BACKGROUND AND OBJECTIVE:Treatment of metastatic hormone-sensitive prostate cancer (mHSPC) has evolved from androgen-deprivation therapy (ADT) alone to combination therapy with androgen receptor pathway inhibitors. Although apalutamide (APA), abiraterone (ABI), and enzalutamide (ENZA) improve outcomes when added to ADT, direct comparative trials between androgen receptor pathway inhibitor-based doublets are lacking. METHODS:Our systematic search was conducted on 22 September 2025, in PubMed, Embase, and the Cochrane Library databases. Studies including patients with mHSPC treated with APA, ABI, or ENZA plus ADT were eligible if they contained real-world data and reported at least one outcome: overall survival (OS), PSA50, PSA90, PSA ≤0.2 ng/mL, time to castration-resistant prostate cancer, biochemical progression-free survival, grade ≥3 adverse events, or treatment discontinuation (TDC). Pooled hazard ratios (HRs) and odds ratios (ORs) were calculated using inverse variance random-effects models. KEY FINDINGS AND LIMITATIONS:In total, 17 retrospective studies comprising 18 626 patients were included. Compared with ABI, APA was associated with improved OS (HR 1.27; 95% confidence interval [CI] 1.09-1.47; P = 0.002), PSA90 (OR 0.70; 95% CI 0.54-0.91; P = 0.019), PSA <0.2 ng/mL (OR 0.49; 95% CI 0.25-0.95; P = 0.039), and castration-resistant prostate cancer (HR 1.40; 95% CI 1.05-1.88; P = 0.023). APA also demonstrated higher PSA90 response rates than ENZA (OR 0.67; 95% CI 0.5-0.9; P = 0.017). TDC due to adverse events was lower with ABI than with APA (OR 0.56; 95% CI 0.37-0.86; P = 0.029), with no significant difference between ENZA and APA (P = 0.10). CONCLUSIONS AND CLINICAL IMPLICATIONS:In real-world settings, APA-based doublets were associated with more favourable efficacy outcomes with ABI, whereas ABI- and ENZA-based regimens were associated with lower TDC rates. ABI and ENZA demonstrated comparable efficacy and safety profiles, supporting individualized ARPI selection in mHSPC.
OBJECTIVES:To develop and validate explainable machine learning (ML) models predicting urinary stone composition from routinely available clinical variables and standardised morphological features, and to quantify the incremental value of morphology. PATIENTS AND METHODS:This retrospective cohort study included consecutive patients undergoing endourological treatment or spontaneous stone expulsion, with laboratory analysis showing a major component exceeding 50% of stone composition, between 2019 and 2024. The outcome was dominant stone composition, classified into five categories: calcium oxalate monohydrate (COM), calcium oxalate dihydrate (COD), calcium phosphate, uric acid, and cystine. Predictors included demographics, comorbidities, stone metrics, procedural details, and Daudon-based morphological descriptors. Data were split into stratified training and validation cohorts (80% and 20%, respectively). Predictor stability was assessed using repeated-resampling multiclass Least Absolute Shrinkage and Selection Operator (LASSO). Multiple supervised classifiers (logistic regression, support vector machine, random forest, ExtraTrees, Adaptive Boosting [AdaBoost] variants, Extreme Gradient Boosting [XGBoost], Categorical Boosting [CatBoost]) were fine-tuned using GridSearch. Discrimination was assessed using macro-averaged one-vs-rest area under the curve (AUC) and accuracy. Explainability relied on SHapley Additive exPlanations (SHAP). RESULTS:Among 442 patients (median age 51 years; 67% male), stone composition was COM in 41.0% (n = 181), COD in 24.9% (n = 110), calcium phosphate in 19.7% (n = 87), uric acid in 10.9% (n = 49), and cystine in 3.6% (n = 16). LASSO stability highlighted reproducible predictors, including age, hereditary disease type, stone density, maximal diameter, and location. Clinical-only models achieved good discrimination (macro-AUC up to 0.809). Adding morphological features markedly improved performance, with ensemble models achieving excellent discrimination in validation (macro-AUC up to 0.983 with CatBoost). Morphological variables ranked among the strongest contributors on SHAP. CONCLUSIONS:A clinical-only model can predict the major stone component and may support preoperative decision-making. Performance further improved when morpho-constitutional features were added, confirming Daudon's classification as the ground truth; however, this combined model relies on intra- and postoperative descriptors and is best regarded as an intra- or postoperative decision-support tool rather than a preoperative one. External prospective validation is needed before clinical implementation.
