The 2026 European Association of Urology and American Society of Clinical Oncology (EAU-ASCO) guideline update reflects significant developments in the diagnosis and management of penile cancer. This review summarises the key changes and contrasts them with previous recommendations, with particular focus on staging, treatment, quality of life and emerging personalised approaches. The summary is based on a critical appraisal of the full 2026 guideline and its underpinning systematic reviews, with comparison to earlier versions. Recommendations were informed by structured literature assessment and expert panel consensus, incorporating evaluation of benefits and harms, evidence uncertainty and patient values. Major updates include refined pathological risk stratification, routine ultrasound (US)-guided nodal assessment, and broader guidance on organ-preserving surgery. There is support for selective genomic testing and clearer, restructured algorithms are introduced, including newly developed flow diagrams for nodal management, alongside an expanded evidence base for systemic therapy. Greater emphasis is placed on survivorship, centralisation of care and rationalisation of follow-up. However, many recommendations remain informed by retrospective data and expert consensus, reflecting the rarity of the disease and limited prospective evidence. The updated guideline promotes more nuanced selection of organ-preserving strategies, earlier detection of regional lymphatic disease, and holistic palliative care, while reinforcing the central role of shared decision-making. The new guidance for penile cancer aims to improve care, personalise treatment and better address quality of life, while acknowledging that further research is still needed.
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.
Aquablation is an innovative robotic waterjet procedure designed to treat benign prostatic obstruction (BPO) by combining real-time transrectal ultrasound (TRUS) guidance with automated tissue removal using water jets. With its increasing adoption throughout Europe, there is a crucial need for structured and validated training materials. This research represents an opportunistic expert evaluation conducted within a European School of Urology (ESU) educational setting and provides preliminary validity evidence by assessing the face and content validity of an Aquablation training simulator, focusing on realism, procedural accuracy, and suitability for training. A cross-sectional validation study was conducted involving expert endourologists who are familiar with Aquablation. Participants completed standardized questionnaires to assess face and content validity, using 4-point Likert scales. Descriptive statistics were computed, along with measures of internal consistency (Cronbach’s α) and Content Validity Indices (I-CVI, S-CVI/Ave, S-CVI/UA). Face validation demonstrated a high degree of realism and strong consensus across all items, achieving a Cronbach’s alpha of 0.92. Content validation showed excellent agreement, with an S-CVI/Ave of 0.91 and an S-CVI/UA of 0.50. Experts unanimously supported the model’s integration into structured Aquablation training programs. The expert validation confirms the simulator’s educational relevance and procedural accuracy, supporting its use as a training platform for Aquablation within lower urinary tract endoscopy education. Next steps will include defining curriculum components guided by CTA/Delphi and establishing objective performance metrics; subsequent work will evaluate construct and predictive validity across multiple centers. The online version contains supplementary material available at 10.1007/s11701-026-03388-4.
The European Association of Urology (EAU) produces an annual guidelines document based on the most recent evidence for the diagnosis, treatment, and follow-up of testicular cancer (TC). To summarize the 2026 version of the EAU Guidelines on TC and highlight the main changes compared to the previous version. A multidisciplinary team of clinicians with specific expertise in the disease (urologists, medical oncologists, radiation oncologists, and pathologists) reviewed the results of a comprehensive appraisal of the published literature on the topic since the last Guidelines update paper in 2023. Recommendations based on the highest available level of evidence are presented across TC stages, histologies and prognostic categories regarding diagnosis, primary management, detection and treatment of relapse and survivorship care. Areas of lack of strong recommendation consensus are highlighted. The 2026 version of the EAU Guidelines on TC collates the highest available scientific evidence to standardize the management of patients with TC.
Although individual rare and complex diseases (RDs) affect small patient populations, together they impact an estimated 27–36 million people across the European Union. Addressing this major public health challenge has been a long-term priority for the European Union, leading to the establishment of the European Reference Networks (ERNs) in 2017. ERNs are cross-border networks connecting clinical expert centres to share knowledge, improve and harmonise diagnosis and care for patients with rare and complex diseases. Since their inception, 24 ERNs have united 1,606 expert centres across 375 hospitals in all EU Member States and Norway. Their activities span multidisciplinary clinical collaboration, patient-centred governance, education and training, and the development of clinical guidelines. Over 4900 extremely rare or difficult cases have been discussed among experts without requiring the patients to travel abroad when expertise was not available in their own countries. A key factor for this success is the cross-border IT platform - known as the Clinical Patient Management System 2.0 - provided by the European Commission for medical discussions, which enables experts to share patient data, including medical images and lab results, in a secure and protected environment that is fully compliant with all relevant security and data privacy requirements. ERNs have demonstrated resilience in crises such as the COVID-19 pandemic and the war in Ukraine, providing rapid, coordinated responses to sustain care for vulnerable patient groups. The first formal evaluation in 2023 confirmed that more than 95% of member centres met quality standards, underscoring the networks’ maturity and effectiveness. Moving into the next phase, the Joint Action JARDIN (2024–2027) aims to integrate ERNs into national healthcare systems to ensure sustainability and equitable access to high-quality RD care. ERNs exemplify European solidarity and innovation in healthcare, transforming how rare disease expertise is shared and applied across borders. Their continued integration into national systems will be pivotal to achieving a truly cohesive European Health Union that delivers improved outcomes for all patients with rare and complex diseases.
