BACKGROUND AND OBJECTIVE:Perioperative and postoperative complications after major urologic oncologic surgeries are common and clinically significant. Standardised complication grading and reporting are critical for benchmarking, quality improvement, and patient counselling. Our aim was to provide a comprehensive global assessment of complications following radical cystectomy (RC), radical and partial nephrectomy (RN and PN), radical prostatectomy (RP), radical nephroureterectomy (RNU), and retroperitoneal lymph node dissection (RPLND). METHODS:This international, multicentre observational study included 130 034 procedures (29 098 RC, 75 001 RP, 24 476 major kidney surgery, 1459 RPLND) from 180 centres in 33 countries worldwide. Complications were graded using the Clavien-Dindo classification and quantified via the Comprehensive Complication Index, with descriptive analysis of complications at 30 d and 90 d. KEY FINDINGS AND LIMITATIONS:Complication rates varied by procedure. RC had the highest morbidity, with 30-d grade I-II complication in 40% and grade III-V in 16%, and a 90-d mortality rate of 2.3%. RP had low complication rates (grade I-II: 10-15%; grade III-V: 5-8%; mortality <0.05%), although extended pelvic lymph node dissection increased the incidence of high-grade events to 10%. Morbidity and mortality were generally low after PN; 90-d mortality was higher with open RN, reaching 1.7%. RNU and RPLND had moderate rates of major complications (up to 14%) and low mortality (<1%). Retrospective data collection, potential heterogeneous reporting of complications between centres, and incomplete follow-up in some cases may affect the generalisability of the results. CONCLUSIONS AND CLINICAL IMPLICATIONS:This standardised global data set is the largest assessment of perioperative morbidity across urologic oncologic procedures to date, and provides important real-world evidence. RC remains the most morbid procedure, while RP had markedly lower complication rates. Standardised reporting and international benchmarking are essential to improve surgical safety and guide quality improvement worldwide.

Surgical complications remain a major source of preventable morbidity, mortality, and health care expenditure, but existing frameworks such as the Clavien-Dindo classification and Comprehensive Complication Index are clinician-centred and intervention-focused and fail to capture cumulative patient-centred outcomes. This protocol outlines the Complications After Major and Minor Urological Surgery (CAMUS) initiative, a global, multiphase effort to redefine complication reporting, risk stratification, and outcome measurement in urological surgery. CAMUS aims to address these limitations via an integrated, seven-arm programme combining retrospective and prospective data analysis, consensus development, and digital infrastructure design. Arm 1 has assembled a retrospective data set of 130 034 major urological procedures from 180 centres across 33 countries, the largest of its kind. Arms 2 and 3 have completed Delphi surveys with physicians (n = 1113) and pilot nursing participants (n = 20) and has generated consensus on novel grading domains and highlighted the importance of multidisciplinary perspectives. Arm 4 will incorporate patient-reported outcomes and behavioural economics methods to quantify subjective burdens, while arm 5 will develop the CAMUS Intraoperative and Postoperative Risk and Difficulty Estimation Index (IPRADES) for surgical risk and difficulty prediction. Arms 6 and 7 will build a secure e-database and dictionary and prospectively validate the system using >2000 new cases. Statistical methods include multivariable regression, meta-analysis of individual patient data, and machine-learning approaches to model predictors of morbidity and mortality. Outputs will be benchmarked internationally to facilitate both clinician- and patient-driven definitions of complication severity. Ultimately, CAMUS will deliver a reproducible, patient-inclusive classification system with broad applicability to clinical practice, audits, education, and policy. By integrating more than 130 000 procedures with global Delphi consensus, CAMUS represents the most comprehensive complication classification initiative undertaken in surgery. Its outputs are expected to improve transparency, standardise reporting, and inform patient-centred risk stratification worldwide.

