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.
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 aimed to develop and evaluate MUSeg-PSV, a real-time deep-learning framework for segmentation of the prostate gland and seminal vesicles on 29-MHz micro-ultrasound (MicroUS), intended to support anatomical orientation during MicroUS-guided prostate biopsy and local staging of prostate cancer. MicroUS data from 14 patients (21 full-length videos; 2588 annotated frames) were used to train and test MUSeg-PSV, a lightweight single-stage convolutional model based on YOLOv11s-seg. Two training strategies were compared: a standard configuration with basic augmentations and an augmentation-rich configuration incorporating advanced spatial and photometric transformations. Model performance was assessed on a held-out test set using mean average precision (mAP), dice similarity coefficient (DSC), expected calibration error (ECE) and Brier score. Real-time feasibility was evaluated through inference latency and qualitative assessment of temporal consistency on unseen videos. The augmentation-rich model outperformed the standard configuration, yielding a 21% relative increase in mAP and a 4.6-fold improvement in seminal vesicle AP (0.183 → 0.842). Prostate DSC increased from 0.675 to 0.770 (p = 4.4 × 10-5), while seminal vesicle DSC remained robust (0.892 vs. 0.876), reflecting a controlled trade-off with substantially improved SV detection (AP: 0.183 → 0.842). Calibration improved markedly, with ECE decreasing from 0.558 to 0.156 and Brier score from 1.000 to 0.196 (p < 0.01). Qualitative evaluation confirmed smooth, temporally coherent overlays and consistent delineation of challenging anatomical regions. End-to-end latency (28-35 ms/frame; ~35 fps) demonstrated compatibility with real-time clinical deployment. MUSeg-PSV enables reliable, real-time multiclass segmentation of high-frequency MicroUS, providing stable delineation of the prostate and seminal vesicles at clinically viable frame rates. These results support the potential of AI-assisted MicroUS to enhance operator orientation during MicroUS-guided prostate biopsy and local staging, and to promote standardised identification of seminal vesicles within prostate cancer diagnostic and staging workflows.
To develop and validate machine learning models for predicting 30-day major morbidity and mortality in patients undergoing radical cystectomy (RC) using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) and to compare performance against a logistic regression model. We identified 11 241 patients from the ACS-NSQIP database 2020-2024 who underwent radical cystectomy. Demographics and comorbidities were extracted along with targeted variables from the NSQIP RC-targeted database. The cohort was split into a training and an independent validation dataset. Predictive models were developed for logistic regression, random forest (RF) and XGBoost. Model performance was evaluated using the area under the receiver operating characteristic (ROC) curve, SHapley Additive exPlanations (SHAP) analysis, sensitivity, specificity and Brier scores. Of 11 241 patients, 2691 (23.9%) experienced at least one major complication, and 185 (1.6%) died within 30 days. Overall complications were 6365 (56.62%). Non-survivors were significantly older (72.65 ± 10.14 vs. 68.50 ± 10.32 years, p < 0.001). Patients with major morbidity had lower mean albumin levels (3.92 ± 0.56 vs. 4.01 ± 0.48, p < 0.001). Logistic regression identified high BMI (OR 1.15, p < 0.001), black race (OR 1.34, p = 0.003), Hispanic ethnicity (OR 1.37, p = 0.009), prior pelvic surgery (OR 1.15, p = 0.002) and continent diversions (OR 1.46, p = 0.001) as predictors of 30-day major morbidity, while low frailty (mFI-5 ≤ 1; OR 0.72, p = 0.001) and higher preoperative albumin (OR 0.88, p < 0.001) were protective. For 30-day mortality, increasing age (OR 1.42, p < 0.001) was the strongest risk factor. For 30-day morbidity, the XGBoost model achieved the highest AUC 0.796 (95% CI: 0.783-0.814). For 30-day mortality, the RF model showed superior discrimination with an AUC of 0.921 (95% CI: 0.908-0.934). SHAP analysis showed predictors of major morbidity were frailty, BMI and advanced age, whereas predictors of mortality were age, ASA class and preoperative creatinine levels. Decision curve analysis showed net clinical benefit for all three models. The web-based tool can be accessed and used for prediction (https://cystectomyai.streamlit.app/). We developed and validated machine learning models for 30-day major morbidity and 30-day mortality following radical cystectomy. These findings support the integration of machine learning into clinical workflows to enhance preoperative counselling and personalized risk reduction.
