European urology focus最新文献

Background and objective: Transurethral resection of bladder tumor (TURBT) is one of the procedures most often performed by trainee urologists. ENTRY is a cooperative partnership aimed at improving the training of urology residents. Metrics for TURBT were published after a Delphi consensus process involving experts. The aim of this study was to assess the reliability and construct validity (via known-group and convergent validity) of objective metrics for characterizing the intraoperative performance of TUTBT as optimal versus suboptimal.

Methods: Thirty videos of TURBT performed by experts (n = 15) and novices (n = 15) were evaluated by three experienced urologists trained to reliably and independently score TURBT performance using the metrics previously developed. The videos were anonymized and the assessors were blinded to the surgeon, hospital, and expertise. The inter-rater reliability score was assessed and surgical errors were reported using a dummy dichotomous variable. A two-sample Wilcoxon rank-sum (Mann-Whitney) test was applied for between-group comparisons.

Key findings and limitations: The median number of overall errors was 1 (interquartile range [IQR] 0-2) in the expert group versus 5 (IQR 4-7) in the novice group, with a median difference of -4 errors (95% confidence interval [CI] -5 to -3; p = 0.001). The median number of noncritical errors per TURBT procedure was 1 (IQR 0-2) in the expert group versus 3 (IQR 2-4) in the novice group, with a median difference of -2 errors (95% CI -3 to -1; p = 0.001). The median number of critical errors was 0 (IQR 0-1) for the expert group versus 2 (IQR 2-3) for the novice group, with a median difference of -2 errors (95% CI -3 to -1; p = 0.001). We compared the performance of the expert and novice groups, which revealed a concordance index of 0.6 for noncritical errors, 0.73 for critical errors, and 0.66 for overall errors.

Conclusions and clinical implications: Our study demonstrates the construct validity of metrics developed for the quality of TURBT performance. This represents a further step in establishing a quality-assured structured and standardized training program for TURBT.

Background and objective: Overactive bladder (OAB) symptoms are prevalent in patients with bladder outlet obstruction (BOO). Although the pathogenesis of OAB in men with BOO is still under investigation, OAB symptoms might persist following an outflow surgery. It is, thus, crucial to prognosticate preoperatively the outcome of a deobstructive operation. This review aims to systematically investigate the preoperative factors that could prognosticate the persistence of OAB symptoms following deobstruction surgery in males.

Methods: This is a systematic review of the current literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Randomised controlled trials and observational studies of both prospective and retrospective design were considered eligible for the analysis. The Quality in Prognosis Studies tool was used for assessing the risk of bias.

Key findings and limitations: Thirty studies, involving 8043 patients who had persistent storage symptoms following surgical BOO relief, were included. Across adjusted analyses, older age and a higher baseline storage symptom burden were the most frequently associated factors, though findings were inconsistent. Urodynamic measures such as detrusor overactivity, bladder capacity, and detrusor contractility showed heterogeneous results, with some positive and some protective signals. Other factors (eg, prostate volume, prostate-specific antigen, maximum flow rate, postvoid residual, and comorbidities) were uniformly null. Overall certainty of evidence was very low, reflecting inconsistency, imprecision, and reliance on single-study signals.

Conclusions and clinical implications: Current evidence is of limited quality; no preoperative factor demonstrated robust prognostic value. Older age and a greater storage symptom burden may be associated with persistence in some adjusted models, whilst urodynamic prognostic factors remain uncertain.

Background and objective: The choice between different urinary diversion types carries distinct implications for physical appearance and psychosocial outcomes. This systematic review aims to synthesize current evidence on how different urinary diversion types influence patients' body image and decision regret.

Methods: In this prospectively registered systematic review (CRD420251079300), we searched MEDLINE, Embase, and Web of Science in June 2025 for studies reporting body image and decision regret outcomes in patients undergoing urinary diversion after radical cystectomy for bladder cancer. Data were synthesized descriptively, and the risk of bias was assessed using the Risk Of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool.

