BACKGROUND:Radical cystectomy with pelvic lymph node dissection (PLND) remains the standard treatment for muscle-invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) improves survival, and recent immunochemotherapy trials have reported complete pathological responses in up to 60% of patients, increasing interest in bladder-sparing strategies. However, the ability to accurately identify patients without residual pelvic lymph node metastases after NAC remains limited. OBJECTIVE:To evaluate the association between pathological response in the bladder and pelvic lymph node status after NAC in patients with MIBC undergoing radical cystectomy (RC) and PLND. DESIGN, SETTING, AND PARTICIPANTS:This retrospective, multi-institutional cohort study included 751 patients with MIBC treated with NAC followed by RC and PLND between 2000 and 2021 across 26 institutions. INTERVENTION:Neoadjuvant chemotherapy followed by RC and PLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:The primary outcome was residual lymph node involvement (ypN+). Multivariable logistic regression was used to identify factors associated with ypN+. RESULTS AND LIMITATIONS:Overall, 175 patients (23%) achieved a complete pathological response in the bladder (ypT0), 102 (14%) were downstaged to non-muscle-invasive disease (ypTa/ypTis/ypT1), and 185 (25%) had residual lymph node involvement. On multivariable analysis, cN+ disease before NAC was associated with higher odds of ypN+ (OR 1.97, 95% CI 1.32-2.94), whereas ypT0 (OR 0.11, 95% CI 0.05-0.21) and ypTa/ypTis/ypT1 (OR 0.24, 95% CI 0.12-0.47) were associated with lower odds of ypN+. Notably, 5% of ypT0 and 10% of downstaged patients harboured residual lymph node metastases. Limitations include potential selection bias and centre-level variability in surgical and pathological assessment, which may affect the generalizability of the findings. CONCLUSIONS:Current clinical and radiological variables cannot reliably exclude residual pelvic lymph node disease, even in patients achieving ypT0-1. Novel imaging techniques and liquid biomarkers require validation before bladder-sparing approaches can be safely expanded.

Shock wave lithotripsy (SWL) remains the main alternative to endoscopic surgery for distal ureteral stones. This study evaluated whether ultrasound (US)-guided SWL improves stone-free rates (SFR) compared with radiographic (RX) targeting. We conducted a multicenter retrospective analysis of patients undergoing SWL for distal ureteral stones. Two cohorts were compared according to targeting modality (US-guided vs. RX-guided). Baseline characteristics, stone parameters, and procedural details were collected. SFR was assessed via US or CT scan at first follow-up and at 3 months. Multivariable logistic regression identified predictors of SFR. A total of 151 patients were included (77 US-guided, 74 RX-guided). Baseline demographic and stone characteristics were comparable between groups. US-guided SWL achieved significantly higher SFRs at first follow-up (76.7

INTRODUCTION:To evaluate the feasibility, safety, and patient satisfaction of Double-J (DJ) ureteral stenting using a flexible cystoscope under local anesthesia (LA). MATERIALS AND METHODS:We analyzed prospectively collected data from all patients who underwent DJ stent insertion or replacement using flexible single-use cystoscope under LA between February 2022 and September 2024 at two tertiary referral centers. Failure was defined as the inability to effectively complete the scheduled stent insertion or replacement. Pain was assessed using the Visual Analog Scale, whereas overall patient satisfaction and willingness to undergo future ureteral stenting under LA were also recorded. RESULTS:A total of 189 consecutive procedures were performed, including 131 (69.3%) unilateral and 31 (16.5%) bilateral DJ replacements and 22 (11.6%) unilateral and 5 (2.6%) bilateral DJ insertions. The median patient age was 76 years (interquartile range [IQR] 66-80), the median Charlson Comorbidity Index was 8 (IQR 6-12), and the median hospital stay was 0 days (0-0.25). Technical failure occurred in 13 cases (7.3%). Causes of failure were DJ encrustation, urethral stricture, or inability to identify the ureteral orifice (9 cases, 69.2%). These cases were effectively managed by percutaneous nephrostomy (PNS) or stent placement under sedation. Four (30.8%) procedures were interrupted because of pain felt by patients. Complications included one case of stent migration necessitating ureteroscopy, three cases necessitating PNS placement, and 10 grade 2 complications (5.6%). Overall, 170 patients (89.9%) expressed willingness to undergo the same procedure under LA in the future. CONCLUSION:These results demonstrate that DJ stenting using a flexible cystoscope under LA in an outpatient setting is a feasible, safe, and well-tolerated procedure. It offers a high success rate with a low incidence of minor complications.

