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.
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.
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Thulium fibre laser (TFL) offers a wide range of power settings during ureteroscopic (URS) lithotripsy, yet the impact of power selection on intraoperative laser-use dynamics remains unclear. The objective of this study was to characterise differences in laser activation patterns between low-power (LP) and high-power (HP) TFL during sheathless URS. This was a predefined secondary analysis of intraoperative laser data collected during a randomised clinical trial comparing LP (0.4-0.6 J × 10 Hz; 4-6 W) and HP (0.4-0.8 J × 20-40 Hz; 16-18 W) TFL URS lithotripsy. Flexible URS was performed without a ureteral access sheath. Laser system logs provided time-stamped activation and pause events with microsecond precision. Laser-use dynamics were characterised using a predefined set of complementary metrics, including active laser time (ALT), laser operating time (LOT), total activation count, activation durations, pause durations and operator duty cycle (ODC = ALT/LOT). Group comparisons used Holm-Bonferroni-adjusted p values. Data from 72 LP and 74 HP procedures were analysed. ALT was longer with LP (23 vs. 13 min; p < 0.001), whereas LOT was similar (31 vs. 30 min; p = 0.194). LP had a lower activation count (55 vs. 89; p < 0.001) and longer activations (median 24 s vs. 7 s; p < 0.001). Empirical cumulative distribution function analysis showed 89.4% of LP activations lasted ≤30 s compared with 97.2% for HP (p < 0.001). Total pause time was shorter in LP (8 vs. 14 min; p < 0.001), resulting in a higher ODC (73% vs. 49%; p < 0.001). LP and HP TFL lithotripsy result in distinctly different laser-use dynamics during sheathless URS. LP supported sustained, continuous lasing, whereas HP yielded fragmented activation requiring frequent pauses. Coupled with superior stone-free outcomes in the parent trial, these findings suggest that preserving clear endoscopic visibility and more active lasing may be more impactful than increasing laser power.
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.
There is no information regarding challenges faced by European urology residents in starting a family. The aim of this study was to examine pregnancy and parenting experiences and policies during urology residency, identify regulatory gaps and provide recommendations for standardized European guidelines. A cross-sectional English-language electronic survey targeted urology residents and young urologists across Europe. The 44-item, self-administered survey was pilot-tested and iteratively revised with European Society of Residents in Urology (ESRU) board members. Data were collected between August and October 2024 from ESRU, the European Association of Urology (EAU) and the European School of Urology (ESU) via mailing lists and social media platforms. From 387 respondents, 237 (61%) were females and 255 (66%) were residents. Written policies on pregnancy and parenthood management were reported by 112 (29%) respondents. Formal discussions on pregnancy and parenting were reported to be absent from 319 (82%) respondents, though 228 (59%) agreed about their importance. Among 250 non-childbearing participants, parenthood was postponed due to fears of missing training opportunities in 130 (92%) female versus 76 (86%) male respondents and due to fears of missing career opportunities in 122 (86%) female versus 62 (70%) male respondents. Concerns about falling behind peers in training were present in 119 (84%) female versus 58 (66%) male respondents (p < 0.001). Across all participants, 283 (87%) and 277 (85%) supported adjusting residency working and training schedules, respectively, upon return to work to ensure the completion of residency requirements. Both male and female respondents strongly endorsed standardized European guidelines on pregnancy and parenting in urology residency. This survey highlights the significant barriers to family planning in European urology residency. Fear of career setbacks and training disruptions drives parenthood delays. Standardized policies are needed to support residents while maintaining training requirements and career progression during pregnancy and parenthood.
Perineural invasion (PNI) detected on prostate needle biopsy is a well-established indicator of adverse pathology, while the prognostic role of PNI quantification has recently been suggested. We herein aimed to determine whether PNI quantification could universally stratify risks by separately assessing subgroups of patients based on biopsy Grade Group (GG). We quantified actual PNI foci in the entire systematic sextant biopsy specimens from 840 men, including 580 (69.0%) exhibiting no PNI and evaluated long-term oncologic outcomes following radical prostatectomy. PNI was detected in 1 (n = 177; 21.1%), 2 (n = 48; 5.7%) or 3-6 (n = 35; 4.2%) of 6 biopsy sites/parts, while 1 (n = 156; 18.6%), 2 (n = 53; 6.3%) or 3-10 (n = 51; 6.1%) PNI foci were present on each biopsy. In the entire cohort, we confirmed a significantly higher risk of biochemical recurrence in patients with PNI (vs. no PNI; P < 0.001), multi-site PNI (vs. single-site PNI; P < 0.001) or multifocal PNI (vs. unifocal PNI; P < 0.001). In subgroup analyses, significant differences in the risk of postoperative recurrence between the absence vs. presence of PNI were observed only in patients with GG3 or GG4 cancer. In contrast, the prognostic distinction between single-site vs. multi-site PNI or unifocal vs. multifocal PNI was evident in patients with GG2 or GG3 cancer, but not in those with GG1 or GG4-5 cancer. In multivariable analysis, multifocal PNI, but not multi-site PNI, was independently associated with worse recurrence-free survival in the GG2 (hazard ratio 5.866, P = 0.004) and GG3 (hazard ratio 2.716, P = 0.021) groups. Meanwhile, PNI on prostatectomy was confirmed in 98.1% of biopsy PNI-positive cases but was still detected in 72.2% of biopsy PNI-negative cases. Quantification of actual PNI foci across all systematic biopsy sites may provide valuable prognostic information, particularly in patients with GG2-3 cancer. Notably, the mere presence of biopsy PNI may not universally predict poorer outcomes.
