European urology focus最新文献

Background and objective: Radiomics and artificial intelligence (AI)-based imaging models offer a noninvasive approach to preoperative risk stratification in localized renal cell carcinoma (RCC), where existing prognostic tools remain limited. We conducted a systematic review and meta-analysis to evaluate their predictive performance and methodological quality for recurrence and survival outcomes.

Methods: A systematic review was conducted in PubMed and Scopus from inception through April 2025. Radiomics and AI models were assessed for prognostic accuracy regarding 5-yr fixed-time recurrence-free survival (RFS) and overall survival after surgery for localized RCC. The extracted data included model type, radiomic features, validation methods, and area under the curve (AUC). Methodological quality was assessed using the APPRAISE-AI framework. Pooled 5-yr AUCs were synthesized using a prespecified random-effect model; heterogeneity was quantified (Q and τ²) and explored using a prespecified analysis restricted to external validation-only cohorts and sensitivity analyses.

Key findings and limitations: Thirty studies (n = 17 639) were included, predominantly retrospective and computed tomography (CT) based. The most predictive and frequently retained radiomic features were from the gray-level co-occurrence matrix and shape families. A meta-analysis of 20 radiomic model cohorts showed a pooled AUC of 0.87 (95% confidence interval [CI]: 0.84-0.90) for 5-yr RFS (Q = 271.08; p < 0.001; τ² = 0.0037). External validation cohorts showed a pooled AUC of 0.86 (95% CI: 0.83-0.88; Q = 12.81; p = 0.172; τ² = 0.0004). APPRAISE-AI revealed overall moderate methodological quality (median score: 54/100), with limited adherence to TRIPOD-AI and underuse of explainability tools.

Conclusions and clinical implications: Radiomic models for localized RCC built on standardized CT protocols and robust segmentation, and incorporating shape and texture features combined with clinical variables demonstrated high prognostic accuracy. Our meta-analysis confirms that such models predict recurrence and survival outcomes accurately.

Background and objective: Treatment options for metastatic or recurrent penile squamous cell carcinoma (PSCC) progressing after first-line platinum-based chemotherapy are limited, and no standard subsequent-line systemic therapy exists. We systematically reviewed the efficacy, safety, and survival outcomes of second- and later-line systemic treatments in this setting.

Methods: A systematic review, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, was performed across PubMed, Scopus, Embase, Medline, Web of Science, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL), and International Clinical Trials Registry Platform (from inception to June 2025). Eligible studies enrolled adult males receiving systemic chemotherapy, immunotherapy, or targeted therapy after progression on first-line treatment. The primary outcomes were overall (OS) and progression-free (PFS) survival; the secondary outcomes included objective response rate, disease control rate, duration of response, adverse events (AEs), and quality of life (QoL).

Key findings and limitations: Seventeen studies (seven nonrandomized trials and ten case series; 367 patients) were included. Evidence quality was low due to small cohorts, heterogeneity, and potential bias. The reported median OS ranged from 4.3 to 9.5 mo and PFS ranged from 1.3 to 4.8 mo. Targeted therapies showed the most favorable OS (6.7-9.5 months) and lowest grade 3-4 AE rates (0-30%), followed by immunotherapy and chemotherapy. Biomarker-driven benefit was observed in patients with human papillomavirus positivity, programmed death-ligand 1 expression, or actionable genomic alterations (eg, PIK3CA, RAD51, and NOTCH1). QoL data were reported in only two studies, underscoring a major evidence gap. Interpretation is limited by the absence of randomized studies, inconsistent reporting, and the inability to distinguish second-line from later-line therapies in most studies.

Conclusions and clinical implications: No standard systemic therapy exists beyond first-line treatment for metastatic or recurrent PSCC. Targeted agents and immune checkpoint inhibitors show encouraging activity in biomarker-selected subgroups. Prospective biomarker-guided trials and international collaborations are needed, while multidisciplinary management and clinical trial enrollment remain essential for optimizing outcomes for this rare malignancy.

Background and objective: Socioeconomic disparities in opportunistic prostate-specific antigen (PSA) testing for prostate cancer (PCa) are well known. To explore whether the introduction of organised prostate cancer testing (OPT) was associated with reduced disparities, we compared associations between socioeconomic status and PSA testing among invited and ineligible men.

Methods: A register- and population-based cohort study was conducted including all men in Stockholm County invited to OPT in 2022-2023 (OPT invitees, aged 50 yr, born in 1972-1973) and a concurrently ineligible control group (OPT ineligible, aged 52-53 yr, born in 1969-1971). A sensitivity analysis included men aged 50-51 yr in 2017-2018 (born in 1966-1968). Associations with PSA testing were analysed using logistic regression, with educational level, civil status, income, and birth country/region as socioeconomic indicators. Z tests compared associations between cohorts.