BACKGROUND AND OBJECTIVE:Radiotherapy (RT) is a key curative option for localized prostate cancer (PC). However, data on late genitourinary toxicity, especially adverse events requiring urgent care or hospitalization, remain limited. The aim of the Italian Registry of Radiotherapy-Associated Disorders and Urological Treatment & Evaluation (IRRADIaTE) is to characterize the burden and management of severe genitourinary adverse events following prostate RT across multiple high-volume centers in Italy. METHODS:A prospective, observational, multicenter registry was established in 2024 across 20 Italian institutions. Men with localized PC previously treated with curative, adjuvant, or salvage RT who presented with late (≥6 mo) genitourinary complications requiring urgent medical attention were enrolled. Demographics, treatment details, and outcomes were collected. Toxicity grading followed Common Terminology Criteria for Adverse Events. Primary endpoints were prespecified as (1) the cumulative incidence of grade 3-5 events with death as a competing risk and (2) hospitalization-free survival from RT completion. Analyses were descriptive and adjusted for prespecified confounders only. Key findings and limitations Among 321 patients, 50% received primary RT, and 50% postprostatectomy RT. At the time of admission, 43% presented with grade 3-5 genitourinary toxicity. Over 5 yr, the hospitalization-free survival rate declined from 86% to 42%. Higher cumulative incidence of severe events was observed in the primary RT group. The percentage of patients who did not require major surgery to manage RT-related complications decreased from 81% (95% confidence interval [CI] 76-97%) at 12 mo after RT to 66% (95% CI 48-79%) at 60 mo. Differences in baseline age and comorbidity profiles between the RT treatment settings must be acknowledged. Because the registry enrolls only men presenting with complications, population-level incidence and causal effects cannot be inferred. CONCLUSIONS AND CLINICAL IMPLICATIONS:Late genitourinary toxicity after prostate RT is substantial and often resource-intensive. Differences observed by treatment setting are associational; attribution of causal mechanisms and treatment effects requires dedicated causal-inference studies.

Background/Objective: Parastomal hernia (PSH) following radical cystectomy (RC) with ileal conduit represents a significant late complication. Preventive strategies have been described but are not yet routinely incorporated into clinical practice. We conducted a systematic review of the current literature to assess the efficacy of PSH preventive techniques for ileal conduit. Methods: A literature search of PubMed/MEDLINE, Scopus, CENTRAL, and Web of Science databases was conducted from 2010 to December 2024 following PRISMA guidelines. Inclusion criteria were patients undergoing RC with ileal conduit, evaluation of at least one PSH preventive strategy and reporting of PSH incidence or relevant postoperative outcomes. Eligible designs included RCTs and non-randomized cohort studies. Exclusion criteria included urinary diversions other than ileal conduit, non-bladder-related indications, non-extractable outcome data, and non-original publications. Results: Three randomized controlled trials (RCTs) and nine non-randomized studies were included in the analysis. Studies investigating both mesh and non-mesh preventive techniques were considered. Clinical PSH recurrence rates following mesh placement ranged from 0.0% to 11.1% among the included studies. RCTs using mesh placement reported conflicting conclusions regarding its protective effects. For non-mesh preventive strategies, clinical PSH recurrence rates ranged from 0.0% to 11.5%. The only RCT focusing on non-mesh approaches reported positive protective effects for the experimental group. All procedures were safe, with no significant increase in complication rates compared to conventional interventions. Conclusions: The low quality of current evidence prevents definitive conclusions regarding the protective effects of both mesh and non-mesh preventive approaches. High-quality evidence is needed to make conclusive statements on this topic. Patients at high risk for PSH development should be offered personalized preoperative counselling and the opportunity to participate in ongoing RCTs.

