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This study aimed to evaluate the maximum bone scan index in the jaw (BSIJmax) before the development of clinical medication-related osteonecrosis of the jaw (MRONJ) in patients with prostate cancer. We retrospectively analysed 135 patients with prostate cancer and bone metastases who received bone-modifying agents (BMAs) between 2008 and 2025. Bone scintigraphy data were collected at baseline and during the BMA treatment. BSIJmax was calculated using computer-assisted diagnostic software (BONENAVI). Primary endpoints were BSIJmax in the maxilla and mandible before the clinical diagnosis of MRONJ, compared with baseline values. Secondary endpoints included area under the receiver operating characteristic curves (AUCs) for diagnosing MRONJ using BSIJmax in the maxilla and mandible. Among 135 patients, 27 developed MRONJ during a median follow-up of 74 months (interquartile range, 41-124 months). Mandibular BSIJmax values before the clinical diagnosis of MRONJ were significantly higher than baseline values (0.090 vs. 0.027, p < 0.001), whereas maxillary values showed no significant change. The AUC for mandibular BSIJmax in diagnosing MRONJ was 0.803. A mandibular BSIJmax cut-off of 0.033 yielded a sensitivity and specificity of 85% and 71%, respectively, for the diagnosis of MRONJ. The mandibular BSIJmax increased before the clinical diagnosis of MRONJ. The incorporation of BSIJmax into bone scintigraphy may enable early detection of MRONJ and timely intervention in patients with prostate cancer receiving BMA therapy.
This study aimed to externally validate the European Association of Urology (EAU) biochemical recurrence (BCR) risk stratification in a North American population after radical prostatectomy (RP) and radiation therapy (RT), where validation remains lacking despite prior European and Asian validation. We identified all patients with BCR after RP or RT between 1995 and 2023 from a North American institutional database and classified them by EAU criteria. Primary outcome was prostate cancer-specific mortality (CSM). We calculated Harrell's concordance indices (C-index) and used competing-risk regression to assess associations between EAU risk groups and CSM, comparing performance to multivariable models including age, clinical stage, Gleason grade, PSA doubling time and time to BCR. Among the 940 patients (646 RP, 294 RT; 40.5% African American), 563 (59.9%) had low-risk and 377 (40.1%) high-risk BCR. The 10-year cumulative incidence of CSM was 3.6% versus 12% for low-risk versus high-risk RP patients and 18.4% versus 49.5% for low-risk versus high-risk RT patients. EAU high-risk BCR was associated with increased CSM in both groups (RP: HR 2.83, 95% CI 1.47-5.46; RT: HR 3.98, 95% CI 2.43-6.53). The EAU classification showed moderate discrimination (Harrell's C-index 0.62 for RP, 0.69 for RT). Multivariable models including clinical variables demonstrated a Harrell's C-index of 0.76 for both RP and RT. This first North American validation confirms moderate EAU discriminative ability. For RP patients, low 10-year CSM in low-risk BCR (3.6%) supports surveillance. However, low-risk RT BCR showed substantial CSM (18.4%), exceeding high-risk RP (12%), suggesting current criteria inadequately stratify risk after RT.
To investigate the potential of the Haematuria Cancer Risk Score (HCRS) to improve the real-world investigation pathway for suspected bladder cancer. Data were retrospectively analysed for all consecutive patients referred with suspected urinary tract cancer on a faster diagnostic pathway to five UK institutions between January and April 2025. The HCRS cut-off score of ≥82 was used to define a 'HCRS high risk' population. The co-primary outcomes were the ability to calculate HCRS in the referred population from the information provided by primary care and the cancer detection rate. In total, 1944 referrals were received, median age of 71 years (IQR 61-78), 1186/1944 (61%) were male, and 1586/1944 (82%) had sufficient information to calculate the HCRS. Of the cohort with HCRS scores, overall 165/1586 (10%) had bladder cancer. The HCRS was ≥82 in 176/437 (40%) of those with non-visible haematuria (NVH); in total, 6/176 (3%) had bladder cancer; and using HCRS in the NVH group alone, no case of muscle-invasive bladder cancer (MIBC) would have been missed. The HCRS was ≥82 in 1062/1149 (92%) with visible haematuria (VH), of whom 150/1062 (14%) had bladder cancer. Adopting a strategy of using HCRS and upper tract imaging in combination for the whole cohort would have resulted in two cases of NMIBC being missed for the NVH cohort and one case of NMIBC being missed for the VH cohort. No cases of MIBC or upper tract urothelial cancer would have been missed. HCRS is a simple innovation, which demonstrates clear potential when combined with upper tract imaging to improve current UK risk stratification to determine which patients referred with haematuria need flexible cystoscopy.
