Could Use of a Flexible and Navigable Suction Ureteral Access Sheath Be a Potential Game-changer in Retrograde Intrarenal Surgery? Outcomes at 30 Days from a Large, Prospective, Multicenter, Real-world Study by the European Association of Urology Urolithiasis Section.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the stone-free status (SFS) rate and complications after flexible ureteroscopy (fURS) for treatment of renal stones using a flexible and navigable suction (FANS) ureteral access sheath. METHODS: Data for adults undergoing fURS in 25 centers worldwide were prospectively collected (August 2023 to January 2024). Exclusion criteria were abnormal renal anatomy and ureteral stones. All patients had computed tomography scans before and within 30 d after fURS with a FANS ureteral access sheath. SFS was defined as follows: grade A, zero fragments; grade B, a single fragment ≤2 mm; grade C, a single fragment 2.1-4 mm; and grade D, single/multiple fragments >4 mm. Data for continuous variables are presented as the median and interquartile range (IQR). Multivariable logistic regression was performed to evaluate predictors of grade A SFS. KEY FINDINGS AND LIMITATIONS: The study enrolled 394 patients (59.1% male) with a median age of 49 yr (IQR 36-61). The median stone volume was 1260 mm3 (IQR 706-1800). Thulium fiber laser (TFL) was used in 45.9% of cases and holmium laser in the rest. The median lasing time was 18 min (IQR 11-28) and the median operative time was 49 min (IQR 37-70). One patient required a blood transfusion and 3.3% of patients had low-grade fever. No patient developed sepsis. Low-grade ureteral injury occurred in eight patients (2%). The grade A SFS rate was 57.4% and the grade A + B SFS rate was 97.2%, while 2.8% of patients had grade C or D SFS. Eleven patients underwent repeat fURS. Multivariable analysis revealed that a stone volume of 1501-3000 mm3 (odds ratio 0.50) and of >3000 mm3 (odds ratio 0.29) were significantly associated with lower probability of grade A SFS, while TFL use was associated with higher SFS probability (odds ratio 1.83). Limitations include the lack of a comparative group. CONCLUSIONS AND CLINICAL IMPLICATIONS: fURS using a FANS ureteral access sheath resulted in a high SFS rate with negligible serious adverse event and reintervention rates. PATIENT SUMMARY: We looked at 30-day results for patients undergoing telescopic laser treatment for kidney stones using a special type of vacuum-assisted sheath to remove stone fragments. We found a high stone-free rate with minimal complications.

Scoping Review of Experimental and Clinical Evidence and Its Influence on Development of the Suction Ureteral Access Sheath.

The ureteral access sheath (UAS) has been a boon and a bane in flexible ureteroscopy (FURS), with its merits and demerits well established. Its design and dimensions were instrumental in reshaping the way flexible scopes were used and were key adjuncts to establishing retrograde intrarenal surgery (RIRS) as a standard of care in the endourological management of renal stones. With the ever-changing landscape of RIRS over the decades shaped by technological advancements in lasers and flexible scopes, the UAS has also continuously evolved. The utility of suction in endourology has recently changed the way RIRS is performed and is a game changer for FURS outcomes. With strong clinical and experimental evidence to support its use, the UAS has undergone a transformative change in the recent past, with its ability to monitor intrarenal pressure and provide a superior vacuum-cleaner effect that improves the trifecta of RIRS, namely an improved single-stage stone-free rate (SFR), minimise complications, and reduce reinterventions. Our comprehensive review outlines the key clinical and experimental evidence and traces the developments that were key to modifying the traditional UAS into a flexible and navigable suction ureteric access sheath (FANS) and highlights how the design and modifications, in turn, influence the ability to push the boundaries of RIRS.

Perioperative renal function change and oncological outcomes of radical nephroureterectomy in patients with upper tract urothelial carcinoma: A multicenter retrospective study.