781 Background: Trimodality therapy (TMT) with transurethral resection followed by radiation of the urinary bladder and chemotherapy is associated with similar long-term survival rates compared to radical cystectomy (RC) for well-selected patients. Nevertheless, salvage RC may become necessary in 10% of patients receiving TMT. We aimed to assess the perioperative and long-term outcomes of salvage RC after prior TMT through a large multinational cohort study. Methods: We included patients with pure urothelial cancer of the urinary bladder. Patients undergoing salvage RC after prior TMT due to recurrence in the urinary bladder from 11 high-volume centers were matched with a propensity score matching on a 1:1 ratio with patients without prior TMT undergoing primary RC. The two groups were adjusted for institution, age, histological status, ASA score, and surgical technique. Results: We included 108 patients (54 per group) with a median age of 74 years (IQR: 66-78). The two groups did not differ in terms of operative time (TMT: 250 versus non-TMT: 251 minutes, p = 0.9), intraoperative blood loss (TMT: 550ml versus non-TMT: 600ml, p = 0.2), and perioperative Clavien-Dindo complications (p = 0.9). At a follow-up of 16 months (IQR: 6-38), 45 (42%) deaths occurred. Prior TMT was associated with higher mortality rates in the survival analysis (log-rank test: p = 0.037). Accordingly, the progression rates were higher in patients with prior TMT (log-rank test: p = 0.047). Conclusions: Salvage RC after TMT is associated with similar perioperative outcomes compared to primary RC. Nevertheless, patients undergoing salvage RC after TMT may present worse progression rates and overall survival in the long term. Therefore, systemic therapies should be considered in patients with recurrence after TMT.

Background and objective:The use of robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion has increased rapidly in the past decade. The approximation of the ileum toward the urethral stump could be a demanding step. Whereas the techniques for reconstruction have been described in detail, a comprehensive depiction of strategies to facilitate neobladder-urethral approximation is lacking. This manuscript and video collection provide a summary of the techniques and maneuvers suggested by RARC surgeons. Methods and surgical procedure:This is a cross-sectional study in collaboration with the European Association of Urology Robotic Urology Section (ERUS) Scientific Working Group that evaluates strategies for ileourethral approximation and anastomosis from surgeons performing RARC with an intracorporeal neobladder. To this purpose, a survey was developed by a single institution with input from experts. The survey included questions on caseload, types of diversions, ileal approximation, and techniques and strategies for overcoming challenges in an ileourethral anastomosis. Responders were recruited among experts from scientific societies and were asked to rate the importance of these tricks on a Likert scale. A video collection was developed thereafter. Key findings and limitations:Twenty-one surgeons were involved, with five of them having an individual caseload of >300 cases. The Studer (n = 9) and Bordeaux (n = 9) reconstructions were most used; four operators declared the use of more than one type of diversion. Ileourethral approximation is considered a demanding part of intracorporeal neobladder reconstruction for 86% of participant surgeons. It is perceived as difficult in approximately one out of four surgical cases. Ten surgeons reported at least one conversion to ileal conduit due to impossible ileal descent. The posterior reconstruction was ranked as a useful trick to aid in an ileourethral anastomosis for ten surgeons (48%); a reduction in the Trendelenburg position by nine (43%), the use of small incisions in the mesentery was useful for six (29%) and opening the ileal segment before the anastomosis for five (24%) surgeons. Conclusions:Some strategies and techniques are available to facilitate ileal descent toward the pelvis to achieve a tension-free ileourethral anastomosis. The knowledge and application of these tricks are important to cope with this demanding step and make intracorporeal neobladder reconstruction easier and safer. Patient summary:The robotic realization of a neobladder through an intracorporeal approach could be demanding. The associated video presents some surgical strategies to make this step easier and safer, to ensure the achievement of a tension-free neobladder-urethral anastomosis.

This retrospective cohort study aims to evaluate the long-term outcomes of superselective transcatheter arterial embolization in patients with high-flow priapism. All patients treated with arterial embolization at our center between 2002 and 2017 for high-flow priapism were included. Demographic and clinical data were collected and analyzed. In July 2022, patients were reassessed using specific questions about their satisfaction with the treatment. Erectile function was evaluated using the International Index of Erectile Function-5 (IIEF-5) and the Erection Hardness Score (EHS). Thirteen men, with a median age of 30 years (IQR: 24-37), were included in the study. Superselective arterial embolization using permanent occlusive agents was performed in all cases. The blood flow in the fistula was interrupted leading to complete penile detumescence in all patients. At a median follow-up of 175 months (IQR: 74-197), the median IIEF-5 score was 24 (IQR: 21-25) and the median EHS was 4 (IQR: 3-4), indicating preserved erectile function. Additionally, 92.3% of patients expressed satisfaction with the treatment. Superselective transcatheter arterial embolization with non-absorbable agents demonstrates effectiveness and durability as a treatment for high-flow priapism, with preserved erectile function observed over a follow-up period exceeding 10 years. Nonetheless, the interpretation of these findings is limited by the study's small sample size and retrospective design.

