The widespread use of cross-sectional imaging has increased the incidental detection of small renal masses (SRMs). In this context, overtreatment represents a major concern, particularly for lesions < 2 cm. Most evidence derives from retrospective registries, whereas prospective data remain limited. This multi-center, prospective, non-randomized clinical trial was conducted in five European centers between January 2015 and July 2021. Seventy-six patients aged > 50 years with asymptomatic, unilateral SRM < 2 cm were enrolled and followed under a structured prospective active surveillance (AS) protocol with periodic axial imaging. Active treatment was recommended according to predefined progression criteria or patient preference. The primary endpoint was event-free survival (EFS); secondary endpoints included treatment-free survival (TFS), overall survival (OS), and cancer-specific mortality (CSM). 69 patients were included in the analyses. After a median follow-up of 88 months, 8-year EFS and TFS were 66

INTRODUCTION:Peyronie's disease causes penile curvature and painful erections, potentially impairing quality of life; surgical grafts are employed to correct curvature and restore penetrative sexual function. OBJECTIVES:This study aimed to summarize the evidence on perioperative and functional outcomes of surgical grafting procedures for Peyronie's disease. METHODS:A systematic review was conducted following the PRISMA guidelines. Databases including PubMed, EMBASE, Scopus, Google Scholar, and the Cochrane Library were searched up to April 1, 2023. Eligible studies included retrospective or prospective reports on patients aged 18 years or older treated with various graft materials, including vein, dermal, buccal mucosa, small intestinal submucosa, human cadaveric, and bovine pericardium. Quality was assessed using the JBI Critical Appraisal Checklist. Due to data heterogeneity and a lack of comparative studies, no quantitative synthesis was performed. The systematic review was registered on PROSPERO-CRD42024508997. The review focused on perioperative outcomes, erectile function changes, and complication rates associated with different graft materials. RESULTS:Out of 521 articles identified from 1933 to 2023, 71 studies involving 2692 patients met the inclusion criteria. Six studies were prospective, and the remainder were retrospective. Quality assessment revealed a high or severely high risk of bias across all included studies. Erectile function worsened in 0%-70% of patients, with complication rates ranging from 0% to 50%. No comparative studies among graft types were identified. CONCLUSION:Various graft materials offer reliable perioperative and functional outcomes for Peyronie's disease; however, further comparative studies are essential.

Surgical resection is the standard treatment for nonmetastatic renal cell carcinoma, yet survival outcomes vary significantly among patients. Current prognostic models lack precision and cannot be applied preoperatively. Here we show the development and validation of a preoperative, interpretable machine learning model to estimate cancer-specific mortality. Using real-world clinical data from 2536 patients and an independent external validation cohort of 580 patients, we combine random survival forests with white-box models to ensure clinical transparency. Our survival tree model relies on exactly eight preoperative features, including tumor size, lymph node involvement, and performance status. We demonstrate that this model outperforms the established GRANT model, achieving a C-index of 0.88 and a Brier score of 0.02 on the external cohort, with notable accuracy in the first year postsurgery. Finally, we provide this tool as a web-based application to facilitate personalized, preoperative risk stratification.