Key findings and limitations: A total of 33 754 OPT invitees and 76 535 OPT-ineligible men were included. PSA testing was higher among OPT invitees (39%) than among OPT-ineligible men (13%) across all socioeconomic strata. In adjusted models, higher education was associated with increased testing among OPT invitees (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.73-2.06), but not among OPT-ineligible men (OR 1.03, 95% CI 0.94-1.12; p < 0.001). Income was associated with increased testing in both groups, particularly among OPT-ineligible men (OR 3.56, 95% CI 3.28-3.87 compared to 2.18, 95% CI 2.01-2.37; p = 0.006). Being born outside the Nordic countries was associated with lower uptake among OPT invitees. The sensitivity analysis aligned with the main findings. Limitations include potential residual confounding.

Conclusions and clinical implications: While OPT increased PSA testing overall, socioeconomic disparities persisted. Targeted strategies are needed to ensure equitable participation.

Background and objective: Prostate-specific antigen density (PSAD) can improve the accuracy of the prostate cancer (PCa) diagnostic pathway when combined with multiparametric magnetic resonance imaging (mpMRI). However, it is unknown how the risk of clinically significant PCa (csPCa) at each PSAD value varies according to prostate volume in patients with positive mpMRI findings (Prostate Imaging-Reporting and Data System [PI-RADS] score ≥3).

Methods: The study included 1731 patients with positive mpMRI findings who underwent MRI-targeted biopsy (TBx) plus systematic biopsy (SBx). The predicted risk of csPCa as a function of PSAD was plotted to explore how the appropriate PSAD cutoff varies according to prostate volume.

Key findings and limitations: Overall, 30%, 48%, and 22% of patients had PI-RADS 3, 4, and 5 lesions, respectively. csPCa was diagnosed in 56% of patients. Overall, the median predicted risk of csPCa corresponding to PSAD of 0.10 ng/ml/ml was 37% for prostate volume <45 ml, and 15% for prostate volume between 60 and 100 ml. For PI-RADS 3 lesions, patients with a prostate volume <40 ml had csPCa risk of >10% irrespective of their PSAD. For prostate volume >40 ml, the PSAD cutoff corresponding to csPCa risk of 10% varied between 0.10 and 0.15 ng/ml/ml. The main limitations of the study include the retrospective design and the tertiary referral center setting.

Conclusions and clinical implications: The predictive value of PSAD for csPCa detection varies according to prostate volume. The added value of PSAD in detecting csPCa in men with PI-RADS 3 lesions is greater for those with prostate volume >40 ml.

Background and objective: The introduction of the purpose-built single-port (SP) robotic platform has paved the way for the development of regionalized surgical approaches, as evident by the advent of low anterior access (LAA) SP retroperitoneal robot-assisted partial nephrectomy (rRAPN). Our aim was to evaluate perioperative outcomes of LAA SP-rRAPN in comparison to the standard transperitoneal multiport (MP) robotic approach.

Methods: We performed a retrospective review of the institutional review board-approved, prospectively maintained database of the SP Advanced Research Consortium (SPARC) to identify all consecutive patients who underwent RAPN between 2015 and 2025. We applied 1:1 propensity score matching (PSM) for analysis to ensure comparable baseline characteristics, including comorbidities, renal function, and tumor complexity.

Key findings and limitations: Of 2306 patients, our PSM analysis included 302 LAA SP-rRAPN cases and 302 MP-RAPN cases. Following PSM, the two cohorts demonstrated comparable operative time, estimated blood loss, surgical margin status, and incidence of major postoperative complications. A history of abdominal surgery was more common in the SP group (55.1% vs MP 42.7%; p = 0.005). Postoperatively, the SP cohort had significantly shorter hospital stay (<24 h: SP 41.6% vs MP 10.9%; p < 0.001), lower postoperative pain (median highest pain score: SP 5 vs MP 6; p < 0.001), and less frequent need for opioids (SP 46.3% vs MP 93.1%; p < 0.001). Notably, no SP patients experienced postoperative ileus or respiratory complications such as atelectasis, pleural effusion, or pneumonia.

Conclusions and clinical implications: This study highlights the safety and efficacy of LAA SP-rRAPN, which has perioperative outcomes comparable to those for the transperitoneal MP robotic approach. Moreover, LAA SP-rRAPN offers additional benefits, including enhanced postoperative recovery with lower morbidity, and provides a viable surgical alternative for patients with complex abdominal surgical history.

Background and objective: We assessed long-term urinary continence (UC) and erectile function (EF) in patients treated with robot-assisted radical prostatectomy (RARP) and tested their effect on treatment decision regret (DR).

Methods: We identified 126 patients treated with RARP by a single high-volume surgeon between 2018 and 2021 with at least 4 yr of follow-up and complete functional assessment from a prospectively maintained institutional database. Patients were offered penile rehabilitation (PR) with phosphodiesterase type 5 inhibitors and/or intracavernosal injections, and pelvic floor rehabilitation (PFR) with physiotherapist support. UC was defined as the use of 0-1 safety pads/d. EF was defined as erection sufficient for sexual intercourse. DR was measured using the validated Decisional Regret Scale (DRS), which ranges from 0 (no regret) to 100 (maximum regret). Multivariable Cox and logistic regression models predicting EF/UC recovery and DR were fitted.