Background/Objectives: Radical cystectomy (RC) is a complex urologic procedure that, when performed using an open surgical approach, carries a high risk of surgical site complications (SSCs), which can lead to prolonged recovery, increased healthcare costs, and higher morbidity. Incisional negative-pressure wound therapy (iNPWT) has demonstrated benefits in enhancing wound healing in various surgical settings, but its effectiveness in the context of RC remains underexplored. This study aimed to evaluate the impact of iNPWT on the incidence of SSCs following RC compared to standard surgical dressings using the PICO® system. Methods: A cohort of 146 patients who underwent RC between 2015 and 2021 was divided into two groups: those treated with standard dressings (Group 1, n = 80) and those who received iNPWT (Group 2, n = 66). Patient-related, surgical, and pathological variables were compared between the groups. Categorical variables were analyzed using the chi-square or Fisher's exact test, while continuous variables were assessed using Student's t-test. Univariate logistic regression models were applied to evaluate the association between iNPWT use and 90-day SSCs, as well as to identify risk factors for complications. Results: Group 2 (iNPWT) had a higher prevalence of chronic comorbidities, including chronic kidney disease, but fewer active smokers compared to Group 1. Higher body mass index, prolonged operative time, and uncontrolled diabetes were significantly associated with the development of SSCs. The incidence of SSCs within 90 days was significantly lower in the iNPWT group (7.6%) compared to the standard dressing group (22.5%) (p = 0.03). iNPWT use was associated with a substantially reduced risk of SSCs (OR: 0.282), demonstrating a protective effect. Conclusions: Prophylactic application of iNPWT following RC significantly reduced the incidence of surgical site complications compared to standard dressing. These findings support the potential of iNPWT as a valuable adjunct in perioperative wound management. While encouraging, these results warrant validation in prospective, randomized studies. Tailored postoperative strategies and identification of patient-specific risk factors remain essential components in SSC prevention and reflect the growing importance of precision medicine in surgical oncology.

A scrotal mass is often identified by the patient as an abnormal lump during self-palpation. Scrotal lumps can be caused by cystic lesions or solid tumours of the testis or paratesticular structures, trauma, inflammations or testicular torsion, varicocele, fluid collections, inguinoscrotal hernia or tumours of the scrotal wall. When a patient presents with a scrotal mass, it is extremely important to collect a detailed history which includes duration of symptoms, whether the mass is painful or painless, change in size of mass, sexual history, concomitant lower urinary tract symptoms, previous history of surgery, infertility or mumps and family history of testicular cancer.

Prostate cancer (PCa) is one of the most common malignancies in men, where early and accurate detection is crucial. While PSA testing has been the diagnostic standard, its limited specificity leads to unnecessary biopsies and missed significant cancers. Urinary biomarkers such as PCA3 and TMPRSS2-ERG and multi-marker assays (MyProstateScore, SelectMDx, and ExoDx) offer a promising alternative. This narrative review examines their diagnostic performance and clinical utility with the aim of understanding whether they can be integrated with the established tests and exams already in use. A literature search of PubMed, Scopus, and Medline identified some relevant recent studies (2010–2025). The findings show that PCA3 and TMPRSS2-ERG improve specificity over PSA, while multi-marker tests enhance risk stratification and reduce unnecessary procedures. MPS integrates urinary biomarkers with PSA, achieving over 95% sensitivity and negative predictive value for clinically significant cancers. SelectMDx demonstrates ~90% negative predictive value, and ExoDx assesses urinary exosomes to predict aggressive disease. Despite their advantages, challenges persist, including variability in performance, cost, and accessibility. Urinary biomarkers represent a major step toward more precise, less invasive diagnostics, with future research needed to optimize clinical integration and cost-effectiveness.

OBJECTIVES:To evaluate the temporal trends in types of urinary diversion (UD) used after radical cystectomy (RC) in a large, multicentre, international cohort over the past two decades. MATERIALS AND METHODS:We analysed 6469 patients who underwent RC between 2004 and 2024 at 23 international tertiary referral centres. Trends in UD type (cutaneous ureterostomy [UCS], ileal conduit [IC], and neobladder) were assessed using estimated annual percentage change (EAPC). Multivariable analysis (MVA) models identified preoperative predictors of UD type. EAPC was applied to evaluate temporal changes in the patient characteristics associated with UD type. RESULTS:Overall, 882 (14%), 3611 (56%) and 1976 patients (31%) underwent UCS, IC, and neobladder procedures, respectively. IC remained the most common UD, without significant temporal change (P = 0.1). UCS use increased from 2% to 22% (EAPC 9.9%; P < 0.001), while neobladder use declined from 41% to 19% (EAPC -2%; P = 0.009). MVA showed that older age, comorbidities, and advanced disease were associated with higher rates of UCS and lower rates of neobladder use (all P < 0.005). Neoadjuvant chemotherapy (NAC) was inversely linked to UCS, while robot-assisted RC and male sex favoured neobladder use (all P < 0.005). EAPC showed rising proportions of male patients (EAPC 6.7%), patients aged >70 years (1.2%), patients with a Charlson Comorbidity Index ≥3 (8.3%), patients who received NAC (10.4%) and patients with cT2-cN0 disease (0.5%; all P < 0.05). CONCLUSION:Over two decades, a marked increase in UCS use has been observed, alongside a decline in neobladder reconstruction. These trends coincided with a shift toward older, more comorbid patients undergoing RC. Evolving patient profiles and surgical practices underscore the need for tailored UD strategies and optimised peri-operative management.

