European urology focus最新文献

Technology has driven the evolution of endourology over the past decades. Endoscopic stone surgery could benefit greatly from integration of artificial intelligence to refine diagnostics and enhance training and postoperative care. However, ethical, accessibility, and cost challenges need to be addressed to realise the full potential of artificial intelligence in this setting. PATIENT SUMMARY: Our mini-review describes current and future applications of artificial intelligence (AI) for telescopic surgery for stones in the urinary tract. It is likely that AI-driven devices will be used from diagnosis to surgery, but ethical issues need to be clearly defined before AI can be widely used in clinical practice.

Antimuscarinics are historically considered the cornerstone for pharmacological treatment of overactive bladder syndrome (OAB). The more recent introduction of β3 adrenoreceptor agonists has increased the range of therapeutic possibilities, but it is still not possible to determine a priori which drug class should be used first. Considering the comparable effectiveness in terms of symptom improvement, the choice should take into account the different tolerability profile of these drugs according to the patient's clinical features (age, neurologic disease and comorbidities, and risk factors for adverse events). In the absence of specific characteristics that guide the choice towards one of these drug classes, shared decision-making with the patient that takes into account their personal values, preferences, and expectations should be undertaken. PATIENT SUMMARY: We provide recommendations on choice of the first drug type to use in treating overactive bladder. Two drug classes with similar effectiveness but different side effects are available. The decision on which medication to use first should take into account the patient's characteristics and their personal values, preferences, and expectations.

Virtual interactive three-dimensional modeling is a novel visualization tool that could improve preoperative surgery planning and intraoperative navigation. The 3DPN trial seeks to assess its value for robot-assisted partial nephrectomy in comparison to conventional computed tomography imaging in a multicenter randomized controlled setting.

Background and objective: Patients with muscle-invasive bladder cancer (MIBC) who develop a recurrence after radical cystectomy (RC) have poor outcomes. This study aims to evaluate the safety and efficacy of adjuvant radiotherapy (ART) in mitigating pelvic recurrences in high-risk MIBC patients. We report on survival outcomes, health-related quality of life (HRQoL), and hematological toxicity for these patients.

Methods: A multicentric phase 2 trial was conducted from August 2014 to October 2020, in which 72 high-risk MIBC patients received ART after RC. High risk was defined by the presence of one or more of the following criteria: pT3 stage and lymphovascular invasion, pT4 stage, fewer than ten lymph nodes removed, positive lymph nodes, and positive surgical margins. Using intensity-modulated radiotherapy, patients with pelvic lymph nodes ± cystectomy bed (in case of a positive surgical margin) received 50 Gy in 25 fractions. Outcomes were local relapse-free rate (LRFR), clinical relapse-free survival (CRFS), overall survival (OS) (Kaplan-Meier statistics), HRQoL (European Organisation for Research and Treatment of Cancer QLQ-C30/QLQ-BLM30 surveys), and hematological toxicity (Common Terminology Criteria for Adverse Events grading).

Key findings and limitations: The median follow-up of patients without a recurrence was 39 mo. At 2 and 5 yr, LRFRs were 81% (95% confidence interval [CI] 71-91%) and 79% (95% CI 68-89%), CRFS rates were 32% (95% CI 21-42%) and 20% (95% CI 11-30%), and OS rates were 48% (95% CI 36-59%) and 34% (95% CI 22-45%), respectively. At the end of ART, several symptoms worsened, most returning to baseline within the first few months. Diarrhea showed the greatest deterioration, recovering to baseline score only partially. Hematological toxicity of incidence grade ≥2 included lymphopenia (75%), neutropenia (2%), thrombopenia (2%), and anemia (17%). Limitations include the single-arm design and the limited availability of blood samples and surveys.

Conclusions and clinical implications: ART after RC is well tolerated and leads to a favorable local control rate, supporting its use in clinical practice.

Background and objective: Management of young men with primary bladder neck obstruction (PBNO) and dysfunctional voiding (DV) is challenging. We systematically reviewed evidence on diagnostic strategies and treatment outcomes in men aged 18-50 yr with PBNO or DV.

Methods: We conducted a comprehensive bibliographic search on the Embase, Medline, and Cochrane Library databases in July 2024.

Key findings and limitations: Twenty-five publications were identified. Videourodynamics represents the standard diagnostic approach. Standard therapies for PBNO include alpha-blockers (ABs) as the first-line approach and bladder neck incision (BNI) in patients failing medical therapy. Pooled estimates of total International Prostate Symptom Score (IPSS) and maximum urinary flow rate (Q_max) improvements at 3 mo in patients receiving ABs are 7.0 points and 4.0 ml/s, respectively. The incidence of ejaculatory dysfunction (EjD) and failure rates range from 47% to 50% and from 23% to 52%, respectively. Corresponding figures in patients undergoing surgery are 11.2 points, 6.9 ml/s, 0-88.8%, and 11.1-13.3%, respectively. OnabotulinumtoxinA, as experimental second-line therapy in PBNO, provides 2-mo mean total IPSS and mean Q_max improvements of 14.1 points and 9.1 ml/s, respectively, with a 0% EjD rate. However, improvements deteriorate over time. Behavioral modifications plus biofeedback represent the only approach in patients with DV, providing symptom improvement of at least 50% in 83% of patients at 3 mo. Limits of evidence include few studies, mainly retrospective design, heterogeneous populations, small sample sizes, lack of direct comparisons, and short follow-up.