PURPOSE:With the availability of prostate-specific membrane antigen positron emission tomography scans, it is controversial whether pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP) is still the most reliable and accurate staging modality for lymph node assessment. Furthermore, the oncological benefit of PLND remains unclear. The aim of this study was to assess whether omitting PLND in patients undergoing RP for prostate cancer (PCa) is associated with the risk of tumor recurrence and progression to metastasis. MATERIALS AND METHODS:In this longitudinal multicenter cohort study, we reviewed data of 2346 consecutive patients with PCa who underwent RP with (n = 1650) and without (n = 696) extended PLND between January 1996 and December 2021. Recurrence-free survival and metastasis-free survival (MFS) were analyzed as a time-to-event outcome using Kaplan-Meier analyses with log-rank tests. To assess the effect of PLND, we created multivariable Cox proportional hazards models adjusting for relevant clinical and demographic characteristics. RESULTS:Median follow-up was 44 months. There was no difference in recurrence-free survival between men who had a PLND and those who did not (HR, 1.07, 95% CI, 0.87-1.32, P = .52). Patients with D'Amico high-risk disease (PSA >20 µg/L and/or International Society of Urological Pathology grade group ≥4) demonstrated a significantly prolonged MFS if they underwent PLND (HR, 0.57, 95% CI, 0.36-0.91, P = .02). PLND also improved MFS in patients with intermediate-risk disease (HR, 0.48, 95% CI, 0.25-0.90, P = .023). Further significant prognostic variables for MFS on multivariable Cox proportional hazards regression were PSA, International Society of Urological Pathology grade group, and pathological T-stage. CONCLUSIONS:PLND improves MFS in patients with D'Amico intermediate-risk and high-risk PCa and may therefore be considered in men undergoing RP.

This protocol will outline the development of the CAMUS Intra- and Postoperative Risk and Difficulty Estimation Indices (IPRADES), a tool designed to predict perioperative outcomes and surgical complexity in major urological procedures. Its objective will be to enhance preoperative planning and risk stratification by systematically evaluating a range of patient-, organ-, and surgery-specific factors. The study will be conducted in three phases. Firstly, expert consensus will be established through a Delphi survey involving experienced high-volume surgeons to identify key parameters influencing surgical difficulty and complications. Secondly, data will be collected from the CAMUS Collaboration database and augmented with additional parameters from a prospective open cystectomy database. Thirdly, using this extensive dataset, a nomogram will be developed to evaluate the association between the identified parameters and postoperative complications, as well as to quantify their predictive values. Each parameter will be assigned a weighted significance, which will be integrated into the final risk prediction model. Statistical analyses will incorporate multivariable regression models to identify predictors of complications and mortality. The model’s performance will be evaluated through c-statistics, Hosmer-Lemeshow tests, and Brier scores, with internal validation performed via dataset splitting and bootstrap resampling. Additionally, the study will compare the predictive accuracy of universal versus procedure-specific models. The tool will not only account for patient and surgical factors, but also incorporate the influence of surgeon experience and learning curves on surgical outcomes. A web-based calculator will be developed to facilitate seamless integration into daily clinical practice, providing real-time risk assessments. Following validation, the CAMUS IPRADES tool will refine surgical planning, optimise resource allocation, and enhance patient counselling. By delivering data-driven risk assessments, it will further enable surgeon and institutional benchmarking, thereby contributing to education, training, and clinical research. Ultimately, this tool will play a pivotal role in advancing the quality and safety of urological surgeries.

Risk assessment plays a critical role in surgical decision-making and influences patient care, resource allocation, surgical planning, and postoperative outcomes. Accurate stratification facilitates better treatment selection and planning, and identification of teaching cases. Existing tools such as POSSUM and the Surgical Apgar Score are widely used but focus primarily on general surgery and often lack urology-specific considerations or integration of intraoperative factors. Urological surgery requires a dedicated tool that accounts for preoperative factors (eg, prostate size, tumour extent), intraoperative findings (eg, fibrosis, adhesions), and patient-specific complexities. We propose a comprehensive scoring system for risk and surgical difficulty that ranges from 0 (no risk) to 100 (procedure abandonment or death) covering five parameter categories: preoperative patient characteristics; intraoperative patient factors; preoperative organ-specific parameters; intraoperative organ-specific factors; and unexpected postoperative conditions. The aims of the proposed system are to improve surgical planning, enhance risk prediction, and identify suitable teaching cases. By incorporating surgeon-specific factors such as case volume and learning curves, the system stratifies procedures by difficulty and can facilitate comparisons between surgeons and hospitals. The system can also promote transparency in patient counselling and may improve the quality of patient consent. Once validated, the scoring system could be integrated into standard practice to improve surgical care, resource allocation, and research efforts. Despite challenges such as comprehensive data collection, this tool offers significant potential to enhance surgical outcomes and multidisciplinary decision-making. Patient summary: Risk assessment is essential in helping surgeons and anaesthetists to make better decisions before, during, and after surgery. The aim of our work is to create a tool that predicts potential risks and challenges during surgery and makes it easier to prepare for these challenges. This tool can improve management of resources and surgical planning, and may ensure smooth recovery after an operation. Finally, it could also help patients and their families to understand the potential risks involved, giving them clearer information about what to expect and making the process more transparent and reassuring.

