European urology focus最新文献

Background and objective: Intravesical recurrence after induction bacillus Calmette-Guérin (BCG) therapy is common in non-muscle-invasive bladder cancer (NMIBC), but longitudinal, real-world data using contemporary definitions of the BCG-exposed (BCG-E) phenotype remain limited, which constrains trial design. We assessed long-term clinical outcomes and clinical trajectories for a large BCG-exposed cohort treated at a single tertiary care center to establish pragmatic benchmarks to inform patient counseling, surveillance strategies, and the design and interpretation of bladder-sparing studies.

Methods: We conducted a retrospective cohort study for adults with histologically confirmed high-grade NMIBC treated with intravesical BCG at Moffitt Cancer Center between 1988 and 2024. Relevant clinical data were extracted from electronic medical records into a prespecified database, including detailed BCG doses and timing and features of each recurrence episode. Initial management followed contemporary standards, with subsequent intravesical therapy or radical cystectomy (RC) after shared decision-making. Patients were classified as BCG-unresponsive (BCG-UR) or BCG-E, with BCG adequacy defined as previously published. Time-to-event endpoints were analyzed using Kaplan-Meier estimates and multivariable Cox proportional-hazards models; baseline characteristics were compared using Fisher's exact and Wilcoxon rank-sum tests.

Key findings and limitations: Of 1076 NMIBC patients treated with BCG, 470 were classifiable: 245 (52.1%) were BCG-E, of whom 173 (70.6%) were resistant and 72 (29.4%) experienced delayed relapse, and 225 (47.9%) were BCG-UR. In the BCG-E group, 50.2% experienced recurrence and 15.5% experienced progression; median recurrence-free survival (RFS) was 27.2 mo. The 5-yr survival rate estimates were 32.25% for RFS, 79.3% for progression-free survival (PFS), 84.5% for metastasis-free survival (MFS), and 65.0% for overall survival (OS). Recurrence was associated with worse PFS (p < 0.001) and MFS (p = 0.03), but not OS (p = 0.2). RC was performed in 45 patients (18.4%). No consistent survival differences were observed across salvage therapies (62.0% BCG, 18.4% gemcitabine + docetaxel, 5.3% single-agent chemotherapy, 1.2% trials, 13% surveillance),. Multivariable OS estimates were computed. Addition of recurrence to the model did not improve discrimination; age and performance status were the strongest predictors of OS.

Conclusions and clinical implications: We present comprehensive outcomes for and an in-depth characterization of clinical trajectories in BCG-E NMIBC, for which salvage intravesical BCG is predominant and oncologic results are durable. These data provide pragmatic benchmarks for the interpretation and design of bladder-sparing trials in this setting.

Background and objective: Robot-assisted radical prostatectomy (RARP) is widely used for localised prostate cancer (PC). As surgical techniques and oncological outcomes have matured, attention has increasingly turned to patient-reported outcome measures (PROMs) and experience measures (PREMs), driven not only by interest in functional recovery but also by broader health care trends, including shared decision-making, patient empowerment, and value-based care models. Digital health platforms may facilitate this evolution, yet real-world evidence on their feasibility and impact is limited. Our objective was to assess the acceptability, feasibility, and clinical relevance of digital telemonitoring using a certified mobile health application after RARP.

Methods: We conducted a prospective, multicentre cohort study involving 465 patients undergoing RARP across 32 French centres. All used the Betty digital health platform for perioperative monitoring. The primary outcome was patient-reported satisfaction with perioperative care. Secondary outcomes were pain trajectories, analgesic use, urinary continence, erectile function, and correlations between satisfaction and recovery endpoints. PROM data were collected preoperatively and up to 6 mo postoperatively.

Key findings and limitations: The questionnaire completion rate at 6 wk was 86%. Satisfaction was high (median score 9-10), and pain and analgesic use declined steadily over 30 d. The pad-free rate was 59% at 6 wk and 78% at 6 mo. International Index of Erectile Function-5 scores remained low (median 3, interquartile range 1-5 at 6 mo). Satisfaction was correlated with lower pain at postoperative day 7 (r = -0.391, p = 0.001), lower incontinence scores (r = -0.324, p = 0.009), and less impact of incontinence (r = -0.420, p = 0.002). The main limitations are the inclusion of only app users and the absence of nerve-sparing data.

Conclusions and clinical implications: Certified digital telemonitoring after RARP is feasible, well accepted, and linked to high satisfaction. Early pain and continence recovery influence the patient experience. These results support the integration of structured PROM/PREM tracking into standard pathways for real-time monitoring and patient-centred care.

Background and objective: Trimodal therapy (TMT)-comprising transurethral resection of the bladder tumor, chemotherapy, and radiotherapy-offers a bladder-preserving alternative to radical cystectomy for selected patients with muscle-invasive bladder cancer (MIBC). However, the optimal criteria for patient selection and prognostication remain inadequately defined. A systematic review and meta-analysis was conducted to optimize the selection of MIBC patients who are likely to have better survival outcomes from TMT.