To systematically evaluate management strategies and associated outcomes of iatrogenic ureteric injuries, focusing on clinical success, renal unit loss, and the need for subsequent endoscopic or reconstructive procedures. A pre-registered protocol (CRD420251184018) guided a comprehensive search of PubMed and EMBASE databases. Observational studies reporting outcomes of ≥20 patients treated for iatrogenic ureteric injury with complete data on follow-up were included. Risk of bias was assessed using Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I). Random-effects meta-analysis with PLOGIT transformation was applied, stratifying results by treatment type and timing. Meta-regression examined the association of treatment modality with outcomes adjusting for the timing of reconstruction. A total of 30 studies were included (1517 patients), all retrospective and characterised by substantial heterogeneity in definitions and follow-up practices. ROBINS-I indicated serious risk of bias in most domains. The pooled clinical success rate was 87% (95% confidence interval [CI] 80-91%), with high heterogeneity I2 = 76.0% due to different follow-up protocols, success outcomes, type and timing of management. Studies dominated by reconstructive procedures (15 studies) had higher success (91%, 95% CI 84-95%), than those primarily using endoscopic techniques (six studies; 66%, 95% CI 58-73%). Renal unit loss occurred in 2.3% (95% CI 1.5-3.6%). No differences in loss of renal unit were found. Additional endoscopic interventions were required in 3% (95% CI 2-4%) and further reconstructive surgery in 5% (95% CI 3-9%). Meta-regression showed endoscopic index management was associated with lower odds of success (odds ratio [OR] 0.14, 95% CI 0.05-0.40) and higher need for further reconstruction (OR 5.64, 95% CI 1.61-19.8). Across retrospective and heterogeneous studies, reconstructive-dominant management of iatrogenic ureteric injuries was associated with higher clinical success compared with endoscopic-dominant approaches, while renal unit loss remained uncommon. Endoscopic management was feasible in selected cases but was more frequently followed by additional endoscopic or reconstructive interventions.
Augmented reality and related extended-reality technologies have been increasingly investigated in urology to support procedures characterized by complex three-dimensional anatomy and limited intraoperative visualization. This review synthesizes recent original evidence on augmented reality/extended-reality applications in urology across clinical practice and training, with a focus on procedural planning, intraoperative guidance, and educational outcomes. A total 25 studies were identified. In Endourology, randomized studies in percutaneous nephrolithotomy (58-175 patients) showed improved anatomical understanding, shorter renal access times (50-60% reduction), changes in access strategy in 30% of cases, higher stone-free rates, and fewer intermediate-grade complications, with inconsistent effects on operative duration and fluoroscopy exposure using augmented reality/extended-reality applications.In robotic urology, most evidence concerns oncological surgery. Feasibility and comparative studies in robot-assisted partial nephrectomy (20-105 patients) confirmed rapid augmented reality co-registration and acceptable perioperative safety. In radical prostatectomy, comparative and randomized data (92-133 patients) suggested lower positive surgical margin rates at preserved neurovascular bundles and improved early continence recovery, without consistent differences in short-term oncological outcomes. Applications to pelvic lymph node dissection and highly complex renal surgery remain exploratory.Educational and training applications represent the most mature domain, with randomized and validation studies (12-43 trainees) consistently demonstrating improved technical performance, procedural efficiency, and reduced cognitive workload using immersive or mixed-reality platforms, including remote training solutions. Current augmented reality/extended-reality applications in urology show reproducible benefits in anatomical understanding, procedural planning, and selected technical steps, particularly in endourology and surgical training. Clinical outcome evidence remains heterogeneous and largely limited to short-term or surrogate endpoints, while broader adoption is constrained by technical robustness, workflow integration, and scalability. Ongoing randomized studies and advances in automation and artificial intelligence-driven registration are expected to better define the role of augmented reality/extended-reality in routine urological practice.