BACKGROUND:The preoperative glycemic control of diabetic patients may increase the risk of penile prosthesis (PP) infection, but the published literature remains controversial. AIM:To systematically review and meta-analyze available evidence on the impact of diabetes mellitus (DM) and glycemic control on PP infection. The study was completed under the auspices of the European Society for Sexual Medicine Surgical Academy. METHODS:An comprehensive Medline, Embase, and Cochrane search was performed including the keywords: ("penile prosthesis" and "diabetes mellitus"). Only English-language articles published between January 1, 1969 and May 31, 2024 were included. OUTCOMES:The primary outcome measure was the risk of PP infection in diabetic patients. The secondary outcome measure was the contribution of glycemic control on PP infection rate. RESULTS:Out of 182 retrieved articles, 11 were included in the study, summarizing 10 024 subjects with a mean age of 59.7 years, and a mean follow-up of 37.2 months. Overall, a PP infection rate of 4.3[3.9-4.8]% was observed. The PP infection rate increased according to baseline HbA1c levels, and the latter result was confirmed following adjustment for age and trial duration (P < .0001). Accordingly, PP infection rate was more than 2-times higher when trials with a mean HbA1c ≥ 8% were compared to the rest of the sample (9.1[7.5;11.0] vs 3.8[3.2;4.5]%; Q = 43.18; P < .0001). CLINICAL IMPLICATIONS:Optimization of the preoperative glycemic control may reduce PP infection rate in diabetic patients. STRENGTHS AND LIMITATIONS:The present study provides evidence supporting a significant increased risk of PP infection for patients with DM and pre-operative HbA1c ≥ 8%. Analysis was primarily derived from retrospective studies, which represent a significant source of bias. The exclusion of those studies including less than 70% of diabetic patients can represent a further source of bias. CONCLUSION:The present study shows a significant association between pre-operative HbA1c and PP infection rate. Further studies are advisable in order to better clarify the best threshold of HbA1c that is acceptable prior to implant surgery in diabetic patients.

BACKGROUND:Transgender individuals assigned male at birth (AMAB) may choose to preserve their fertility prior to starting gender-affirming hormone therapy (GAHT). However, limited data exist regarding the baseline reproductive and hormonal characteristics of this population before and after GAHT. OBJECTIVES:To characterize semen quality and hormonal profiles in transgender AMAB individuals prior to GAHT and compare findings with cisgender men and with transgender individuals who discontinued GAHT for at least 3 months. MATERIALS AND METHODS:This retrospective study included transgender AMAB individuals from two tertiary andrology centers who underwent sperm cryopreservation before GAHT initiation (treatment-naïve group). Clinical evaluation included anthropometric measures, testicular volume assessment, varicocele detection, and sex hormone measures. Semen parameters were analyzed according to WHO criteria and compared with those of cisgender men and previously treated transgender individuals. RESULTS:Thirty-two treatment-naïve transgender AMAB individuals were included. Hormonal parameters were generally within reference ranges. Only 46.9% of treatment-naïve individuals met WHO criteria for normozoospermia, compared with 75.5% of cisgender controls. Compared with nine previously treated individuals, estradiol levels were higher and seminal volume lower. A higher frequency of seminal abnormalities was observed, although not statistically significant. CONCLUSIONS:A substantial proportion of treatment-naïve transgender AMAB individuals exhibited impaired semen parameters prior to GAHT initiation. Prior GAHT exposure showed a trend toward poorer semen quality. These findings support early fertility counseling and preservation in transgender individuals prior to GAHT initiation.

Background: Endoscopic kidney-sparing surgery (eKSS) is increasingly adopted for the management of selected patients with upper tract urothelial carcinoma (UTUC). Laser energy is central to tumor ablation during eKSS; however, multiple laser platforms with distinct physical and thermal properties are currently available, and their comparative oncological and safety profiles remain poorly defined. This systematic review aims to summarize the available evidence on oncological outcomes and perioperative complications associated with laser-based endoscopic treatment of UTUC and to explore potential differences according to laser technology. Methods: A systematic literature search identified 25 eligible studies published between 1997 and 2024, including 1344 patients treated with laser-assisted eKSS. All included studies were non-randomized, predominantly retrospective, and characterized by moderate-to-serious risk of bias. Holmium:YAG, Thulium:YAG (thu:YAG, continuous-wave and pulsed), thulium fiber laser (TFL), Neodimio:YAG (Nd:YAG), diode lasers, and combination platforms were reported. Results: Ipsilateral upper tract recurrence was common across all laser categories, with weighted proportions ranging approximately from 27% to 52% and substantial inter-study heterogeneity. Progression and conversion to radical nephroureterectomy (RNU) were relatively infrequent overall, with numerically weighted proportions observed in thu:YAG-based cohorts. Major complications (Clavien-Dindo ≥ III) were rare across all laser technologies, although a trend toward a higher weighted proportions was observed in Ho:YAG- and Nd:YAG-based series. Minor complications were more frequently reported and highly heterogeneous. Conclusions: Available evidence supporting laser selection in endoscopic kidney-sparing management of UTUC is limited and largely descriptive. Thulium:YAG and TFL platforms seem to demonstrate encouraging trends toward lower progression and conversion to-radical-nephroureterectomy rates; however, these findings are derived from heterogeneous, non-comparative studies with limited follow-up. No standard laser platform can currently be recommended over others based on existing data. Prospective, comparative, and methodologically robust studies are required to determine whether laser technologies confer clinically meaningful advantages in oncological control or safety for UTUC treated with eKSS.