OBJECTIVES:To examine sexual satisfaction, function, and orgasm following genital gender-affirming surgeries (GGAS) among transgender and gender-diverse (TGD) patients; we used the GENDER-Q, a validated instrument for TGD individuals seeking gender-affirming care that enables a more comprehensive evaluation of sexual experience. PATIENTS AND METHODS:Our cross-sectional survey was distributed via e-mail to patients; surveys were completed in May 2025. The primary outcome was sexual satisfaction measured by the GENDER-Q Sexual Well-Being scale. Secondary outcomes measured the relationship between ability to orgasm and orgasm changes pre- and postoperatively with identity, sexual wellness, social acceptance, body image, mental health, and surgical outcomes. RESULTS:Of 765 eligible individuals, 295 (39%) responded; 103 (35%) underwent vulvoplasty and 192 (65%) underwent vaginoplasty. In all, 89% were transgender women, and 80% were at least 1-year postoperative. Sexual satisfaction did not differ by age, surgery type, race/ethnicity, revision history, timing of first postoperative orgasm, or anxiety symptomology. Higher sexual satisfaction was associated with postoperative orgasm and absence of orgasm-related pain and correlated positively with higher scores on the GENDER-Q Orgasm, Social Acceptance, Surgery Outcome, and Body Image scales. In all, 80% of participants able to orgasm preoperatively reported postoperative orgasm, while 29% who did not experience orgasm preoperatively achieved orgasm postoperatively. Inability to orgasm postoperatively was associated with older age and lower Sexual Well-Being and Surgery Outcome scores. CONCLUSION:These findings underscore the multifactorial nature of sexual well-being after GGAS and highlight the value of assessing sexual function before and after surgery. Longitudinal studies are needed to further characterize sexual health trajectories following GGAS.
OBJECTIVE:To evaluate the diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (18F-FDG PET/CT) for detecting inguinal and pelvic lymph node metastases in penile squamous cell carcinoma (SCC). METHODS:A systematic review and meta-analysis of diagnostic accuracy studies was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were systematically searched, and studies reporting sufficient data to construct 2 × 2 tables were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Pooled estimates were calculated using random-effects models. RESULTS:A total of 16 studies were included in the qualitative synthesis and eight in the meta-analysis. The pooled sensitivity was 0.84 (95% confidence interval [CI] 0.74-0.90) and specificity was 0.85 (95% CI 0.75-0.91). The diagnostic odds ratio was 20.57 (95% CI 9.76-43.37). The positive likelihood ratio was 3.49, and the negative likelihood ratio was 0.25, indicating moderate ability to confirm disease but limited capacity to exclude it. The hierarchical summary receiver operating characteristic curve demonstrated overall good diagnostic performance. CONCLUSIONS:Use of 18F-FDG PET/CT shows good diagnostic performance for nodal staging in penile SCC, particularly as a confirmatory tool. However, its limited ability to exclude disease, especially in clinically node-negative patients, supports its use within a multimodal diagnostic approach rather than as a standalone test.