BACKGROUND: The effect of radical nephroureterectomy (RNUx) on postoperative renal function in patients diagnosed with upper tract urothelial carcinoma (UTUC) has not been thoroughly explored. METHODS: We conducted a retrospective analysis including 785 patients who underwent RNUx for UTUC. We assessed the preoperative and postoperative estimated glomerular filtration rates (eGFRs) and factors related to the decline in eGFR. Additionally, we examined the effect of comorbidities (diabetes or hypertension) on the postoperative eGFR at 1 year. Cox proportional hazard models were employed to investigate the clinical effect of RNUx on oncological outcomes, including non-urothelial tract recurrence-free survival (NUTRFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS: The median preoperative and postoperative eGFR levels were 54.7 and 40.6 ml/min/1.73 m2 respectively. The proportions of patients with preoperative and postoperative eGFR ≥60 mL/min/1.73 m2 were 35.9% and 5.1%, respectively. The median decline in the eGFR after surgery was 26.8%. Patients with preoperative eGFR <60 ml/min/1.73 m2 demonstrated significantly lower odds of a postoperative decline in eGFR of 25% or more. The effect of comorbidities on postoperative eGFR at 1 year was significant (P = 0.048). The 3-year NUTRFS, CSS, and OS rates were 72.9%, 85.2%, and 81.5%, respectively. Preoperative chronic kidney disease was an independent factor associated with inferior NUTRFS, CSS, and OS. CONCLUSION: Different degrees of impairment of renal function occur among UTUC patients. Only 5.1% of patients retain a postoperative eGFR ≥60 ml/min/1.73 m2. Preoperative renal impairment was linked to reduced odds of postoperative eGFR decrease and associated with survival. In addition, the presence of comorbidities had a significant effect on the decline in eGFR. These findings emphasize the importance of developing evidence-based perioperative treatment strategies for UTUC patients with impaired renal function.

Safety and Efficacy of Immediate Hyperthermic Intravesical Chemotherapy Following Transurethral Resection of Bladder Tumour (I-HIVEC).

The recurrence rate following endoscopic treatment of non-muscle-invasive bladder cancer (NMIBC) remains high. Standard treatment includes intravesical instillation of chemotoxic agents such as mitomycin C (MMC) to reduce recurrence. It is postulated that upfront administration of hyperthermic intravesical MMC (HIVEC) immediately after transurethral resection of bladder tumour (TURBT) may enhance its efficacy, but evidence from human trials is scant. This pilot study explored the safety of immediate intravesical MMC instillation following TURBT using a conductive HIVEC system (Combat BRS). Patients diagnosed with papillary bladder tumours scheduled for TURBT were recruited. Among 29 patients treated with HIVEC, there was minimal additional postoperative morbidity. The majority (79.3%) were discharged after a hospital stay of 1 d, and no patient required bladder irrigation. There were six grade I-II adverse events (20.7%) and one grade III event (3.4%). No recurrences were observed within 3 mo, and the 12-mo recurrence rate was 4.5%. The study findings demonstrate that immediate HIVEC MMC instillation following TURBT is safe. Further research is needed to assess long-term efficacy in comparison to standard cold MMC. PATIENT SUMMARY: Non-muscle-invasive bladder cancer is treated with tumour removal via a telescope inserted into the bladder through the urethra (called TURBT). We tested the safety of treating the bladder with a warm solution of a chemotherapy drug (mitomycin C) immediately after TURBT, as this may prevent tumour recurrence. The treatment was safe and well tolerated. Further trials are needed with more patients and longer follow-up to confirm the results.

Site-Specific Differences of Eligibility for Adjuvant Immunotherapy Among Urothelial Carcinoma Patients Treated With Radical Surgery: Results From a Multicenter Cohort Study.