In ARASENS, risk of death was significantly reduced by 32.5% with darolutamide in combination with androgen deprivation therapy (ADT) and docetaxel (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.57-0.80; p < 0.001) in patients with metastatic hormone-sensitive prostate cancer (mHSPC). We assessed efficacy and safety of darolutamide in European patients from ARASENS. Patients were randomized 1:1 to darolutamide 600 mg or placebo twice daily in combination with ADT and docetaxel. Primary endpoint was overall survival. Secondary endpoints included time to metastatic castration-resistant prostate cancer (mCRPC), time to pain progression, time to first symptomatic skeletal event (SSE), time to initiation of subsequent systemic antineoplastic therapy, and safety. In ARASENS, 472 (36%) patients were from Europe; 240 received darolutamide and 232 received placebo. Patient baseline characteristics were similar to those of the overall population. Darolutamide reduced the risk of death by 37% (HR, 0.63; 95% CI, 0.48-0.83), and delayed time to mCRPC, time to pain progression, time to first SSE, and time to initiation of subsequent systemic antineoplastic therapy compared with placebo. Incidences of serious treatment-emergent adverse events (TEAEs) were lower with darolutamide versus placebo (37.9% vs. 43.1%) compared with the overall population (44.8% vs. 42.3%). In European patients with mHSPC, darolutamide improved overall survival and secondary endpoints including time to mCRPC and time to pain progression. Darolutamide was well tolerated with similar incidence of TEAEs between treatment groups. Efficacy and safety findings in European patients were consistent with the overall ARASENS population.
To synthesise current international guidance on lutetium-177-labelled prostate-specific membrane antigen (177Lu-PSMA) radioligand therapy (RLT) across the prostate cancer disease spectrum, with emphasis on metastatic castration-resistant prostate cancer (mCRPC) and emerging earlier-line indications. A structured literature overview was conducted. PubMed, EMBASE, and official repositories of major urological, oncological, and nuclear medicine societies were searched from inception to 31 October 2025 for prostate cancer guidelines. National and international guidelines or consensus statements published in English were eligible if they provided explicit recommendations regarding 177Lu-PSMA-RLT in their most recent version. Documents without therapeutic recommendations or superseded by updated versions were excluded. Six major society guidelines were included: European Association of Urology (EAU 2025), American Urological Association/Society of Urologic Oncology (AUA/SUO 2023), National Comprehensive Cancer Network (NCCN 2025), Canadian Urological Association (CUA 2024), American Society of Clinical Oncology (ASCO 2025), and European Society for Medical Oncology (ESMO 2020). The joint European Association of Nuclear Medicine/Society of Nuclear Medicine and Molecular Imaging (EANM/SNMMI 2023) procedural guideline and expert consensus from the Advanced Prostate Cancer Consensus Conference (APCCC 2024) were also reviewed. All societies except ESMO, which has not yet updated its guidance on PSMA-RLT, endorse 177Lu-PSMA-617 for PSMA-positive mCRPC following prior androgen receptor pathway inhibitor (ARPI) and taxane chemotherapy, supported by Level 1 evidence from the VISION and TheraP trials. Following PSMAfore, NCCN version1.2025, and more cautiously the EAU 2025 guideline, acknowledge expansion into taxane-naïve patients progressing after ARPI therapy. The recommended regimen remains 7.4 GBq every 6 weeks for up to six cycles with concurrent androgen deprivation therapy and multidisciplinary oversight. International guidelines largely converge on patient selection, dosing, and multidisciplinary implementation of PSMA-RLT. Ongoing trials including PSMAfore, PSMAddition, UpFrontPSMA, ENZA-p, and LuTectomy are expected to further define its role in earlier and combination treatment settings.
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Risk stratification of rhabdomyosarcoma (RMS) requires accurate staging, with histological nodal assessment being of critical importance for specific tumour sites. This report explores the value of surgical nodal staging in bladder-prostate rhabdomyosarcoma (BP-RMS). Patients with BP-RMS enrolled in the RMS2005 and MTS2008 trials (2005-2016) were reviewed for the staging methodology and outcome. Significant differences in 5-year overall and progression-free survival were observed for the 224 patients with BP-RMS of different Tumour-Node-Metastasis (TNM) stages (p<0.0001). Nodal staging was by imaging in all but 7/224 (3.1%) patients at presentation. Despite the opportunity for nodal sampling at surgery in 175 patients, no nodes were obtained in 120/175 (68.6%). Nodal sampling at surgery after 4-8 chemotherapy cycles in 48 patients, identified tumour in 6/37 (16.2%) patients considered N0 by imaging (all aged <10years with favourable histology >5cm tumours) and observed no tumour in 8/11 (72.7%) deemed N1, prompting changes to local therapy in 9/14 (64.3%). Overall, surgical nodal assessment did not impact on local/nodal progression/relapse (12/55, 21.8%) as compared to staging by imaging alone (29/166, 16.9%, p=0.548; data missing for 3 patients). Pathological nodal assessment also failed to show benefit on locoregional events for patients with significantly poorer outcome, namely those aged >10years (p=0.446) or with unfavourable histology (p=0.613). The specific targeting of nodal basins by radiotherapy showed no impact on outcome (p=1.000). In contrast to other sites, surgical nodal sampling, undertaken in 24.6% (in 3.1% at diagnosis), does not significantly impact outcome of BP-RMS, despite imaging-pathological discordance prompting changes to treatment for affected patients.