Conclusions and clinical implications: Diagnosis of PBNO/DV in young men requires the integration of anatomical and functional data. ABs represent the first-line approach for PBNO followed by BNI in cases of failure. Behavioral modification plus biofeedback represents the only strategy tested for DV. Given the low quality of evidence, a shared decision-making approach for diagnosis and treatment is required.

The gut microbiome may represent a new pillar in human health. As we move beyond the small data sets used for comparison, we will need to consider the bidirectional implications of interactions between diet/lifestyle (inputs) and metabolites (outputs) in interventional clinical trials to maximize the beneficial impact in health and disease.

Background and objective: Current data on bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) do not differentiate outcomes by clinical stage. The purpose of this study is to investigate the role of tumor stage in oncologic outcomes in BCG-unresponsive NMIBC undergoing bladder-sparing therapies.

Methods: Demographic and outcome data for patients with BCG-unresponsive NMIBC were reviewed at ten institutions. The Kaplan-Meier method was used to determine survival differences between the T1 ± carcinoma in situ (CIS), Ta alone, and CIS ± Ta groups. Exploratory analyses were conducted as follows: (1) T1 alone versus Ta alone versus CIS ± T1/Ta and (2) T1/Ta alone versus CIS ± T1/Ta.

Key findings and limitations: Among 401 patients, 137 (34%) were T1 ± CIS, 104 (26%) Ta alone, and 160 (40%) CIS ± Ta. Disease progression (p < 0.001), metastasis (p < 0.001), and bladder cancer mortality (p = 0.009) were increased in the T1 ± CIS group versus the Ta alone and CIS ± Ta groups. Cystectomy occurred most often in the CIS ± Ta and T1 groups (p = 0.002). Similar increases were noted in progression (p < 0.001), metastasis (p < 0.001), and bladder cancer mortality (p = 0.004) in T1 alone patients versus the Ta alone and CIS ± T1/Ta groups. There were no differences in outcomes between the T1 alone and T1 + CIS groups. No significant differences in metastasis, bladder cancer mortality, or all-cause mortality were noted when comparing papillary disease only with any CIS. The primary limitation of this study is likely a selection bias due to the retrospective nature of the cohort.

Conclusions and clinical implications: Presence of T1 disease is generally associated with worse oncologic outcomes compared with Ta or CIS. T1 and Ta should not be grouped together during comparison with CIS. Radical cystectomy appears largely driven by the presence of CIS.

Background and objective: Real-world data exploring the perioperative outcomes of different surgical treatments for benign prostatic hyperplasia (BPH) are lacking. We aimed to assess the trends of BPH surgeries and compare their perioperative outcomes.

Methods: We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005-2022), and performed multiple patient-level analyses.

Key findings and limitations: Our study included 1 355 845 surgical treatments for BPH. Of these, 1 084 650 (79.9%) were transurethral resection of the prostate (TURP), 90 735 (6.9%) simple prostatectomy, 64 325 (4.7%) holmium laser enucleation of the prostate (HoLEP), 58 406 (4.3%) laser vaporization, 25 747 (1.9%) electrovaporization, 15 241 (1.1%) thulium laser enucleation of the prostate (ThuLEP), 7873 (0.58%) prostate incision, 3298 (0.24%) water ablation, 2724 (0.2%) water vapor thermal therapy, 1235 (0.09%) prostate stent, 1100 (0.08%) transurethral needle ablation of the prostate, and 511 (0.03%) prostatic urethral lift. The use of HoLEP, ThuLEP, water ablation, and water vapor thermal therapy has increased exponentially in the last years. After adjusting for the major risk factors in the multivariate regression analysis, simple prostatectomy was associated with the worst outcomes compared with TURP, followed by electrovaporization. On the contrary, HoLEP and ThuLEP were associated with favorable outcomes, in terms of sepsis, ureteral stent placement, transfusion, admission to the intensive care unit, hospital stay, and mortality, compared with TURP. Similarly, minimally invasive surgical therapies were associated with high safety compared with TURP. Nevertheless, our findings are based on retrospective billing data and are prone to a selection bias.

Conclusions and clinical implications: The trends and perioperative outcomes of BPH surgery should be taken into consideration to improve clinical decision-making and patient outcomes.