European urology focus最新文献

Background and objective: Aquablation and laser enucleation of the prostate (LEP) are treatments for alleviation of lower urinary tract symptoms (LUTS) that have not yet been directly compared in a prospective randomized trial. This study was designed to evaluate these treatments in terms of LUTS improvement and safety in men with large prostates.

Methods: WATER III is an investigator-initiated, international, multicenter, nonblinded, prospective noninferiority trial that includes randomized and nonrandomized participants. Eligible patients had moderate to severe LUTS and a large prostate volume (80-180 ml). The primary efficacy endpoint was the change in International Prostate Symptom Score (IPSS) from baseline to 3 mo. The primary safety endpoint was the incidence of Clavien-Dindo (CD) grade ≥2 or persistent CD grade 1 complications that had not resolved by 3 mo. Bayesian analyses were used to assess noninferiority.

Key findings and limitations: A total of 202 men were enrolled in the study, of whom 186 underwent surgery (98 Aquablation, 88 LEP). At 3 mo, data were available for 170 patients, including 66 randomized and 104 nonrandomized men. Both treatments showed similar mean IPSS improvement at 3 mo: -12.9 ± 6.9 with Aquablation versus -13.1 ± 7.5 with LEP, with an estimated difference of 0.93 (95% credible interval [CrI] -1.48 to 3.53) and noninferiority probability of >0.999. The incidence of CD grade ≥2/persistent grade 1 complications was 40.8% in the Aquablation group versus 56.8% in the LEP, with an estimated difference of -9.4% (95%CrI -31.8% to 12.9%; noninferiority probability 0.952). Retrograde ejaculation was less frequent after Aquablation (14.8% vs 77.1%; p < 0.001). Persistent stress urinary incontinence (SUI) was absent following Aquablation versus 9.3% after LEP (p < 0.05).

Conclusions and clinical implications: Aquablation demonstrated noninferior short-term LUTS relief and similar safety compared to LEP, with superior ejaculation preservation and avoidance of SUI in short-term follow-up.

Shared decision-making (SDM) is recognised as a cornerstone of patient-centred care, yet progress in embedding SDM in urology has been inconsistent. The European Association of Urology (EAU) Patient Office convened urologists, nurses, and patient advocates at two consensus meetings (Paris, France, March 2024; Rome, Italy, November 2024) to define core SDM principles and identify barriers to implementation. The outcome was the SHINE-URO framework, comprising six principles: open discussion of harms and benefits; exploration of patient values and goals; provision of clear and guideline-based information; creation of safe environments for sensitive topics; addressing misinformation and patient skills; and offering information before consultations. Key barriers to implementation included time constraints; accessibility and inclusion challenges; professional role concerns; underuse of "no treatment" as an option; and insufficient involvement of family members and caregivers. This multidisciplinary collaboration has delivered a consensus definition of SDM in urology and a roadmap for its implementation. Adoption of SHINE-URO in clinical practice requires system-level support, resources, and training to ensure equitable, patient-centred care. PATIENT SUMMARY: We developed a new framework for shared decision-making in urology called SHINE-URO. This framework focuses on clear information, patient values, and preparation before consultations. This will help patients in making informed choices about their care together with their doctors.

Background and objective: The increasing prevalence of benign prostatic hyperplasia leads to an ever growing number of surgeries in elderly patients, despite limited data on perioperative outcomes. The objective of this study was to analyze perioperative outcomes in patients older than 80 yr undergoing holmium laser enucleation of the prostate (HoLEP).

Methods: A retrospective analysis of 12 346 cases of HoLEP from 2008 to 2024 was conducted, identifying 1821 octogenarians. Propensity score matching was performed based on the following parameters: intake of anticoagulants, presence of a urinary catheter on the day of surgery, and prostate size. Perioperative outcomes and postoperative complications of a total of 1519 matched datasets were analyzed.

Key findings and limitations: In the unmatched population, patients older than 80 yr had larger prostates, took anticoagulants more often, and were more likely to have a urinary catheter at admission compared with younger patients (p < 0.001). After matching, these variables were well adjusted in both groups. Operating and catheterization times did not differ between both groups. The risk of a failed first voiding trial was significantly higher in octogenarians (12% vs 6.6%; p < 0.001) and led to a higher catheterization rate at discharge in the octogenarian group. No statistical difference was seen in other postoperative complications. Limitations are the retrospective study design and concomitant selection bias.

