This review aims to provide a comprehensive analysis of the anatomy of the retroperitoneal and abdominal fascias. We analyzed papers published in the past 70 years in the databases of Pubmed, Embase and Scielo. We excluded case reports, editorials and opinions of specialists. Studies were excluded if they lacked clear anatomical descriptions of the fascias, if full-text access was unavailable, or if they were published in languages other than Portuguese, English, or Spanish. This narrative review addresses the anatomical integration, surgical techniques, and functional importance of the fascias. Renal fascia is a dense connective tissue encasing kidney, perirenal fat, adrenal gland; composed of anterior (Gerota's) and posterior (Zuckerkandl-related/renal) layers that fuse laterally and superiorly. Toldt fascia is a plane formed where the mesocolon (ascending or descending) fuses to the posterior parietal peritoneum / posterior abdominal wall. The lateroconal fascia is a lateral continuation of the renal fascia where anterior and posterior renal layers fuse to form a sheet toward the lateral abdominal wall and Fredet's fascia is a fusion plane between the visceral peritoneum of the hepatic flexure/transverse mesocolon and the anterior surface of the duodenum/pancreatic head (anterior to pancreatic head/duodenum) with a critical landmark in right colectomy.
Horseshoe kidney is an uncommon congenital fusion anomaly that can make renal tumor surgery especially challenging because of altered rotation, limited mobility, variable vascular supply, and an unpredictable collecting system (1-7). This video presents a robot-assisted partial nephrectomy for a high-complexity renal tumor in this setting. A 33-year-old man, with ECOG 0 and no relevant comorbidities, was diagnosed with a 7.5-cm solid renal mass in the central posterior portion of the left moiety of a horseshoe kidney. The lesion had a RENAL score of 10p. Contrast-enhanced computed tomography and three-dimensional reconstruction were used to understand the relationship between the tumor, aberrant vessels, renal hilum, and collecting system, supporting the decision to attempt nephron-sparing surgery (5, 8). Surgical technique and results: The procedure was performed through a transperitoneal robotic approach with the patient in right lateral decubitus using the Da Vinci Si platform. Port placement followed a standard renal robotic configuration, with a paramedian supraumbilical camera port, three robotic working ports along a craniocaudal lateral axis, a caudal fourth-arm port, and two medial assistant ports for suction, exposure, and support during renorrhaphy. After exposure of the horseshoe kidney and left hilar dissection, two arterial branches and one renal vein were identified. Tumor excision was performed under vascular control, with 20 minutes of warm ischemia and no collecting system opening, followed by two-layer absorbable renorrhaphy with adjunctive hemostatic agents. The operative time was 150 minutes. No transfusion, conversion, drain placement, or relevant immediate complication occurred. The urinary catheter was removed after 24 hours, and the patient was discharged 72 hours after surgery. Pathology showed clear cell renal cell carcinoma, Fuhrman grade 3, pT2N0M0, with negative surgical margins. During 12 months of oncologic follow-up, renal function remained stable and semiannual imaging showed no evidence of recurrence. Contemporary video reports have also emphasized the feasibility of advanced robotic renal surgery and complex partial nephrectomy strategies in selected patients (9, 10). In a carefully selected patient, robot-assisted partial nephrectomy supported by three-dimensional planning was feasible for a complex renal tumor in a horseshoe kidney, with negative surgical margins, preserved renal function, and no recurrence during 12 months of follow-up.
