Surgical Experience and Functional Outcomes after Laparoscopic and Robot-Assisted Partial Nephrectomy: Results from a Multi-Institutional Collaboration.

Background: In patients treated with partial nephrectomy, prior evidence showed that peri-operative outcomes, such as complications and ischemia time, improved as a function of the surgical experience of the surgeon, but data on functional outcomes after surgery are still scarce. Methods: We retrospectively analyzed data of 4011 patients with a single, unilateral cT1a-b renal mass treated with laparoscopic or robot-assisted partial nephrectomy. The operations were performed by 119 surgeons at 22 participating institutions between 1997 and 2022. Multivariable models investigated the association between surgical experience (number of prior operations) and acute kidney injury (AKI) and recovery of at least 90% of baseline estimated glomerular filtration rate (eGFR) 1 yr after partial nephrectomy. The adjustment for case mix included age, Body Mass Index, preoperative serum creatinine, clinical T stage, PADUA score, warm ischemia time, pathologic tumor size, and year of surgery. Results: A total of 753 (19%) and 3258 (81%) patients underwent laparoscopic and robot-assisted partial nephrectomy, respectively. Overall, 37 (31%) and 55 (46%) surgeons contributed only to laparoscopic and robotic learning curves, respectively, whereas 27 (23%) contributed to the learning curves of both approaches. In the laparoscopic group, 8% and 55% of patients developed AKI and recovered at least 90% of their baseline eGFR, respectively. After adjusting for confounders, we did not find evidence of an association between surgical experience and AKI after laparoscopic partial nephrectomy (odds ratio [OR]: 0.9992; 95% confidence interval [CI]: 0.9963, 1.0022; p = 0.6). Similar results were found when 1-year renal function was the outcome of interest (OR: 0.9996; 95% CI: 0.9988, 1.0005; p = 0.5). Among patients who underwent robot-assisted partial nephrectomy, AKI occurred in 11% of patients, whereas 54% recovered at least 90% of their baseline eGFR. On multivariable analyses, the relationship between surgical experience and AKI after surgery was not statistically significant (OR: 1.0015; 95% CI: 0.9992, 1.0037; p = 0.2), with similar results when the outcome of interest was renal function one year after surgery (OR: 1.0001; 95% CI: 0.9980, 1.0022; p = 0.9). Virtually the same findings were found on sensitivity analyses. Conclusions: In patients treated with laparoscopic or robot-assisted partial nephrectomy, our data suggest that the surgical experience of the operating surgeon might not be a key determinant of functional recovery after surgery. This raises questions about the use of serum markers to assess functional recovery in patients with two kidneys and opens the discussion on what are the key steps of the procedure that allowed surgeons to achieve optimal outcomes since their initial cases.

Digital Twins in Urological Oncology: Precise Treatment Planning via Complex Modeling.

Digital twins can revolutionize personalized medicine by providing virtual simulations for optimized treatment planning and patient care. Digital twins can enhance precision in oncology and surgery, although challenges regarding data and model complexity necessitate ongoing multidisciplinary collaboration for effective implementation.

PSMA PET-targeted Biopsy for Prostate Cancer Diagnosis: Initial Experience From a Multicenter Cohort.

OBJECTIVE: To describe the initial experience with PSMA-PET/CT-guided biopsy in European referral centres. METHODS: This multicenter observational cohort study was endorsed by the Young Academic Urologist (YAU) Prostate Cancer Group of the EAU and conducted across 6 tertiary-level European centres. PSMA-guided biopsies were carried out in a cognitive/fusion manner for all the recruited patients with or without MRI-guided biopsies and/or standard biopsy (SB). PCa and clinical significant PCa (csPCA) detection rate (DR) at prostate biopsy was assessed. Uni- and multivariable models were employed to identify features related to csPCA. RESULTS: Overall, 72 patients were recruited. The topographic location of the dominant lesion depicted by PSMA PET/CT was significantly associated with the location of csPCa, especially in the biopsy naïve cohort. The DR for PCa and csPCa of PSMA-PET/CT-guided biopsies was significantly higher than SB (0.40 ± 0.43 vs 0.23 ± 0.29, and 0.36 ± 0.44 vs 0.21 ± 0.30, respectively, both P <.05) but did not surpass MRI-guided biopsies (0.40 ± 0.43 vs 0.47 ± 0.44, and 0.36 ± 0.44 vs 0.47 ± 0.34, respectively, both P >.05). PSMA-PET/CT-guided biopsy performed better in the biopsy naïve than in the repeated biopsy setting. A SUVmax cut-off value equal to 4.8 provided the best results for detecting csPCa. CONCLUSION: Our real-world data illustrate the potentialities of PSMA-PET/CT-guided biopsy in diagnosing PCa. Specifically, in biopsy naïve patients with suspicion of high-risk disease, the use of PSMA-PET/CT-targeted biopsy can be considered. Additionally, in the context of repeated biopsies, a PSMA-PET/CT target biopsy might be advisable over the SB.