OBJECTIVES:To compare internal JJ stenting, external transanastomotic stenting and stentless repair after Anderson-Hynes pyeloplasty in children. PATIENTS AND METHODS:A systematic review and network meta-analysis of children with pelvi-ureteric junction (PUJ) obstruction undergoing Anderson-Hynes pyeloplasty. The MEDLINE, EMBASE, Cochrane Library and Web of Science databases were searched from inception to February 2025. Randomised and non-randomised comparative studies were included. Network meta-analysis compared JJ stenting, external stenting and no stenting. Risk of bias and certainty of evidence were assessed. RESULTS:A total of 26 studies including 3298 children were analysed. Overall complications did not differ significantly between strategies and operative success was high. External stenting was associated with lower odds of major complications compared with no stenting (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33-0.93). The JJ and external stenting were associated with lower odds of major urine leakage or urinoma compared with stentless repair (OR 0.20, 95% CI 0.07-0.60; and OR 0.20, 95% CI 0.07-0.61, respectively). Minor complications were similar between strategies, as were stent-related complications between JJ and external stenting. JJ stenting was associated with higher odds of urinary tract infection or pyelonephritis compared with no stenting, but with shorter hospital stay compared with external stenting. Certainty of evidence was low or very low for most outcomes. CONCLUSION:Paediatric pyeloplasty achieves high success rates regardless of drainage strategy. Stented approaches may reduce major leakage-related complications compared with stentless repair, while JJ stents may increase infectious complications. Drainage strategy should remain individualised.
OBJECTIVES:To evaluate if bladder washing cytology (BWC) provides a diagnostic benefit in the initial evaluation of patients with neuro-urological disorders. PATIENTS AND METHODS:This prospective cross-sectional study investigated a consecutive series of patients with lower urinary tract symptoms referred for neuro-urological evaluation at our department of neuro-urology who underwent urethro-cystoscopy (UC) and BWC from 2018 to 2023. RESULTS:Among 581 neurological patients, 274 (47.2%) were females. Tumour-suspicious findings leading to surgical intervention were detected in 17 (2.9%) by UC alone and in three (0.5%) by BWC but unsuspicious UC, respectively. Overall, relevant histological findings after transurethral bladder surgery (TUBS) were detected in eight (1.4%, 95% confidence interval [CI] 0.6-2.7%) patients: keratinising squamous metaplasia (two) and non-muscle-invasive urothelial carcinoma (six), all were initially identified by UC. Three patients refused surgery, two of whom had positive BWC without suspicious lesion in UC. Sensitivity and specificity of BWC referenced to UC alone were 0% (95% CI 0.0-36.9%) and 99.7% (95% CI 98.7-99.9%), respectively. Adding BWC to UC increased costs by 22.8% without improving tumour detection. The main study limitation was the lack of true positives in BWC. CONCLUSIONS:Bladder washing cytology in addition to UC is not justified in the initial evaluation of patients with neuro-urological disorders as decision making regarding TUBS is based on UC findings. Moreover, omission of BWC saves relevant costs without compromising patient safety.
OBJECTIVES:To systematically identify, appraise and synthesise artificial intelligence (AI) and machine-learning (ML) models that predict treatment response and clinical outcomes after intravesical bacillus Calmette-Guérin (BCG) in non-muscle-invasive bladder cancer (NMIBC), a setting in which current risk calculators underperform, and identifying non-responders has become urgent as alternatives to BCG enter practice. METHODS:PubMed, EMBASE and Web of Science were searched through April 2026 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines (International Prospective Register of Systematic Reviews [PROSPERO] number CRD420261376808). Studies developing or validating AI/ML models for BCG-associated outcomes with a quantitative performance metric were included. Risk of bias was assessed with the Prediction model Risk Of Bias ASsessment Tool (PROBAST). Evidence was synthesised along a clinically oriented framework: AI as a perceptual tool (extracting signal from histology or imaging) or integrative tool (re-weighting clinicopathological, molecular, or urinary variables). RESULTS:A total of 15 studies (>24 900 patients) were included: seven perceptual, eight integrative. By input data, six used digital pathology, two radiomics, two genomics/transcriptomics, four clinicopathological markers, and one urinary biomarkers. The digital-pathology Computational Histology Artificial Intelligence (CHAI) platform, validated across 12 international centres, stratified high-grade recurrence (hazard ratio [HR] 2.08), progression (HR 3.87) and BCG-unresponsive disease (HR 2.31), and was the only model providing a first signal of predictive value, demonstrating a significant BCG vs gemcitabine/docetaxel interaction (P = 0.029). Integrative models PROGRxN-BCa (concordance index [C-index] 0.79) and DeepSurv (C-index 0.881) outperformed standard calculators but with modest gains (ΔC-index 0.05-0.10). Only 40% of studies performed external validation, none prospectively; five were at high risk of bias. CONCLUSION:Perceptual AI, particularly digital pathology, has the highest external validation and provides the only biomarker with a first signal of predictive value for BCG vs alternatives, increasingly relevant in the context of the global BCG shortage. Integrative models such as PROGRxN-BCa and DeepSurv outperform standard calculators with incremental gains and are freely accessible. Prospective validation, systematic calibration reporting and treatment-by-biomarker interaction analyses, ideally embedded in trials such as the BRIDGE trial (ClinicalTrials.gov identifier: NCT05538663), remain priorities before clinical adoption.