Kidney transplant units worldwide face the challenge of decreasing length of hospital stay (LOHS) after transplantation, while maintaining optimal outcomes and excellence in care. The Hospital-at-Home (HaH) model has already been applied with this goal after complex surgical procedures, but evidence in solid-organ transplantation is lacking. At our Institution, we implemented a protocol for early transfer at HaH for kidney transplant recipients (KTR) starting from post-operative day 4. We report herein the outcomes of the first 100 KTRs managed with this protocol, compared with a historical cohort from a time-period (2013-2019) when the HaH protocol was not operative yet. Controls were 1:1 matched with a propensity score (PSM) using a caliper of 0.05 on 13 key donor and recipients' characteristics, type of immunosuppression and delayed graft function. Results show no differences for 1-year rejection, renal function, patient and graft survival. Importantly, patients transferred to HaH had significantly shorter median LOHS (5[4-6] versus 9[8-15] days, P < 0.001). The median duration of HaH admission was 5[3-11] days. The combined duration of hospital plus HaH admission in the modern cohort (10[8-18] days) was not different from historical cohort LOHS (P = 0.117). Readmission rates at 30 and 90 days were similar between groups. This optimized management translated into lower costs of the HaH cohort (31874 ± 9114 versus 35780 ± 15720€, P = 0.033) for the whole transplantation process, mainly driven by reduced ward stay and in-hospital medication. We conclude that, in our experience, early transfer to HaH after transplantation optimized health-associated resources, while maintaining adequate clinical outcomes.
The Ureteral Stent Symptom Questionnaire (USSQ) is the gold standard for evaluating stent-related symptoms. While validated in multiple languages, no validated Greek version currently exists. To perform a cross-cultural adaptation, and psychometric evaluation of the Greek USSQ. The USSQ was translated and culturally adapted following established forward-backward translation methodology. A cohort of 100 patients with temporary ureteral stents was prospectively enrolled and completed the Greek USSQ at predefined time points. Psychometric evaluation included internal consistency, test-retest reliability, construct validity, convergent validity, and responsiveness after stent removal. Comparative correlation was performed using International Prostate Symptom Score (IPSS), International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS), and 36-Item Short Form Health Survey (SF-36) questionnaires. Internal consistency was good for urinary symptoms (α = 0.82), pain (α = 0.79), work performance (α = 0.77), and general health (α = 0.74), while sexual matters demonstrated moderate consistency (α = 0.68). Test-retest reliability was strong with ICC values ranging from 0.72 to 0.86. Significant correlations were found with IPSS (ρ = 0.68, p < 0.001), ICIQ-FLUTS (ρ = 0.52, p < 0.01), and SF-36 domains (ρ = -0.55 to -0.62, p < 0.001). All domains showed statistically significant improvement following stent removal (p < 0.001). The Greek version of the USSQ demonstrates strong reliability, validity, and responsiveness, confirming its suitability for clinical and research use in evaluating ureteral stent-related symptoms in Greek-speaking populations.
Despite superior accuracy of next-generation imaging (NGI) over conventional imaging (CI), its integration into prostate cancer management remains heterogeneous. We describe real-world imaging strategies for primary staging and restaging at biochemical recurrence (BCR) in the Spanish cohort of the RING registry, and identify clinical factors associated with NGI use and stage reclassification. RING is a prospective, non-interventional, multicentre registry. This analysis included 213 men from six Spanish centres (January 2025-January 2026) undergoing imaging for primary staging (n = 156) or BCR restaging (n = 57). Logistic regression evaluated predictors of NGI use and escalation to NGI after CI. Overall, 63/213 (29.6%) underwent CI only, 114/213 (53.5%) NGI only, and 36/213 (16.9%) both modalities. Among treatment-naïve patients, ISUP ≥ 4 independently predicted NGI use (adjusted OR 3.86, 95% CI 1.35-12.2; p = 0.015). In the BCR cohort, NGI predominated (89.5%). In the both-imaging subgroup (n = 36), CI-to-NGI escalation occurred in 33/36 (91.7%), with stage migration in 16/33 (48.5%): 7 upgrades (43.8%) and 9 downgrades (56.2%). Predictors of escalation were ISUP ≥ 4 (adjusted OR 7.3, 95% CI 1.81-37.5; p = 0.009), higher PSA (OR 1.9 per log2 doubling; p = 0.047), and younger age (OR 0.89/year; p = 0.017). NGI was the dominant strategy at BCR and in high-grade primary disease. When added after indeterminate CI, NGI reclassified staging in nearly half of patients, with both upgrades and downgrades observed. Further registry follow-up will determine whether imaging pathway influences treatment decisions and long-term patient outcomes.