Complication rate across the minimally invasive surgical treatments (MISTs): where do we stand? A systematic review of the literature.

BACKGROUND: Over the past decade, the range of surgical options to benign prostatic obstruction (BPO) has expanded significantly with the advent of minimally invasive surgical therapies (MISTs). Nevertheless, the available evidence in the field is heterogeneous. Efficacy and safety thresholds are yet to be determined. OBJECTIVE: To evaluate perioperative and long-term complications after MISTs - including Aquablation, steam injection (Rezum), Transperineal laser ablation of the prostate (TPLA), implantation of a prostatic urethral lift (PUL) and temporary implantable nitinol device (iTIND) - in patients with lower urinary tract symptoms due to BPO. EVIDENCE ACQUISITION: A systematic literature search was conducted in January 2024 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy used PICO criteria (Patients, Interventions, Comparisons, Outcomes) [1], focusing specifically on patients with BPH-associated LUTS who underwent MIST or other comparative treatments, aiming to assess both perioperative and long-term safety outcomes. Article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. EVIDENCE SYNTHESIS: The initial electronic search identified 3660 records, of which 24 ultimately met the inclusion criteria and were included in the analysis. Overall, Aquablation was associated with a higher major complications rate of 14% (IQR 6-22), particularly in the case of patients with prostates <70 ml. PUL showed a higher early postoperative acute urinary retention rate (10.9%, IQR 9.2-12.3%), while 1.4% of patients treated with iTIND experienced major perioperative complications. Urinary tract infections were mostly reported in series assessing TPLA and Rezum. CONCLUSIONS: The adoption of MISTs for LUTS due to BPH is associated with a varied spectrum of perioperative and long-term complications. Our findings showed an acceptable safety profile with specific complications dependent on the type of MIST performed, highlighting the importance of individualized patient selection and procedure-specific considerations.

Robot-assisted nephroureterectomy: surgical and mid-term oncological outcomes in over 1100 patients (ROBUUST 2.0 collaborative group).

OBJECTIVE: To analyse surgical, functional, and mid-term oncological outcomes of robot-assisted nephroureterectomy (RANU) in a contemporary large multi-institutional setting. PATIENTS AND METHODS: Data were retrieved from the ROBotic surgery for Upper tract Urothelial cancer STtudy (ROBUUST) 2.0 database, an international, multicentre registry encompassing data of patients with upper urinary tract urothelial carcinoma undergoing curative surgery between 2015 and 2022. The analysis included all consecutive patients undergoing RANU except those with missing data in predictors. Detailed surgical, pathological, and postoperative functional data were recorded and analysed. Oncological time-to-event outcomes were: recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Survival analysis was performed using the Kaplan-Meier method, with a 3-year cut-off. A multivariable Cox proportional hazard model was built to evaluate predictors of each oncological outcome. RESULTS: A total of 1118 patients underwent RANU during the study period. The postoperative complications rate was 14.1%; the positive surgical margin rate was 4.7%. A postoperative median (interquartile range) estimated glomerular filtration rate decrease of -13.1 (-27.5 to 0) mL/min/1.73 m2 from baseline was observed. The 3-year RFS was 59% and the 3-year MFS was 76%, with a 3-year OS and CSS of 76% and 88%, respectively. Significant predictors of worse oncological outcomes were bladder-cuff excision, high-grade tumour, pathological T stage ≥3, and nodal involvement. CONCLUSIONS: The present study contributes to the growing body of evidence supporting the increasing adoption of RANU. The procedure consistently offers low surgical morbidity and can provide favourable mid-term oncological outcomes, mirroring those of open NU, even in non-organ-confined disease.