OBJECTIVES:To perform a meta-analysis comparing the outcome of antegrade versus retrograde ureteroscopy for the management of large proximal ureteric stones. METHODS:A systematic review and meta-analysis of randomized controlled trials was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, with registration in PROSPERO (CRD420251085029). Randomized controlled trials comparing antegrade and retrograde ureteroscopy for proximal ureteric stones ≥10 mm were included. The primary outcome was stone-free rate. Secondary outcomes included auxiliary procedure rates, operative time, length of hospital stay, postoperative haematuria, postoperative fever, and ureteral strictures. Data were analysed using Review Manager V5.4, and the quality of the evidence was assessed using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) tool. RESULTS:A total of 14 trials including 1432 patients were analysed. Retrograde ureteroscopy achieved lower stone-free rates than antegrade ureteroscopy (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.20-0.44) and required more auxiliary procedures (OR 5.83; 95% CI 3.86-8.82). Antegrade ureteroscopy was associated with longer hospital stay (mean difference [MD] 1.29 days, 95% CI 1.24-1.35) and longer operative time (MD 12.03 min, 95% CI 11.34-12.72). Postoperative haematuria was less frequent with retrograde ureteroscopy (OR 0.40; 95% CI 0.25-0.64), whereas postoperative fever (OR 0.93; 95% CI 0.60-1.42) and ureteral strictures (OR 3.70; 95% CI 0.76-18.07) did not differ significantly between approaches. The certainty of evidence ranged from moderate to very low, mainly due to the risk of bias and heterogeneity. CONCLUSIONS:For large proximal ureteric stones, antegrade ureteroscopy offers superior stone clearance and fewer auxiliary procedures than retrograde ureteroscopy, at the cost of longer operative time, longer hospital stay, and higher haematuria rates. These findings support antegrade ureteroscopy when definitive single-stage stone clearance is the primary treatment goal.
OBJECTIVES:To evaluate the feasibility and accuracy of an artificial intelligence (AI) model to assist surgeons through automated real-time detection and segmentation of key anatomical structures during robot-assisted single-port transvesical enucleation of the prostate (STEP). PATIENTS AND METHODS:This retrospective single-centre study utilised surgical videos from patients undergoing single-port robot-assisted transvesical prostate enucleation performed by a single expert surgeon. Selected frames extracted from these surgical videos were manually annotated to identify anatomical landmarks during the key step of the procedure. The structures annotated were the bladder neck, prostatic adenoma, and the peripheral zone. A convolutional neural network based on the You Only Look Once version 11 architecture was trained using these annotated frames. Model performance was quantitatively assessed through recall, precision, F1-score, Intersection over Union, Dice Similarity Coefficient, and mean average precision (AP). Real-time performance was assessed qualitatively through visual inspection and confirmed quantitatively by measuring frame inference speeds. RESULTS:The study included 611 annotated frames derived from 37 surgical videos. The model demonstrated strong detection performance, with class-specific F1-scores of 0.88 (adenoma), 0.69 (bladder neck), and 0.70 (peripheral zone). Segmentation accuracy, measured by Dice Similarity Coefficient, resulted in adenoma: 0.86; bladder neck: 0.83; peripheral zone: 0.82. Mean AP across all anatomical classes was 0.43. The model consistently operated at >60 frames/s, confirming real-time applicability without perceptible lag. CONCLUSIONS:This pilot study demonstrates the potential utility of AI to provide intraoperative anatomical guidance during STEP, establishing a foundation for future clinical integration and performance optimization.