The objective of this study is to evaluate the outcomes of an initial series of single-port robot-assisted ureterolysis (SP-RAU) in patients with retroperitoneal fibrosis (RPF). We prospectively collected surgical and clinical data from all consecutive patients undergoing SP-RAU at our institution between April 2016 and May 2024. The primary endpoint was the achievement of a stent-free status at 12 months. Overall, 16 patients (21 renal units) underwent SP-RAU with a minimum follow-up of 12 months. All five patients with bilateral disease were managed with a staged approach in two separate surgical sessions. RPF was idiopathic in 37% and secondary in 62% of cases. Four procedures (19%) were aborted due to extensive fibrosis or high vascular risk (one unilateral right, two unilateral left and one second-stage left unit). These patients had significantly longer preoperative stent duration (60 vs. 9 months; p = 0.006). Among the 17 completed procedures, no open conversions, intraoperative complications or transfusions occurred. Median operative time was 215 min (IQR 195-240), and median blood loss was 10 ml (IQR 10-20). Median length of stay was 11.5 h (IQR 7.8-26), with 52% of patients discharged the same day. At a median follow-up of 25 months (IQR 18-50), complete symptom resolution was achieved in 82% of renal units, whereas 64% remained stent-free at 12 months. The main limitations are the small sample size, single-surgeon experience and absence of a comparator arm. SP-RAU is a safe and feasible minimally invasive option for managing RPF. It achieves good functional success with minimal morbidity and enables same-day discharge in over half of patients. Larger multicentre studies with longer follow-up are needed to confirm these findings and establish the role of SP-RAU in the management of RPF.
Performing partial nephrectomy (PN) for suspected renal cell carcinoma (RCC) requires a careful clamping strategy to balance blood loss and postoperative kidney function. For better prediction of individual kidney perfusion, the proposed DIPLANN-tool visualizes arterial perfusion zones using 3D models from CT scans to support surgeons in planning selective clamping (SC). We hypothesize that using 3D perfusion zone (3DPZ) models allows for more frequent and more accurate SC during robot-assisted PN (RAPN). Furthermore, it might also benefit patients' health and insight. PODRACING (Planning Operative strategy using a Digital Renal Artery ClampING tool) is a multicentre randomized controlled trial, evaluating the potential benefits of 3DPZ models. Patients will be randomized 1:1 to either the experimental group (DIPLANN-tool + CT) or the control group (conventional CT alone). The primary endpoint entails planning and performing, as planned, an SC strategy. Key secondary endpoints include the performed clamping strategy (SC vs main artery clamping [MAC]) and the difference in kidney function at 6 months postoperative. Other secondary and exploratory outcomes include different aspects regarding patients' health, patients' insight and surgeons' benefits. All adult patients with cT1-2 N0 M0 renal cancer planned to undergo RAPN with multiphase CT scan with arterial phase available are eligible for inclusion. Apart from the availability of a 3DPZ model (during a preoperative study visit, while planning the surgical strategy and intraoperatively), study procedures are identical for the study group and control group. For the primary endpoint, the surgeon needs to lock his/her final clamping strategy on the study website. The surgeon can use his/her preferred operating method for RAPN (no limitations in surgical approach or robotic system) and postoperative hospitalization course. Postoperative visits entail visits at 1 month, 3 months, 6 months and 12 months. The trial is registered on ClinicalTrials.gov with identifier NCT06536439.1 The study was approved by the Belgian Federal Agency for Medicines and Health Products. Eudamed number: CIV-23-11-044854.