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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 study aimed to evaluate the association between lesion echogenicity on micro-ultrasound (micro-US) and the presence and grade of prostate cancer. We prospectively analysed 229 prostate lesions from 181 men undergoing micro-US-guided transperineal biopsy at UCLA. Lesions were visually graded as hyperechoic, isoechoic or hypoechoic relative to the central zone, which served as an internal reference due to its consistent tissue characteristics and low malignancy risk. Biopsy targeting was confirmed by visualizing the needle tract within the lesion. The primary outcome was the detection rate of Grade Group (GG) ≥ 2 cancer across echogenicity categories. Secondary analyses included associations with PSA density and MRI-derived apparent diffusion coefficient (ADC) values, given that ADC is associated with tissue cellularity. Statistical comparisons were performed using chi-square and Kruskal-Wallis tests, with post hoc pairwise analyses where appropriate. GG ≥ 2 cancer detection rates increased with decreasing echogenicity: 22% in hyperechoic, 56.2% in isoechoic and 62.4% in hypoechoic lesions (p < 0.01). Hypoechoic lesions also exhibited a higher proportion of GG ≥ 3 cancers (p < 0.05). ADC values declined progressively from hyperechoic to hypoechoic lesions (median: 980, 851 and 751, respectively; p < 0.01), suggesting higher tissue cellularity. Regression analysis demonstrated no meaningful interaction between PRI-MUS and echogenicity. PSA density did not significantly differ among echogenicity groups. Lesion hypoechogenicity on micro-US is strongly associated with higher grade prostate cancer and lower ADC values, suggesting a link to tissue cellularity. These findings support the incorporation of echogenicity as a diagnostic marker within the micro-US PRI-MUS framework, potentially enhancing the accuracy of prostate cancer risk stratification.
Obesity rates are rising among prostate cancer patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). This review evaluates the anthropometric tools used to study this group and their correlation with surgical outcomes. Our objective is to identify which obesity metrics have been measured against clinically relevant surgical outcomes in patients undergoing RALP to enable more accurate risk stratification and improved patient counselling. Five databases (Ovid, Medline, Web of Science, Cochrane, Scopus) were systematically searched in March 2025 for studies examining obesity metrics and RALP outcomes. Inclusion criteria: English-language studies from the last 15 years with ≥15 patients undergoing transperitoneal RALP. Two independent reviewers screened articles and assessed bias using the Newcastle-Ottawa Scale. Data on anthropometric tools, patient demographics, obesity definitions and outcomes were extracted and analysed descriptively. Search strategy yielded 15 papers in total demonstrating that body mass index (BMI) is the only anthropometric tool used in surgical research to assess obese patients for relevant outcomes from RALP. Outcomes observed were categorised as functional, oncological and perioperative. Most studies examined a combination of all three. The data consistently utilises BMI to measure obesity in RALP patients, with numerous surgical outcomes explored in the literature. However, there is a paucity of studies examining alternative obesity metrics. Given the abdomino-pelvic site of prostatectomy, metrics that more accurately assess body fat distribution in this anatomical area may be more appropriate for research and clinical practice.
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 aims understand the outcomes following intradetrusor onabotulinumtoxinA injections and sacral neuromodulation (SNM) in a national cohort of male Medicare beneficiaries with overactive bladder (OAB). This is a retrospective cohort study of a 100% sample of fee-for-service male Medicare beneficiaries undergoing first-time onabotulinumtoxinA injections or SNM test procedures from 2014 to 2016. The primary outcome was repeat onabotulinumtoxinA injections within 1 year of index injections and placement of implantable pulse generator (IPG) within 90 days of a SNM test procedure. Overall, 11 286 male beneficiaries were included; 31.4% who underwent onabotulinumtoxinA injections had repeat injections within 1 year and 56.0% who underwent SNM test procedures had an IPG implant within 90 days. Repeat onabotulinumtoxinA injections were less likely among men who were ≥85 years (adjusted relative risk [aRR] 0.85, 0.75-0.96) versus ages 65-74. IPG implantation was more likely following staged versus percutaneous nerve evaluation (PNE; aRR 1.57, 1.50-1.64) and among beneficiaries in the lowest versus highest of socioeconomic quartile (aRR 1.10, 1.03-1.18). Rates of repeat treatments following index onabotulinumtoxinA injections among older men were lower than those previously reported among younger, predominantly female populations, whereas rates of IPG implantation were similar. Interestingly, frailty and comorbidity were not associated with these claims-based treatment outcomes following either procedure, but certain non-clinical variables were associated with IPG implantation following SNM. While these outcomes cannot distinguish symptom improvement from discontinuation because of lack of efficacy, adverse events or patient preference, they provide important insights into real-world treatment patterns for a patient population which is under-sampled in the OAB literature.
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.
