European urology focus最新文献

Background and objective: Up to 50% of patients with prostate cancer experience prostate-specific antigen (PSA) relapse following primary radical prostatectomy (RP). Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is increasingly being used for staging after RP owing to its high detection rate. Our aim was to compare outcomes for patients who received salvage radiotherapy (sRT) with versus without PSMA PET guidance.

Methods: In this observational case-control study, the control group consisted of 344 patients from the SAKK09/10 trial (sRT without PSMA PET guidance from 2011 to 2014). The treatment group consisted of 1548 patients from a retrospective multicenter cohort (PSMA PET-guided sRT from July 2013 to 2020). Data were collected up to November 2023. Patients with pN1 status at RP, initial cM1 status, cM1 status on PET, or PSA >0.5 ng/ml were excluded. Patients with detectable PSA after RP who were treated with sRT were eligible. We assessed 3-yr biochemical recurrence-free survival (BRFS) and metastasis-free survival (MFS).

Key findings and limitations: The study population of 717 patients comprised a control group (n = 255) with median follow-up of 75 mo and a PSMA PET group (n = 462) with median follow-up of 31 mo. In the PSMA PET cohort, 103 patients (22.3%) had PSMA-positive pelvic lymph nodes (PLNs), 85 (18.4%) received androgen deprivation therapy (ADT), and 104 (22.5%) underwent PLN irradiation. The BRFS rate at 3 yr was 71% (95% confidence interval [CI] 64-78%) for the control group and 77% (95% CI 72-82%) for the PSMA PET group. The PSMA PET group had favorable BRFS at 18-24 mo after sRT (hazard ratio 0.32, 95% CI 0.0.14-0.75; p = 0.01) and a lower rate of lymph node relapse after sRT (standardized mean difference 0.603). The MFS rate at 3 yr was 89.2% (95% CI 84.6-94.1%) for the control group and 91.2% (95% CI 88.1-94.4%) for the PSMA PET group.

Conclusions and clinical implications: Our results suggest a moderate improvement in short-term BRFS if PSMA PET is used to guide sRT. One possible reason is individualized PLN coverage facilitated by PET. MFS was not improved by PSMA PET guidance for sRT.

Patients' summary: For patients who experience recurrence of prostate cancer after surgical removal of their prostate, salvage radiotherapy (sRT) is a further treatment option. We found that a type of scan called PSMA PET (prostate-specific membrane antigen positron emission tomography) to identify recurrence and guide sRT can improve recurrence-free survival because of better targeting of pelvic lymph nodes that may contain cancer cells.

From bacillus Calmette-Guérin to cutting-edge research, the microbiome has played an integral role in urology treatments and will continue to do so for many generations to come.

Background and objective: Radical cystectomy (RC) is the standard treatment for muscle-invasive bladder cancer (MIBC). It is highly invasive and associated with perioperative risks, while bladder-preserving trimodality therapy (TMT) offers a less invasive alternative with preferable quality of life for selected patients. We aimed to compare oncological outcomes of TMT and RC in MIBC patients, and evaluate TMT-specific outcomes.

Methods: In December 2023, PubMed, Scopus, and Web of Science were searched for studies on MIBC patients treated with TMT. Pairwise meta-analyses were conducted to compare overall survival (OS) and cancer-specific survival (CSS) between MIBC patients treated with TMT and RC, utilizing hazard ratios (HRs). We included only matched cohort studies to minimize selection bias. TMT-specific outcomes, such as response, recurrence, and toxicity rates, were pooled separately.

Key findings and limitations: Eighty-seven studies (n = 28 218) were identified. No significant differences in OS (HR: 1.05; 95% confidence interval [CI]: 0.78-1.40) and CSS (HR: 1.05; 95% CI: 0.69-1.58) were found for TMT compared with RC. In patients treated with TMT, the complete response was achieved in 74.4% (95% CI: 69.1-79.1), the estimated rate of intravesical recurrence was 23.1% (95% CI: 19.0-27.7), and the rate of grade ≥3 acute toxicity was 11.4% (95% CI: 4.0-28.4).

