Société Internationale d’Urologie Journal

Background/Objectives: Penile appearance is an important endpoint for hypospadias surgery. It is difficult to achieve good cosmetic results in patients with complications following hypospadias repair. Currently, there is not much data on factors which influence patient-reported outcomes of salvage hypospadias repair. Methods: A retrospective analysis of a prospectively maintained database on salvage hypospadias repair was performed. This cross-sectional study included 112 patients who were treated in our center for complications of previous attempts at hypospadias repair. We used the Penile Perception Score (PPS) questionnaire to evaluate cosmetic outcomes. The difference between the PPS value before salvage hypospadias surgery and the value at follow-up was the primary outcome of this study. The incidence of various cosmetic problems and the impact of patient-related and surgery-related factors on cosmetic outcome were secondary outcomes of this study. Results: Median PPS prior to salvage surgery was 9 (interquartile range (IQR): 6–13); this increased to 13 (IQR: 11–14) after surgery (p < 0.001). Surgical interventions resulted in a statistically significant improvement for most of the cosmetic concerns, with the exception of buried penis, where the change was borderline (p = 0.063). Age group (at presentation), staged repair, and use of a tunica vaginalis flap were all statistically associated with a good cosmetic outcome on univariate analysis. Multivariate logistic regression analysis revealed that age group (>39 years vs. ≤25 years: odds ratio (OR) = 0.193, 95% confidence interval (CI) = 0.06–0.627, p = 0.006) and staged salvage hypospadias repair (OR = 5.919, 95% CI = 1.706–20.54, p = 0.005) were associated with good cosmetic outcomes. Conclusions: Most cosmetic problems associated with failed hypospadias repair are manageable, and these should be properly addressed during salvage surgery. Younger patients may have better cosmetic outcomes of salvage hypospadias surgery. Multiple-stage repair may offer an advantage in terms of the final appearance of external genitalia in this setting. Full article

Background/Objectives: This study aims to assess changes in seminal parameters and sperm DNA fragmentation (SDF) index after empirical oral antibiotic therapy in infertile men with baseline SDF index > 15%. Methods: This retrospective, paired, uncontrolled pre- and post-intervention study included 98 infertile men with elevated baseline SDF index. Semen samples were obtained before treatment and at least two months after simultaneous oral treatment with ciprofloxacin 1000 mg/day for 21 days and doxycycline 100 mg/day for 10 days. Semen volume, sperm concentration, total sperm count, progressive motility, sperm morphology, round cell concentration, and SDF index were assessed before and after treatment. Results: After treatment, conventional semen parameters did not change significantly. Round cell concentration decreased from 0.3 to 0.2 × 10⁶/mL (p = 0.003), and median SDF index decreased from 30% to 20% (p < 0.0001). Conclusions: Empirical oral antibiotic therapy was associated with reductions in the SDF index and round cell concentration in this cohort. Because microbiological confirmation and an untreated control group were lacking, causality cannot be established, and controlled studies are required before routine clinical adoption. Full article