'The climate emergency is also a health emergency' (England 2024). Climate change directly impacts the health of the human population through events such as earthquakes, flooding, heatwaves and drought, which increase the risk of injury, displacement, disruption of food supplies, infectious diseases and mental ill health (England 2024; Lenzen et al. 2020; Tennison et al. 2021; The Lancet Respiratory Medicine 2023). The impact on population health of these climate events, alongside indirect health consequences such as increased prevalence of respiratory conditions due to air pollution, places an increased burden on health services (Royal College of Physicians 2017). The environmental footprint of healthcare services contributes between 1% and 5% towards total global environmental impacts (Lenzen et al. 2020; Tennison et al. 2021). Reducing the impact of the healthcare system on climate change has the potential to benefit population health through improved air quality and diet, and increased activity levels (Mailloux et al. 2021). Due to the lack of systematic reviews which consider carbon emissions associated with the patient pathway within individual specialities, further research is needed to enable the identification and transformation of the most carbon-intensive clinical pathways, while ensuring future models of care can be delivered in a cost-effective manner without increasing emissions or compromising patient care. In 2008, the Climate Change Act set national targets for the 100% reduction of carbon emissions in England to 1990 levels by 2050 ('Climate Change Act' 2008). Within the United Kingdom, the National Health Service (NHS) has an important role in helping to achieve these targets, as the organisation accounts for 4% of England's carbon footprint (NHS England 2022). The UK government's Greener NHS team from NHS England asked the Exeter Policy Research Programme Evidence Review Facility to bring together and analyse research which assesses different ways carbon emissions resulting from hospital-led care can be reduced, without affecting the care patients receive in hospitals, at home and in clinics. Work focusing on identifying and delivering interventions to reduce carbon emissions within known carbon hotspots, such as NHS estates and facilities, travel and transport, supply chain, and certain medicines and medical and anaesthetic gases that have high global warming potential is already underway, alongside examining the effectiveness of different models of care delivery across all specialities (NHS England 2022; NHS Shared Business Services 2022). Evidence focusing on the effectiveness of interventions in reducing carbon emissions within secondary healthcare would be a useful complement to this work. An approach which considers the patient pathway may be beneficial in identifying interventions which consider wider healthcare systems and thus have a meaningful impact on reducing carbon emissions. This review was commissioned by the Greener NHS team and could serve as a useful case study for wider net-zero ambitions elsewhere in the world. We aimed to carry out a systematic review examining the effectiveness of interventions in reducing the carbon footprint within specific medical specialities in secondary healthcare and explored where this evidence could inform the patient care pathway. In July 2023, we searched a selection of bibliographic databases with coverage of both health care and environmental science journals, including MEDLINE, Embase and Environment Complete, which we supplemented by inspecting the HealthcareLCA database, conducting forwards and backwards citation chasing on all studies which met our inclusion criteria, searching reference lists of topically relevant reviews, and searching Google Scholar and a selection of relevant websites. We included studies using any comparative study design evaluating any intervention intended to reduce the environmental impact of a procedure, process, treatment, or pathway delivered within secondary healthcare in the following specialities: cardiology, gastroenterology, obstetrics, oncology, ophthalmology, orthopaedics and trauma, radiology, renal, respiratory and high volume, low complexity surgeries (specifically: ear, nose, and throat [ENT], gynaecology and urology). We extracted descriptive data regarding study sample, intervention/control group, carbon emission methodology, PROGRESS-PLUS criteria (related to equity) and environmental, patient and cost outcomes. We appraised the quality of studies using life cycle assessment (LCA) methods with a predetermined scoring system informed by Weidema's (1997) guidelines (B.P.W. 1997). We synthesised findings from studies drawing on LCA methods and non-LCA studies separately using narrative synthesis. Within each group, studies were clustered into five broad intervention categories: (1) Accessing care, (2) Product level, (3) Care delivery, (4) Setting and (5) Multiple components. We examined and explained patterns across studies within the same speciality which evaluated similar interventions. We also developed an evidence and gap map (EGM) to highlight where evidence relevant to the review aims could inform a generic patient care pathway for each speciality and future research on lower carbon pathways. Input from the Greener NHS team at NHS England, LCA methods experts and patient and public representatives was incorporated throughout. Eighty-eight studies (92 articles) met eligibility criteria, 28 used LCA-informed methods to calculate carbon emissions (19 of these utilised a full LCA approach). Of the LCA studies, 9 were of Low risk of bias, 14 of Medium risk of bias and 5 of High risk of bias. Urology (n = 14), gastroenterology (n = 13), oncology/radiation oncology (n = 13) and renal (n = 