BACKGROUND:Laser lithotripsy is central to the endoscopic management of renal and ureteral stones. Thulium:YAG (Tm:YAG) laser has emerged as a promising platform, although clinical evidence on its safety, effectiveness, and real-world performance remains limited. The aim of this article is to evaluate the clinical performance, effectiveness, and safety of Tm:YAG laser lithotripsy in patients undergoing URS/ULT or RIRS at a high-volume center. METHODS:Patients undergoing URS/ULT or RIRS for urolithiasis with the Tm:YAG laser were prospectively enrolled at a single high-volume institution between December 2023 and February 2026. Demographic, clinical, radiological, intraoperative, and postoperative variables were collected. Continuous variables were reported as mean and standard deviation or median with interquartile range, as appropriate. Mann-Whitney U Tests assessed associations between perioperative variables and postoperative outcomes in the overall cohort and separately in renal and ureteral stone cohorts. Stone-free rate (SFR) and clinically significant stone-free rate (CSSFR; residual fragments ≤3 mm) were evaluated on 4-week follow-up imaging. Complications were classified according to the Clavien-Dindo system. RESULTS:Median stone diameter was 10.65 mm (IQR 7.3-16), median stone volume was 623 mm3 (IQR 203-2142), and median stone density was 1183 HU (IQR 867-1445). Mean operative time was 65.3±43.2 minutes, median laser activation time was 21.1 minutes (IQR 13.6-36.8), and median total laser energy was 8.2 kJ (IQR 2.4-23.1). At 4 weeks, overall SFR was 85.6%, including 80.5% in the renal cohort and 92.1% in the ureteral cohort; CSSFR was 89.8%. Postoperative complications occurred in 27 patients (6.3%), with no Clavien-Dindo grade ≥III events. Failure to achieve SFR or CSSFR was associated with greater stone burden, higher stone density, longer operative and laser activation times, higher total laser energy, and lower ablation speed. CONCLUSIONS:In this prospective high-volume single-center cohort, Tm:YAG laser lithotripsy demonstrated favorable efficacy and safety for renal and ureteral stones, supporting its feasibility for URS/ULT and RIRS. Comparative studies are needed to define its role among established laser technologies.
BACKGROUND:Pediatric urolithiasis guidelines recommend ESWL, RIRS, or PCNL for stones within the 10-20 mm range but this broad interval often complicates treatment selection. This systematic review aimed to define a clearer, evidence-based stone size cutoff to improve clinical decision-making. METHODS:A systematic review and meta-analysis were performed (PROSPERO CRD420251012163) according to PRISMA 2020 guidelines. Pediatric studies published from 2014 to 2025 were searched across major databases. Eligible studies reported stone size and at least one outcome, including stone-free rate, residual fragments, retreatment, or complications. Studies without quantitative data were excluded. Early and long-term complications as well as instrumentation were analyzed. Pooled estimates were calculated using random-effects models. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS:Seventy-six study arms (N.=5294) reported stone size data. The pooled mean was 16.03 mm (95% CI 14.60-17.47; I2=99.9%). Stones treated with ESWL averaged 12.29 mm, RIRS 12.49 mm And PCNL 20.16 mm, indicating PCNL was used for larger stones (P<0.001). In 113 studies reporting SFR, pooled rates were 0.801 for ESWL, 0.826 for RIRS And 0.893 for PCNL, with PCNL showing higher SFRs. Considerable heterogeneity was observed And differences in complication profiles and instrumentation were identified as important factors influencing treatment outcomes beyond stone-free rates alone. CONCLUSIONS:A 15-mm stone size threshold appears clinically meaningful and provides clearer guidance than the traditional 10-20 mm range in children. ESWL and RIRS are appropriate options for stones <15 mm, whereas PCNL is more suitable for larger stones. Beyond stone-free rates, complication profiles and instrumentation should be considered when selecting treatment. Study heterogeneity and potential publication bias remain important limitations.
