenced by low resolved images in z-direction. Moderate volume changes are indicated by mean minimum and maximum Jacobian determinants of 0.44 up to 1.88. No deformation foldings were detected. The mean average divergence of the deformation fields range from 0.08 to 0.16 and the mean harmonic energies vary from 0.08 to 0.58. CONCLUSION: The proposed registration solutions enable the combined use of information from multimodal imaging and provide an excellent basis for patient assessment and primary planning for liver radioembolization.

Predictive SIRT dosimetry based on a territorial model.

BACKGROUND: In the planning of selective internal radiation therapy (SIRT) for liver cancer treatment, one major aspect is to determine the prescribed activity and to estimate the resulting absorbed dose inside normal liver and tumor tissue. An optimized partition model for SIRT dosimetry based on arterial liver territories is proposed. This model is dedicated to characterize the variability of dose within the whole liver. For an arbitrary partition, the generalized absorbed dose is derived from the classical partition model. This enables to consider normal liver partitions for each arterial perfusion supply area and one partition for each tumor for activity and dose calculation. The proposed method excludes a margin of 11 mm emitting range around tumor volumes from normal liver to investigate the impact on activity calculation. Activity and dose calculation was performed for five patients using the body-surface-area (BSA) method, the classical and territorial partition model. RESULTS: The territorial model reaches smaller normal liver doses and significant higher tumor doses compared to the classical partition model. The exclusion of a small region around tumors has a significant impact on mean liver dose. Determined tumor activities for the proposed method are higher in all patients when limited by normal liver dose. Activity calculation based on BSA achieves in all cases the lowest amount. CONCLUSIONS: The territorial model provides a more local and patient-individual dose distribution in normal liver taking into account arterial supply areas. This proposed arterial liver territory-based partition model may be used for SPECT-independent activity calculation and dose prediction under the condition of an artery-based simulation for particle distribution.