To evaluate treatment patterns and inter-hospital variation of cT1a renal cell carcinoma (RCC) in seven Dutch teaching hospitals. In this historical multicenter cohort study, adults diagnosed with cT1a renal cancer (2019-2022) were identified through the Netherlands Cancer Registry. Clinical data were extracted from electronic records. Primary outcome was initial treatment. Descriptive statistics and subgroup analyses assessed variation. Logistic regression analyses identified factors associated with active treatment. We included 501 patients with 544 cT1a renal cancer tumours. Mean age was 66 years, 40% were overweight (BMI 25-29.9), and 40% had severe comorbidity (CCI ≥ 5). Active treatment was initiated for 65% of tumours, ranging from 44% to 85% between hospitals (p < 0.001). The types of treatment modalities used differed significantly between hospitals. This variation persisted after stratifying for comorbidity and tumour complexity. Independent factors associated with active treatment were Charlson comorbidity index (CCI) (OR = 0.77 95%CI [0.72-0.83], p < 0.001) RENAL Nephrometry score (OR = 1.16 95%CI [1.04-1.28], p = 0.006), and hospital of diagnosis (p < 0.001). After adjustment for case mix, hospital of diagnosis remained a significant predictive factor (p < 0.001). Study limitations include potential selection bias and limited generalizability. Substantial inter-hospital variation exists in cT1a RCC management, which is not fully explained by patient- or tumour characteristics. To reduce unwarranted variation and improve care, transparent care pathways, routine outcome measurement, shared decision-making and inter-hospital benchmarking are needed.
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.
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.
To evaluate the incidence and predictive factors of early penile prosthesis (PP) infection within a contemporary regional cohort in the North of England. A retrospective review of all PP implantations was conducted at a tertiary urology and andrology centre between 2018 and 2025, with variables including age, BMI, smoking, relevant comorbidities, pre-operative HbA1C, immunosuppressant use and device-related variables. Data were analysed using SPSS v29, with univariate logistic regression performed to identify factors of early infection (≤30 days). A p-value < 0.05 was considered statistically significant. A total of 103 patients underwent PP implantations. Mean age at implant was 59.4 ± 9.9 years. The comorbidity burden of diabetes, hypertension and dyslipidaemia was 35.0%, 49.5% and 39.8%, respectively, with mean pre-operative HbA1C at 45.6 mmol/mol. Notably, 9.7% of patients were on chronic immunosuppressive therapy. Early prosthetic infection was identified in six patients (5.8%). On univariate analysis, there was a strong association between immunosuppressant use and infection (50.0% vs 7.2%, p = 0.02; OR 12.0, 95% CI 1.7-85.0). The variables of age, BMI, diabetes, hypertension, dyslipidaemia, HbA1C and implant type were not associated with infection. In this contemporary regional study, early PP infection was identified in 5.8% of the cohort, with chronic immunosuppressant use being the dominant predictor of infection. Other metabolic, clinical and implant factors were not predictive of infection. This demonstrates immunosuppression being a persistent biological vulnerability requiring risk stratification and targeted perioperative strategies. Larger, prospective multicentre studies are required to further validate its impact and inform evidence-based infection-prevention protocols.
The objective of this study is to assess the efficacy, safety and change in quality of life associated with ICI-BCG (I + M) compared to BCG (I + M) in patients with BCG-naïve HR-NMIBC. A systematic search was run on PubMed, Embase and CENTRAL from inception to 29 October 2025. Phase 3 randomized controlled trials comparing safety, efficacy and quality of life (QOL) for patients with BCG-naïve HR-NMIBC receiving ICI-BCG (I + M) versus BCG (I + M): hazard ratios (HR) and 95% confidence interval (95% CI) for HG-RFS (high-grade recurrence free survival), odds ratio (OR) and 95% CI for Grade ≥3 treatment-related adverse events (G3 + TRAEs), and mean difference (MD) and 95% CI for changes in quality of life (QOL measured using EORTC QLQ C30). A priori defined subgroups included presence of CIS, presence of papillary tumours, age <65 or ≥65 years, male/female, and BCG strain. Pooled results indicated that ICI-BCG (I + M) was not associated with a reduction in HG-RFS (HR: 0.78; 95% CI: 0.59-1.02). However, on sensitivity analysis excluding ALBAN (for differences in trial design and patients included), ICI-BCG (I + M) was associated with a reduction in HG-RFS (HR: 0.68; 95% CI: 0.54-0.85) with an absolute risk reduction of 4.4-7.3% in 36-month HG-RFS. ICI-BCG (I + M) was associated with an increased risk of G3 + TRAEs (OR: 4.76; 95% CI: 3.01-7.53). ICI-BCG (I + M) was associated with a non-clinically significant decline in QOL (MD: -3.25; 95% CI: -5.11 to -1.39). Heterogeneity between trials was minimal (τ 2 < 1). Risk of bias was low in all included studies. This pooled analysis provides data for patient-specific counselling on the use of ICI-BCG (I + M) for BCG-naive HR-NMIBC.
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.
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.
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.