To investigate the impact of stone composition on peroperative and postoperative outcomes in patients undergoing percutaneous nephrolithotomy (PCNL). We retrospectively analyzed data from 152 patients who underwent PCNL at our institution between January 2020 and August 2024. Patients were divided into subgroups based on stone composition: calcium oxalate, calcium phosphate, uric acid, cystine, and struvite. We compared peroperative and postoperative outcomes, including stone-free rates, complications, and the need for auxiliary procedures, between the groups. The overall stone-free rate was 63.8%. When complications were grouped as minor and major according to Clavien, no statistically significant difference was found between the groups in terms of patient characteristics, stone characteristics and perioperative techniques. When patient characteristics, stone characteristics and perioperative data were compared between stone compositions, statistically significant differences were found between the groups in terms of age, gender, comorbidity, The American Society of Anesthesiologists (ASA) score, stone size and stone density. Stone-free rates varied significantly based on stone composition (p = 0.024). There was a statistically significant association between stone composition and postoperative sepsis (p < 0.001). Stone composition can significantly impact stone-free rates and postoperative complications in patients undergoing PCNL. These results underscore the importance of considering stone composition when planning PCNL and tailoring treatment strategies (Figure 1).
Male infertility has been associated with various environmental, physiological, and genetic factors. In recent years, the widespread use of mobile phones has raised concerns regarding exposure to electromagnetic radiation (EMR). EMR emitted from mobile devices may adversely affect male reproductive function by inducing oxidative stress and impairing spermatogenesis. This study aimed to evaluate the potential protective effects of vitamin E and N-acetylcysteine (NAC) against EMR-induced testicular damage in rats. A total of 35 adult male Wistar rats were randomly divided into five groups (n = 7 per group): control, EMR exposure, EMR + NAC, EMR + vitamin E, and EMR + NAC + vitamin E. Rats were exposed to EMR generated by a mobile phone operating in the GSM frequency band (900/1800 MHz) in active call mode, positioned at a fixed distance of 15 cm from the cages, for 3 h daily over 28 days. The specific absorption rate (SAR) was based on manufacturer-reported values. Biochemical analyses were performed to assess total antioxidant capacity (TAC), glutathione peroxidase (GPX), superoxide dismutase (SOD), and malondialdehyde (MDA) levels. Data distribution was evaluated using the Shapiro-Wilk test, and group comparisons were conducted using the Kruskal-Wallis test with appropriate post-hoc analyses. Significant differences were observed among groups in terms of total antioxidant capacity (TAC) (p < 0.001). TAC levels were reduced in the EMR-only group compared to controls, whereas antioxidant supplementation (NAC and/or vitamin E) resulted in increased TAC levels. Post-hoc analyses demonstrated significant improvements in TAC in treatment groups compared to both control and EMR-only groups. However, no statistically significant differences were observed among groups for GPX, SOD, and MDA levels (p > 0.05). N-acetylcysteine (NAC) and vitamin E may exert partial protective effects against EMR-induced oxidative alterations in rat testes, particularly as reflected by improvements in total antioxidant capacity. However, given that other oxidative stress markers did not demonstrate statistically significant differences, these findings should be interpreted with caution. Further experimental and clinical studies with larger sample sizes and detailed histopathological evaluation are required to better elucidate the potential therapeutic role and clinical relevance of these antioxidant agents.