11) were the most common specialities represented. Across different specialities, most evidence was found in the first three stages of the patient care pathway (Initial assessment/diagnostic tests, initial treatment, or routine follow-up). The exception was the renal speciality, where most evidence was within 'Ongoing care' segment. There was limited evidence within the 'Discharge' segment of the care pathway across all specialities. Evidence relating to the wider healthcare setting was clustered within gastroenterology (n = 5) and radiology specialities (n = 5). The two largest groups of evidence were for studies evaluating telehealth (n = 26) and reuseable equipment (n = 13) interventions. Telehealth interventions were predominantly evaluated using non-LCA methods (n = 23). While carbon-emissions favoured telemedicine interventions versus face-to-face care, these calculations often only considered patient-travel saved and did not account for carbon emissions associated with other parts of the delivery of the service, such as digital technology used or energy use of building or clinic equipment for face-to-face appointments, or wider impact on the patient care pathway such as potential need to travel for additional primary care appointments. The majority of patient and cost outcomes favoured telemedicine interventions, although most were based on non-statistical analyses. Interventions comparing carbon emissions associated with the use of reuseable versus disposable surgical equipment represented the largest group of studies using LCA methods. For studies within gastroenterology, reuseable equipment was associated with reduced carbon emissions. Within urology, this finding was reversed, although questions regarding the accuracy of use of characterisation factors, quantity of materials used in disposable versus reuseable equipment packs and how carbon emissions were assigned to the reprocessing of reuseable equipment mean confidence in this finding is uncertain. While waste management/reduction interventions were associated with reduced carbon emissions, interventions were highly heterogeneous, with limited consideration of patient or cost outcomes. Eight non-LCA studies found that reduced carbon emissions were associated with energy conservation interventions, such as turning equipment off when not in use or choosing imaging techniques with lower energy use, the majority of which were conducted within radiology/radiotherapy settings. This systematic review synthesises quantitative evidence evaluating the effectiveness of interventions intended to reduce carbon emissions within high-volume secondary healthcare specialities. It highlights a highly heterogeneous evidence base, and the methodological limitations associated with studies based on LCA and non-LCA methods. While we identified several large clusters of studies evaluating similar interventions within the same speciality, future research needs to address these methodological limitations to support confident decision-making within policy commissioning and clinical practice. Our EGM displays the included evidence according to individual speciality along the patient pathway, enabling evidence users to identify research which meets their requirements as well as identifying potential gaps where further research may be required.
The oncological risk of patients with Ta high-grade (TaHG) non-muscle-invasive bladder cancer (NMIBC) remains uncertain. We aimed to evaluate the oncological outcomes of TaHG patients treated with Bacillus Calmette-Guérin (BCG) by applying the 2021 European Association of Urology (EAU) and the American Association of Urology (AUA) risk stratifications and assessing the prognostic value of individual risk factors. We identified 529 TaHG patients without carcinoma in situ (CIS) treated with BCG from 16 tertiary centers between 2003 and 2024. BCG failure was defined as the development of BCG-unresponsive status, BCG relapsing status or identification of muscle invasive bladder cancer during follow-up. TaHG patients were stratified according to the number of EAU and AUA risk factors in three groups (0, 1, 2-3 risk factors), and in intermediate risk (IR-TaHG) and high-risk (HR-TaHG) according to both EAU and AUA risk stratifications. Cumulative incidence analyses and Cox regression models analyzed the 5-yr risk of HG-recurrence, progression and BCG failure among TaHG patients stratified according to the number of EAU and AUA risk factors. At a median follow-up of 40 months (IQR: 37-42), 114 (22%) TaHG patients experienced a HG-recurrence, 49 (9%) patients had progression and 107 (20%) had BCG failure. No differences in the risk of HG-recurrence, progression and rates of BCG failure were detected in TaHG patients stratified according to the number of EAU or AUA risk factors (all P < 0.05). No differences in the risk of 5-year HG-recurrence were observed between IR-TaHG and HR-TaHG patients according to both EAU (26% vs. 31%, P = 0.10) and AUA risk stratifications (24% vs. 29%, P = 0.07). Similarly, no differences in the 5-yr risk of progression were detected among IR-TaHG and HR-TaHG according to EAU (13% vs. 15%, P = 0.3) and AUA risk stratifications (12% vs. 15%, P = 0.2). No differences in the risk of BCG failure were observed between IR-TaHG and HR-TaHG according to both EAU and AUA risk stratifications (all P > 0.05). We observed no differences in HG-recurrence, progression, or BCG failure rates among patients with TaHG NMIBC, regardless of the number of EAU or AUA risk factors harbored. These findings may speculatively support the increasing need for BCG-adapted risk stratification and the consideration of all TaHG tumors without CIS as a homogenous population with a similar oncological risk, regardless of individual risk factors.