Background/Objectives: Double-J (DJ) ureteral stents are prone to luminal occlusion, which causes renal dysfunction and complicates exchange. Risk stratification in chronically stent-dependent patients is poorly defined, and the management of confirmed occlusion is not standardised. We aimed to identify independent risk factors for DJ stent occlusion in a chronically stent-dependent population and to evaluate stent-type substitution at first confirmed occlusion. Methods: We conducted a single-centre retrospective cohort study at a tertiary urology service in Melbourne, Australia (January 2023 to December 2025). Patients requiring three or more sequential DJ replacements were eligible. Mechanical occlusion was defined as inability to pass a guidewire through the stent lumen at fluoroscopic exchange, an objective intraoperative surrogate; clinical failure events (nephrostomy conversion, septic admission, or acute kidney injury requiring intervention) were recorded separately. Midstream urine culture and pre-exchange renal ultrasound were obtained at each visit. Cox proportional hazards modelling with robust patient-level clustering was performed. Results: We analysed 125 ureters (97 patients) over a mean follow-up of 20.6 months. Occlusion occurred in 55 ureters (44.0%). Four predictors were robust to Bonferroni correction: indwelling urethral catheter (hazard ratio [HR] 4.62), urinary stone disease versus malignant disease (HR 4.02), retroperitoneal fibrosis versus malignant disease (HR 3.24), and bacteriuria at exchange (HR 2.76). Two further associations, Eastern Cooperative Oncology Group (ECOG) performance status 2 to 4 (HR 2.31) and prior pyelonephritis (HR 1.89), did not survive correction and are exploratory. After stent-type substitution at first occlusion, 43 of 55 ureters (78.2%) had no further occlusion without interval shortening. Summer accounted for 45.1% of events (p < 0.001). Conclusions: In chronically stent-dependent patients, several factors were independently associated with DJ stent occlusion, four of them robust to multiple-comparison correction. Stent-type substitution was associated with occlusion-free outcomes in most cases without interval shortening; because the analysis was uncontrolled and regression to the mean cannot be excluded, this observation is hypothesis-generating. All hazard estimates are exploratory in view of an events-per-variable ratio below ten and a survivor-selected cohort, and apply only to patients with established chronic stent dependency. Prospective randomised evaluation is warranted. Full article

Background/Objectives: On 1 November 2023, the Medicare Benefits Schedule (MBS) introduced major reforms to prostate-specific antigen (PSA) testing in Australia, extending the minimum re-test interval for average-risk men (item 66655) from 12 to 23 months and introducing a new annual high-risk item (66654). These changes were aimed at reducing overscreening, aligning practice with national guidelines, and improving cost efficiency; however, their real-world impact on PSA utilisation, downstream diagnostic activity, and health-system costs has not been evaluated. Methods: We performed a national, population-level analysis of all reimbursed PSA tests (items 66655 and 66654) and prostate magnetic resonance imaging (MRI) scans (item 63541) from November 2021 to October 2025 using MBS claims data. Monthly utilisation trends were examined descriptively and modelled using interrupted time-series segmented regression with Newey–West heteroscedasticity- and autocorrelation-consistent standard errors. Economic impacts were estimated using schedule fees. MRI trends were assessed to explore early signals of downstream diagnostic change. Results: Prior to the reform, average-risk PSA testing (item 66655) averaged 61,704 claims per month (median 62,526). After November 2023, utilisation fell immediately to 49,620 and stabilised at a lower mean of 44,702 claims per month (median 43,495), representing a sustained 27.6 percent reduction. High-risk PSA testing (item 66654) accounted for 130,739 claims post-reform (10.9 percent of monthly post-reform PSA activity), but the increase in high-risk testing did not offset the reduction in average-risk claims; total PSA claims fell from 61,704 to 50,149 per month (−18.7 percent). Interrupted time-series modelling confirmed a large, significant step decrease for item 66655 (−23,191 claims, 95% confidence interval (CI) −31,215 to −15,167; p < 0.001) and for total PSA testing (−16,876 claims, 95% CI −25,899 to −7853; p < 0.001). In contrast, prostate MRI utilisation increased from 3854 to 4454 monthly scans (+15.6 percent) with no significant step-change at the time of the reform (p = 0.74) but a significant acceleration in post-reform growth (+49 scans/month, p = 0.0095). The reform resulted in an estimated net saving of $2.8 million in annual PSA expenditure. Conclusions: The November 2023 MBS reforms led to a large, immediate, and durable reduction in reimbursed PSA screening among average-risk men, while high-risk testing increased modestly but remained proportionally small. Total PSA testing declined meaningfully, producing substantial cost savings for Medicare. Rising MRI utilisation indicates that downstream diagnostic activity did not fall in parallel with reimbursed PSA claims, though this trend may reflect independent drivers of MRI growth rather than preserved screening vigilance. Reductions varied by jurisdiction, with two smaller jurisdictions showing net increases over the study window, underscoring that the national pattern was not uniform. Full article