BACKGROUND: The CheckMate274 trial has reported enhanced disease-free survival rates in patients with stage pT3-4/ypT2-4 or pN+ urothelial carcinoma (UC) undergoing adjuvant nivolumab therapy. This study compares prognostic differences between urothelial carcinoma of the bladder (UCB) and upper tract urothelial carcinoma (UTUC). METHODS: We retrospectively analyzed data from 719 patients with UC who underwent radical surgery, stratifying to patients at stage pT3-4 and/or pN+ without neoadjuvant chemotherapy (NAC) or at ypT2-4 and/or ypN+ with NAC (potential candidates for adjuvant immunotherapy), and to those who were not candidates for adjuvant immunotherapy. We used Kaplan-Meier curves to assess oncological outcomes, particularly nonurothelial tract recurrence-free survival (NUTRFS), cancer-specific survival (CSS), and overall survival (OS). Risk factors were identified by Cox regression analysis. RESULTS: Kaplan-Meier curves showed significantly lower NUTRFS, CSS, and OS for potential adjuvant immunotherapy candidates than for noncandidates in each UCB and UTUC group. NUTRFS, CSS, and OS did not differ significantly between adjuvant immunotherapy candidates with UBC or UTUC. Trends were similar among patients ineligible for adjuvant immunotherapy. Pathological T stage (pT3-4 or ypT2-4), pathological N stage, and lymphovascular invasion (LVI) were independent predictors of oncological outcomes on multivariate analysis. CONCLUSION: The criteria for adjuvant immunotherapy candidates from the CheckMate 274 trial can also effectively stratify UC patients after radical surgery. Substantial clinical significance is attached to LVI status as well as to pathological T and N status, suggesting that LVI status should be considered when selecting suitable candidates for adjuvant immunotherapy.

A prospective evaluation of the effect of finasteride on prostate health index (phi).

PURPOSE: 5-alpha reductase inhibitor (5ARI) reduces prostate-specific antigen (PSA) by half but its effect on prostate health index (phi) is unknown. This study aims to investigate this effect and to enable accurate interpretation of phi in men with elevated PSA and on 5ARI. METHODS: This is a prospective study evaluating the effect of finasteride on PSA, free PSA (fPSA), [ - 2]proPSA (p2PSA) and phi at 6 and 12 moths in men with PSA 4-20 ng/mL, no prior 5ARI use, and one negative prostate biopsy within 6 months before recruitment. The 5ARI Finasteride (5 mg/day) for 1 year was offered if International Prostatic Symptom Score (IPSS) was ≥ 8 at baseline. 5ARI group included patients taking finasteride, while control group included patients not on finasteride. The blood results were compared with t-test between baseline and different time points in each group and between groups at 1 year. RESULTS: 164 men fit the inclusion criteria and 150 were analyzed. In 5ARI group (n = 100) at 1 year, mean PSA reduced by 51.4% from 8.9(± SD 3.7) to 4.4(± SD 2.8)ng/mL (paired t-test, p < 0.001), fPSA reduced by 52.4% from 1.6(± 0.6) to 0.8(± 0.4)ng/mL (p < 0.001), p2PSA reduced by 55.3% from 18.4(± 8.8) to 8.3(± 5.6)pg/mL (p < 0.001), and phi reduced by 34.2% from 33.7(± 11.9) to 22.4(± 12.5) (p < 0.001). PSA and phi values in the control group remained static over 1 year and significantly higher than those in 5ARI group. CONCLUSION: This study demonstrated p2PSA and phi are reduced by about 55% and 34% in men on 5ARI. A conversion factor of division by 0.66 is needed for phi in men on finasteride to allow the interpretation and use of phi in men on 5ARI.

Hemopatch to Prevent Lymphatic Leak after Robotic Prostatectomy and Pelvic Lymph Node Dissection: A Randomized Controlled Trial.

This study investigates whether the application of Hemopatch, a novel hemostatic patch, could prevent lymphatic leak after robotic-assisted radical prostatectomy (RARP) and bilateral pelvic lymph node dissection (BPLND). This is a prospective, single-center, phase III randomized controlled trial investigating the efficacy of Hemopatch in preventing lymphatic leak after RARP and BPLND. Participants were randomized to receive RARP and BPLND, with or without the use of Hemopatch, with an allocation ratio of 1:1. The primary outcome is the total drain output volume. The secondary outcomes include blood loss, operative time, lymph node yield, duration of drainage, drain output per day, hospital stay, transfusion and 30-day complications. A total of 32 patients were recruited in the study. The Hemopatch group had a significantly lower median total drain output than the control group (35 mL vs. 180 mL, p = 0.022) and a significantly lower drain output volume per day compared to the control group (35 mL/day vs. 89 mL/day, p = 0.038). There was no significant difference in the other secondary outcomes. In conclusion, the application of Hemopatch in RARP and BPLND could reduce the total drain output volume and the drain output volume per day. The use of Hemopatch should be considered to prevent lymphatic leakage after RARP and BPLND.