3D virtual models and augmented reality for radical prostatectomy: a narrative review.

BACKGROUND AND OBJECTIVE: The increasing popularity of three-dimensional (3D) virtual reconstructions of two-dimensional (2D) imaging in urology has led to significant technological advancements, resulting in the creation of highly accurate 3D virtual models (3DVMs) that faithfully replicate individual anatomical details. This technology enhances surgical reality, providing surgeons with hyper-accurate insights into instantaneous subjective surgical anatomy and improving preoperative surgical planning. In the uro-oncologic field, the utility of 3D virtual reconstruction has been demonstrated in nephron-sparing surgery, impacting surgical strategy and postoperative outcomes in prostate cancer (PCa). The aim of this study is to offer a thorough narrative review of the current state and application of 3D reconstructions and augmented reality (AR) in radical prostatectomy (RP). METHODS: A non-systematic literature review was conducted using Medline, PubMed, the Cochrane Database, and Embase to gather information on clinical trials, randomized controlled trials, review articles, and prospective and retrospective studies related to 3DVMs and AR in RP. The search strategy followed the PICOS (Patients, Intervention, Comparison, Outcome, Study design) criteria and was performed in January 2024. KEY CONTENT AND FINDINGS: The adoption of 3D visualization has become widespread, with applications ranging from preoperative planning to intraoperative consultations. The urological community's interest in intraoperative surgical navigation using cognitive, virtual, mixed, and AR during RP is evident in a substantial body of literature, including 16 noteworthy investigations. These studies highlight the varied experiences and benefits of incorporating 3D reconstructions and AR into RP, showcasing improvements in preoperative planning, intraoperative navigation, and real-time decision-making. CONCLUSIONS: The integration of 3DVMs and AR technologies in urological oncology, particularly in the context of RP, has shown promising advancements. These technologies provide crucial support in preoperative planning, intraoperative navigation, and real-time decision-making, significantly improving the visualization of complex anatomical structures helping in the nerve sparing (NS) approach modulation and reducing positive surgical margin (PSM) rate. Despite positive outcomes, challenges such as small patient cohorts, lack of standardized methodologies, and concerns about costs and technology adoption persist.

Neoadjuvant and Adjuvant Immune-based Approach for Renal Cell Carcinoma: Pros, Cons, and Future Directions.

CONTEXT: Immune-oncology strategies are revolutionising the perioperative treatment in several tumour types. The perioperative setting of renal cell carcinoma (RCC) is an evolving field, and the advent of immunotherapy is producing significant advances. OBJECTIVE: To critically review the potential pros and cons of adjuvant and neoadjuvant immune-based therapeutic strategies in RCC, and to provide insights for future research in this field. EVIDENCE ACQUISITION: We performed a collaborative narrative review of the existing literature. EVIDENCE SYNTHESIS: Adjuvant immunotherapy with pembrolizumab is a new standard of care for patients at a higher risk of recurrence after nephrectomy, demonstrating a disease-free survival and overall survival benefit in the phase 3 KEYNOTE-564 trial. Current data do not support neoadjuvant therapy use outside clinical trials. While both adjuvant and neoadjuvant immune-based approaches are driven by robust biological rationale, neoadjuvant immunotherapy may enable a stronger and more durable antitumour immune response. If neoadjuvant single-agent immune checkpoint inhibitors demonstrated limited activity on the primary tumour, immune-based combinations may show increased activity. Overtreatment and a risk of relevant toxicity for patients who are cured by surgery alone are common concerns for both neoadjuvant and adjuvant strategies. Biomarkers helping patient selection and treatment deintensification are lacking in RCC. No results from randomised trials comparing neoadjuvant or perioperative immune-based therapy with adjuvant immunotherapy are available. CONCLUSIONS: Adjuvant immunotherapy is a new standard of care in RCC. Both neoadjuvant and adjuvant immunotherapy strategies have potential advantages and disadvantages. Optimising perioperative treatment strategies is nuanced, with the role of neoadjuvant immune-based therapies yet to be defined. Given strong biological rationale for a pre/perioperative approach, there is a need for prospective clinical trials to determine clinical efficacy. Research investigating biomarkers aiding patient selection and treatment deintensification strategies is needed. PATIENT SUMMARY: Immunotherapy is transforming the treatment of kidney cancer. In this review, we looked at the studies investigating immunotherapy strategies before and/or after surgery for patients with kidney cancer to assess potential pros and cons. We concluded that both neoadjuvant and adjuvant immunotherapy strategies may have potential advantages and disadvantages. While immunotherapy administered after surgery is already a standard of care, immunotherapy before surgery should be better investigated in future studies. Future trials should also focus on the selection of patients in order to spare toxicity for patients who will be cured by surgery alone.