Cisplatin-based neoadjuvant chemotherapy (NAC) is the standard of care for cT2-4aN0M0 bladder cancer (BCa) patients candidates for radical cystectomy (RC). This study examines changes in NAC administration over time and its impact on survival within a large, real-world multicenter cohort. Our analysis included cT2-4aN0M0 BCa patients from 23 tertiary referral centers who underwent RC and pelvic lymph-node dissection with or without NAC administration between 2004 and 2024. The estimated annual percentage change (EAPC) was used to analyze the temporal trend of NAC administration and pathological complete response rates (pT0) over time. Subsequently, we relied on 1:1 propensity score matching (PSM) for age, sex, cT stage, Charlson Comorbidity Index (CCI), and smoking habit. Multivariable logistic regression (MLR) model addressed the association of pT0 and NAC exposure. Survival analyses consisted of Kaplan–Meier plots (KM) and multivariable Cox regression models (MCR) addressing cancer-specific mortality (CSM) and overall mortality (OM) according to NAC exposure. Overall, 3,138 patients were identified. Of these, 859 (27

The majority of cases of acute scrotum are due to one of these three causes: trauma, torsion and inflammation. Acute scrotum syndrome of any origin always merits immediate evaluation to prevent testicular function and chronic irreversible complication. Correct differential diagnoses between these conditions are mandatory because uncorrected diagnosis could lead to catastrophic consequence. Often physical examination is not sufficient to avoid suspicious conditions that require surgical correction and then imaging. High-resolution ultrasound is the imaging modality of choice for the examination of superficially located scrotal sac and its contents. Greyscale ultrasonography in combination with colour or power Doppler imaging is a well-accepted technique for assessing scrotal lesions and testicular perfusion. In this chapter, clinical features, greyscale and colour Doppler US appearance of testicular torsion, trauma and inflammation are described.

BACKGROUND AND OBJECTIVE:Trimodality therapy (TMT) with transurethral resection followed by radiation of the urinary bladder and chemotherapy is associated with similar long-term survival rates to radical cystectomy (RC) for well-selected patients. Nevertheless, salvage RC may become necessary in 10% of patients receiving TMT. We aimed to assess the perioperative and long-term outcomes of salvage RC after prior TMT through a large multinational cohort study. METHODS:We included patients with pure urothelial cancer of the urinary bladder. Patients undergoing salvage RC after prior TMT due to recurrence in the urinary bladder from 13 high-volume centers were matched with a propensity score analysis in a 1:1 ratio with patients without prior TMT undergoing primary RC. The two groups were adjusted for institution, age, histological status, American Society of Anesthesiologists score, and surgical technique (open or minimally invasive RC). KEY FINDINGS AND LIMITATIONS:We included 118 patients (59 per group) with a median age of 73 yr (interquartile range [IQR]: 66-79). Seven patients (11%) developed severe, grade 4 or 5 perioperative complications during RC after prior TMT. The 30- and 90-d survival rates of salvage RC after prior TMT were 93% and 91%, respectively. RC in patients with prior TMT was associated with higher blood loss by 297 ml (95% confidence interval [CI]: 73-520, p = 0.010) and higher odds of admission to the intensive care unit (odds ratio: 2.8, 95% CI: 1.2-6.7, p = 0.017) than primary RC in matched patients. At a median follow-up of 10 mo (IQR: 5-34), 29 deaths occurred in patients requiring RC after prior TMT. Prior TMT was associated with worse overall survival than primary RC (hazard ratio: 1.9, 95% CI: 1.2-4.1, p = 0.032). CONCLUSIONS AND CLINICAL IMPLICATIONS:Salvage RC after TMT and primary RC have comparable perioperative outcomes. Patients undergoing salvage RC after TMT may have worse overall survival in the long term, likely reflecting tumor biology.