The aim of this paper is to evaluate fellowship outcomes 10 years after implementation of the European Association of Urology Robotic Section (ERUS) structured curriculum for robot-assisted radical prostatectomy (RARP), with a focus on completion rates and reasons for non-completion. Data were obtained from institutional records and a trainee survey. The primary outcome was fellowship completion (i.e., Certificate of Excellence achievement). Secondary outcomes included reasons for non-completion and satisfaction. Completion rates were analysed annually, with trends assessed using the Cochran-Armitage test and log-linear regression for the Estimated Annual Percentage Change (EAPC). Comparisons before and after introduction of a procedural diary (2023) and between pandemic and non-pandemic years used Fisher's Exact Test. Among 126 fellows, a total of 42 (33%) completed the fellowship by achieving the Certificate of Excellence. The trainee survey achieved a response rate of 77%, supporting the representativeness of the collected data. The main barriers to fellowship completion included limited console access (49%), insufficient programme duration (20%), logistical difficulties (20%) and COVID-19-related disruptions (11%). Despite these limitations, overall satisfaction with the fellowship was high (83%), with particularly strong approval of the ORSI hands-on training week (100%). Completion rates demonstrated a progressive increase over time, rising from 20% in 2018 to 52% in 2023. The Cochran-Armitage test confirmed a statistically significant upward trend in completion rates over the study period (p < 0.001), while log-linear regression analysis showed a numerical but non-significant EAPC of 13% (95% CI -0.6 to 28.6). Although 2023 represented the highest observed completion rate, this peak was not significantly different from previous years (OR 2.63, 95% CI 0.91-7.63). The RARP ERUS Fellowship remains a benchmark in robotic training, but unsatisfactory completion rates highlight the need for improvement. Recent reforms, including the procedural diary, show promise and warrant expansion.
Urethroplasty remains the gold standard treatment of recurrent urethral stricture disease (USD). While the literature extensively discusses urethroplasty outcomes in various contexts, there remains a need for focussed exploration into its efficacy, specifically in cases arising from transurethral resection of the prostate (TURP)-related strictures. To evaluate and compare different anterior urethroplasty techniques and their effectiveness in a large homogenous cohort of USD secondary to TURP. A multicentre retrospective cohort study was conducted in three reconstructive urology centres in Poland, which are the referral centres for USD repair. This included patients who underwent urethral reconstruction surgery between 2015 and 2022 because of urethral stricture secondary to TURP. In all patients, the stricture was diagnosed and evaluated prior to urethroplasty by retrograde urethrography and/or voiding cystourethrography. Basic demographic and medical data including the length and localisation of the stricture, as well as details about performed urethral reconstruction and follow-up data regarding the recurrence of the stricture and reintervention were recorded. The primary outcome was re-intervention-free survival after urethroplasty. Statistical analysis was performed using STATA 18 (StataCorp). One hundred forty-seven patients underwent urethroplasty because of recurrent anterior USD secondary to TURP with a mean age of 69 years. Ninety-nine patients (67%) had a bulbar stricture, 35 (24%) had a penile urethra stricture, while 13 patients (9%) were diagnosed with penobulbar stricture. The mean length of the stricture was 24 mm, and it was significantly different among different localisations (penile - 30 mm, bulbar - 16 mm, penobulbar - 67 mm; p < 0.05). Half of the patients (73-50%) were treated with anastomotic urethroplasty (including transecting and non-transecting techniques), 60 (41%) with augmentation urethroplasty, seven (5%) with substitution urethroplasty and seven (5%) underwent perineal or penile urethrostomy. Follow-up data were available for 138 patients (94%). In the median follow-up of 19.5 months, 19 patients (13.8%) had another procedure because of the recurrence of USD. Longer stricture length was independently associated with an increased risk of recurrence. Around 103/120 patients (85.8%) were overall satisfied with the treatment. USD secondary to TURP can present with various clinical manifestations, with short bulbar strictures being the most common location. The outcomes of urethroplasty are highly favourable, resulting in high levels of patient satisfaction, but do not depend on surgical technique.