Prognostic significance of residual tumor at restaging transurethral bladder resection in high-risk non-muscle-invasive bladder cancer.

PURPOSE: To assess prognostic significance of residual tumor at repeat transurethral resection (reTUR) in contemporary non-muscle-invasive bladder cancer (NMIBC) patients. METHODS: Patients were identified retrospectively from eight referral centers in France, Italy and Spain. The cohort included consecutive patients with high or very-high risk NMIBC who underwent reTUR and subsequent adjuvant BCG therapy. RESULTS: A total of 440 high-risk NMIBC patients were screened, 29 (6%) were upstaged ≥ T2 at reTUR and 411 were analyzed (T1 stage: n = 275, 67%). Residual tumor was found in 191 cases (46%). In patients with T1 tumor on initial TURBT, persistent T1 tumor was found in 18% of reTUR (n = 49/275). In patients with high-grade Ta tumor on initial TURBT, T1 tumor was found in 6% of reTUR (n = 9/136). In multivariable logistic regression analysis, we found no statistical association between the use of photodynamic diagnosis (PDD, p = 0.4) or type of resection (conventional vs. en bloc, p = 0.6) and the risk of residual tumor. The estimated 5-yr recurrence and progression-free survival were 56% and 94%, respectively. Residual tumor was significantly associated with a higher risk of recurrence (p < 0.001) but not progression (p = 0.11). Only residual T1 tumor was associated with a higher risk of progression (p < 0.001) with an estimated 5-yr progression-free survival rate of 76%. CONCLUSIONS: ReTUR should remain a standard for T1 tumors, irrespective of the use of en bloc resection or PDD and could be safely omitted in high-grade Ta tumors. Persistent T1 tumor at reTUR should not exclude these patients from conservative management, and further studies are needed to explore the benefit of a third resection in this subgroup.

Robot-assisted Single-port Radical Prostatectomy with the SHURUI SP and da Vinci SP Platforms: Comparison of the Technology, Intraoperative Performance, and Outcomes.