Conclusions and clinical implications: The oncological outcomes of TMT were comparable with those of RC, with an acceptable toxicity profile. TMT appears as a safe and effective treatment for appropriately selected MIBC patients who want to preserve their bladder. However, evidence from high-volume controlled trials is needed.

Patient summary: Well-selected patients with nonmetastatic muscle-invasive bladder cancer can be treated with "trimodality therapy" to preserve the bladder. So far, the reported outcomes are comparable with those of radical surgery, and we found no signs of excess toxicity.

Standard laboratory cultures and biomarkers for urologic conditions have limitations that have led to great interest in microbiome testing in urology. Microbiome testing may play a role in clinical urology in the future in areas such as diagnosis of infections, biomarkers for diagnosis and prognosis of functional and oncological conditions, and targeted microbial modulation to augment existing treatment modalities and reduce disease risk.

Background and objective: The feasibility and safety of a robotic approach for postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in testicular cancer have been demonstrated, but data on long-term oncological outcomes of this procedure are limited. Our aim was to evaluate oncological outcomes following robotic PC-RPLND in this setting.

Methods: This retrospective cohort study included consecutive patients with testicular cancer treated with robotic PC-RPLND at 11 academic centers worldwide between 2011 and 2023. Patient characteristics, clinicopathological findings, and oncological outcomes were recorded. Recurrence-free survival (RFS) was estimated via the Kaplan-Meier method.

Key findings and limitations: A total of 173 patients were included, of whom 159 underwent pure robotic PC-RPLND; 14 cases were converted to open surgery. Among the pure robotic cases, 152 (96%) had nonseminoma, 122 (77%) had International Germ Cell Cancer Collaborative Group good risk, and 120 (76%) had a postchemotherapy mass size ≤5 cm. Salvage chemotherapy was received by ten patients (6%). Median estimated blood loss, operative time, and length of hospital stay were 100 ml, 300 min, and 2 d, respectively. Final pathology revealed necrosis/fibrosis in 64 cases (40%), teratoma in 78 (49%), and viable germ-cell tumor in 17 (11%). At median follow-up of 22 mo (interquartile range 7-50), eight patients had disease recurrence, which was in-field in three cases. One port-site recurrence was identified. The median time to recurrence was 7 mo. The 4-yr RFS rate was 93%. Two cancer-related deaths were recorded. Subgroup analysis revealed that patients with conversion to open surgery were more likely to have a larger preoperative mass and received salvage chemotherapy before RPLND. In addition, conversion to open surgery was associated with a higher rate of perioperative complications; however, oncological outcomes were statistically similar to those for pure robotic PC-RPLND. The main limitation of the study is its retrospective nature.

Conclusions and clinical implications: Robotic PC-RPLND in testicular cancer is associated with acceptable intermediate-term oncological outcomes in appropriately selected patients.

Patient summary: In this large multicenter study, we investigated the outcomes of robotic surgery after chemotherapy for advanced testicular cancer. We found that robotic surgery yields acceptable cancer control results.

Background and objective: The aim of our review was to comprehensively evaluate the impact of pulse modulation technology in the field of endourology, with a focus on laser lithotripsy and prostate enucleation.

Methods: A systematic search was conducted in the PubMed, MEDLINE, and Scopus databases for articles published during the past 20 yr (January 2004-July 2024). Article selection adhered to the Population, Intervention, Comparator, Outcome (PICO) framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In vivo, ex vivo, in vitro, and clinical studies that reported on the impact of pulse modulation technologies in laser lithotripsy or prostate enucleation in comparison to a standard references or as a standalone report, with a focus on stone ablation efficiency, safety, tissue ablation, and hemostasis, were eligible. A total of 29 articles were included.