Chronic idiopathic urinary retention and Fowler's syndrome are a debilitating problem primarily affecting women, characterised by an inability to urinate in the absence of any identifiable structural or other cause. An increasingly wide range of multifactorial predisposing, precipitating, and perpetuating biopsychosocial factors are being recognised. This has led to interest in nonsurgical treatments that may complement existing surgical approaches. We reviewed existing literature on nonsurgical management and combined this information with collective multidisciplinary professional and lived experience, to produce a new definition of chronic idiopathic urinary retention (the Fife Definition) and a framework for the assessment and nonsurgical treatment for women with chronic idiopathic urinary retention. The article provides a stepped care approach to nonsurgical treatment including explanation and formulation, basic bladder healthcare, optimising catheterisation, management of relevant comorbidities, multidisciplinary treatment and additional treatment options and emerging therapies.
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This study aims to externally validate the preoperative risk evaluation for partial nephrectomy (PREP) score, recently introduced to predict the risk of major complications after partial nephrectomy based on patient characteristics, in a large multi-institutional cohort of robot-assisted partial nephrectomy (RAPN) patients. A retrospective review was performed on the IRB-approved, multi-institutional United States Kidney Cancer Data Network (US-KIDNET) to identify 10 154 patients who underwent RAPN from 2018 to 2025. Major complications were defined as Clavien-Dindo grade III-V within 30 days. Patients were assigned to risk categories for major complications based on weighted comorbidities, as defined by the PREP score, and the alignment of predicted complication rates with actual complication rates was evaluated. Discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). Calibration was examined using the Hosmer-Lemeshow (HL) goodness-of-fit test. Subgroup analysis was performed by robotic platform and surgical approach. Exploratory univariate and multivariate logistic regression were performed to evaluate associations between individual PREP components and major complication rates. All computations were performed in Python (v3.8). A total of 8615 patients who underwent RAPN were included in the final validation cohort. The PREP score did not perform well in this robotic surgery cohort, with limited overall discrimination (AUC 0.547; 95% CI 0.518-0.580). On calibration, the model's predicted probabilities were not well-aligned with observed outcomes (HL χ2 = 150.2; p < 0.001). Performance did not differ significantly across robotic platform or surgical approach subgroups. In the adjusted analysis, coronary artery disease (CAD, aOR 2.22), chronic obstructive pulmonary disease (COPD, aOR 2.75), chronic kidney disease (CKD, aOR 1.48), and obesity (aOR 1.73) were independently associated with major complications, but not congestive heart failure (CHF; aOR 0.50, p = 0.36). Our real-world external validation for the PREP score demonstrates that this score does not perform well in a large, multicentre, robotic cohort. Our findings suggest that coefficient re-estimation, rather than simple recalibration, may be required.
To use real-world data to determine the clinical risk factors that are predictive of metastatic disease in high-risk prostate cancer (PCa) patients undergoing staging [68Ga]Ga-Prostate-Specific Membrane Antigen (PSMA)-11 positron emission tomography combined with computed tomography (PET/CT). Subjects with newly diagnosed PCa who underwent [68Ga]Ga-PSMA-11 PET/CT between 1/2/20 and 1/4/23, with one or more of three major risk factors (prostate-specific antigen (PSA) ≥ 20, MRI T-stage ≥ 3 or International Society of Urological Pathology (ISUP) grade ≥ 3) were included. Metrics collected included [68Ga]Ga-PSMA-11 PET/CT primary index tumour maximum standardized uptake value (SUVmax), TNM stage, tumour histology, patient age, body mass index and treatment type. A total of 525 subjects were eligible for inclusion. A total of 22.1% had nodal or distant metastases on the baseline [68Ga]Ga-PSMA-11 PET/CT (11.8% with one major risk factor, 25.6% with two and 43.5% with three). All three major risk factors (PSA ≥ 20, MRI T-stage ≥ 3, ISUP grade ≥ 3) and the presence of a higher percentage of positive biopsy cores were significant independent risk factors for the presence of metastatic disease on multivariable analysis. Primary index tumour SUVmax was associated with clinical risk factors, including ISUP grade in the surgical cohort. A total of 146 (27.8%) subjects underwent a radical prostatectomy, and 379 (72.2%) received non-surgical management (including 242 (46.1%) who received curative intent radiotherapy (RT)). This study provides real-world validation of the clinical risk factors used for the ProPSMA study for [68Ga]Ga-PSMA-11 PET/CT scan eligibility, which represent significant independent risk factors for the presence of nodal or distant metastases on baseline [68Ga]Ga-PSMA-11 PET/CT.