Thermal ablation offers a safer, less invasive, and more cost-effective curative-intent treatment for selected patients with primary and metastatic liver tumours than surgery; when done with appropriate technique, ablation can deliver similar oncological outcomes. However, effectiveness in routine practice varies because structured training, planning, and procedural governance remain scarce. These international multidisciplinary, multi-society guidelines-formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology-define key domains contributing to procedural difficulty and practice variation in liver tumour thermal ablation. A Delphi consensus initiative held in Innsbruck, Austria, engaged 72 experts across three iterative rounds of scoring across 135 statements grouped into five domains: credentialing, indications, approach, procedural factors, and safety measures. Consensus was achieved for 94 (70%) of 135 statements. The least invasive route-typically percutaneous-should be prioritised, and margin adequacy was reaffirmed as the principal technical goal. Procedural difficulty was considered context-dependent, shaped by tumour factors, institutional infrastructure, and operator experience. Organ displacement techniques were endorsed to maintain safety and expand treatable indications. Complex ablations should be done by experienced operators (more than 100 previous cases), with programmes underpinned by structured training, multidisciplinary team participation, and routine audit. Future efforts should develop and validate practical tools such as difficulty scoring systems, standardised procedural reporting templates, and comprehensive training curricula to improve consistency, standardisation, and clinical outcomes globally.
Current risk stratification for non-clear cell renal cell carcinoma (nccRCC) is largely derived from clear cell RCC (ccRCC) data. We evaluated recurrence patterns following surgery for nccRCC and compared the prognostic performances of various international guidelines. We retrospectively analyzed patients with surgically managed nonmetastatic nccRCC (2003-2015). Patients were stratified by American Urological Association (AUA), European Association of Urology (EAU), and National Comprehensive Cancer Network (NCCN) risk groups. Model performance was assessed via C-index, integrated Brier score (IBS), and calibration plots. Optimal surveillance duration was defined as the time required to capture 95% of recurrences and the time until the 10-yr conditional recurrence risk fell below 5%, accounting for non-RCC deaths as a competing risk. Papillary RCC (pRCC) was the most common subtype (420/712, 59%). Median follow-up was 11.6 yr (IQR: 133-148 mo). Recurrences occurred in 116 patients, most frequently in the abdomen (44/116, 38%). The 5-yr recurrence-free survival (RFS) was 86% (95% confidence interval [CI]: 83-89). Chromophobe RCC (chRCC) had the lowest stage-adjusted subdistribution hazard of recurrence (sHR) (sHR: 0.21, 95% CI: 0.12-0.40). AUA risk-stratification schema provided higher discrimination and lower prediction error (C-index 0.69, IBS 0.104) compared with that of EAU (C-index 0.67, IBS 0.118) and NCCN (C-index 0.66, IBS 0.115). Late recurrences (>5 yr) were common, comprising 27% of all observed recurrences. As a single-center, retrospective study, these findings may not be broadly generalizable. Surveillance duration metrics should be interpreted with caution. Outcomes in this predominantly pRCC and chRCC cohort challenge the current nccRCC surveillance guidelines: abdominal recurrences were the most common, supporting continued cross-sectional imaging. Late recurrences (>5 yr) argue against stopping surveillance at 5 yr and highlight the need for improved risk-adapted surveillance schedules. Current national guidelines for postsurgery follow-up for kidney cancer are based on its most common type. However, their appropriateness for less common forms remains unknown. This study shows that the less common form, non-clear cell renal cell carcinoma, primarily comes back after surgery in the abdomen and can often come back more than 5 yr postoperatively. Therefore, doctors should monitor these patients for a longer duration and focus on abdominal imaging to enable earlier detection. Advancing practice.