Conclusions and clinical implications: Our data indicate that HoLEP is safe in patients older than 80 yr and perioperative outcomes are generally comparable with those of younger patients. Octogenarians had a significantly higher incidence of a failed first voiding trial, which should be considered in postoperative management.

Background and objective: Transperineal (TP) prostate biopsy is increasingly favored over the transrectal (TR) approach because of a lower risk of infection, but comparative data on cancer detection remain limited. We analyzed a large institutional cohort to compare detection rates and disease location between the TP and TR approaches.

Methods: We included all men on active surveillance undergoing prostate biopsy at Memorial Sloan Kettering Cancer Center during the 26-mo transition from TR to TP. Data included demographics, biopsy method, histopathology, and magnetic resonance imaging (MRI) findings. The primary outcome was detection of high-grade cancer (Gleason grade group ≥2). Multivariable logistic regression was adjusted for clinical and imaging variables. Clustered standard errors were used to account for repeat biopsies.

Key findings and limitations: We identified 1387 biopsies performed in 1304 patients from January 2020 to February 2023. Among all biopsies, 522 (38%) contained high-grade cancer and 602 (43%) contained grade group 1 disease. The empirical rate of high-grade cancer detection was 39% with TP versus 37% with TR biopsy (adjusted odds ratio 0.86, 95% confidence interval 0.66-1.10; p = 0.2). TP biopsy had a higher yield for high-grade anterior disease in comparison to TR biopsy (21% vs 9%; p < 0.001) but a lower yield for high-grade posterior disease (28% vs 34%; p = 0.044). Stratification by Prostate Imaging-Reporting and Data System score on MRI revealed consistent detection patterns across biopsy approaches when assessing disease location.

Conclusions and clinical implications: We found no significant difference in the overall detection rate for high-grade cancer between the TR and TP approaches, but there was some evidence of differences by tumor location, with TP biopsy better in sampling anterior tumors, and TR biopsy favoring posterior detection. These findings support the need for further studies, including randomized trials incorporating MRI and detailed location data, to clarify differences between the biopsy approaches in detection rates for different anatomic locations.

Background and objective: Percutaneous nephrolithotomy (PCNL) is a common urological procedure recommended as first-line treatment for large renal calculi. This systematic review aimed to determine the mortality associated with PCNL in managing kidney stone disease (KSD).

Methods: In line with the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines, a literature search was conducted across Medline, Embase, CINAHL, and the Cochrane Library. The inclusion criteria included English articles of adult and paediatric patients that reported on mortality from PCNL. The extracted data included patient demographics, comorbidities, number of mortalities, and cause of mortality.

Key findings and limitations: Sixty-five articles were included, which reported on 634 844 patients over a time period spanning from 1983 to 2024. A total of 2777 mortalities were identified. The overall weighted proportion mortality rate for adult studies, excluding selected patient cohorts, was 0.24%. The overall weighted proportion paediatric mortality rate was 0.6%, and mortality rates for other specific patient subgroups varied. Where the cause of death was reported, the most common causes of death in patients were sepsis (35.6%), myocardial infarction (23.3%), haemorrhage (12.2%), and pulmonary embolism (11.1%).

Conclusions and clinical implications: Mortality rates from PCNL have remained stable and low over the lifetime of the procedure, with a slight reduction in reported mortality rates over time, despite increasing prevalence of KSD and patient comorbidities. Reporting of mortalities from PCNL has increased in recent years, with the most common causes of mortality identified being sepsis, myocardial infarction, and haemorrhage. Careful patient selection, with the identification and mitigation of risk factors, is vital in reducing the risk of mortality from PCNL.

The management of non-muscle-invasive bladder cancer (NMIBC) is undergoing a major paradigm shift driven by molecular biomarkers, artificial intelligence (AI), and a better understanding of the tumor microenvironment and bladder microbiome. Traditional risk stratification based on stage and grade fails to capture the biological heterogeneity of NMIBC and its variable clinical behavior. Recent evidence highlights the prognostic and dynamic value of urinary and circulating tumor DNA for detecting aggressive disease, anticipating recurrence, and guiding treatment escalation. In parallel, AI-based models that integrate clinicopathological variables and computational histology significantly outperform current guideline-based risk calculators and thus allow refined patient stratification. Furthermore, emerging data demonstrate that immune infiltration patterns and microbiome composition influence response to intravesical therapies, particularly bacillus Calmette-Guérin. Together, these advances support a unified molecular-digital framework that integrates biomarkers, AI, and immunomicrobial profiling to personalize surveillance and treatment strategies. This evolving approach hold promise for optimizing bladder preservation and improving oncological outcomes in NMIBC. PATIENT SUMMARY: Combining tumor DNA tests, artificial intelligence tools, and analysis of the immune and microbial environment in the bladder may improve assessment of risk for patients with non-muscle-invasive bladder cancer. This approach could allow more personalized treatment and follow-up.