Nonmuscle-invasive bladder cancer (NMIBC) is a clinically heterogeneous disease, characterized by a high recurrence rate and a progression risk that are challenging to predict. Although traditional risk models based on histopathology and clinical staging are widely used, their ability to inform personalized treatment remains limited. Recent advances in molecular profiling have provided a more comprehensive understanding of NMIBC biology. This article synthesizes current evidence regarding the molecular determinants, highlighting their roles in enhancing prognostication and informing personalized therapy. Integrating these molecular insights into contemporary risk stratification frameworks is enabling treatment strategies that align with tumor biology to optimize patient outcomes.
The present study aims to identify risk factors and evaluate treatment approaches in adult patients diagnosed with pyelonephritis requiring hemodialysis. A comprehensive literature search was conducted using various electronic databases, published between 2004 and 2024. Totally, 24 articles reporting adult patients diagnosed with pyelonephritis who underwent hemodialysis were included. Risk factors and treatment modalities were categorized, and patient outcomes were grouped into recovered, deteriorated, or death after treatment. In the analyzed studies, 28 patients, middle-aged males, were predominantly diagnosed with emphysematous pyelonephritis affecting either right or left kidney, with Escherichia coli identified as the predominant pathogen in urine cultures. Key risk factors included poorly controlled diabetes, immunosuppression, renal transplantation, obstructive uropathy and recurrent urinary tract infection. All patients initially received conservative treatment with antibiotics, antimicrobial therapy, and fluid resuscitation. Minimally invasive procedures were used in 42.8% patients while 50% underwent surgical interventions. Of the 28 patients, 23 survived, with 21 recovering fully and 2 experiencing deteriorations. The findings of this study emphasize the importance of early identification of risk factors in patients with severe pyelonephritis requiring hemodialysis. Recognizing these factors at an early stage allows for timely and targeted interventions, which can potentially reduce complications and mortality among high-risk patients. In addition, identifying effective treatment methods aid in informed decision-making for managing severe cases. Since this study primarily includes case reports, all results are merely descriptive and intended to generate hypotheses. However, there is a need for large-scale and well-designed studies to better understand the impact of treatment approaches and to establish more evidence-based management strategies for patients with pyelonephritis requiring hemodialysis.
Ureteral calculi are a common cause of acute urologic morbidity, and semirigid ureteroscopy is a standard treatment when spontaneous passage fails. The relative effectiveness and safety of laser lithotripsy (LL) versus pneumatic lithotripsy (PL) remain clinically important questions. To compare LL (Holmium:YAG or Thulium fiber) with PL for ureteral stones in adults undergoing semirigid ureteroscopy, focusing on early stone-free rate (SFR) and key perioperative outcomes. We searched PubMed, Scopus, CENTRAL, and Google Scholar from inception to 4 September 2025 for randomized controlled trials (RCTs). Eligible studies included adults (⩾18 years) undergoing semirigid ureteroscopy comparing LL with PL. The primary outcome was early SFR (1-4 weeks). Secondary outcomes included operative and lithotripsy times, stone migration, complications, hospital stay, DJ stenting, auxiliary procedures, and late SFR (>4 weeks). Meta-analyses used fixed- or random-effects models as appropriate. Trial Sequential Analysis (TSA), Egger's test, Begg-Mazumdar, and trim-and-fill assessed robustness and publication bias. Certainty of evidence was evaluated using GRADE. The review was registered in PROSPERO (CRD420251207635). Eighteen RCTs (n = 2791) were included. LL significantly improved early SFR (OR 2.02; 95% CI 1.59-2.58) and late SFR, reduced stone migration, postoperative fever, overall complications, DJ stenting, and auxiliary procedures. Operative time and procedure-related injuries were similar, while lithotripsy time was longer for LL. TSA confirmed conclusive evidence for early SFR. No substantial publication bias was detected. GRADE rated evidence as high for early SFR and stenting. LL provides superior stone clearance and better overall clinical outcomes than PL, with comparable operative safety. It should be considered the preferred intracorporeal modality during semirigid ureteroscopy for ureteral stones.