BACKGROUND:The therapeutic landscape of metastatic hormone-sensitive prostate cancer (mHSPC) has expanded significantly with triplet regimens, raising questions about their real-world applicability. This study evaluates the efficacy and safety of darolutamide- and abiraterone-based triplets using real-world data from the ARON-3 study. METHODS:A retrospective analysis was conducted on 247 mHSPC patients treated with DARO+DOCE+ADT or ABI+DOCE+ADT across 37 institutions in 14 countries. Key outcomes included progression-free survival (PFS), overall survival (OS), PSA kinetics, and safety. A propensity score was estimated based on key clinical variables and included as a covariate in Cox regression models to adjust for baseline imbalances between treatment groups. RESULTS:Data from 247 patients receiving triplet therapy were analyzed. The median OS for the entire cohort was not reached (NR). The median PFS was 24.8 months (95% CI: 18.7-33.6), with NR for DARO+DOCE+ADT and 21.5 months (95% CI: 13.1-25.2) for ABI+DOCE+ADT (P=0.007). In patients with visceral metastases, DARO+DOCE+ADT demonstrated superior outcomes, achieving higher OS rates at 6 months (97% vs. 83%, P=0.002) and 12 months (92% vs. 74%, P<0.001) compared to ABI+DOCE+ADT. The safety profiles of both regimens were comparable, although grade 3-4 fatigue was more frequently observed in the ABI+DOCE+ADT group. After adjusting for baseline imbalances through propensity score inclusion in multivariate models, the differences in OS (P=0.103) and PFS (P=0.135) between treatment groups did not reach statistical significance, although a numerical trend favoring DARO+DOCE+ADT was observed. CONCLUSIONS:Both regimens demonstrate efficacy, with DARO+DOCE+ADT offering superior outcomes in high-volume disease, especially visceral metastases. Nonetheless, the limited sample size and potential biases highlight the need for further follow-up and biomarker-driven studies in larger cohorts to refine treatment strategies.
BACKGROUND:This study aimed to develop and validate a novel preoperative nomogram to predict stone-free status (SFS) in patients undergoing retrograde intrarenal surgery (RIRS) for kidney stones. METHODS:A total of 312 patients who underwent RIRS were retrospectively analyzed. Robust predictors were selected using the intersection of the least absolute shrinkage and selection operator (LASSO) regression and the Boruta algorithm. Eight machine-learning algorithms were trained and compared. The optimal model was determined based on the receiver operating characteristic curve (ROC), Decision-curve analysis (DCA), and other evaluation indicators, with 5-fold cross-validation performed for internal validation. The best-performing algorithm (LogisticTEST) was further interpreted using Shapley Additive Explanations (SHAP) and visualized through a nomogram. Internal validation was performed with 1,000 bootstrap resamples. RESULTS:Seven key predictors were identified, including stone volume, mean stone density, calyx pelvic height, inferior pole stone, laser mode, Operative Team Proficiency Score, and Number of stones. Among all models, LogisticTEST demonstrated the best discrimination (AUC=0.965) and the greatest clinical net benefit on DCA. SHAP analysis reveals that laser mode is the most critical predictor influencing stone-free status, and the predictive capability of SFS for each patient can be well clinically explained through SHAP. The logistic-based nomogram exhibited strong calibration and interpretability, providing an intuitive clinical decision-support tool. CONCLUSIONS:A machine learning-driven logistic model incorporating laser mode and team experience accurately predicted postoperative SFR following RIRS. Future multi-centre external validation and prospective studies are required to validate our findings.