Technique, outcome and changes in prostate dimensions in patients with urinary retention managed by aquablation.

PURPOSE: This study aimed to investigate the functional and urodynamic outcome of Aquablation in patients with acute urinary retention (AUR) on catheters. METHODS: Men aged 50-70 who failed medical treatment of BPO with AUR failing to wean off urethral catheter were recruited to undergo Aquablation. Individuals were assessed pre-operatively and at 3 and 6 months after surgery. The primary outcome was defined by the success rate of weaning off catheter. Secondary outcomes were measured by a change in prostate size, symptom scores and urodynamic parameters. RESULTS: Twenty patients underwent Aquablation between June 2019 and September 2020. Mean duration of the urethral catheter in-situ was 5.9 ± 4.9 weeks and mean prostate size of the cohort pre-operatively was 60.8 ± 15.8 cc. A second pass Aqaublation treatment was performed in 14 patients. Five patients failed to wean off the catheter on the first attempt after surgery, requiring another attempt 1 week later which were all successful. At 3 months after the operation, a significant reduction in prostate volume was observed (60.8 ± 15.8 cc vs 24.9 ± 10.3 cc, p < 0.001). No change in international index of erectile function (IIEF) was found (baseline: 16.1 ± 5.8; 3-month: 14.9 ± 6.4; p = 0.953). Mean bladder outlet obstruction index was 14.2 ± 23.0 at 6 months upon urodynamic assessment with 75% of patients had a resolution of detrusor overactivity. Reduction in prostate length was found to be more significant than a reduction in width and height after Aquablation (R = 0.693, p = 0.039). CONCLUSION: From the early data of a single centre, Aquablation was shown to provide a consistent improvement in symptoms, uroflowmetry and urodynamic parameters in patient with a urethral catheter. Results from our study suggest that improvement from Aquablation is reproducible in patients with AUR.

eLearning and transurethral prostate surgery: virtual tools for a real training.

PURPOSE OF REVIEW: In the recent two decades, technological breakthrough has tremendously expanded the scope of transurethral prostate surgery. New gadgets and energy devices keep emerging to tackle benign prostatic obstruction, which was dealt with mainly by transurethral resection of prostate in the old days. Although this trend appears fascinating, it also means that urologists need quality training to attain surgical safety in performing these new surgeries. E-learning and simulation training may play an important role in modern urology training. RECENT FINDINGS: In this review, we would describe, using up-to-date evidence, the key components of simulation training, the types of simulators currently in use and their respective advantages and limitations. SUMMARY: Modern simulation technology enables surgical training in a realistic, reproducible and risk-free environment. Simulation training has been proven to improve both performers' confidence and objective scores in various transurethral prostate surgeries. Its use should therefore be advocated.

Understanding the Composition of a Successful Tweet in Urology.

BACKGROUND: Little is known about the key composition of a successful tweet in urology. OBJECTIVE: To investigate for predictors of engagement with urology content on Twitter. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study based on 2-wk Twitter data surrounding a major international urology conference. INTERVENTION: We examined the engagement for all original tweets containing the hashtags for the European Association of Urology conference ("#EAU19" and/or "#EAU2019"). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Study outcomes included engagement with tweets, as measured by the number of "likes" and "retweets." Tweet- and Twitter user-related parameters of each individual tweet were recorded. Multiple linear regression analyses were performed to investigate for predictors of likes and retweets. RESULTS AND LIMITATIONS: From March 9 to 22, 2019, there were a total of 37 222 tweets. Among them, 3534 were "original tweets" that had 31 889 likes and 10 031 retweets. On multivariable analysis, the word count, number of mentions, and presence of a photo were predictors of likes and retweets. An increasing number of hashtags were associated with fewer likes. The number of "followings" and "followers" of the contributor, and their time since joining Twitter did not have any associations with the number of likes or retweets. The major limitation of the study is the lack of assessment about the quality of the tweet content. CONCLUSIONS: Based on the Twitter data from a urology conference, we concluded that the word count, number of mentions, and presence of a photo within the tweet were associated with audience engagement. PATIENT SUMMARY: We could engage the audience more successfully by increasing the number of words and mentions, and including a photo within a tweet. The results formulated the basic principles in creating successful tweets for sharing urological knowledge.