This study aimed to evaluate whether the preoperative FAN score-composed of the fibrosis-4 (Fib-4) index, albumin-bilirubin (ALBI) score and neutrophil-lymphocyte ratio (NLR)-predicts recurrence-free, cancer-specific and overall survival after radical cystectomy for bladder cancer. We retrospectively analysed 1121 patients who underwent radical cystectomy at 13 institutions between April 2010 and March 2024. Associations between the FAN score and recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) were evaluated. Prognostic performance was assessed in an independent cohort of 296 patients from three institutions. FAN score distribution was 0 (n = 600, 53.5%), 1 (n = 409, 36.5%) and ≥2 (n = 112, 10.0%). Patients with a FAN score ≥2 had significantly worse RFS (median: not reached vs 12.3 months; p < 0.0001), CSS (not reached vs 22.8 months; p < 0.0001) and OS (112.5 vs 16.1 months; p < 0.0001) than those with a FAN score ≤1. On multivariable analysis, a FAN score ≥2 was an independent predictor of poorer RFS (HR 2.12, 95% CI 1.55-2.91; p < 0.0001), CSS (HR 2.80, 95% CI 2.00-3.92; p < 0.0001) and OS (HR 2.70, 95% CI 2.03-3.59; p < 0.0001). These associations were consistently observed in an independent cohort of 296 patients. The FAN score is an independent prognostic marker of adverse outcomes after radical cystectomy for bladder cancer and may help stratify patients for perioperative management and follow-up.
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.
The aim of this study is to evaluate the feasibility and perioperative outcomes of robotic-assisted resection of selected non-genitourinary retroperitoneal tumours (RA-RTR) performed by urologists with established experience in robotic retroperitoneal lymph node dissection (RA-RPLND) within a specialised centre. A retrospective analysis was conducted of all patients undergoing RA-RPLND for testicular cancer and RA-RTR for non-genitourinary tumours between January 2022 and May 2025. Procedures for renal, adrenal and upper tract urothelial malignancies were excluded. All operations were performed using a four-port da Vinci Xi® platform. Forty-five patients were included: 27 RA-RPLND and 18 RA-RTR. RA-RTR patients were older (median 50 vs. 36 years, p = 0.024). Preoperative tumour size was larger in RA-RTR (56 mm vs. 20 mm, p < 0.001), although specimen dimensions were similar. Operative time was longer for RA-RPLND (143 vs. 90 min, p = 0.045). Estimated blood loss (40 vs. 20 mL, p = 0.077) and length of stay (1 vs. 2 days, p = 0.272) were comparable. No conversions or transfusions occurred. Complication rates did not differ (14.8% vs. 5.6%, p = 0.333), and all cases achieved negative margins. Comparable perioperative outcomes between RA-RTR and RA-RPLND indicate that these surgeries can be performed in specialised centres by urologists experienced in complex retroperitoneal 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.
This study aims to validate the diagnostic accuracy of a novel urine-based DNA methylation test in patients with suspected upper tract urothelial carcinoma (UTUC) on CT urography and to assess its potential to eliminate the need for diagnostic ureterorenoscopy (URS) in selected patients, expedite treatment and identify high-grade tumours suitable for neoadjuvant chemotherapy. We prospectively collected urine samples from 46 consecutive patients with suspected UTUC in computed tomography and analysed them using the Bladder CARE™ methylation test. Test performance was evaluated against final pathology from URS biopsies and/or surgical specimens. We performed Youden Index analysis to optimise diagnostic cut-off values and assessed correlations between Bladder CARE Index (BCI) levels and tumour characteristics, particularly grade differentiation. Using the manufacturer's cut-off (BCI > 2.5), the test demonstrated 95% sensitivity, 69% specificity, 70% positive predictive value and 95% negative predictive value (NPV), significantly outperforming cytology (11% sensitivity). An optimised, study-derived cut-off (4.35) further improved specificity to 92% with sensitivity and NPV remaining ≥95%. Importantly, a higher threshold (BCI > 10) yielded 100% specificity and 100% PPV, although at the expense of sensitivity (65%). Median BCI values differed between high-grade (38.6) and low-grade tumours (9.45), suggesting utility for non-invasive grade assessment. BCI also correlated with tumour size (β = 12 mm per log10 increase, p = 0.08). This novel urine-based DNA methylation test offers high diagnostic accuracy for UTUC detection. However, clinical interpretation should be threshold dependent. While BCI values >2.5 show high sensitivity, the PPV of 70% indicates a relevant proportion of false-positive results, and diagnostic URS remains warranted in this range. In contrast, high positive values (BCI > 10) demonstrated 100% specificity and PPV and could enable direct progression to definitive surgery without diagnostic URS, avoiding procedure-related complications and expediting treatment. The correlation with tumour grade addresses a critical need for identifying candidates for neoadjuvant chemotherapy without invasive tissue diagnosis.