To evaluate intrarenal fluid temperature (IFT) changes during high-power Holmium:YAG (Ho: YAG) laser activation using a 6.3 Fr single-use ureteroscope in an in vivo porcine model replicating human anatomy. Three female pigs underwent flexible ureteroscopy with and without ureteral access sheath (UAS), and with or without artificial stone presence. A 150 W Ho:YAG laser was applied at varying energy settings (10 W to 60 W) using a 200 μm fiber. IFT was recorded continuously for 30 s per condition using a thermocouple. A total of 192 measurements were analyzed, with 43 °C set as the thermal injury threshold. Across all configurations, IFT remained below 43 °C. Higher laser settings (40 W and 60 W) were associated with statistically significant IFT increases (P < .01), but without surpassing cytotoxic thresholds. The use of UAS consistently reduced IFT compared to conditions without a ureteral access sheath. The presence of stone slightly attenuated the temperature rise, potentially due to partial laser energy absorption. The 6.3 Fr ureteroscope demonstrated favorable safety across scenarios. In this in vivo model simulating renal anatomy, high-power Ho:YAG lithotripsy with the 6.3 Fr single-use ureteroscope did not result in thermal injury. UAS use and proper irrigation remain essential to controlling IFT. Findings suggest that device miniaturization combined with procedural awareness can enhance safety during high-power lithotripsy. Further clinical validation is warranted.
Obturator nerve reflex (ONR) remains a relevant intraoperative challenge during transurethral resection (TUR) of lateral wall bladder tumors (LWBT), even with bipolar technology. Identifying patients at increased risk may improve surgical safety and decision-making. We retrospectively analyzed 737 patients who underwent bipolar TUR between July 2019 and October 2025. Patients with LWBT were grouped according to the intraoperative occurrence of ONR. Demographic, tumor-related, and perioperative variables were compared. ROC analyses and multivariable logistic regression analysis were performed. Three hundred and four patients with LWBT were included, and ONR occurred in 36 cases (11.8%). Patients with ONR had significantly larger tumor size (50 vs. 25 mm, P = .006). In multivariable analysis, increasing LWBT size (OR:1.02, P = .041) and older age (OR:1.04, P = .048) were independently associated with ONR. ROC analysis demonstrated a modest predictive ability for tumor size (AUC = 0.643) and age (AUC = 0.614). A tumor size of approximately 30 mm and age ≥65 years provided clinically relevant thresholds for ONR risk. Overall complication rates, bleeding-related outcomes, and bladder perforation rates were similar between groups, although catheterization duration was longer in patients with ONR. Despite bipolar technology, ONR occurs in a meaningful proportion of patients undergoing LWBT resection. Larger tumor size and advanced age were independently associated with ONR risk, although their discriminatory ability was modest. These parameters may provide supportive information for preoperative risk assessment and help guide individualized consideration of preventive strategies.
To evaluate whether adding PSMA PET-detected lymph node involvement to established nomograms (Briganti-2019 and MSKCC) improves prediction of pathologic lymph node metastasis(LNM) in prostate cancer. Retrospective, registry-based, multi-center cohort coordinated by the Turkish Urooncology Association, with data from 10 centers. We included 301 men undergoing radical prostatectomy with extended pelvic lymph node dissection (ePLND) and preoperative 68Ga-PSMA PET/CT. For each nomogram, we fitted a baseline model and a model with the addition of PSMA PET nodal involvement (positive/negative). Discrimination (AUC) was compared using the DeLong test; model fit with the likelihood-ratio (LR) test; clinical utility with decision curve analysis (DCA). For Briganti-2019, AUC numerically increased from 0.744 to 0.828 (ΔAUC +0.084; DeLong P = .342), with improved fit (Δ-2LL 12.633; P < .001). For MSKCC, AUC numerically increased from 0.813 to 0.830 (ΔAUC +0.017; DeLong P = .620), with better fit (Δ-2LL 9.306; P = .002). DCA showed a consistent net-benefit gain for Briganti-2019 with PSMA PET across 5%-20% thresholds (largest around 15%), whereas gains for MSKCC were modest and confined to higher thresholds. Adding PSMA PET/CT nodal status improved model fit and suggested potential incremental clinical utility, particularly for Briganti-2019; however, statistically significant improvement in discrimination was not demonstrated by DeLong testing. PSMA PET/CT and clinical nomograms may be considered complementary tools for selecting candidates for ePLND.