Background/Objectives: Urinary incontinence after radical prostatectomy remains a significant concern affecting postoperative quality of life. This study aimed to investigate whether the early postoperative International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score is associated with mid-term urinary continence outcomes, using a patient-reported outcome approach. Methods: We retrospectively analyzed patients who underwent robot-assisted radical prostatectomy between May 2020 and July 2023 at the International University of Health and Welfare Narita Hospital and completed follow-up at one and six months postoperatively. Urinary incontinence severity was assessed using the ICIQ-SF (range 0–21, with higher scores indicating more severe symptoms). The primary outcome was incontinence at 6 months, defined as any pad use. Multivariable logistic regression and exploratory receiver operating characteristic (ROC) analyses were performed. Results: A total of 74 patients with complete follow-up data at both time points were included in the analysis. The ICIQ-SF score at one month was significantly associated with urinary incontinence at six months in both univariable and multivariable analyses. In the adjusted model, a higher one-month ICIQ-SF score independently predicted urinary incontinence at six months (odds ratio 1.15; 95% confidence interval 1.04–1.27; p = 0.005). Age, body mass index, and nerve-sparing status were not significantly associated with incontinence at six months. Exploratory ROC analysis demonstrated acceptable discriminative ability (area under the curve (AUC) 0.74, 95% confidence interval (CI) 0.61–0.87). A cut-off value of 13 yielded a sensitivity of 76.9% and a specificity of 59.1%. Conclusions: The ICIQ-SF score assessed one month after radical prostatectomy significantly predicts persistent urinary incontinence at six months. Early postoperative ICIQ-SF assessment may help identify patients at higher risk of persistent urinary incontinence. Further prospective studies are warranted to determine whether risk-stratified postoperative management based on early ICIQ-SF assessment improves clinical outcomes. Full article

Background/Objectives: To evaluate the surgical and functional outcomes of robot-assisted simple prostatectomy (RASP) for men with bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), aiding informed clinical decision-making. Methods: We conducted a prospective study of 69 patients undergoing RASP for BPH-related LUTS or acute urinary retention (AUR). Three high-volume robotic urologists from a single center, utilising a modified Millins technique, performed the RASP procedures. Pre-operative data included demographics (age, prostate-specific antigen (PSA), prostate volume), LUTS measures (International Prostate Symptom Score (IPSS), quality-of-life (QOL), flow rates, pad use), and intraoperative parameters (operative time, blood loss, histology, hospital stay). Postoperative outcomes were collected at 6–8 weeks and included symptom scores, flow rates, pad use, and patient satisfaction. Data were analysed using descriptive statistics and multivariate linear logistic regression; significance was set at 95% confidence. Results: Median patient age was 74 years (interquartile range (IQR) 72–77) with a median prostate volume of 143 cc (IQR 123–195) and preoperative IPSS of 19 (IQR 15.0–23.0). Median console time was 60 min (IQR 50.0–65.0), estimated blood loss was 350.0 mL (IQR 200–500), and specimen weight was 105.5 g (IQR 67.25–132.5). Median hospital stay was 1.0 day; all patients passed their trial of void (TOV) postoperatively, with an IPSS improvement of 78.9% (12 points), QOL improvement of 75% (3 points), maximum flow rate (Qmax) increase of 16.3 mL/s and an overall patient satisfaction of 10 out of 10 (extremely satisfied), independent of specimen size, operative duration, or pad usage. Conclusions: RASP appears to be a safe and effective surgical option for men with high-volume BPH and bothersome LUTS, offering substantial symptom improvement and excellent patient satisfaction. Its advantages may extend to patients with very large prostates or concurrent bladder pathology. However, findings are limited by our modest sample size and short follow-up. Larger prospective and comparative trials are warranted to better define the role of RASP in the treatment algorithm for BPH. Full article