This study aims to investigate the role of urinary microbiota in renal cell carcinoma; we analysed urinary microbiota in kidney cancer patients and explored its potential role as biomarker. Samples were collected from 49 males (28 patients planned to undergo systemic therapy and 21 healthy volunteers). Two samples were collected from each patient, one prior to treatment and one after 8 to 12 weeks of systemic therapy. Microbiota was analysed by 16S rRNA sequencing. Microbiota diversity, taxonomic composition and relative abundance were compared between groups and longitudinal samples. Amplicon sequence variant (ASV) richness was higher in renal cancer patients (p = 0.042) than controls. Beta diversity also differed between patients and controls by means of Jaccard (p = 0.001), Bray-Curtis (p = 0.008), and nonweighted UniFrac metrics (p = 0.001). Acetobacter, Lacticaseibacillus, Alloscardovia, Brevibacterium and the family Propicionibactericeae had higher relative abundance in cancer patients, while Prevotella, Microbacterium and Sphingomonas were more abundant in controls. Beta diversity differed between pretreatment and posttreatment samples (p = 0.008). After systemic treatment, we found an increased relative abundance for Prevotella, Rothia, Bradyrhizobium, Methylobacterium/Methylobrum, Porphiromonas and Fusobacterium and a decreased one for the Burkeholderia-Caballeronia-Paraburkholderia group. Higher ASV richness was predictive of poor prognosis for RCC patients (p = 0.043) but not of treatment response. Urinary microbiota in patients with renal cell carcinoma differed from controls. Changes in microbiota composition were observed after systemic treatment. Urinary microbiota should be further investigated as a potential biomarker in renal cell carcinoma.
Reservoir placement during three-piece inflatable penile prosthesis (IPP) implantation is the step most commonly associated with serious intraoperative complications. The reservoir is traditionally positioned within the space of Retzius, where it lies in close proximity to the bladder, bowel and major pelvic vessels. Although injuries are uncommon, damage to these structures can result in significant morbidity, particularly in patients with prior pelvic surgery, radiotherapy or distorted pelvic anatomy. As prosthetic surgery expands to more complex patient populations, surgeons must be prepared to recognise and manage these complications when they occur. This review focuses on the intraoperative injuries associated with reservoir insertion during IPP surgery and provides a practical framework for their recognition and management. Bladder, bowel and vascular injuries are discussed with emphasis on intraoperative warning signs, methods of confirmation and immediate management strategies. Key principles of repair, haemorrhage control and involvement of specialist surgical teams are outlined. Guidance is also provided on intraoperative decision-making, including when reservoir relocation, staged implantation or procedure abandonment may be appropriate to minimise the risk of prosthesis infection and other complications. Alternative reservoir placement techniques are briefly discussed in the context of risk reduction, particularly for patients with hostile pelvic anatomy. However, the primary aim of this review is to provide pragmatic guidance for surgeons confronted with intraoperative complications during reservoir insertion. Early recognition, prompt management and a structured approach to intraoperative decision-making are essential to minimise morbidity and preserve the favourable functional outcomes associated with IPP surgery.