Objective To assess the long‐term safety of nerve‐sparing radical prostatectomy (NSRP) in men with high‐risk prostate cancer (PCa) by comparing survival outcomes, disease recurrence, the need for additional therapy, and perioperative outcomes of patients undergoing NSRP to those having non‐NSRP. Patients and methods We included consecutive patients at a single, academic centre who underwent open RP for high‐risk PCa, defined as preoperative prostate‐specific antigen level of > 20 ng/mL and/or postoperative International Society of Urological Pathology Grade Group 4 or 5 (i.e., Gleason score ≥ 8) and/or ≥pT3 and/or pN1 assessing the RP and lymph node specimen. We calculated a propensity score and used inverse probability of treatment weighting to match baseline characteristics of patients with high‐risk PCa who underwent NSRP vs non‐NSRP. We analysed oncological outcome as time‐to‐event and calculated hazard ratios (HRs). Results A total of 726 patients were included in this analysis of which 84% ( n = 609) underwent NSRP. There was no evidence for the positive surgical margin rate being different between the NSRP and non‐NSRP groups (47% vs 49%, P = 0.64). Likewise, there was no evidence for the need for postoperative radiotherapy being different in men who underwent NSRP from those who underwent non‐NSRP (HR 0.78, 95% confidence interval [CI] 0.53–1.15). NSRP did not impact the risk of any recurrence (HR 0.99, 95% CI 0.73–1.34, P = 0.09) and there was no evidence for survival being different in men who underwent NSRP to those who underwent non‐NSRP (HR 0.65, 95% CI 0.39–1.08). There was also no evidence for the cancer‐specific survival (HR 0.56, 95% CI 0.29–1.11) or progression‐free survival (HR 0.99, 95% CI 0.73–1.34) being different between the groups. Conclusion In patients with high‐risk PCa, NSRP can be attempted without compromising long‐term oncological outcomes provided a comprehensive assessment of objective (e.g., T Stage) and subjective (e.g., intraoperative appraisal of tissue planes) criteria are conducted.

Lymphovascular invasion, whereby tumour cells or cell clusters are identified in the lumen of lymphatic or blood vessels, is thought to be an essential step in disease dissemination. It has been established as an independent negative prognostic indicator in a range of cancers. We therefore aimed to assess the impact of lymphovascular invasion at the time of prostatectomy on oncological outcomes. We performed a multicentre, retrospective cohort study of 3495 men who underwent radical prostatectomy for localised prostate cancer. Only men with negative preoperative staging were included. We assessed the relationship between lymphovascular invasion and adverse pathological features using multivariable logistic regression models. Kaplan–Meier curves and Cox proportional hazard models were created to evaluate the impact of lymphovascular invasion on oncological outcomes. Lymphovascular invasion was identified in 19% (n = 653) of men undergoing prostatectomy. There was an increased incidence of lymphovascular invasion-positive disease in men with high International Society of Urological Pathology (ISUP) grade and non-organ-confined disease (p < 0.01). The presence of lymphovascular invasion significantly increased the likelihood of pathological node-positive disease on multivariable logistic regression analysis (OR 15, 95%CI 9.7–23.6). The presence of lymphovascular invasion at radical prostatectomy significantly increased the risk of biochemical recurrence (HR 2.0, 95%CI 1.6–2.4). Furthermore, lymphovascular invasion significantly increased the risk of metastasis in the whole cohort (HR 2.2, 95%CI 1.6–3.0). The same relationship was seen across D’Amico risk groups. The presence of lymphovascular invasion at the time of radical prostatectomy is associated with aggressive prostate cancer disease features and is an indicator of poor oncological prognosis.