Key findings: Pulse modulation is a feature mostly implemented for Ho:YAG laser generators. Preclinical studies on pulse modulation have demonstrated promising results for both stone fragmentation and laser-tissue interaction. Clinical studies that investigated technologies such as the Vapor Tunnel, Virtual Basket, and Moses have revealed better efficiency in comparison to the short-pulse modality. While there have been modest improvements in hemostasis and operating time, there has been no obvious improvement in outcomes after prostate surgery.

Conclusions and clinical implications: While in vitro studies have shown that pulse modulation improves stone fragmentation, reduces retropulsion, and maintains thermal safety, clinical outcomes are more variable. For prostate enucleation, the benefits are less consistent. Pulse modulation may improve efficiency, primarily by reducing operating times, but key outcomes such as stone-free and complication rates remain comparable to those with standard modalities.

Patient summary: Our review shows that pulse modulation technology improves the effectiveness and safety of laser treatments for kidney stones. However, the benefits of this technology for prostate surgery are still uncertain, highlighting the need for more research.

Background and objective: The European Association of Urology (EAU) Panel on Renal Transplantation released an updated version of the renal transplantation (RT) guidelines. This report aims to present the 2024 EAU guidelines on RT.

Methods: A broad and comprehensive scoping exercise covering all areas of RT guidelines published between May 31, 2020 and April 1, 2023 was performed. Databases covered by the search included Medline, Embase, and the Cochrane Libraries. Previous guidelines were updated, and levels of evidence and grades of recommendation were assigned.

Key findings and limitations: It is strongly recommended to offer pure or hand-assisted laparoscopic/retroperitoneoscopic surgery for living donor nephrectomy. One should not base decisions regarding the acceptance of a donor organ on histological findings alone, since this might lead to an unnecessary high rate of discarded grafts. For the ureterovesical anastomosis, a Lich-Gregoir-like extravesical technique protected by a ureteral stent is the preferred technique. A list of RT patients with a history of appropriately treated low-stage/grade renal cell carcinoma or prostate cancer should be made without additional delay. In the potential donor kidney, the main surgical tumoral approach is ex vivo tumor excision and finally transplantation. It is also strongly recommended to perform initial rejection prophylaxis with a combination therapy of a calcineurin inhibitor (preferably tacrolimus), mycophenolate, steroids, and an induction agent (either basiliximab or antithymocyte globulin). The long version of the guidelines is available at the EAU website (www.uroweb.org/guidelines).

Conclusions and clinical implications: These abridged EAU guidelines present updated information on the clinical and surgical management of RT for incorporation into clinical practice.

Patient summary: The European Association of Urology has released the renal transplantation guidelines. Implementation of minimally invasive surgery for organ retrieval and the latest evidence on transplant surgery as well as on immunosuppressive regimens are key to minimizing rejection and achieving long-term graft survival.

Background and objective: We analysed gender trends for urology trainees and consultants across nine European countries (Spain, UK, Netherlands, Norway, Germany, France, Belgium, Italy, and Switzerland) over a 10-yr period (2012-2022) to gain insight into gender dynamics in urology and determine if there is increasing representation of women in the profession. This information will help in the development of more effective strategies to promote gender equality.

Methods: Data from the past decade were collected, encompassing trainee and consultant records nationally. The project focused on gender demographics within the field of urology, looking at trends in the nine countries. Information was obtained from national registries and supplemented with additional data sources where necessary.

Key findings and limitations: Our results reveal significant variations in gender composition of urology trainees, displaying a slight increase in the presence of female trainees across most countries. This trend was particularly remarkable in Spain and Belgium where the proportion of female urologists exceeded 50%, indicating a potential generational shift within the field. Furthermore, among consultants, there was a global annual increase of 6.7% in female representation, with notable rises in the UK, France, Swiss and Belgium. These trends were also reflected in the membership affiliation data of the European Association of Urology during the same timeframe.

Conclusions and clinical implications: The observed growth in female trainees and consultants offers valuable insights for educational and workforce planning. It is important to understand the evolving dynamics in the field of urology, especially for trainee demographics. Furthermore, the potential engagement of this with more countries could provide a comprehensive view of urology trends across Europe and worldwide.