Key findings and limitations: Of 1837 records screened, 31 studies comprising 5180 patients were included: 24 assessed body image (n = 4552), six decision regret (n = 579), and one both (n = 49). Diversion types comprised orthotopic neobladder (n = 1848), ileal conduit (n = 2970), continent cutaneous diversion (n = 61), cutaneous ureterostomy (n = 206), and ureterosigmoidostomy (n = 95). Most studies evaluated body image using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Bladder Cancer Module (EORTC QLQ-BLM30; 13 studies) or Body Image Scale (seven studies). Decision regret was measured via the Decision Regret Scale (two studies) or custom questionnaires (five studies). Among 17 comparative studies on body image and six on decision regret, most reported favorable body image and lower decision regret in patients with continent versus incontinent urinary diversions. Most studies exhibited moderate to serious risks of bias, primarily due to retrospective designs, missing response data, and incomplete reporting of diversion-specific questionnaire participation.

Conclusions and clinical implications: Urinary diversion choice after radical cystectomy affects body image and decision regret, with continent options generally linked to better psychosocial outcomes. Given the heterogeneity of current evidence, patient-centered counseling, expectation management, and social support are essential to improve long-term satisfaction and quality of life.

Background and objective: In metastatic hormone-sensitive prostate cancer (mHSPC), health-related quality of life (HRQoL) is key for personalised treatment decisions. We compared the impact of different mHSPC treatment strategies on HRQoL, tackling a previously unaddressed challenge in comparing the outcomes across different patient-reported outcome measures (PROMs).

Methods: A systematic review was conducted of prospective studies reporting HRQoL outcomes of androgen deprivation therapy (ADT) alone or with placebo, radiotherapy, abiraterone, apalutamide, enzalutamide, and/or docetaxel in mHSPC (CRD42021227902). Databases were searched in April 2022 and April 2024. HRQoL domains across different PROMs were harmonised using the Wilson and Cleary model. A frequentist network meta-analysis (NMA) compared 12-mo treatment effects using standardised mean differences (SMDs) with 95% confidence intervals (CIs). Statistical significance was defined as p < 0.05.

Key findings and limitations: Of the 24 articles included, nine were analysed in the NMA (eight trials, n = 6248). ADT + abiraterone resulted in significantly less pain than ADT + placebo (SMD: -0.22, 95% CI [-0.33; -0.10], p < 0.001), ADT + apalutamide (SMD: -0.17, 95% CI [-0.31; -0.02], p = 0.022), and ADT + enzalutamide (SMD: -0.23, 95% CI [-0.37; -0.09], p = 0.001). Less fatigue was observed with ADT + abiraterone versus ADT + enzalutamide (SMD: -0.45, 95% CI [-0.88; -0.02], p = 0.041). ADT + abiraterone showed significantly better physical functioning than ADT + enzalutamide (p = 0.015) and ADT + placebo (p = 0.032). Both were also associated with significantly worse general health perception than ADT alone, ADT + docetaxel, and ADT + radiotherapy. General health perception and overall quality of life were significantly better with ADT + abiraterone than with ADT + enzalutamide, ADT + apalutamide, and ADT + placebo (p < 0.001). The limitations include heterogeneity (0-76%) and few eligible trials.

Conclusions and clinical implications: HRQoL outcomes differ across treatment strategies for mHSPC. At 12 mo, ADT + abiraterone yielded the most favourable HRQoL profile.

Background and objective: Obstruction by urolithiasis may be the reason for a percutaneous nephrostomy (PCN) or the placement of an internal stent. High-quality evidence is scarce. The objective of this study is to investigate whether a PCN is noninferior to an internal stent with regard to effectiveness (time to clinical recovery).

Methods: In this nationwide randomised controlled noninferiority trial performed in 11 secondary and tertiary care hospitals in the Netherlands, we randomised 204 patients for either a PCN or an internal stent. The primary outcome was the time to recovery.

Key findings and limitations: Baseline characteristics were comparable. Fourteen participants crossed over from the PCN group to the internal stent group, of whom most (n = 11) crossed over due to technical failure, as opposed to four crossovers from the internal stent group to the PCN group. The mean time to recovery was 1.7 d (standard deviation [SD] 1.7) in the PCN arm and 1.5 d (SD 1.5) in the internal stent group. The mean difference was 0.3 (95% confidence interval -0.2 to 0.7) and did not exceed the noninferiority margin of 1 d (noninferiority p < 0.01). No statistically significant difference was observed in the percentage of participants with adverse events, nor were we able to demonstrate a statistically significant difference in the number of events of Clavien-Dindo grade ≥3a. The current study revealed a notably high rate of crossovers due to technical failure.