The European Association of Urology (EAU), American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines (GL) represent key international standards for clinical practice. We assessed the adherence to EAU-AUA- NCCN GL in a large real-world multicenter cohort of patients with Upper Tract Urothelial Carcinoma (UTUC), treated with nephroureterectomy. A multicenter retrospective analysis from the ROBUUST (ROBotic surgery for Upper tract Urothelial cancer STudy) registry was performed to assess the region-specific adherence rates to guidelines (GL) for perioperative treatments and their impact on oncological outcomes was evaluated with the Kaplan-Meier method. Out of 2307 patients, excision was the most adopted approach for bladder cuff management world-wide (USA 88.6%, EU 90.5%, Asia 89.8%). Postoperative bladder instillation (intravesical chemotherapy) was implemented in 28.4% of all cases and did not impact bladder recurrence-free survival (log rank P=0.45). Lymphadenectomy (LND) in high-risk disease was underused in both locally advanced (cT3-4: USA 35.8%, EU 46.8%, A 25%) and cN+ stages (USA 41.9%, EU 47.9%, A 43%). LND was not associated with better cancer-specific survival (CSS) across all stages (log rank P≥0.53). Adjuvant chemotherapy (AdCHT) was administered overall in 27.8% of pT2-T4 cases, with a significantly higher adoption in Asia (P=0.03); while in pN+ disease, AdCHT rate was 30.2% and did not convey any advantage in CSS (P=0.58). Retrospective design is the main limitation of the present study. The present contemporary "real world" data suggests poor adherence to current EAU-AUA guidelines for key indicators of quality care such as perioperative bladder instillation of chemotherapy, performance of LND and administration of adjuvant chemotherapy for advanced disease. These findings highlight the need of improving the implementation of these guideline driven treatment strategies.
Neoadjuvant therapy is well established for pure muscle-invasive urothelial carcinoma; however, its role in tumors with histological variants remains controversial, particularly outside European and North American cohorts. This study evaluated the impact of neoadjuvant therapy in Latin American patients with urothelial carcinoma and histological variants undergoing radical cystectomy. We conducted a retrospective analysis of patients who underwent radical cystectomy between 2005 and 2025 at a tertiary oncology center. Patients with urothelial carcinoma and histological variants identified on transurethral resection or cystectomy specimens were included. Clinical, pathological, and oncologic outcomes were collected. Survival outcomes were compared between patients treated with and without neoadjuvant therapy. The initial cohort included 733 patients, with a mean age of 67 years; 66.3% were male. The most frequent variants were squamous (56%), glandular (11.2%), and micropapillary (8%). Among patients receiving neoadjuvant therapy, complete pathological response (pT0) occurred in 10% (n = 5) and positive surgical margins in 12% (n = 6), compared with 4.65% (n = 6) and 18.6% (n = 24), respectively, in those treated with upfront surgery. No significant survival differences were observed in the overall cohort. In the squamous variant, pT0 was achieved in 8% (n = 2) of patients receiving neoadjuvant therapy versus 1.32% (n = 1) without it. In the micropapillary variant, pT0 rates were 16.67% (n = 2) with neoadjuvant therapy and 25% (n = 3) without, while nodenegative disease (pN0) occurred in 66.67% (n = 8) and 50% (n = 6), respectively. In the glandular variant, neoadjuvant therapy was associated with numerically higher pT0 rates (20% vs. 8.33%) and improved survival outcomes; however, these findings should be interpreted cautiously given the limited sample size and number of events. In this largest Latin American cohort to date, neoadjuvant therapy conferred a clear oncologic benefit only in patients with glandular differentiation. For other histological variants, upfront radical cystectomy remains the preferred approach when complete resection is feasible.