Key findings and limitations: The median age was 64 yr. D'Amico risk groups distribution was 12 (9.5%) low-, 62 (49%) intermediate, and 52 (41%) high-risk. At median follow-up of 51 mo, 57 patients experienced EF recovery and 102 experienced UC recovery. The group that received PR (n = 70, 56%) had a higher 48-mo EF recovery rate versus the group that did not receive PR (66% vs 22%; hazard ratio 2.9; p = 0.004). The majority of patients (n = 111, 88%) received PFR, and the 48-mo UC recovery rate was 83% in the overall cohort. Median DRS at last follow-up was 20, with low DR (DRS ≤15) reported by 50 patients (40%) and mild DR (DRS ≤25) by 78 (62%). Only long-term UC recovery was independently associated with mild DR (odds ratio 4.0; p = 0.010).

Conclusions and clinical implications: While PR correlated with better EF recovery, only UC recovery was the key determinant of DR after RARP.

Background and objective: This study compares 30-d perioperative outcomes between suction mini percutaneous nephrolithotomy (S-mPCNL) and nonsuction mPCNL (NS-mPCNL).

Methods: This prospective multicenter study involved 20 surgeons from 14 countries. The primary outcome was the 30-d stone free rate (SFR) on computed tomography. Propensity score matching (PSM) was used to adjust for baseline differences between the two groups. Multivariable logistic regression was used to evaluate factors associated with 100% SFR and the overall complication rate.

Key findings and limitations: PSM for 1915 patients (1534 S-mPCNL, 381 NS-mPCNL) yielded a cohort of 664 S-mPCNL and 309 NS-mPCNL cases for analysis. Baseline and stone characteristics were well matched. The 30-d 100% SFR (grade A) was high in both groups and did not significantly differ (85% vs 87%; odds ratio [OR] 0.97, 95% confidence interval [CI] 0.63-1.49; p = 0.9). The S-mPCNL group had a shorter median operative time (43 vs 57 min), higher intraoperative SFR according to visual inspection or fluoroscopy (82% vs 70%), and lower blood transfusion rate (1.3% vs 3.6%). There was no between-group difference in infectious complications. Multivariable analysis revealed that stone volume (OR 0.93, 95% CI 0.87-0.99; p = 0.021) and single-step dilatation (OR 3.28, 95% CI 1.85-5.81; p < 0.001) were significantly associated with grade A SFR. Limitations include variability in practice.

Conclusions and clinical implications: Suction during mPCNL improves intraoperative stone clearance rates and reduces the operative time, with no significant difference in 30-d SFR or infectious complications. Both S-mPCNL and NS-mPCNL achieve high rates of zero residual fragments.

Background and objective: Intravesical recurrence after induction bacillus Calmette-Guérin (BCG) therapy is common in non-muscle-invasive bladder cancer (NMIBC), but longitudinal, real-world data using contemporary definitions of the BCG-exposed (BCG-E) phenotype remain limited, which constrains trial design. We assessed long-term clinical outcomes and clinical trajectories for a large BCG-exposed cohort treated at a single tertiary care center to establish pragmatic benchmarks to inform patient counseling, surveillance strategies, and the design and interpretation of bladder-sparing studies.

Methods: We conducted a retrospective cohort study for adults with histologically confirmed high-grade NMIBC treated with intravesical BCG at Moffitt Cancer Center between 1988 and 2024. Relevant clinical data were extracted from electronic medical records into a prespecified database, including detailed BCG doses and timing and features of each recurrence episode. Initial management followed contemporary standards, with subsequent intravesical therapy or radical cystectomy (RC) after shared decision-making. Patients were classified as BCG-unresponsive (BCG-UR) or BCG-E, with BCG adequacy defined as previously published. Time-to-event endpoints were analyzed using Kaplan-Meier estimates and multivariable Cox proportional-hazards models; baseline characteristics were compared using Fisher's exact and Wilcoxon rank-sum tests.

Key findings and limitations: Of 1076 NMIBC patients treated with BCG, 470 were classifiable: 245 (52.1%) were BCG-E, of whom 173 (70.6%) were resistant and 72 (29.4%) experienced delayed relapse, and 225 (47.9%) were BCG-UR. In the BCG-E group, 50.2% experienced recurrence and 15.5% experienced progression; median recurrence-free survival (RFS) was 27.2 mo. The 5-yr survival rate estimates were 32.25% for RFS, 79.3% for progression-free survival (PFS), 84.5% for metastasis-free survival (MFS), and 65.0% for overall survival (OS). Recurrence was associated with worse PFS (p < 0.001) and MFS (p = 0.03), but not OS (p = 0.2). RC was performed in 45 patients (18.4%). No consistent survival differences were observed across salvage therapies (62.0% BCG, 18.4% gemcitabine + docetaxel, 5.3% single-agent chemotherapy, 1.2% trials, 13% surveillance),. Multivariable OS estimates were computed. Addition of recurrence to the model did not improve discrimination; age and performance status were the strongest predictors of OS.

Conclusions and clinical implications: We present comprehensive outcomes for and an in-depth characterization of clinical trajectories in BCG-E NMIBC, for which salvage intravesical BCG is predominant and oncologic results are durable. These data provide pragmatic benchmarks for the interpretation and design of bladder-sparing trials in this setting.