BACKGROUND:Prostate cancer (PCa) is the second most common cancer in men. For patients with high-volume metastatic PCa (mPCa) who are fit for docetaxel, a triplet therapy regimen consisting of androgen deprivation therapy (ADT), chemotherapy, and an androgen receptor pathway inhibitor (ARPI) is recommended. Adding local radiotherapy to triplet therapy has been shown to alleviate symptoms and reduce disease progression. However, the benefit of combining triplet therapy with local surgery remains unclear and warrants further investigation in the present study. STUDY DESIGN:This is an open-label, prospective, two-arm, multicentre, randomised controlled trial. ENDPOINTS:Primary endpoints are progression-free survival (PFS) and the 1-year PFS rate. Disease progression is defined as prostate-specific antigen (PSA) progression, radiological progression, or unequivocal clinical progression. Secondary endpoints include overall survival (OS) and health-related quality of life (HRQoL). PATIENTS AND METHODS:Patients aged 18-75 years with high-volume mPCa will receive ADT (triptorelin 15 mg every 3 months), four-six cycles of chemotherapy (docetaxel 75 mg/m2 every 3 weeks), and an ARPI (rezvilutamide 240 mg once daily). Patients achieving a PSA level ≤0.2 ng/mL and deemed suitable candidates for surgery will be enrolled. A total of 88 eligible patients will be randomised in a 1:1 ratio. The control group will continue treatment with triptorelin and rezvilutamide, while the experimental group will receive robot-assisted cytoreductive prostatectomy in addition to triptorelin and rezvilutamide. Baseline PSA levels will be recorded and re-examined at each chemotherapy cycle and every 3 months thereafter. Radiological evaluations will be performed every 6 months. Clinical progression will be assessed based on pain severity, performance status, and the need to initiate new anticancer therapy. HRQoL will be evaluated every 3 months. PFS and OS will be estimated using Kaplan-Meier curves and compared with the log-rank test. TRIAL REGISTRATION:Chinese Clinical Trial Registry: ChiCTR2600121819.
OBJECTIVES:To predict spontaneous stone passage (SSP) in uncomplicated acute ureteric colic (AC) using non-contrast computed tomography (NCCT)-based radiomics and machine learning (ML). PATIENTS AND METHODS:This retrospective single-centre study included consecutive patients presenting with stone-related uncomplicated AC between January 2022 and March 2024, confirmed by NCCT. Initial and 4-week follow-up clinical and imaging data were collected, including SSP status. After anonymisation, a semi-automated density-based stone segmentation was performed using 3DSlicer. Radiomic features were extracted (PyRadiomics_v3.1.1). Significant features were selected using the Least Absolute Shrinkage and Selection Operator (LASSO) method. After data splitting (training [80%]-validation [20%]), nine ML models were trained with hyperparameter fine-tuning to predict SSP on the validation set. The primary performance metric was the area under the curve (AUC). RESULTS:A total of 428 patients were included, with a median (interquartile range [IQR]) age of 45 (32-56) years. Most ureteric stones were solitary, with a median (IQR) maximum stone diameter (MSD) of 5.3 (4.1-6) mm and stone volume of 68.8 (22-78.1) mm3. The majority of the stones were proximal rather than distal: 59.6%, were located in the upper ureter, 9.1%, in the middle, and 30.8% in the lower ureter. A pelvic phlebolith was present in 50.9% of cases. The overall SSP rate was 47.9%. Following LASSO selection, seven radiomic features were used for model training and validation: image-original_mean (mean value of all voxels), image-original_maximum (maximum voxel value), original_glrlm_RunEntropy (heterogeneity in grey level run lengths), original_gldm_DependenceVariance (structure irregularity), original_gldm_LargeDependenceEmphasis (voxel homogeneity), original_gldm_LargeDependenceHighGreyLevelEmphasis (homogenous regions with high voxel intensity), original_gldm_LargeDependenceLowGreyLevelEmphasis (homogenous regions with low voxel intensity), along with SSP status. The random forest algorithm achieved the best performance of all tested models with an AUC of 0.79 (95% confidence interval 0.68-0.88) on the validation set (accuracy = 0.72, F1-score = 0.72, sensitivity = 0.69, specificity = 0.76). CONCLUSION:Predicting SSP in uncomplicated AC is feasible using radiomics features extracted from NCCT. Hybrid models, including the stone location could improve their performance. External validation is required, and developing an automated ureteric stone detection algorithm would be necessary to create a fully stand-alone clinical tool.