Background/Objectives: Infant male circumcision (IMC) is a long-established religious practice in Jewish, Muslim, and some Orthodox Christian communities. Since 2007, access to non-therapeutic request IMC in Australia has gradually shifted from the public healthcare system to the private sector. However, the equity implications of this shift, particularly for socio-economically disadvantaged religious families, have received limited scholarly attention. This study explores the potential equity impacts of this policy environment, with a focus on low-income families in the Greater Sydney region. Methods: A desk-based Equity-Focused Health Impact Assessment (EFHIA) was conducted using publicly accessible data from the Australian Bureau of Statistics (ABS) and Medicare Benefits Schedule (MBS). Suburbs in the Greater Sydney region with the highest proportion of Jewish, Muslim, and Orthodox Christians were identified and the proportion of households with children experiencing financial vulnerability were compared across these suburbs. Findings were discussed using an equity and healthcare-access lens. Results: Suburbs with higher proportions of Muslim residents consistently demonstrated a higher proportion of households living with financial vulnerability compared with suburbs with higher proportions of Jewish and Orthodox Christian households. These findings suggest greater potential exposure to financial barriers when accessing private IMC services among Muslim-majority suburbs. In turn, such barriers may increase reliance on lower-cost, unaccredited circumcision providers, with possible risk of complications. Conclusions: The privatisation of request IMC in Australia is likely to disproportionally affect socio-economically disadvantaged religious families, particularly within Muslim communities, potentially generating an inequitable barrier to safe circumcision. Policy responses should focus on mitigating access barriers and safety risks through accredited provider registries, standardised parental information, regulatory oversight, and targeted community-based financial support mechanisms. Full article

Background/Objectives: Double-J stents (DJS) cause clinically significant lower urinary tract symptoms (LUTS) in 58–80% of patients following ureteroscopy (URS). The distal vesical coil is regarded as the primary anatomical source of trigonal irritation and detrusor instability. The single-J stent (SJS) eliminates this element while preserving the proximal renal pigtail for anti-migration anchorage. This study aimed to evaluate the safety and patient-reported symptom outcomes of a modified SJS compared with standard DJS following elective URS for ureteric stone disease. Methods: A prospective, single-arm, within-patient feasibility study was conducted in 28 adults undergoing elective URS at Austin Health, Melbourne, Australia (Human Research Ethics Committee (HREC)/25658/Austin-2025; NCT07535580). A modified SJS was fashioned from a commercially available 7Fr Bander™ ureteral diversion stent (Cook Medical, G14780) by trimming the shaft to 28 cm and affixing a 7 cm Prolene retrieval suture (Ethicon NW807) to the blunt distal end. The primary outcome was a cystoscopically confirmed SJS migration rate at removal (pre-specified feasibility threshold ≤5%). Secondary outcomes included change in Ureteral Stent Discomfort Test (USDT) total and domain scores (paired analysis, n = 24), adverse events, and patient preference. Results: The clinically significant migration rate was 0% (0/28); 27/28 stent tips were freely floating within the bladder, with one asymptomatic tip at the ureteric orifice at the scheduled removal visit. Mean total USDT score decreased from 39.92 ± 2.00 (DJS) to 30.42 ± 1.73 (SJS)—a mean absolute reduction of 9.50 points (23.8%; p < 0.001), a magnitude consistent with clinically relevant change, although a USDT-specific minimum clinically important difference has not been independently validated. All six USDT domains improved significantly (all p ≤ 0.014). No adverse events were recorded. All 28 patients (100%) reported they would choose the SJS again. Conclusions: The modified SJS demonstrated a favourable safety profile and was associated with lower patient-reported symptom scores than the preceding DJS across all USDT domains in this uncontrolled within-patient comparison. Because stent design, stone burden, and dwell time differed between the two assessment phases, these differences should be regarded as hypothesis-generating and provide a feasibility basis for a prospective randomised controlled trial evaluating the SJS following URS. Full article