Survival outcomes of Chinese metastatic prostate cancer patients following primary androgen deprivation therapy in relation to prostate-specific antigen nadir level.

AIM: To evaluate the progression-free survival (PFS), cancer-specific survival (CSS) and overall survival (OS) of Chinese metastatic prostate cancer patients following primary androgen deprivation therapy (ADT) in relation to prostate-specific antigen (PSA) nadir level. METHODS: All Chinese prostate cancer patients with bone metastases who were treated with primary ADT from 2000 to 2009 were included. Patients' and disease characteristics were recorded. Patients were categorized into two PSA nadir groups (≤1.0 and >1.0 ng/mL). Associations of PSA nadir with PFS, CSS and OS were analyzed with Kaplan-Meier and Cox regression analyses. The survival outcomes of the two PSA nadir groups were presented. RESULTS: Four hundred nineteen patients were included in the study. PSA nadir appeared to be a good predictor for PFS (hazard ratio [HR] 1.86, 95% confidence interval [CI] 1.35-2.56, P < 0.001), CSS (HR 1.60, 95% CI 0.98-2.64, P = 0.063) and OS (HR 1.77, 95% CI 1.20-2.41, P < 0.001) upon multivariate Cox regression analyses. In the PSA nadir groups of ≤1.0 and >1.0 ng/mL, the median PFS were 15 and 10 months, and the 1-year PFS rates were 64% and 40%, respectively; the median CSS were 42 and 27 months, and the 5-year OS rates were 53% and 28%, respectively; and the median OS were 41 and 24 months, and the 5-year OS rates were 45% and 19%, respectively. CONCLUSIONS: Higher PSA nadir was associated with shorter PFS, CSS and OS in Chinese metastatic prostate cancer patients following primary ADT. The survival outcomes may serve as references in deciding the best treatment strategy in Chinese prostate cancer patients.

Prognostic significance of time to prostate-specific antigen (PSA) nadir and its relationship to survival beyond time to PSA nadir for prostate cancer patients with bone metastases after primary androgen deprivation therapy.

BACKGROUND: This study investigated the prognostic significance of time to the prostate-specific antigen nadir (TTPN) and its relationship to survival beyond TTPN in metastatic prostate cancer after primary androgen-deprivation therapy (ADT). METHODS: All metastatic prostate cancer patients treated with primary ADT from 2000 to 2009 were reviewed. The prognostic significance of TTPN in predicting progression-free survival (PFS) beyond TTPN and overall survival (OS) beyond TTPN was analyzed using the Cox regression model. The median PFS and OS were plotted against TTPN on a monthly interval. The PFS beyond TTPN and the OS beyond TTPN with reference to TTPN were calculated and presented. RESULTS: The study enrolled 419 patients with a median follow-up period of 38 months. The findings showed that TTPN was a significant prognostic indicator for both PFS beyond TTPN (hazard ratio [HR] 0.72, 95 % confidence interval [CI] 0.52-0.99, p = 0.04) and OS beyond TTPN (HR 0.65, 95 % CI 0.47-0.90, p = 0.01) according to Cox regression analyses. The relationship between TTPN and survival beyond TTPN consisted of three phases. In the first phase (<3 months for PFS and <6 months for OS), the survival beyond TTPN increased with TTPN. In the second phase (3-17 months for PFS and 6-20 months for OS), the survival beyond TTPN remained relatively static. In the third phase (>17 months for PFS and >20 months for OS), the survival beyond TTPN increased exponentially with TTPN. CONCLUSIONS: In this study, TTPN was a good prognostic indicator for PFS beyond TTPN and OS beyond TTPN in metastatic prostate cancer cases after primary ADT. Different TTPNs had different implications for predicting survival beyond TTPN.