The objective of this manuscript is to present intracavernous therapy to readers, serving as a model and guide for physicians on how to introduce and manage it in their patients. Furthermore, we propose a strategy designed to ensure maximum safety with minor complications and provide an effective implementation of intracavernosal injection (ICI) therapy for the management of erectile dysfunction (ED). While phosphodiesterase type 5 inhibitors (PDE5i) are recognized as first-line therapy, approximately one-third of patients do not achieve satisfactory clinical outcomes, highlighting the importance of ICI as a highly effective second-line option. This comprehensive review details patient selection, drug formulation, structured patient education, stepwise dose titration, management of adverse events, and longitudinal follow-up. This approach is intended to minimize treatment-related complications, enhance patient confidence and adherence, and optimize long-term therapeutic outcomes. By suggesting a standardized clinical application of ICI therapy, this review aims to address key barriers that currently restrict its broader adoption in routine clinical practice.
Predictive biomarkers for immune checkpoint inhibitors (ICIs) are largely identified retrospectively, but their prospective clinical utility remains unproven. Here, we report DUTRENEO, a prospective randomized phase 2 trial testing whether a retrospectively validated 18-gene bulk tumor inflammation signature (TIS) can guide neoadjuvant ICI therapy in muscle-invasive bladder cancer. The trial does not meet its primary endpoint, and this demonstrates that bulk gene-expression stratification does not sufficiently enrich for responders. To define the biology underlying this failure, we generate single-cell spatial transcriptomic profiles of 377 genes in ∼5.4 million cells across large tissue areas. Response is governed by spatial architectures invisible to bulk assays, including CD8+ T cell proximity to cancer cells, localized checkpoint co-expression within epithelial cancer-rich neighborhoods, and fibroblast-rich immune-excluded communities in non-responders. We provide a quantitative framework showing that ≥77 genes and ≥3-mm tissue diameter regions preserve predictive spatial signal at scalable throughput. The registration details of the trial are EudraCT 2017-002246-68.
To evaluate the prognostic value of tumor size in patients with low-risk upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). A retrospective multicenter European analysis was conducted on 3987 patients treated for UTUC at 17 academic institutions. After applying the exclusion criteria, 328 low-risk UTUC patients (pTaN0M0, low grade, unifocal, without hydronephrosis) were included in the analysis. Patients were stratified by tumor size in the RNU specimen: <1cm, 1-1.9cm, and ≥2cm. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were evaluated using Kaplan-Meier analysis. Univariable Cox regression analysis was used to evaluate the association between tumor size and disease recurrence. Because other confounding factors intrinsic to the study design were excluded, no multivariable analysis was performed. After a median follow-up of 4.2 [3.9; 4.5] years, 41 (12.5%) patients experienced disease recurrence. Kaplan-Meier analysis showed that tumors ≥2cm were significantly associated with lower RFS compared to tumors of 1-1.9cm and <1cm (81% vs. 95% and 97%, respectively; P<0.05). CSS and OS did not differ significantly among groups (all P>0.05). Univariable Cox regression analysis confirmed that tumor size ≥2cm was a significant predictor of disease recurrence with HR=7.18; 95%CI=[2.94-17.5]; P<0.001. Tumor size ≥2cm is associated with an increased disease recurrence in low-risk UTUC. These findings align with the European Association of Urology guidelines, supporting the inclusion of tumors up to 2cm within the low-risk category.
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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.