BACKGROUND:Outcomes of cytoreductive nephrectomy with tumor thrombectomy are poorly characterized in the literature. The objective of this study was to report survival in patients with metastatic renal cell carcinoma with tumor thrombus who underwent cytoreductive nephrectomy with tumor thrombectomy. METHODS:This was a retrospective, multi-institutional study. To be included, patients required an imaging confirmed diagnosis of metastatic renal cell carcinoma with a tumor thrombus on either computerized tomography and/or magnetic resonance imaging and underwent cytoreductive nephrectomy with tumor thrombectomy. Tumor thrombus was graded using the Mayo Clinic classification system. Overall survival, cancer-specific survival, and progression-free survival were evaluated. Cox proportional hazards regression and competing risks regression was used to assess the significance of demographic variables, treatment characteristics, and location of metastases on survival time-to-event measures within five years of surgery. RESULTS:Overall, 131 patients were included. Median number of metastatic sites at the time of cytoreductive nephrectomy was one. Fifty-six (44%) patients had a level I thrombus, 31 (24%) had a level II, 20 (16%) had a level III, and 20 (16%) had a level IV thrombus. Median overall survival was 1.7 years, cancer-specific survival was 2.2 years, and progression-free survival was 1.1 years. Systemic symptoms at diagnosis, larger preoperative tumor size, and adrenal metastases conferred a greater hazard of death (P<0.05). Brain metastasis conferred a greater hazard of cancer-specific death (P<0.05). CONCLUSIONS:Identification of patients most likely to benefit from cytoreductive nephrectomy with tumor thrombectomy remains elusive. Multiple patient specific factors could aid in prediction of survival postoperatively.
BACKGROUND:Recently a nomogram has been developed to predict prostatic inflammation. Aim of our study is to validate the prostatic inflammation nomogram (PIN) for predicting the presence of prostatic inflammation in men with lower urinary tract symptoms (LUTS). METHODS:A consecutive series of men (≥40 years) with benign prostatic hyperplasia (BPH)/LUTS scheduled for prostatic surgery or transrectal ultrasound-guided (TRUS) prostate biopsy were enrolled. The presence of inflammation in the prostatic tissue samples, assessed according to the Irani score, was determined. Inflammation was classified using the Irani score into two categories: 0-2 (no/minimal inflammation) and 3-6 (moderate/severe inflammation). The discrimination, calibration, and net benefit of the nomogram were evaluated. RESULTS:A total of 429 patients (mean age 70 years) were recruited. Overall, 257/429 (60%) presented with prostatic inflammation. On multivariable binary logistic regression analysis diabetes mellitus (OR=2.28; P=0.006), higher storage International Prostate Symptom Score score (OR=1.17; P<0.001), a prostate volume greater than 50 mL (OR=2.14; P<0.001), a positive urine dipstick test for leukocytes (OR=4.37; P<0.001) and a history of previous urinary tract infections (OR=2.34; P<0.001) were predictors of inflammation. Receiver operating characteristic analysis showed the nomogram with an AUC of 0.76 (95% CI: 0.72-0.81). Calibration was fair, and the nomogram demonstrated clinical net benefit within a probability range of 30% to 85%. CONCLUSIONS:The PIN nomogram showed good predictive ability and net benefit. Its use may help individualize treatment for LUTS by identifying candidates for therapies targeting prostatic inflammation.
INTRODUCTION:Bacillus Calmette-Guérin (BCG) immunotherapy remains the standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC). While the European Association of Urology (EAU) guidelines recommend initiating BCG treatment no later than 4-6 weeks following transurethral resection of bladder tumors (TURBT), delays in BCG administration are not uncommon due to factors such as pathological assessment timelines, patient-related issues, healthcare system limitations, and drug shortages. This systematic review aims to evaluate the impact of delayed BCG therapy or unconventional schedules on oncological outcomes, trying to establish the best treatment option for these patients. EVIDENCE ACQUISITION:A comprehensive literature search was conducted across multiple databases (PubMed, Scopus, Web of Science) for studies published from January 2010 to the present. After screening 262 publications, relevant prospective and retrospective studies, systematic reviews, and meta-analyses were included. EVIDENCE SYNTHESIS:We retrieved 14 manuscripts evaluating different BCG schedule or doses. Only two papers specifically referred to the delay in the treatment of high risk NMIBC. The findings highlight that the delays in initiating the BCG therapy beyond 6 weeks are associated with worse recurrence-free survival (RFS), progression-free survival (PFS), and cancer-specific survival (CSS) rates. However, evidence on the progression to MIBC or metastatic disease remains inconclusive, with only a few studies suggesting a potential impact. Despite these delays, even reduced dose or shortened BCG regimens appear to offer some level of protection against disease progression. CONCLUSIONS:This review emphasizes the importance of adhering to standard BCG treatment schedules to minimize the risk of recurrence and suggests that, in cases of unavoidable delay, strict endoscopic follow-up is crucial and an optimal treatment in case of cancer relapse must be offered. Further prospective studies are needed to conclusively determine the long-term effects of delayed therapy.