BACKGROUND:Racial disparities in prostate cancer are well-documented, with Black men experiencing twice the mortality of White men. While prior studies suggest these disparities reflect inequitable access rather than biology, only few studies have examined this in the biochemical recurrence setting, where screening and initial treatment biases are eliminated. We compared cancer-specific mortality and other-cause mortality between non-Hispanic Black (NHB) and non-Hispanic White (NHW) men with biochemical recurrence after initial treatment. METHODS:This retrospective single health system study included patients who developed BCR after radical prostatectomy or radiation therapy between 1995 and 2023. Primary outcome was cancer-specific mortality. Fine-Gray competing risk models assessed race-CSM association, stratified by treatment and adjusted for European Association of Urology biochemical recurrence risk classification. RESULTS:Among 968 patients (431 NHB, 44.5%; 537 NHW, 55.5%), median follow-up was 5.5 years from biochemical recurrence. Other-cause mortality was similar (Gray's test p = 0.35 radical prostatectomy, p = 0.41 radiation therapy). Ten-year cancer-specific mortality estimates were similar after radical prostatectomy (6.7% both races; NHB versus NHW HR 0.91, 95% CI 0.49-1.71, p = 0.8) and radiation therapy (NHB 26.7% versus NHW 32.4%; HR 0.71, 95% CI 0.44-1.14, p = 0.16). Limitations include single-center design and retrospective methodology. CONCLUSIONS:In this racially diverse single-center cohort, we found no racial disparities in cancer-specific mortality or other-cause mortality after biochemical recurrence. These findings support that racial disparities reflect modifiable access barriers rather than biological differences, emphasizing the importance of equitable care delivery.

Background: International guidelines recommend further diagnostic evaluation for patients with an elevated prostate-specific antigen (PSA; >4 ng/mL). However, real-world adherence to these recommendations remains poorly characterized. We aimed to quantify the proportion of patients receiving appropriate diagnostic work-up after an elevated PSA and to identify factors associated with adherence. Methods: We conducted a retrospective cohort study using the Epic Cosmos database (USA). Among 15,369,304 individuals undergoing PSA testing between 2017 and 2024, we included patients aged 40–75 years with at least 1 year of follow-up. Patients with prior prostate cancer, prostate MRI, or biopsy were excluded. The primary outcome was appropriate diagnostic work-up, defined as repeat PSA within 6 months and/or prostate MRI or biopsy within 12 months after an elevated PSA. Predictors included PSA level, age, race, Charlson Comorbidity Index, Area Deprivation Index, and ordering department. Findings: The final cohort included 1,002,947 patients. Overall, 49.1% received appropriate diagnostic work-up. Rates increased from 43.7% in 2017 to 55.5% in 2024. Patients receiving appropriate work-up had higher PSA levels (mean 5.5 vs 5.1 ng/mL; p<0.001) and were younger (mean 65 vs 66 years; p<0.001). They were more frequently White (73.1% vs 71.8%; p<0.001), had lower Area Deprivation Index (median 0.44 vs 0.46; p<0.001), fewer severe comorbidities (13.6% vs 14.5%; p<0.001), and were more often privately insured (39.1% vs 33.1%; p<0.001) and partnered (71.4% vs 67.9%; p<0.001). These associations were confirmed in multivariable analyses. Interpretation: In this large, contemporary cohort, approximately half of patients with elevated PSA did not receive guideline-concordant diagnostic evaluation. Despite modest improvement over time, substantial disparities persist, particularly across sociodemographic and clinical factors. These findings highlight an important gap in prostate cancer care and support the need for targeted strategies to improve adherence to diagnostic guidelines.Funding: None.