Treatment of upper tract urothelial carcinoma (UTUC) depends on risk stratification and tumour characteristics. Kidney-sparing surgery (KSS) is preferred for low-risk disease, whereas radical nephroureterectomy (RNU) is the standard for high-risk UTUC. Intravesical recurrences (IVR) are common after both treatment modalities, but their impact on survival remains unclear. To assess the IVR rate and cumulative hazard following UTUC treatment and oncological outcomes based on the presence of IVR during follow-up. Second, the relation between UTUC and IVR tumour grade in patients treated with endoscopic KSS (eKSS). A single-centre study, including non-metastatic UTUC patients treated between 2010 and 2023. Analysis was performed in a cohort of patients without a history of bladder cancer. In total 164 patients were selected; 85 treated with eKSS, 79 by RNU. Overall, 91 patients (55%) developed an IVR, 53 (62%) after eKSS and 38 (48%) after RNU, during a median follow-up of 33 months (IQR 11-72). eKSS-treated patients showed a significantly higher cumulative hazard for IVR (HR 0.6, 95% CI 0.42-0.95, p = 0.02). The CSS and MFS were comparable between patients with or without IVR during follow-up. In patients treated by eKSS, we found IVR upgrading in 24% of patients treated with eKSS. Patients treated by eKSS showed a higher cumulative hazard of IVR, without an impact on oncological outcomes. These findings support the use of kidney-sparing approaches in well-selected cases and highlight the need for proper follow-up including the bladder and evaluate IVR preventive measures as intravesical instillations.
This study aims to investigate the impact of high-grade complications (i.e., Clavien-Dindo Classification [CDC] Grade ≥III) on quality of life (QoL) and psychosocial distress (PD) in the early period after radical cystectomy (RC) and urinary diversion. The study relied on prospectively collected data of patients undergoing 3 weeks of inpatient rehabilitation (IR) after RC and urinary diversion (ileal conduit [IC] or ileal neobladder [INB]) between 04/2018 and 12/2019. Patients were surveyed on QoL (EORTC QLQ-C30) and PD (QSC-R10) by validated questionnaires at the beginning and the end of IR. Information about complications before the start of IR was taken from the hospital discharge letters and patient interview. Overall, 842 patients were enrolled. High-grade complications occurred in 25.5% of patients. Men (27.4% vs. 17.6%, p = 0.011) and patients with an INB (28.9% vs. 22.6%, p = 0.037) were significantly more susceptible to high-grade complications. At the beginning of IR, health-related QoL (HRQoL), role and social functioning were significantly lower in patients with a high-grade complication. Both HRQoL and the proportion of patients with high PD improved significantly during IR (p < 0.001, respectively). A multivariable linear regression analysis identified high-grade complications to significantly impact HRQoL (p = 0.013). Meanwhile, age (p = 0.001), INB (p = 0.019) and high-grade complications (p = 0.01) significantly contributed to PD. High-grade complications after RC and urinary diversion significantly impair short-term QoL and PD, warranting constant physical and psychosocial monitoring.
This work aimed to analyse the expression of and correlation between folate transporters FOLR1, FOLR2, SLC19A1 (reduced folate carrier, RFC), and FOLH1 (PSMA mRNA) in a large cohort of prostate cancer samples, with the goal of better understanding the nature of aggressive disease with low PSMA expression. A total of 55 329 radical prostatectomy (RP) tumour specimens tested with the Decipher prostate genomic classifier (Veracyte, CA) were identified from the Decipher GRID database (NCT02609269). Transcriptome-wide mRNA expression and baseline clinicopathologic data were retrieved. Logistic regression assessed associations between gene expression, pathological Gleason grade group (GG) 4-5, lymph node invasion (LNI), seminal vesicle invasion (SVI), and very high Decipher score (>0.85). This cohort had a median age of 65 years and PSA of 4.9 ng/mL. FOLR1and FOLR2 showed no correlation with PSMA. High FOLR2 and RFC were associated with very high Decipher scores and GG4-5. In the lowest 10% PSMA group, high FOLR2 correlated with high Decipher scores, GG4-5, LNI, and SVI (all p < 0.001). Limitations include the retrospective design and the inability to distinguish FR-β expression from immune cell infiltration. Our large-scale study of transcriptome demonstrates FOLR2 gene expression is associated with aggressive prostate cancer in samples with low expression of PSMA. Future prediction of disease risk could be enhanced by using FOLR2 as a molecular target for identifying aggressive prostate cancer in cases of low PSMA.