Conclusions and clinical implications: The STent Or NEphrostomy study proved a PCN to be noninferior to an internal stent in terms of the time to clinical recovery. Either option for drainage is an effective method of treatment, as long as patient-specific risk factors for technical failure of the procedure are considered.

Background and objective: A local anaesthetic ultrasound-guided transperineal (LATP) prostate biopsy has advantages over transrectal ultrasound (TRUS)-guided biopsy, with improved magnetic resonance imaging (MRI)-guided prostate cancer detection and lower rates of infection-related complications. However, uncertainty remains regarding the cost effectiveness of an LATP biopsy compared with a TRUS biopsy.

Methods: Between December 2021 and September 2023, the TRANSLATE randomised clinical trial allocated 1126 men to receive either a TRUS (n = 564) or an LATP (n = 562) biopsy at ten sites in the UK. All men were biopsy naïve and underwent prebiopsy MRI. Participants were followed up for 4 mo after a biopsy. The economic analysis is a within-trial analysis at 4 mo after biopsy, conducted from a National Health Service perspective. We assessed resource use, health care costs, and quality-adjusted life years (QALYs) across 4 mo of follow-up from an intention-to-treat perspective. We addressed missing data using multiple imputation. Incremental cost-effectiveness ratios were calculated, with uncertainty characterised using nonparametric bootstrapping. The TRANSLATE trial is registered at ISRCTN (ISRCTN98159689) and is complete.

Key findings and limitations: The total mean costs over the 4 mo of follow-up were £1062 in the LATP arm and £917 in the TRUS arm (adjusted mean difference £149; 95% confidence interval [CI] £61-236, p = 0.001). The total mean QALYs at 4 mo were 0.282 in the LATP arm and 0.284 in the TRUS arm (adjusted mean difference -0.004; 95% CI -0.009 to 0.001, p = 0.098).

Conclusions and clinical implications: An LATP biopsy has a higher mean cost, and no significant difference in mean QALYs, compared with a TRUS biopsy at 4 mo after the procedure. A time of 4 mo is too soon to reflect any impact from the 5.7% diagnostic uplift for LATP versus TRUS biopsy on the detection of intermediate-/high-grade prostate cancer seen in the TRANSLATE trial. A further analysis beyond this period is needed to fully interpret the cost-effectiveness results.

Background and objective: Salvage lymph node dissection (sLND) in recurrent prostate cancer (PC) is still considered experimental due to limited prospective data and sparse long-term outcome reports. This study describes long-term oncological outcomes after sLND in PC patients with suspected lymph node metastases on positron emission tomography/computed tomography after primary therapy and aims to identify predictors for selecting patients who will benefit.

Methods: Biochemical response (BR), biochemical recurrence (BCR), and clinical progression (CP) were assessed in 181 patients. Kaplan-Meier estimations served for time to BCR, CP, initiating androgen deprivation therapy (ADT), and overall survival (OS). Predictors were identified using binary logistic regression and Cox regression models.

Key findings and limitations: The median follow-up was 70.1 mo (interquartile range 42.5-98.0). BR was achieved in 45% (82/181). According to Kaplan-Meier estimates, the 2-yr BCR- and CP-free survival rates were 32.4% and 51.2%, respectively. The 5-yr rates were 11.5% and 26%, respectively. At 2 yr after sLND, 83 of 181 patients had initiated ADT, while 82 remained at risk, corresponding to a Kaplan-Meier estimate of 51.5% without initiation of ADT. An incomplete BR and omission of radiotherapy (RT) after sLND were associated with increased risks of BCR (hazard ratio [HR] 3.29, p = 0.0001 and HR 1.55, p = 0.011, respectively) and CP (HR 2.83, p = 0.0001 and HR 1.59, p = 0.013, respectively). The time from initial therapy to nodal recurrence and a prostate-specific antigen (PSA) level of >2 ng/ml at sLND were associated with BCR. At the end of follow-up, 58% (105/181) had PSA levels below those at sLND. According to the Kaplan-Meier estimate, the 10-yr OS rate was 51.2%. Limitations are the retrospective design and a lack of a control group.

Conclusions and clinical implications: Despite high BCR rates, over half of the patients were ADT free after 2 yr. Selected men with a low tumour burden may benefit from sLND, particularly in a multimodal treatment setting including RT.