Background and objective: The purpose-built SHURUI single-port (SP) robotic platform has recently been introduced for several procedures in urology, general surgery, and gynecology. However, comparative evidence on its performance in relation to earlier models such as the da Vinci SP is lacking. Our aim was to compare the step-by-step techniques and 1-yr outcomes for radical prostatectomy (RP) between the SHURUI SP and da Vinci SP robots. Methods: Data were retrieved from two prospectively maintained databases. The SHURUI SP robot was used to perform RP in 34 patients in China (September 2021 to August 2022); the da Vinci SP robot was used to perform 100 consecutive RP cases in the USA (June 2019 to October 2020). A comparative analysis was conducted before and after 1:1 propensity score matching for age, body mass index, American Urological Association symptom score, prostate size, prostate-specific antigen (PSA) levels, biopsy grade group, and D'Amico risk group. Intraoperative performance and short-term oncological and continence outcomes were compared between the groups. Biochemical recurrence was defined as two consecutive postoperative PSA levels >0.2 ng/ml. Continence was defined as full recovery of urinary control without the use of pads. The Kaplan-Meier method was used to estimate continence recovery curves, and a log-rank test for trend was used to detect ordered differences in continence recovery between the SHURUI SP and da Vinci SP groups after surgery. Key findings and limitations: For the matched SHURUI and da Vinci groups, median age (69 vs 69 yr), median PSA (8.4 vs 7.1 ng/ml), and the proportion of patients with low-risk (33.3% vs 29.6%), intermediate-risk (66.7% vs 63%), and high-risk disease (0% vs 7.4%) were comparable (all p > 0.05). All surgeries were successfully accomplished without conversion. A higher percentage of cases in the SHURUI group involved extraperitoneal access (81.5% vs 0%; p < 0.001) and a pure SP approach (25.9% vs 0%; p = 0.01), while a higher percentage of cases in the da Vinci group had nerve-sparing surgery. The median total operative (215 vs 110 min; p < 0.001) and median console time (162 vs 75 min; p < 0.001) were significantly longer in the SHURUI group. No intraoperative or major postoperative complications were observed in either group. Rates of positive surgical margins (18.5% vs 14.8%; p = 1.0) and extraprostatic extension (14.8% vs 29.6%; p = 0.19) were similar. At median follow-up of 13.5 versus 15.9 mo, none of the patients had experienced biochemical recurrence. At 1 yr after surgery, the continence rate was 96.3% in both groups. Conclusions: Despite differences in driving mechanisms between the two SP robotic systems, RP can be performed safely and effectively with the SHURUI RP robot during the initial learning phase, with similar short-term oncological and continence outcomes to those with the da Vinci SP robot. Patient summary: We compared two surgical robots (SHURUI SP and da Vinci SP) used to perform robotic surgery to remove the prostate through a single keyhole incision instead of multiple incisions. Our results show comparable technology and similar surgical and short-term cancer control outcomes for the two robots.

The impact of bladder cuff excision on outcomes after nephroureterectomy for upper tract urothelial carcinoma: An analysis of the ROBUUST 2.0 registry.

OBJECTIVES: We sought to determine whether bladder cuff excision and its technique influence outcomes after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS AND MATERIALS: A multicenter, international, retrospective analysis using the ROBotic surgery for Upper tract Urothelial cancer Study (ROBUUST) 2.0 registry identified 1,718 patients undergoing RNU for UTUC between 2015 and 2023 at 17 centers across the United States, Europe, and Asia. Data was gathered on (1) whether bladder cuff excision was performed and (2) what technique was used, including formal excision or other techniques (pluck technique, stripping/intussusception technique) and outcomes. Multivariate and survival analyses were performed to compare the groups. RESULTS: Most patients (90%, 1,540/1,718) underwent formal bladder cuff excision in accordance with EAU and AUA guidelines. Only 4% (68/1,718) underwent resection using other techniques, and 6% (110/1,718) did not have a bladder cuff excised. Median follow up for the cohort was 24 months (IQR 9-44). When comparing formal bladder cuff excision to other excision techniques, there were no differences in oncologic or survival outcomes including bladder recurrence-free survival (BRFS), recurrence-free survival (RFS), metastasis-free survival (MFS), overall survival (OS), or cancer-specific survival (CSS). However, excision of any kind conferred a decreased risk of bladder-specific recurrence compared to no excision. There was no difference in RFS, MFS, OS, or CSS when comparing bladder cuff excision, other techniques, and no excision. CONCLUSIONS: Bladder cuff excision improves recurrence-free survival, particularly when considering bladder recurrence. This benefit is conferred regardless of technique, as long as the intramural ureter and ureteral orifice are excised. However, the benefit of bladder cuff excision on metastasis-free, overall, and cancer-specific survival is unclear.

Robotic distal ureterectomy for high-risk distal ureteral urothelial carcinoma: a retrospective multicenter comparative analysis (ROBUUST 2.0 collaborative group).