Methods: A systematic literature search was conducted in MEDLINE, Embase, and Web of Science in February 2025. Eligible studies examined prognostic factors for overall or cancer-specific survival in patients with MIBC undergoing TMT. To reduce the impact of confounding, only multivariable-adjusted estimates were included in the meta-analysis. Pooled hazard ratios (HRs) were calculated using a random-effect model. The risk of bias was evaluated using the Quality In Prognosis Studies (QUIPS) tool (CRD42025641514).

Key findings and limitations: A total of 31 studies, including 9416 patients treated with TMT for MIBC, met the inclusion criteria. Older age (per year increase; HR: 1.03, 95% confidence interval [CI]: 1.01-1.05), poor performance status (Eastern Cooperative Oncology Group ≥2 vs 0-1; HR: 2.47, 95% CI: 1.78-3.43), impaired renal function (HR: 1.47, 95% CI: 1.12-1.92), presence of hydronephrosis (HR: 1.65, 95% CI: 1.17-2.34), advanced T stage (HR: 1.47, 95% CI: 1.23-1.77), nodal involvement (HR: 1.90, 95% CI: 1.10-3.30), and concomitant carcinoma in situ (HR: 1.81, 95% CI: 1.02-3.20) were independently associated with worse overall survival. Limitations included heterogeneity in treatment protocols and potential residual confounding across studies.

Conclusions and clinical implications: Specific patient- and tumor-related factors are significantly associated with prognosis in patients undergoing TMT for MIBC. These findings may aid in refining patient selection and risk stratification for TMT-based bladder-preserving approaches.

Background and objective: Digital pathology-based artificial intelligence (DP-AI) biomarkers are emerging as transformative tools to guide clinical management of patients affected by various malignancies. We aimed to synthesise current evidence regarding their prognostic and predictive utility in urologic cancers.

Methods: In this prospectively registered systematic review (PROSPERO: CRD420251036536), we searched MEDLINE, Embase, and Web of Science in April 2025 for studies evaluating the prognostic and predictive values of DP-AI models in patients with prostate (PCa), bladder (BCa), renal cell (RCC), testicular (TCa), or penile (PeCa) cancer. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Results were tabulated and summarised qualitatively.

Key findings and limitations: Of the 1537 screened individual records, we included 31 studies validating DP-AI models in 21 155 patients. Nineteen studies were conducted in PCa (n = 17 541), six in BCa (n = 2349), five in RCC (n = 1176), and one in TCa (n = 89) patients. Ten PCa studies (n = 8951) utilised the ArteraAI model, including two (n = 2786) showing that it allows identification of patients treated with radiotherapy for clinically localised PCa that can safely omit short-term (subdistribution hazard ratio [sHR] 0.34; 95% confidence interval [CI]: 0.19-0.63) or long-term (sHR 0.55; 95% CI: 0.41-0.73) androgen deprivation therapy. Two studies (n = 894) developed and validated a model allowing identification of patients with non-muscle-invasive BCa poorly responding to Bacillus Calmette-Guérin (HR 2.3; 95% CI: 1.9-2.8), including one study (n = 253) validating a predictive biomarker for patients who may benefit from upfront gemcitabine/docetaxel. Many DP-AI models showed a prognostic association in localised PCa (n = 16 863), metastatic PCa (n = 678), non-muscle-invasive BCa (n = 2069), muscle-invasive BCa (n = 280), localised RCC (n = 1176), and germline TCa (n = 89) settings. None of the included studies assessed DP-AI models prospectively.

Conclusions and clinical implications: DP-AI biomarkers hold promise to improve treatment personalisation through integration into clinical practice. Prospective validation is now required.

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: Kidney-sparing treatments are salvage options for renal cell carcinoma (RCC) after local recurrence. However, there is no level 1 evidence in the literature examining the efficacy of focal therapies (FTs) and partial nephrectomy (PN) in a head-to-head, randomised comparison.

Methods: A systematic search (PROSPERO CRD420251033642) was performed. The present analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.

Key findings and limitations: Overall, 30 studies involving 873 patients were included in the final analysis. Patients with RCC were treated primarily with FTs (n = 376, 43%) and PN (n = 462, 53%). Of FTs, cryoablation was received by 198 (57%) RCC patients. The rates of recurrence for FTs ranged from 4% to 20%, while those for PN ranged from 3% to 19%. The intraoperative complication rates ranged from 2% to 6% for FTs and from 3% to 9% for PN. The postoperative complications rates ranged from 2% to 40% for FTs and from 8% to 40% for PN, while the major postoperative complications rates, defined as Clavien-Dindo ≥3, ranged from 2% to 9% for FTs and from 1% to 18% for PN. The rates of overall survival ranged from 82% to 100% for FTs, and from 96% to 100% for PNs. Limitations included the bias in patients' selection and the absence of time-to-event data.

Conclusions and clinical implications: PN achieved acceptable overall survival, recurrence, and complication profiles, demonstrating its feasibility in a salvage setting. Patient selection is mandatory to identify those best candidates for PN and FT, thereby prioritising oncological outcomes.

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.