OBJECTIVES:To report long-term oncological outcomes for men with clinically localised prostate cancer (PCa) treated with contemporary modalities in a population-based United States cohort. PATIENTS AND METHODS:The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study prospectively enrolled men with clinically localised PCa from 2011 to 2012. Patients were stratified into two groups: favourable prognosis (clinical T stage [cT]1-T2a/bN0M0, prostate-specific antigen [PSA] level ≤ 20 ng/mL, Grade Group 1-2) and unfavourable prognosis (cT2cN0M0, PSA level 20-50 ng/mL, or Grade Group 3-5). Main outcomes were PCa-specific mortality (PCSM), composite progression to advanced disease (metastasis, PCSM event, or systemic therapy), and overall survival (OS). Cox regression models adjusted for demographic and clinical covariates. RESULTS:Of the 2604 men included, 73% were White, 15% Black, and 7% Hispanic. All hazard ratios (HRs) were adjusted for demographic and clinical covariates using multivariable Cox and Fine-Gray models. In the favourable group, compared with surgery, external beam radiotherapy (EBRT; HR 1.5, 95% confidence interval [CI] 1.1-2.1, P < 0.01), brachytherapy (HR 2.1, 95% CI 1.3-3.3, P < 0.01), and active surveillance (HR 1.5, 95% CI 1.1-2.1, P = 0.02) were associated with higher all-cause mortality; the 10-year cumulative incidence of PCSM was ≤1.5% for all five strategies, and progression did not differ. In the unfavourable group, EBRT was associated with worse OS (HR 2.8, 95% CI 1.9-4.3, P < 0.01), with no adjusted differences in PCSM (10-year cumulative incidence 3.5% after surgery vs 8.8% after EBRT) or progression across treatments. CONCLUSION:In this population-based cohort treated with contemporary modalities, the 10-year risk of PCa death was low across all treatment strategies, including active surveillance. OS differences favouring surgery likely reflect residual confounding from baseline health and treatment selection. These findings underscore the importance of patient values and comorbidities in shared decision-making for localised PCa.
OBJECTIVES:To describe contemporary trends in kidney stone disease (KSD)-related inpatient episodes, procedures, and costs in England and Scotland, with emphasis on post-coronavirus disease 2019 (COVID-19) service recovery, socioeconomic variation in Scotland, comparison with other urological procedures, and 10-year healthcare demand and cost projections. MATERIALS AND METHODS:Retrospective descriptive analyses were conducted using English Hospital Episode Statistics (2020-2025) and Public Health Scotland data (2019-2024). KSD-related finished consultant inpatient episodes and procedures were identified using the International Statistical Classification of Diseases and Related Health Problems 10th Revision and Operation and Procedures fourth edition codes, respectively. Procedures were categorised as extracorporeal shockwave lithotripsy, ureterorenoscopy (URS), percutaneous nephrolithotomy, or open. Trends were compared with uro-oncological resections and benign prostate obstruction procedures. Socioeconomic variation was assessed using the Scottish Index of Multiple Deprivation. The 10-year healthcare demand and cost projections, accounting for National Health Service (NHS) cost uplift factors, were modelled using historical data. RESULTS:The COVID-19 pandemic disproportionately reduced KSD-associated activity compared with procedures for bladder and kidney cancer. Although volumes now exceed pre-pandemic levels, inpatient episodes remain below baseline and waiting times remain prolonged. Between 2020 and 2025, inpatient episodes increased by 27.4% in England and 17% in Scotland, with URS accounting for >50% of interventions. KSD procedural volumes are comparable to the combined volume of uro-oncological resections and benign prostatic obstruction procedures. In Scotland, 44% of procedures were performed in the two most deprived socioeconomic quintiles versus 37% in the two least deprived. In England, KSD-associated episodes are projected to increase by 33% to 111 907 (95% confidence interval 96 057-130 373) by 2034-2035, with an estimated cumulative NHS cost of £1.82 billion over the next decade. CONCLUSION:Kidney stone disease exacts a growing burden on healthcare services with incomplete recovery of inpatient care following the COVID-19 pandemic, socioeconomic disparities, and rising healthcare demand. These findings can inform service planning and prioritise evaluation of strategies to improve efficiency, equity, and prevention.