Radical cystectomy (RC) is standard for muscle-invasive disease (MIBC) and utilised frequently in high-risk non-muscle-invasive bladder cancer (NMIBC). Pelvic lymph node dissection (PLND) is routinely performed during RC for MIBC, demonstrating a survival benefit. However, the oncologic value in NMIBC remains uncertain. As such, a systematic review was conducted to determine whether PLND confers an oncologic benefit in NMIBC patients undergoing RC. A systematic search of MEDLINE, Embase and PubMed (January 1989-January 2025) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (CRD42023443011). Eligible studies included NMIBC patients undergoing RC with or without PLND. Data extraction and quality assessment (ROBINS-I, MINORS) were performed independently by two reviewers. Twenty-one retrospective studies (n = 35 793) met inclusion criteria. Lymph node positivity ranged from 0% to 13%. Comparative studies consistently demonstrated improved overall survival and cancer-specific survival with PLND, particularly among pT1 subgroups (pooled 5-year OS = 71.8%, 95% CI 59.3-84.3). Several studies demonstrated a dose-response association between lymph node yield or dissection extent and improved outcomes. Benefits were inconsistent for Ta/Tis disease. Pathological upstaging occurred in 16%-36% of clinically staged cohorts. However, study quality was moderate, with heterogeneity in PLND definitions, staging methods and adjuvant treatment use. PLND appears to improve staging and survival in high-risk NMIBC, especially pT1 disease. Routine PLND for low-risk Ta/Tis disease is unsupported. Standardised definitions of PLND extent and prospective evaluation are needed to confirm its therapeutic role.
Medical therapy is the first-line treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). However, predictors of treatment failure in men with small prostate volume (<30 ml) remain poorly defined. This study aimed to develop and temporally validate a simple bedside risk score for predicting medical therapy failure in this specific subgroup. We performed a retrospective cohort study of 201 men aged ≥50 years with IPSS ≥8 and prostate volume <30 ml who started medical therapy between 2015 and 2025. Treatment failure was defined as surgical intervention, acute urinary retention or IPSS worsening by ≥4 points. Independent predictors were identified using multivariable logistic regression. A practical integer risk score was derived from the strongest predictors. Temporal validation was conducted by splitting the cohort chronologically (derivation set 2015-2020, n = 120; validation set 2021-2025, n = 81). During a median follow-up of 24 months, 66 patients (32.8%) experienced treatment failure. Independent predictors included higher IPSS, greater BPH Impact Index, increased intravesical prostatic protrusion, lower maximum flow rate, higher post-void residual volume and diabetes mellitus. The bedside risk score stratified patients into low-risk (0-3 points: 11.0% failure), moderate-risk (4-7 points: 32.9%) and high-risk (8-13 points: 77.5%) categories. The model demonstrated good discrimination (AUC 0.789; bootstrap-corrected 0.782) and maintained strong performance in temporal validation (derivation AUC 0.799; validation AUC 0.821). This novel bedside risk score reliably predicts medical therapy failure in small-volume BPH using readily available clinical parameters. It may enable early risk stratification and timely intervention, particularly in populations with high diabetes prevalence.