BACKGROUND:The European Association of Urology (EAU), American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines (GL) represent key international standards for clinical practice. We assessed the adherence to EAU-AUA- NCCN GL in a large real-world multicenter cohort of patients with Upper Tract Urothelial Carcinoma (UTUC), treated with nephroureterectomy. METHODS:A multicenter retrospective analysis from the ROBUUST (ROBotic surgery for Upper tract Urothelial cancer STudy) registry was performed to assess the region-specific adherence rates to guidelines (GL) for perioperative treatments and their impact on oncological outcomes was evaluated with the Kaplan-Meier method. RESULTS:Out of 2307 patients, excision was the most adopted approach for bladder cuff management world-wide (USA 88.6%, EU 90.5%, Asia 89.8%). Postoperative bladder instillation (intravesical chemotherapy) was implemented in 28.4% of all cases and did not impact bladder recurrence-free survival (log rank P=0.45). Lymphadenectomy (LND) in high-risk disease was underused in both locally advanced (cT3-4: USA 35.8%, EU 46.8%, A 25%) and cN+ stages (USA 41.9%, EU 47.9%, A 43%). LND was not associated with better cancer-specific survival (CSS) across all stages (log rank P≥0.53). Adjuvant chemotherapy (AdCHT) was administered overall in 27.8% of pT2-T4 cases, with a significantly higher adoption in Asia (P=0.03); while in pN+ disease, AdCHT rate was 30.2% and did not convey any advantage in CSS (P=0.58). Retrospective design is the main limitation of the present study. CONCLUSIONS:The present contemporary "real world" data suggests poor adherence to current EAU-AUA guidelines for key indicators of quality care such as perioperative bladder instillation of chemotherapy, performance of LND and administration of adjuvant chemotherapy for advanced disease. These findings highlight the need of improving the implementation of these guideline driven treatment strategies.
Aim of this review is to evaluate the pharmacological efficacy and safety of Serenoa repens extracts in managing lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). Using PubMed, Web of Science, and the Cochrane database, we identified studies published until November 2023 reporting effect of Serenoa repens extracts on LUTS and BPH. All studies were included in the literature search. The most relevant studies were selected to identify the effects of different extracts of serenoa repens in terms of pharmacology, efficacy and safety. Hexanic extract of Serenoa repens (HESr), presents important anti-inflammatory, antiproliferative, and antiandrogenic activities proven through various in vitro, in vivo, and clinical trials. The current phytotherapeutic landscape is very heterogeneous and limited by the lack of a regulatory framework for herbal substances. There is a clear disparity in the qualitative and quantitative composition of extracts due to varied extractive processes, affecting the therapeutic efficacy. Several studies (prospective randomized clinical trials) demonstrated the clinical efficacy of HESr compared to placebo and other pharmacological treatments. Particularly, HESr improves nocturia and Qmax. Other extraction techniques, such as alcoholic and CO2 need further RCT to better define their efficacy. The review identifies the critical role of Serenoa repens extract in managing LUTS in patients with BPH. Particularly the evidence suggests significant in vitro and in vivo differences in terms of inflammation reduction, symptoms relief and flow improvement depending on the extraction technique.
BACKGROUND:Nowadays, systemic treatment with immune-based combinations for metastatic renal cell carcinoma (mRCC) is the gold standard. However, the benefit of these treatments in patients aged ≥70 years is uncertain. Thus, we evaluate the effectiveness and safety of first-line immune-based combinations in elderly patients with mRCC. METHODS:We retrospectively collected data from mRCC patients who were treated with immune-based combinations in first-line setting at 75 hospitals from 23 countries. Patients were assessed for overall survival (OS), overall response rate (ORR) and severe adverse events (SAEs). The statistical analysis encompassed the Fisher's Exact Test, the Kaplan-Meier methodology, the log-rank test, as well as univariate and multivariate Cox proportional hazards regression models. RESULTS:Of the 1990 mRCC patients included in this analysis, 739 patients were aged ≥70 years. Median OS was 41 months for patients aged <70 years and 30.1 months in patients aged ≥71 years (P<0.001). The age was a prognostic factor in both univariate and multivariate analysis. There was no difference in ORR (52% versus 44%, P=0.262). There was no statistical difference in incidence SAEs as well as dose reductions or treatment discontinuation between elderly and young patients. CONCLUSIONS:This large real-world study with mRCC patients substantiates the effectiveness and safety of first-line immune-based combination treatments in elderly patients. Nonetheless, this population has a lower survival in comparison to younger patients.