OBJECTIVE:To assess the learning curve for radical prostatectomy (RP) with the Versius system (CMR Surgical, Cambridge, UK) and evaluate the transfer of skills from previous robotic and laparoscopic practice. SUBJECTS, PATIENTS AND METHODS:This prospective cohort study included patients with localised prostate cancer undergoing Versius-assisted RP. Four surgeons participated: two with extensive prior robotic experience (>500 Da Vinci Surgical System [Intuitive Surgical Inc., Sunnyvale, CA, USA] RPs) and two with laparoscopic but no robotic background, operating under structured proctoring. Outcomes included objective measures such as console time or novel hand motion volumetry. Proficiency was defined by Learning Curve Cumulative Sum (LC-CUSUM) analysis with thresholds of console time <165/180 min (without/with lymphadenectomy) and absence of significant positive surgical margins. RESULTS:A total of 151 consecutive patients were included. Pre- and postoperative characteristics were comparable across surgeons. There were clinically and statistically significant improvements in operative time and hand motion metrics with increasing experience. Proficiency was achieved after 23 cases by experienced surgeons and after 37 by novel surgeons. The overall positive margin rate was 27.8%, with only two cases exceeding the ≥3 mm threshold in nerve-sparing procedures. Major complications (Clavien-Dindo Grade ≥III) only occurred in four (2.6%) patients. CONCLUSION:Surgical proficiency in Versius-assisted RP was achieved in <40 cases, particularly among surgeons with prior robotic experience. Structured proctoring shortened the learning curve, and hand motion volumetry emerged as an objective marker of skill, supporting its use in training and competency assessment.
OBJECTIVES:To review how response to neoadjuvant therapy (NAT) is assessed in clinical trials of muscle-invasive bladder cancer (MIBC), and to determine whether trial-derived evidence can inform response evaluation in contemporary practice. SUBJECTS/PATIENTS AND METHODS:We searched PubMed, Embase and ClinicalTrials.gov through August 2025 for randomised controlled trials (RCTs) of neoadjuvant chemotherapy, chemo-immunotherapy or immunotherapy in non-metastatic MIBC (cT2-T4a N0-1 M0), and for prospective single-arm chemo-immunotherapy or immunotherapy trials. We extracted data on imaging modality and coverage, endoscopic and biomarker-based assessment, timing, correlation with final pathology and diagnostic accuracy. Given heterogeneity in definitions and reporting, no meta-analysis was performed. RESULTS:We identified 22 studies, including 14 RCTs. Most incorporated response evaluation, yet methods differed widely. Computed tomography (CT) was the most frequent modality in RCTs, whereas bladder magnetic resonance imaging (MRI) predominated in recent single-arm immunotherapy trials. Timing was inconsistent and usually post-treatment; only two trials performed interim assessment. Endoscopic evaluation was concentrated in bladder-preservation trials, and circulating tumour DNA (ctDNA) was used selectively. Only five studies correlated restaging with final pathology; multiparametric MRI scored with nacVI-RADS predicted pathological complete response with 72%-83% accuracy. No trial reported imaging accuracy for distant metastases after NAT. CONCLUSION:Response assessment after NAT in MIBC remains insufficiently standardised. Trial-derived evidence supports cross-sectional imaging before radical local treatment, with CT the most established modality, largely reflecting trial-design conventions and availability rather than demonstrated diagnostic superiority; bladder MRI is more accurate for local restaging. Emerging biomarkers such as ctDNA require validation. Harmonising timing, modalities and response definitions is needed to enable evidence-based treatment adaptation.