This study aimed to investigate whether a machine-learning model improves the assessment of postsurgical recurrence-free survival in patients with non-metastatic clear cell renal cell carcinoma (ccRCC) compared with a Cox proportional hazards (CPH) approach. Patients undergoing curative surgery for non-metastatic ccRCC between 2010 and 2018 were identified from the DaRenCa Study-3, a nationwide register-based cohort study. Three recurrence prediction models were developed: an extreme gradient boosting (XGBoost) model, a feature-matched CPH model and a pathology-based CPH model. The data set was divided into training and test cohorts. Missing data were addressed using multiple imputation for the CPH models, whereas XGBoost handled missing values inherently. Model performance was evaluated using the concordance index (C-index) with 1000 bootstrap resamples. The XGBoost model was also compared with the Leibovich nomogram. Among 2782 patients, with a median follow-up of 7.3 years, 13.7% developed a recurrence. In the test cohort, the XGBoost model showed higher discrimination than both CPH models. Compared with the best performing pathology-based CPH model, XGBoost demonstrated a paired bootstrap difference in Uno's C-index of 0.022 (95% CI 0.005-0.038). The model also identified a subgroup of patients with a very low risk of recurrence (<3% after 10 years) and demonstrated improved clinical risk stratification, with clearer separation between risk groups, higher hazard ratios between groups and larger differences in 5-year recurrence-free survival compared with established models. This improved risk stratification could reduce follow-up imaging by approximately 11% compared with current EAU guideline recommendations. Limitations include the retrospective design and lack of external validation. The XGBoost model provided improved prediction of recurrence compared with CPH models and the Leibovich nomogram, supporting more precise risk stratification. With external validation, this approach may help reduce unnecessary imaging after surgery.
This study aimed to assess the association between body mass index and perioperative outcomes and survival after radical cystectomy for bladder cancer in an Australian cohort. We conducted a retrospective single-centre study of patients undergoing radical cystectomy between 2008 and 2021. Preoperative body mass index (BMI) was analysed categorically and continuously. Outcomes included overall survival (OS), Clavien-Dindo grade ≥2 complications and length of hospital stay. Survival was analysed using Kaplan-Meier methods and multivariable Cox regression adjusting for age, sex, tumour stage, nodal status and chemotherapy. Restricted cubic splines were used to explore non-linear associations. The cohort comprised 135 patients (median age 70 years; median BMI 27.2 kg/m2). Overweight patients had superior OS compared with normal-weight and obese patients (adjusted hazard ratio [HR] 0.42, 95% CI 0.24-0.76). Obesity was associated with higher complication rates and longer hospital stay (p < 0.05). BMI analysed as a continuous variable was not independently associated with OS. Spline modelling demonstrated no significant non-linear association, although the lowest estimated risk occurred in the overweight range. Overweight BMI was associated with improved survival following radical cystectomy, while obesity was linked to greater perioperative morbidity. These findings are consistent with the obesity paradox and underscore the limitations of BMI alone for perioperative risk stratification.
To compare oncological outcomes after extended pelvic lymph node dissection (PLND) versus limited in patients with high-risk prostate cancer (PCa) undergoing curative external beam radiation therapy (EBRT). From 3627 men with PCa at a single centre between 2000 and 2013, 167 with high-risk, age ≤75, Gleason score 6-10, clinical stage T1-T3, PSA < 100 ng/ml, no distant metastases (M1) and node-negative at the obturator fossa, underwent PLND before curative EBRT. Of these, 90 received limited, and 77 underwent extended PLND. Mean follow-up (SD) was 14.9 yr (5.8) for the limited and 12.3 yr (3.3) for the extended PLND. Primary endpoint was biochemical recurrence (BCR), secondary M1, cancer-specific mortality (CSM), overall mortality (OM). HR, KM and Cox regression models adjusted for age and Cambridge prognostic group (CPG) score. RR, RD at 11 yr. Extended PLND was associated with a significantly lower risk for BCR (HR: 0.51, 95% CI: 0.31-0.86, p = 0.01) (RR: 0.43, 95% CI: 0.26-0.69, p = 0.001), lower risk of M1 (HR: 0.22, 95% CI: 0.08-02.65, p = 0.006) (RR: 0.26, 95% CI: 0.09-0.73, p = 0.004) and lower CSM compared with limited PLND (HR: 0.31, 95% CI: 0.08-0.65 p = 0.035) (RR 0.27, 95% CI: 0.08-0.91, p = 0.028). OM did not differ significantly. Extended PLND prior to curative ERBT shows reductions in BCR, M1 and CSM long-term outcomes following extended versus limited PLND. Extended PLND can be considered in cases with high-risk PCa prior to curative EBRT.