European urology focus最新文献

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.

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.

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.

Genital herpes (GH) is a prevalent, lifelong, sexually transmitted infection caused by herpes simplex virus types 1 and 2. Although traditionally managed by dermatologists and infectious disease specialists, GH is increasingly relevant to urologists owing to its clinical complexity and psychosocial impact. This mini-review by the European Association of Urology Guidelines Panel for Urological Infections summarizes updated evidence on GH epidemiology, diagnosis, treatment, and prevention strategies. Diagnosis remains challenging because of atypical presentations; polymerase chain reaction is the preferred diagnostic test. Management mainly relies on nucleoside analogs, with new therapies under investigation. Suppressive treatment reduces recurrences and transmission. Routine screening of asymptomatic individuals is not recommended. Effective counseling and partner notification are critical components of care. PATIENT SUMMARY: Patients with genital herpes should receive clear information on the nature of the infection, the diagnostic process, and treatment options and preventive strategies. Urologists must play a key role in managing symptoms, reducing the risk of transmission, and supporting patients through education and counseling.

Background and objective: Guidelines recommend single-dose antimicrobial prophylaxis (AMP) for transurethral resection (TURP) and photoselective vaporization (PVP) of the prostate. As guideline adherence is low and 3-d AMP is given frequently, we aimed to assess the noninferiority of a single dose compared with 3-d AMP by comparing the incidence of urinary tract infections (UTIs) within 30 d.

Methods: A double-blind, multicenter, randomized, noninferiority trial was conducted comparing single-dose with 3-d AMP in patients assigned to TURP and PVP, assuming a 9% event rate for a clinical diagnosis of a UTI with a 4.4% noninferiority margin.

Key findings and limitations: From anticipated 1574 patients, 728 were recruited and 621 randomized patients were analyzed fully. The study was preliminary stopped due to delayed recruitment and was analyzed exploratively. Following single-dose AMP, 11.0% of patients (95% confidence interval [CI] 7.9%, 15.0%; 33/300) had a clinical diagnosis of UTIs, compared with 8.5% (95% CI 5.8%, 12.1%; 26/307) receiving 3-d AMP (between-group difference 2.5% [95% CI -2.2%, 7.5%]). The rates of UTIs supported by bacteriuria were lower without any difference between groups (single-dose AMP: 3.3% [95% CI 1.8%, 6.0%]; 3-d AMP: 3.3% [95% CI 1.8%, 5.9%]; between-group difference 0.08% [95% CI -2.97%, 3.16%]). Adverse events were rare.

Conclusions and clinical implications: In this randomized trial of transurethral prostate surgery patients, 11.0% of those on single-dose AMP and 8.5% on 3-d AMP were diagnosed with UTIs. The smaller than planned sample size precludes a definite interpretation favoring either group. Diagnoses of UTIs based on symptoms and bacteriuria reduced the overall rates and group differences.

Background and objective: Evidence comparing robot-assisted kidney transplantation (RAKT) with open kidney transplantation (OKT) from living donors in patients with end-stage kidney disease (ESKD) remains limited. We aimed to determine whether RAKT, compared with OKT, results in improved renal function at 1 mo after transplantation and whether it is associated with reduced perioperative complication rates and improved long-term outcomes, including dialysis-free, graft, reintervention-free, and overall survival.

Methods: This is a multicenter retrospective study including patients with ESKD who received RAKT or OKT between June 2015 and December 2023 in seven European academic centers. Missing values of relevant baseline characteristics were estimated through multiple imputation of chained equations. Baseline patients' heterogeneity for age, sex, body mass index, American Society of Anesthesiologists score, Charlson comorbidity index, and preemptive status was balanced using 1:1 nearest neighbor propensity score matching, estimated using logistic regression without replacement. Uni- and multivariable logistic and Cox regression analyses for early postoperative complications and need for reintervention during follow-up, respectively, were performed based on clinical characteristics. Kaplan-Meier estimates and log-rank test were used to compare dialysis-free, graft, reintervention-free, and overall survival according to the surgical approach.

Key findings and limitations: Overall, 733 patients were included. After propensity score matching, two cohorts of 306 patients each with similar baseline characteristics were obtained. The site of transplantation was the right iliac fossa in 240 (78%) and 204 (67%) patients undergoing OKT and RAKT, respectively. RAKT was associated with reduced total vascular anastomosis time (38 vs 32 min, p < 0.001), whereas OKT was associated with reduced surgical time (165 vs 209 min, p < 0.001) and rewarming time (38 vs 45 min, p < 0.001). Overall, early (<30 d) and Clavien-Dindo ≥3 postoperative complication rates were lower in the RAKT group (42% vs 29%, 37% vs 21%, and 12.7% vs 5%; p < 0.001). In the multivariable regression analysis, RAKT was predictive of a lower risk of both early postoperative complications (odds ratio 0.43, interquartile range [IQR]: 0.29-0.62, p < 0.001) and reintervention (hazard ratio 0.38, IQR: 0.22-0.66, p < 0.001), which was confirmed with the Kaplan-Meier estimates.

Conclusions and clinical implications: In experienced centers and appropriately selected recipients, RAKT from a living donor can be adopted to reduce perioperative morbidity and reinterventions without compromising early renal function or long-term patient and graft survival. Further studies should define which subgroups benefit most from RAKT, and evaluate patient-reported outcomes and cost effectiveness.

Background and objective: There is a gender imbalance regarding incidence and mortality in bladder cancer (BC), while gender-specific differences in health-related quality of life (HRQOL) following radical cystectomy (RC) remain unknown. We aimed to assess gender-specific differences in HRQOL after RC in a large prospective propensity score (PS)-matched cohort with follow-up of up to 10 yr.

Methods: A total of 1498 BC patients who underwent RC were included. PS matching of 794 patients (n = 397 female, n = 397 male) was conducted. HRQOL was assessed systematically by applying the European Organisation for Research and Treatment of Cancer (EORTC) quality of life questionnaire QLQ)-C30, QLQ-BLM30, and Functional Assessment of Cancer Therapy-Bladder questionnaires. Separate modelling of longitudinal HRQOL for females versus males was performed. Generalised estimating equations (GEEs) were employed to account for repeated measures. Spearman's rank correlation was applied to identify gender-specific factors influencing HRQOL.

Key findings and limitations: Baseline general HRQOL did not differ between female and male patients (p = 0.162). GEE modelling revealed females to report significantly worse global health status over time (β = 1.7, standard error [SE] = 0.4, p = 0.02). Among patients with disease recurrence, females reported worse general HRQOL than males in long-term follow-up (β = -3.8, SE = 1.7, p = 0.03). For patients without disease recurrence, we did not find a significant difference in general HRQOL between females and males (β = -0.83, SE = 1.2, p = 0.5). A significant correlation between general HRQOL, and urinary continence and physical-, functional-, or emotional well-being was observed for both genders (p range = 0.001-0.02). A strong correlation between social/family well-being and increased HRQOL was found for female (p = 0.001), but not for male (p = 0.1) patients.

Conclusions and clinical implications: Female patients report worse general HRQOL in long-term follow-up after RC, with different gender-specific factors influencing HRQOL.

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.

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.