Background and objective: Surgical treatments for benign prostatic hyperplasia (BPH) have expanded with the diffusion of minimally invasive surgical treatments (MISTs), but concerns persist regarding their long-term durability. This study aimed to provide a comprehensive, real-world description of current treatment trends, retreatment rates, and medication reinitiation up to 5 yr following MISTs and traditional procedures.

Methods: This observational retrospective fixed-cohort study was conducted using Epic Cosmos, including data of 6 450 295 patients and 420 611 procedures between 2014 and 2024. The primary outcome was procedural trend; the secondary outcomes were surgical retreatment and medication reinitiation. Analyses were descriptive and unadjusted for potential confounders due to the aggregated nature of the dataset.

Key findings and limitations: At 5 yr, retreatment rates were higher after prostatic urethral lift (PUL; 16%), transurethral needle ablation of the prostate (15%), transurethral microwave thermotherapy (17%), and Rezūm (14%), and lower after holmium laser enucleation of the prostate (HoLEP)/thulium laser enucleation of the prostate (ThuLEP; 4.4%) and simple prostatectomy (1.2%) when compared with transurethral resection of the prostate (TURP; 7.1%). Medication reinitiation at 5 yr was more common after MISTs (PUL: 21% α-blockers, 25% 5α-reductase inhibitors [5-ARIs], and 27% overactive bladder [OAB] drugs; all p < 0.001; Rezūm: 18% α-blockers, p = 0.001; 22% 5-ARIs, p = 0.05; and 23% OAB drugs, p > 0.99) and lower following traditional procedures, including HoLEP/ThuLEP-11% α-blockers (p < 0.001), 12% 5-ARIs (p < 0.001), and 21% OAB drugs (p = 0.3), and simple prostatectomy-5.4% α-blockers (p < 0.001), 6.5% 5-ARIs (p < 0.001), and 9.4% OAB drugs (p < 0.001), when compared with TURP (15% α-blockers, 17% 5-ARIs, and 23% OAB drugs). Limitations include the use of aggregated electronic health record data subject to coding errors and the inability to adjust for clinical variables such as prostate size and symptom severity.

Conclusions and clinical implications: In this large, real-world cohort, anatomical procedures such as HoLEP, ThuLEP, and simple prostatectomy were associated with the lowest long-term rates of retreatment and medication restart, whereas higher rates were observed with MISTs, particularly PUL and Rezūm. TURP remained the most performed procedure. As the use of MISTs declines after its initial uptake, future studies should clarify which patient characteristics may underlie these observed differences.

Background and objective: This aim of this international expert consensus project was to clarify the appropriate use of urodynamics (UDS) in men with bothersome lower urinary tract symptoms (LUTS) who are considering prostate surgery in light of high-quality published evidence, particularly high-certainty data from the UPSTREAM study, and expert clinical experience.

Methods: A modified version of the Delphi method was used. Postsurgical patients, catheterised patients, and patients with neurological disease were not included. Eight questions covered UDS in specific contexts; four addressed quality assurance.

Key findings and limitations: Consensus was reached on the need for UDS in any of the following circumstances: if the corrected maximum flow rate is ≥13 ml/s; if bothersome urinary urgency is present; if scores are below stated thresholds for overall symptoms or voiding symptoms; if the postvoid residual volume is considered meaningfully elevated; if there is extensive comorbidity; and if incontinence (any type) is identified. Consensus was not reached on the need for UDS in men with scores below the stated threshold for the impact on quality of life. Consensus was achieved for quality assurance in terms of cross-checking UDS pressure traces and derived indices; ensuring the trustworthiness of traces by experienced health care professionals; and review within the individual clinical context. UDS was considered important when benign prostatic obstruction (BPO) is less likely and in cases in which detrusor underactivity or overactivity is more likely. In cases with severe voiding symptoms, UDS was not considered necessary to increase confidence in recommending surgery to treat LUTS.

Conclusions and clinical implications: UDS retains an important role in men with bothersome LUTS considering surgery for presumed BPO. Our consensus recommends specific criteria to guide selective UDS use.