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.
This study aims to evaluate the national trends in the surgical management of male stress incontinence (SUI) in the Australian population over the 21st century. Data was sourced from the Australian Institute of Health and Welfare (AIHW) national morbidity database and Medicare Benefits Schedule (MBS) statistics reports. Annual data from financial years (FY) 2000/01 to 2022/23 was collected. Male SUI procedures are grouped into slings, paraurethral bulking agents (PBA) and artificial urinary sphincters (AUS). The annual procedural counts, revisions and yearly changes were obtained. The estimated subsidy burden was reported as AUD per capita (per 100 000 persons). Between FY2000/01 and 2022/23, the aggregate number of male SUI procedures (excluding revisions) increased by 272% (from 288 to 1072). This is largely driven by the increase in AUS procedures, particularly amongst men aged 70-74 years. Male sling procedures demonstrated a substantial early increase followed by plateauing in recent years, while PBA declined over the same period. Revision procedures increased by 444% (from 41 to 223), largely due to AUS revisions and replacement. Over the same period, the estimated aggregate subsidy burden has increased from $13 749 to $53 269 per capita. The surgical management of male SUI in Australia has been transformative over the past two decades. Trends indicate an increase in male SUI procedures, particularly AUS procedures accompanied by an increase in AUS revision and replacement. These trends reflect both expanding surgical demand and durability of continence devices, which has subsequently led to a substantial increase in estimated subsidy burden.
This work aimed to investigate the role of surgeon experience on operating time and detection rate of clinically significant prostate cancer (csPCa) in a large contemporary cohort undergoing transperineal (TP) MRI-targeted prostate biopsy. We retrospectively reviewed patients who underwent TP MRI-guided prostate biopsies between 10/2018 and 04/2024. Patients with suspicious MRI lesions (PI-RADS 3, 4 and 5) formed the study cohort. All patients underwent MRI-targeted biopsies of suspicious lesions combined with a standard 12-core systematic biopsy. Caseloads-both total and in increments of 50 cases-were calculated for each surgeon. We employed univariable and multivariable Poisson regression models to analyse biopsy duration, and logistic regression models to assess csPCa detection. Out of 3336 MRI-guided TP biopsies, 1148 (34%) involved PI-RADS 3, 1398 (42%) PI-RADS4 and 790 (24%) PI-RADS 5 as index lesions. Most patients (55%) had one suspicious lesion. The median caseload per surgeon was 63 (IQR [interquartile range]: 30-110). Biopsy duration significantly decreased after the first 50 procedures (13 min [95% CI: 10-18] to 10 min [95% CI: 8-15]) and plateaued thereafter. Multivariable Poisson regression demonstrated increased caseload independently associated with shorter biopsy duration (IRR 0.891 [95% CI: 0.833-0.899], p < 0.001). The overall csPCa detection rate was 43%, with no significant correlation to caseload. These findings were consistent across subgroup analyses based on PI-RADS score. This large, contemporary study demonstrated that biopsy duration decreased significantly after approximately 50 cases, indicating a learning curve without compromising the detection rate of csPCa.
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.
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.
The aim of this study was to evaluate long-term safety, urological complication rates and quality of life (QoL) associated with urethral intermittent catheterization (IC) over a 5-year follow-up in adult, established, experienced subjects with longstanding IC use. Prospective, noninterventional, observational cohort study at three European sites. Adults (≥18 years) performing urethral IC with LoFric™ catheters for ≥6 years prior to enrolment were followed for 5 years. Outcomes included symptomatic urinary tract infections (UTIs), urethral strictures, bladder stones, prostatitis, epididymitis, patient-reported outcomes (PROs) and perception of catheters and IC. QoL, including pain and discomfort, anxiousness and depression, self-care and performing usual activities, was evaluated through the EQ 5DL questionnaire. Ninety-eight participants were enrolled (April 2015-August 2018); 49 completed 5-year follow-up (PP). Median age at inclusion was 61 years; 69% were male. Median follow-up was 5 years; mean prior LoFric use was 13 years (range 6-30). Neurological conditions comprised 51% of underlying aetiologies. Across 5 years, there were no significant changes in UTI frequency, other urological complications, EQ-5D tariff, or PRO ratings. At baseline, 59% (PP) reported ≥1 UTI in the prior 12 months versus 55% at Year 5 (p = 0.8036); mean UTIs decreased from 3.93 to 3.63 (p = 0.5434). Urethral stricture reports rose from 6% to 12% (NS). EQ-5D tariff remained stable (mean 0.86 at inclusion and Year 5). In adults with more than a decade of prior IC experience, continued use of hydrophilic LoFric catheters over an additional 5 years was associated with unchanged complication rates and stable QoL and PROs, supporting the long-term safety of IC as a bladder management strategy.