Bacillus Calmette-Guérin (BCG) immunotherapy remains the standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC). While the European Association of Urology (EAU) guidelines recommend initiating BCG treatment no later than 4-6 weeks following transurethral resection of bladder tumors (TURBT), delays in BCG administration are not uncommon due to factors such as pathological assessment timelines, patient-related issues, healthcare system limitations, and drug shortages. This systematic review aims to evaluate the impact of delayed BCG therapy or unconventional schedules on oncological outcomes, trying to establish the best treatment option for these patients. A comprehensive literature search was conducted across multiple databases (PubMed, Scopus, Web of Science) for studies published from January 2010 to the present. After screening 262 publications, relevant prospective and retrospective studies, systematic reviews, and meta-analyses were included. We retrieved 14 manuscripts evaluating different BCG schedule or doses. Only two papers specifically referred to the delay in the treatment of high risk NMIBC. The findings highlight that the delays in initiating the BCG therapy beyond 6 weeks are associated with worse recurrence-free survival (RFS), progression-free survival (PFS), and cancer-specific survival (CSS) rates. However, evidence on the progression to MIBC or metastatic disease remains inconclusive, with only a few studies suggesting a potential impact. Despite these delays, even reduced dose or shortened BCG regimens appear to offer some level of protection against disease progression. This review emphasizes the importance of adhering to standard BCG treatment schedules to minimize the risk of recurrence and suggests that, in cases of unavoidable delay, strict endoscopic follow-up is crucial and an optimal treatment in case of cancer relapse must be offered. Further prospective studies are needed to conclusively determine the long-term effects of delayed therapy.
Purpose To simulate an artificial intelligence (AI)-driven triaging workflow in which an AI system, using high-confidence thresholds, assesses a subset of prostate MRI examinations for clinically significant prostate cancer (csPCa), compare the assessment with stand-alone radiologists, and evaluate the number of examinations triaged by the AI to estimate potential workload reduction. Materials and Methods Data from an international AI confirmatory study (February 2022-November 2023) were used in this retrospective study. MRI examinations of 500 men with suspected csPCa from four European centers were included. Exclusion criteria were prior prostate treatment, prior csPCa, or considerable imaging artifacts. AI-triaging thresholds were calibrated on 100 examinations. The AI system assessed examinations exceeding high-specificity or high-sensitivity thresholds, with the remaining examinations deferred to radiologists. The workflow was simulated on 400 examinations, including examinations from an external site, incorporating assessments from 62 radiologists. Reference standards were histopathology and/or 3 or more years of follow-up. Sensitivity and specificity of the triaging workflow were compared with the conventional workflow using multireader, multicase analysis of variance. Results Among the 400 patients (median age, 66 years; IQR, 60-69 years) included for testing, radiologists achieved a sensitivity of 89.4% (95% CI: 85.8, 93.1) and specificity of 57.7% (95% CI: 52.3, 63.1). The AI-driven pathway maintained comparable sensitivity (89.0%; 95% CI: 85.0, 93.0; P = .36) but improved specificity by 11.5%, reaching 69.2% (95% CI: 64.4, 74.0; P < .001). The AI system triaged and diagnosed 195 of 400 (49%; 95% CI: 173, 216) examinations with sensitivity of 94.7% (95% CI: 89.5, 99.9) and specificity of 94.7% (95% CI: 90.5, 98.9). Conclusion Triaging by this AI system improved simulated diagnostic workflow efficiency without compromising diagnostic accuracy for csPCa. Keywords: Prostate, MRI, Localization, Oncology, Comparative Studies, Diagnosis Supplemental material is available for this article. ClinicalTrials.gov registration no. NCT05489341 © RSNA, 2026.
The indications for robotic surgery in urology continue to expand with the evolution of surgical techniques and technologies. The feasibility of combined robotic/laparoscopic surgery for the treatment of synchronous upper and lower urinary tract malignancies has been previously described. However, to our knowledge, this is the first reported series of robotic-assisted simple prostatectomy (RASP) and robotic/laparoscopic nephrectomies performed in a single operative session. Case 1 involves an 80-year-old non-Hispanic White man of European descent with a history of low-risk prostate cancer who presented with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), and renal cell carcinoma (RCC). Robotic-assisted partial nephrectomy (RAPN) and RASP were performed sequentially, with modified port placements that allowed reuse of several trocar sites. Case 2 involves a 75-year-old North African man with a history of bilateral polycystic kidneys and stage IV chronic kidney disease who presented with LUTS due to BPH and unilateral RCC. This patient underwent RASP and conventional laparoscopic radical nephrectomy (LRN) in a single operative session. The total operative time was 221 min for Case 1 (94 min for RAPN and 77 min for RASP) and 255 min for Case 2 (104 min for LRN and 95 min for RASP). The estimated blood loss was 100 ml and 80 ml, respectively, with no transfusions required. Case 1 was discharged on post-operative day (POD) 1. Subsequent follow-up demonstrated alleviation of LUTS and no evidence of cancer recurrence. Case 2 was discharged on POD 3, with ongoing oncological surveillance. These cases demonstrate that combined RAPN or LRN with RASP can be performed safely even in patients with significant comorbidities. The success of these cases can be attributed to meticulous preoperative planning and involvement of a multidisciplinary care team. When feasible, combined surgery may offer benefits such as decreased risks associated with anesthesia and shorter hospitalizations.