Context: Surgical outcomes and patient morbidity are often surrogate markers of health care quality and efficiency. These parameters can only be used with confidence if the reporting and grading of intra-and postoperative complications are reliable and repro-ducible. Without uniformity and regulation, the risk of under-reporting, and thus signif-icant underestimation of the burden of intra-and postoperative morbidity, is high and should be of great concern to the international surgical community.Objective: To assess the quality and utility of currently available reporting and classifi-cation systems for intra-and postoperative complications, recognise their advantages and pitfalls, discuss the overall implications of these systems for urological surgery, and identify potential solutions for future reporting and classification systems.Evidence acquisition: A comprehensive search was performed using multiple reputable databases and trial registries up to October 25, 2022. Only studies that adhered to pre-defined inclusion criteria were included. Study selection and data extraction were inde-pendently performed by two review authors. The review was performed according to strict methodological guidelines in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement.Evidence synthesis: A total of 13 papers highlighting 13 various complication systems were critically assessed in this review. All studies proposed an intra-or postoperative complication reporting or grading system that was surgically related. At present, there is no single instrument in clinical practice to account for all relevant complication data. Six of the 13 studies were clinically validated (46%) and only three studies were urology -focused (23%). Meta-analysis was not possible.Conclusions: Current individual complication tools are flawed, so there is a need for a novel, all-inclusive, specialty-specific reporting and classification system for intra-and postoperative complications. If successfully validated and integrated worldwide, such an instrument would have the potential to play a significant role in reshaping efficiency in health care systems and improving surgical and patient quality of care.

BACKGROUND:The introduction of robotic surgical systems has significantly impacted urological surgery, arguably more so than other surgical disciplines. The focus of our study was length of hospital stay - patients have traditionally been discharged day 1 post-robot-assisted radical prostatectomy (RARP), however, during the ongoing COVID-19 pandemic and consequential resource limitations, our centre has facilitated a cohort of same-day discharges with initial success.METHODS:We conducted a prospective tertiary single-centre cohort study of a series of all patients (n = 28) - undergoing RARP between January and April 2021. All patients were considered for a day zero discharge pathway which consisted of strict inclusion criteria. At follow-up, each patient's perspective on their experience was assessed using a validated post-operative satisfaction questionnaire. Data were reviewed retrospectively for all those undergoing RARP over the study period, with day zero patients compared to overnight patients.RESULTS:Overall, 28 patients 20 (71%) fulfilled the objective criteria for day zero discharge. Eleven patients (55%) agreed pre-operatively to day zero discharge and all were successfully discharged on the same day as their procedure. There was no statistically significant difference in age, BMI, ASA, Charlson score or disease volume. All patients indicated a high level of satisfaction with their procedure. Median time from completion of surgery to discharge was 426 min (7.1 h) in the day zero discharge cohort.CONCLUSION:Day zero discharge for RARP appears to deliver high satisfaction, oncological and safety outcomes. Therefore, our study demonstrates early success with unsupported same-day discharge in carefully selected and pre-counselled patients.

To enhance the clarity and quality of complication reporting and grading for clinicians and patients, the CAMUS-Collaboration aims to develop the following: (1) a data dictionary; (2) parameters required for reporting; (3) risk-based reporting; (4) nursing and patient opinions; and (5) prospective reporting and grading of short- and long-term complications.

Purpose: Urethral stricture disease is common and has high associated morbidity and impact on quality-of-life. This systematic review and meta-analysis aims to summarise current evidence on the efficacy of local urethral steroids post-direct vision internal urethrotomy (DVIU) for the treatment of urethral strictures in males. Materials and Methods: A comprehensive search was performed using reputable databases and registries, up to 22 February 2022. Only randomised control trials in which participants were randomised to DVIU plus local urethral steroids versus DVIU only were included. Statistical analyses were performed using a random-effects model. Quality of evidence was rated according to the GRADE approach. Results: The search identified seven studies in which 365 participants were randomised to DVIU plus local urethral steroids versus DVIU only. The application of local steroids appeared to reduce recurrence rates (risk ratio, 0.67; 95% confidence interval [CI], 0.49- 0.90) and time-to-recurrence (hazard ratio, 0.58; 95% CI, 0.39-0.85). Qmax also improved following steroid application (mean difference, 0.82; 95% CI,-1.02-2.66); however, this was not statistically significant. No heterogeneity was identified between included studies for all outcomes. The certainty of evidence was downgraded due to study limitations with a small sample size and unclear risk-of-bias related to insufficient trial information. Conclusions: Compared to DVIU alone, adjuvant steroids applied to the urethra may reduce risk of recurrence and time-to -recurrence. These findings were statistically significant and likely also clinically significant given low associated costs and risk. However, more robust randomised trials are necessary to enhance the validity of these outcomes.