BACKGROUND:Radical cystectomy (RC) is the gold standard for muscle-invasive and recurrent high-risk non-muscle-invasive bladder cancer (BCa). Over time, robot-assisted radical cystectomy (RARC) has gained adoption. Despite technological advancements, survival differences may persist between patients treated in earlier versus recent years. This study examines temporal variations in overall survival (OS) among patients undergoing robotic-assisted radical cystectomy (RARC) at a high-volume tertiary robotic center, comparing a historical cohort (2003-2016) with a contemporary one (2017-2024). METHODS:Data from patients undergoing RARC at AZORG Hospital (Aalst, Belgium) between July 2003 and March 2024 were analyzed. Three experienced surgeons performed all procedures. Baseline characteristics were compared, Kaplan-Meier plots illustrated OS, and Cox regression models evaluated overall mortality (OM). An 18-month landmark analysis minimized immortal time bias. RESULTS:Overall, 358 BCa patients underwent RARC (53% historical vs. 47% contemporary). The 3-year OS was 85% for the historical cohort vs. 93% for the contemporary cohort (P=0.001). Multivariable Cox regression showed that treatment in the contemporary cohort was an independent predictor of lower OM (hazard ratio [HR]: 0.52, 95% CI: 0.34-0.83; P=0.006), with further reduction after the 18-month landmark analysis (HR: 0.42, 95% CI: 0.19-0.92; P=0.03). Higher pathological T stage (pT3-4) was associated with increased OM before (HR: 3.9, 95% CI: 2.19-6.95; P<0.001) and after landmark analysis (HR: 2.25, 95% CI: 1.08-4.68; P=0.03). Grade 3-4 Clavien-Dindo complications predicted higher OM before (HR: 2.02, 95% CI: 1.27-3.22; P=0.003), but not after landmark analysis (HR: 2.04; 95% CI: 0.99-4.18; P=0.052). CONCLUSIONS:Patients treated between 2017-2024 had significantly lower OM, with a 50% reduction in mortality risk compared to 2003-2016. Advancements in surgical techniques and perioperative care likely contributed to improved OS. However, pathological T stage remained a strong predictor of OM, highlighting the need for enhanced early detection and disease management despite technological progress.
Transperineal laser ablation (TPLA) is emerging as a minimally invasive, office-based treatment for benign prostatic obstruction, but there is still a lack of evidence regarding its results in large prostates. The aim of this work was to evaluate safety, feasibility, and functional outcomes of TPLA in patients with prostate volume ≥80 mL. Data from consecutive patients undergoing TPLA April 2021 and February 2025 were prospectively collected in a dedicated institutional database, queried to select those patients with a prostate volume ≥80 mL who underwent TPLA. All procedures were performed under local anesthesia in an outpatient setting. A total of 234 patients underwent TPLA during the study period. Of these, 43 met the inclusion criteria for prostate volume and were included in the analysis. At the time of the surgery, 5 patients (12%) had an indwelling catheter and 36 (84%) were on medical therapy for BPO. Preoperative median prostate volume was 96 mL. At a median 12-month follow-up, uroflowmetry and symptom scores improved significantly, with preserved sexual and ejaculatory function. No major complications occurred. The catheter was successfully removed in 3 out of 5 (60%) patients with an indwelling catheter before TPLA. A total of four patients (9%) required additional surgical intervention during follow-up time. Our findings suggest that TPLA may be a safe and effective alternative to conventional surgery even in large prostates, warranting further validation through larger and comparative studies.