BACKGROUND: The role of kidney-sparing surgery in patients with high-risk upper urinary tract urothelial carcinoma is controversial. The present study aimed to assess oncological and functional outcomes of robot-assisted distal ureterectomy in patients with high-risk distal ureteral tumors. METHODS: The ROBUUST 2.0 multicenter international (2015-2022) dataset was used for this retrospective cohort analysis. High-risk patients with distal ureteral tumors were divided based on type of surgery: robot-assisted distal ureterectomy or robot-assisted nephroureterectomy. A survival analysis was performed for local recurrence-free survival, distant metastasis-free survival, and overall survival. After adjusting for clinical features of the high-risk prognostic group, Cox proportional hazard model was plotted to evaluate significant predictors of time-to-event outcomes. RESULTS: Overall, 477 patients were retrieved, of which 58 received robot-assisted distal ureterectomy and 419 robot-assisted nephroureterectomy, respectively, with a mean (±SD) follow-up of 29.6 months (±2.6). The two groups were comparable in terms of baseline features. At survival analysis, no significant difference was observed in terms of recurrence-free survival (P=0.6), metastasis-free survival (P=0.5) and overall survival (P=0.7) between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy. At Cox regression analysis, type of surgery was never a significant predictor of worse oncological outcomes. At last follow-up patients undergoing robot-assisted distal ureterectomy had significantly better postoperative renal function. CONCLUSIONS: Comparable outcomes in terms of recurrence-free survival, metastasis-free survival, and overall survival between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy patients, and better postoperative renal function preservation in the former group were observed. Kidney-sparing surgery should be considered as a potential option for selected patients with high-risk distal ureteral UTUC.

The impact of venous thromboembolism before open or minimally-invasive radical cystectomy in the USA: insurance claims data on perioperative outcomes and healthcare costs.

BACKGROUND: The relationship between venous thromboembolism (VTE) and solid malignancy has been established over the decades. With rising projected rates of bladder cancer (BCa) worldwide as well as increasing number of patients experiencing BCa and VTE, our aim is to assess the impact of a preoperative VTE diagnosis on perioperative outcomes and health-care costs in BCa cases undergoing radical cystectomy (RC). METHODS: Patients ≥18 years of age with BCa diagnosis and undergoing open or minimally invasive (MIS) RC were identified in the Merative™ Marketscan® Research Databases between 2007 and 2021. The association of previous VTE history with 90-day complication rates, postoperative VTE events, rehospitalization, and total hospital costs (2021 USA dollars) was determined by multivariable logistic regression modeling adjusted for patient and perioperative confounders. Sensitivity analysis on VTE degree of severity (i.e., pulmonary embolism [PE] and/or peripheral deep venous thrombosis [DVT]) was also examined. RESULTS: Out of 8759 RC procedures, 743 (8.48%) had a previous positive history for any VTE including 245 (32.97%) PE, 339 (45.63%) DVT and 159 (21.40%) superficial VTE. Overall, history of VTE before RC was strongly associated with almost any worse postoperative outcomes including higher risk for any and apparatus-specific 90-days postoperative complications (odds ratio [OR]: 1.21, 95% CI, 1.02-1.44). Subsequent incidence of new VTE events (OR: 7.02, 95% CI: 5.93-8.31), rehospitalization (OR: 1.25, 95% CI: 1.06-1.48), other than home/self-care discharge status (OR: 1.53, 95% CI: 1.28-1.82), and higher health-care costs related to the RC procedure (OR: 1.43, 95% CI: 1.22-1.68) were significantly associated with a history of VTE. CONCLUSIONS: Preoperative VTE in patients undergoing RC significantly increases morbidity, post-procedure VTE events, hospital length of stay, rehospitalizations, and increased hospital costs. These findings may help during the BCa counseling on risks of surgery and hopefully improve our ability to mitigate such risks.

Incidence, Timing, and Pattern of Atypical Recurrence after Minimally Invasive Surgery for Urothelial Carcinoma.