Patient summary: We looked at the proportion of urology trainees and consultants who are women across Europe. We found that overall, the percentage of females in these roles increased from 2012 to 2022, especially for urology trainees, but there are differences by country. Even if these trends continue, it will take many years before there is equal representation of men and women doctors in urology.

Background and objective: Surgical specialties account for a significant proportion of malpractice litigation claims and complaints to the regulatory body. The aim of our study was to analyse trends and outcomes for urology malpractice claims and complaints to the General Medical Council (GMC) in the UK over the last two decades.

Methods: Data were requested from the GMC and NHS Resolution under the Freedom of Information Act 2000. This included the number of malpractice claims in urology, including damages paid, and annual complaints about urologists to the GMC since 2006. For complaints to the GMC, demographics, case outcomes, and reasons for complaints were also provided.

Key findings and limitations: Over the study period, there was a 2.9-fold increase in successful (settled or closed) malpractice claims (from 2006-2007 to 2022-2023) and a 1.5-fold increase in complaints to the GMC about urologists (from 2007 to 2024). There were 2511 successful malpractice claims, resulting in a total payout of £145 million. The GMC received 1118 complaints regarding 1045 urologists, of which 26.0% (291/1118) were investigated, 2.4% (27/1118) resulted in a hearing, and 0.5% (6/1118) resulted in the doctor involved being erased from the medical register. Demographic distributions, including gender, ethnicity, and place of medical qualification, for the group involved in complaints differed significantly in comparison to the overall urologist population.

Conclusions and clinical implications: The numbers of successful urological malpractice claims and complaints to the regulatory body and associated costs have risen. A small proportion of complaints to the GMC led to a medicolegal hearing and subsequent erasure of the doctors involved from the medical register.

Patient summary: We analysed trends and outcomes for malpractice claims and complaints in urology over the last two decades in the UK. The numbers of successful urological malpractice claims and complaints and associated costs have risen, with a small proportion of doctors removed from the medical register.

Background and objective: Studies in metastatic nonseminomatous germ-cell tumor (NSGCT) suggest that the presence of teratomatous elements in the primary tumor is a risk factor for poor survival. Many guidelines have extrapolated this observation and recommend adjuvant retroperitoneal lymph-node dissection (RPLND) even for clinical stage I (CSI) teratoma confined to the testicle. Our objective was to assess relapse-free survival (RFS), cancer-specific survival (CSS), overall survival (OS) among patients with CSI pure teratoma in comparison to CSI NSGCT.

Methods: Patients with CSI NSGCT managed with surveillance between 1980 and 2023 were identified in the prospectively maintained Princess Margaret Cancer Centre database. We compared cases with pure teratoma with or without somatic transformation in the primary tumor to all other nonteratomatous NSGCTs.

Key findings and limitations: A total of 774 patients with CSI NSGCT were identified, including 63 (8.1%) with pure teratoma and/or somatic transformation in the primary tumor. Median follow-up was 61 mo. The pure teratoma group had superior RFS at 6 yr (85.2% vs 67.9%; p = 0.008). There were no significant differences in 6-yr CSS (100% vs 99.1%; p = 0.92) or OS (97.4% vs 98.1%; p = 0.33). Limitations include the single-center setting and the limited follow-up (median 61 mo), hindering the ability to detect late relapses.

Conclusions and clinical implications: CSI pure teratoma managed with surveillance is associated with a low risk of relapse overall and significantly lower risk of relapse in comparison to other CSI NSGCTs. No patients with CSI teratoma in the study population died of testicular cancer. Guidelines should be revised to include surveillance as a preferred approach for CSI teratoma.

Patient summary: We compared survival rates after testicle removal in clinical stage I testicular cancer for two different tumor types. We found that cancer-specific and overall survival rates were similar for pure teratoma tumors and nonseminoma tumors, and that the recurrence rate was lower for pure teratoma tumors. Our results support surveillance as a suitable option after surgery for patients with clinical stage I testicular teratoma.