Background/Objectives: Penile cancer carries a disproportionate burden of stigma and delayed presentation, with affected men increasingly turning to artificial intelligence (AI) chatbots as an anonymous information source. This study evaluated the quality, readability, understandability, actionability and clinical accuracy of AI chatbot responses to standardised penile cancer patient queries across six publicly available platforms. Methods: Fourteen standardised questions were submitted to ChatGPT-4o, Gemini, Perplexity, Microsoft Copilot, Claude, and DeepSeek, generating 84 responses. The responses were evaluated using DISCERN (information quality, scored 16–80), Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) (understandability and actionability, scored 0–100%), and Flesch–Kincaid grade level (reading complexity, recommended threshold ≤Grade 8). Between-platform and between-domain comparisons used the Kruskal–Wallis test with Dunn’s post hoc analysis. Clinical accuracy was assessed against the 2026 European Association of Urology-American Society of Clinical Oncology (EAU-ASCO) Collaborative Guidelines on Penile Cancer using a three-point ordinal scale across 10 guideline-scorable questions (maximum 20 points per platform); the four questions not addressed by the guidelines were scored separately for factual accuracy against authoritative external evidence. Results: No significant between-platform differences were identified for DISCERN (p = 0.796) or PEMAT-P understandability (p = 0.147). All platforms exceeded the 70% understandability adequacy threshold. Perplexity and Copilot demonstrated significantly higher actionability than all other platforms (100% vs. 75%, p < 0.001). No platforms achieved the recommended Grade 8 reading threshold, with Claude generating significantly more complex responses than ChatGPT-4o and Perplexity (grade 11.4 vs. 8.65 and 8.60, p < 0.05). Significant variation was identified across clinical domains for DISCERN (p < 0.001), Flesch–Kincaid grade level (p < 0.001), and word count (p < 0.001), with treatment-related questions achieving the highest information quality but also generating the most complex responses. Clinical accuracy scores ranged from 13/20 (ChatGPT-4o) to 16/20 (Copilot). Two critical errors were identified: Claude and DeepSeek both recommended bleomycin-containing chemotherapy regimens, directly contradicting the EAU-ASCO Strong recommendation against bleomycin due to pulmonary toxicity risk. Responses to the four survivorship and quality-of-life questions were factually accurate against external evidence in 23 of 24 cases. Conclusions: AI chatbot responses to penile cancer patient queries are broadly understandable but consistently fail to meet recommended readability thresholds and provide limited actionable guidance. Two platforms recommended bleomycin-containing regimens against an EAU-ASCO Strong recommendation; no platforms achieved full guideline concordance. Urologists should counsel patients on the limitations of AI chatbots as a health information source. Full article

Prostate cancer remains one of the most frequently diagnosed malignancies in men worldwide, and despite favorable outcomes for localized disease, progression to castration-resistant prostate cancer (CRPC) represents a major clinical challenge associated with poor prognosis. CRPC is characterized by disease progression despite castrate levels of circulating testosterone and is most commonly diagnosed in the metastatic setting. Although the introduction of second-generation androgen receptor-targeted therapies has improved survival, resistance inevitably emerges. This review overviews the most recent findings in the field of CRPC with particular emphasis on the current understanding of the biological mechanisms of hormone-resistant cancer as well as the evidence on treatment strategies. A comprehensive literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar, focusing mainly on studies published between 2015 and 2025 that investigated molecular and cellular mechanisms of resistance to androgen deprivation therapy and androgen receptor (AR)-targeted treatments. Seventy-eight relevant articles were included in the final synthesis. The reviewed evidence highlights four major categories of resistance mechanisms. First, AR-dependent alterations remain predominant, including AR gene amplification, activating mutations, dysregulation of co-regulators, and expression of constitutively active AR splice variants such as androgen receptor variant 7 (AR-V7). Second, AR-independent or bypass pathways, most notably phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mechanistic target of rapamycin (mTOR), wingless-related integration site (WNT)/β-catenin, mitogen-activated protein kinase (MAPK), and glucocorticoid receptor signaling, enable tumor survival despite AR blockade. Third, lineage plasticity and transdifferentiation to neuroendocrine prostate cancer represent a distinct and increasingly recognized resistance mechanism driven by loss of tumor protein 53 (TP53) and retinoblastoma 1 (RB1) and epigenetic reprogramming. Finally, additional contributors, including intratumoral androgen synthesis, metabolic reprogramming, and tumor microenvironment interactions, further support disease progression. Together, these interconnected mechanisms underscore the biological complexity of CRPC and emphasize the need for biomarker-guided, combination-based therapeutic strategies to overcome resistance and improve patient outcomes. Full article