Abstract Objectives The aim of this study is to gain experienced nursing perspective on current and future complication reporting and grading in Urology, establish the CAMUS CCI and quality control the use of the Clavien‐Dindo Classification (CDC) in nursing staff. Subjects and Methods The 12‐part REDCap‐based Delphi survey was developed in conjunction with expert nurse, urologist and methodologist input. Certified local and international inpatient and outpatient nurses specialised in urology, perioperative nurses and urology‐specific advanced practice nurses/nurse practitioners will be included. A minimum sample size of 250 participants is targeted. The survey assesses participant demographics, nursing experience and opinion on complication reporting and the proposed CAMUS reporting recommendations; grading of intervention events using the existing CDC and the proposed CAMUS Classification; and rating various clinical scenarios. Consensus will be defined as ≥75% agreement. If consensus is not reached, subsequent Delphi rounds will be performed under Steering Committee guidance. Results Twenty participants completed the pilot survey. Median survey completion time was 58 min (IQR 40–67). The survey revealed that 85% of nursing participants believe nurses should be involved in future complication reporting and grading but currently have poor confidence and inadequate relevant background education. Overall, 100% of participants recognise the universal demand for reporting consensus and 75% hold a preference towards the CAMUS System. Limitations include variability in nursing experience, complexity of supplemental grades and survey duration. Conclusion The integration of experienced nursing opinion and participation in complication reporting and grading systems in a modern and evolving hospital infrastructure may facilitate the assimilation of otherwise overlooked safety data. Incorporation of focused teaching into routine nursing education will be essential to ensure quality control and stimulate awareness of complication‐related burden. This, in turn, has the potential to improve patient counselling and quality of care.

Background: Reproducible assessment of postoperative complications is essential for reliable evaluation of quality of care to enable comparison between healthcare centres and ensure transparent patient counselling. Currently, significant discrepancies exist in complication reporting and grading due to heterogeneous definitions and methodolo-gies. Objective: To develop a standardised and reproducible assessment of perioperative com-plications and overall associated morbidity, to allow for the construction of a uniform language for complication reporting and grading. Design, setting, and participants: The 12-part REDCap-based Delphi survey was devel-oped in conjunction with methodologist review and experienced urologist opinion. International urologists, anaesthetists, and intensive care unit specialists will be included. A minimum sample size of 750 participants (500 urologists and 250 critical care specialities) is targeted. Outcome measurements and statistical analysis: The survey assesses participant demo-graphics, opinion on complication reporting and the proposed Complications After Major & Minor Urological Surgery (CAMUS) reporting recommendations, grading of interven-tion events using the existing Clavien-Dindo classification and the proposed CAMUS classification, and rating of various clinical scenarios. Consensus will be defined as >= 75% majority agreement. If consensus is not reached, then subsequent Delphi rounds will be performed under steering committee guidance. Results and limitations: Twenty-one participants completed the draft survey. The med-ian survey completion time was 128 min (interquartile range 88-135). The survey revealed that 90% of participants believe that the current complication classification systems are useful but inaccurate, while 100% of participants believe that there is a uni-versal demand for reporting consensus. Several amendments were made following feed-back. Limitations include complexity of the proposed supplemental grades and time to completion of the survey. Conclusions: To ensure comprehensive and comparable complication reporting and grading across centres worldwide, a conclusive uniform language for complication reporting must be created. We intend to address shortcomings of the current complica-tion reporting and classification systems with a new CAMUS classification system devel-oped through multidisciplinary expert consensus obtained through a Delphi survey. Ultimately, standardisation of urological complication reporting and grading may improve patient counselling and quality of care. Patient summary: The reporting and grading of operative complications that occur dur-ing or after an operation and associated costs provide a means to stratify quality of patient care. Current complication reporting and classification systems are not standard-ised and somewhat inaccurate, and thus significantly underestimate patient morbidity and surgical risk. This Delphi survey will provide the basis for the creation of a uniform complication reporting and grading system. Our new system may allow improved reporting and grading between centres, and ultimately improve patient counselling and care. (c) 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Since the 1990s, laparoscopic surgery has undergone unprecedented change and expansion. The benefit and attraction of minimally invasive surgery to both patients and surgeons alike forced this growth and a necessity to perform more and more complex operations laparoscopically.