The management of urothelial carcinoma has evolved with the introduction of minimally invasive techniques such as laparoscopic or robotic procedures, challenging the traditional approach of open surgery, and giving rise to atypical recurrences (ARs). ARs include port-site metastasis and peritoneal carcinomatosis, yet discrepancies persist among authors regarding their precise classification. Incidence rates of ARs vary widely across studies, ranging from less than 1% to over 10% in both muscle-invasive bladder cancer (MIBC) and upper tract urothelial tumor (UTUC). Peritoneal metastases predominate as the most common ARs in patients with MIBC, while retroperitoneal metastases are prevalent in those with UTUC due to differing surgical approaches. The timing of AR presentation and survival outcomes closely mirror those of conventional recurrences, with which they are frequently associated. Pneumoperitoneum has progressively been regarded less as the cause of ARs, while surgical-related risk factors have gained prominence. Current major surgical-related causes include tumor spillage and urinary tract violation during surgery, avoidance of endo bag use for specimen extraction, and low surgical experience. Factors such as tumor stage, histological variants, and lympho-vascular invasion correlate with the risk of ARs, suggesting a close association with tumor biology. Further studies are required to better understand the incidence, risk factors, characteristics, and outcomes of ARs.

Application of AI in urolithiasis risk of infection: a scoping review.

INTRODUCTION: Artificial intelligence and machine learning are the new frontier in urology; they can assist the diagnostic work-up and in prognostication bring superior to the existing nomograms. Infectious events and in particular the septic risk, are one of the most common and in some cases life threatening complication in patients with urolithiasis. We performed a scoping review to provide an overview of the current application of AI in prediction the infectious complications in patients affected by urolithiasis. EVIDENCE ACQUISITION: A systematic scoping review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) guidelines by screening Medline, PubMed, and Embase to detect pertinent studies. EVIDENCE SYNTHESIS: A total of 467 articles were found, of which nine met the inclusion criteria and were considered. All studies are retrospective and published between 2021 and 2023. Only two studies performed an external validation of the described models. The main event considered is urosepsis in four articles, urinary tract infection in two articles and diagnosis of infection stones in three articles. Different AI models were trained, each of which exploited several types and numbers of variables. All studies reveal good performance. Random forest and artificial neural networks seem to have higher AUC, specificity and sensibility and perform better than the traditional statistical analysis. CONCLUSIONS: Further prospective and multi-institutional studies with external validation are needed to better clarify which variables and AI models should be integrated in our clinical practice to predict infectious events.

Urinary PSA-ZINC biomarker outperforms standard of care in early detection of prostate cancer.

BACKGROUND: Urine is a promising biological fluid for prostate cancer (PCa) diagnostics due to its non-invasive collection and wide range of biomarkers. The aim of this study was to assess the role of urinary PSA (uPSA) and urinary Zinc (uZinc) as biomarkers for the diagnosis of PCa in combination with routine parameters of standard of care (SOC - blood PSA, abnormal DRE, age) and MRI in patients candidates for prostate biopsy. METHODS: Urine samples after prostatic massages were collected from men with suspected PCa scheduled for prostate biopsy. Quantification of uPSA was performed by ECLIA platform and confirmed by ELISA assay, while uZinc measurement was evaluated by ICP-MS and confirmed by colorimetric in vitro assay. Six multivariate logistic regression analysis were performed to assess diagnostic performance of uPSA and uZinc (urine), SOC and MRI alone, and combination of MRI+SOC, MRI+urine and SOC+MRI+urine. The discriminative power of the logistic models was assessed by calculating the area under the receiver operating characteristic (ROC) curves (AUC). RESULTS: Two hundred thirty-eight patients were included in the analysis; 145 of them were diagnosed with PCa. Urine test showed a better discrimination of HS from CP, in respect of uPSA and uZinc alone, both for PCa of any grade and Gleason Score ≥7 (4+3) (AUC 0.804 and 0.823 respectively). ROC curve combining SOC+MRI+urine showed an AUC=0.882, that is statistically different from SOC or MRI alone, or MRI+SOC (P=0.0001, P=0.0001, and P=0.008 respectively). PCa risk algorithm designed considering SOC+MRI+urine results in potential reduction of 57% of unnecessary biopsies compared to the current standard parameters. CONCLUSIONS: The loss of uPSA and Zinc production and secretion during neoplastic transformation of the prostate could potentially represent a hallmark of PCa. Its combination with age, PSA and DRE, as well as with mpMRI could represent an interesting approach to improve the diagnostic accuracy of PCa.