Search Results (63)

Background: Vesicourethral anastomotic stricture (VUAS) remains a clinically relevant complication following radical prostatectomy, with important implications for postoperative urinary function. Minimally invasive approaches may offer technical advantages; however, their impact on stricture formation in patients with microangiopathic risk factors remains incompletely defined. Objective: We aimed to compare the incidence of vesicourethral anastomotic stricture following open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP) in patients with microangiopathic comorbidities and to explore clinical and perioperative factors associated with stricture development. Materials and Methods: A retrospective two-centre cohort study was conducted including 115 patients who underwent radical prostatectomy for clinically localized prostate cancer between 2022 and 2024. All patients had at least one microangiopathic risk factor (diabetes mellitus, hypertension, or coronary artery disease). Seventy-two patients underwent ORP and forty-three underwent LRP. VUAS was defined by obstructive symptoms with endoscopic confirmation requiring intervention within 12 months postoperatively. Univariate analyses and exploratory logistic regression models were performed to assess factors associated with stricture formation. Results: Vesicourethral anastomotic stricture occurred in 21 patients (18.3%). The crude incidence of VUAS was lower after LRP compared with ORP (9.3% vs. 23.6%); however, this difference did not reach statistical significance. Patients who developed VUAS had a significantly higher body mass index, longer operative time, and greater intraoperative blood loss. In exploratory multivariable analyses, body mass index and operative duration were consistently associated with increased odds of stricture, whereas the effect of surgical approach was unstable and imprecise due to limited event numbers. Conclusions: In patients with microangiopathic risk factors, laparoscopic radical prostatectomy was associated with a lower crude incidence of vesicourethral anastomotic stricture compared with open surgery; however, this association was not robust after adjustment. Perioperative and technical factors appear to play a more prominent role in anastomotic healing than surgical approach alone. These findings highlight the importance of optimizing intraoperative conditions to reduce postoperative stricture risk. Full article

Background/Objectives: The role of female surgeons in urology has been steadily increasing. We performed a contemporary review of American Board of Urology (ABU) case logs focused on oncologic procedures and evaluated the role of female surgeons over the past two decades. Methods: Operative logs from ABU examinees from 2003 to 2023 were analyzed. We identified open-approach (OA) and minimally invasive (MIS) radical nephrectomy (RN), partial nephrectomy (PN), radical nephroureterectomy (RNU), radical prostatectomy (RP), and adrenalectomy (RA) using CPT codes. Total case volumes as well as reported fellowship training were recorded and tabulated. The counts and proportions of OA and MIS procedures were analyzed over time and by surgeon gender. Results: From 2003 to 2023, 54,972 surgical procedures were reported to ABU with only 2.1% (1127) being performed by female surgeons. Of these, 32.5% (366) were OA and 67.5% (761) were MIS. Despite the low overall composition of female-performed procedures, the number of surgeries performed by females increased over time. Among female surgeons, the proportion of MIS surgeries increased over time, from 37.5% to 71.5% in 2003–2009 to 2017–2023, respectively. Females versus males performed comparably for OA for RN and RA; however, females performed more open PN, RNU, and RP than their male counterparts. Moreover, the number of procedures performed by oncology fellowship-trained females increased significantly. Conclusions: Our analysis of over twenty years of data submitted to the ABU indicates that the surgical volume of oncologic procedures by female urologists has been increasing. These findings demonstrate the increased contributions by female surgeons to the field urologic oncology. Full article

Background: The widespread adoption of holmium laser enucleation of the prostate (HoLEP) has led to a growing number of men subsequently diagnosed with localized prostate cancer requiring radical prostatectomy (RP). However, anatomical alterations after HoLEP may increase surgical complexity and affect outcomes. This systematic review aimed to synthesize current evidence on perioperative, oncological, and functional outcomes of RP following HoLEP. Methods: A systematic literature search was conducted in PubMed, CENTRAL, and ClinicalTrials.gov through to September 2025 in accordance with PRISMA 2020 guidelines (PROSPERO CRD420251134483). Eligible studies included patients undergoing RP after HoLEP with reported perioperative, oncologic, or functional data. Methodological quality was assessed using the ROBINS-I tool, and results were synthesized narratively. Results: Eight retrospective studies comprising 202 patients were included. RP after HoLEP was technically feasible across open, laparoscopic, and robotic approaches. Operative time and the need for bladder-neck reconstruction were increased, reflecting post-enucleation fibrosis, but major complication rates (<5%) and blood loss were comparable to primary RP. Oncological outcomes were preserved, with positive surgical margin rates of 6–20% and biochemical recurrence rates of 7–15%, similar to those of primary RP. Functional recovery, particularly urinary continence, was slower initially but generally equivalent at 12 months. Erectile function outcomes were variable but satisfactory when nerve-sparing was feasible. Conclusions: Radical prostatectomy after HoLEP is a technically demanding yet safe procedure that achieves oncologic and long-term functional outcomes comparable to primary prostatectomy. Prior HoLEP should not preclude curative surgical management of prostate cancer, provided the operation is performed by experienced surgeons in high-volume centers. Full article

Introduction: Surgical management of prostate cancer has evolved significantly over more than a century, transitioning from open procedures to modern robot-assisted techniques. This narrative review traces the historical progression of surgical treatments for localized prostate cancer, from early approaches to the most recent advancements. Materials and Methods: An extensive literature search was conducted from 1 April to 1 June 2025, using PubMed and cross-referencing citations. The search gathered studies on the evolution of prostate cancer surgery, technical aspects, and comparisons between surgical and non-surgical treatments. Keywords included “PROSTATE CANCER”, “PROSTATE CANCER SURGICAL TREATMENT”, “RADICAL PROSTATECTOMY EVOLUTION”, “ROBOT-ASSISTED RADICAL PROSTATECTOMY”, and “FOCAL THERAPY AND PROSTATE CANCER”. Results: A total of 65 manuscripts, including original articles, systematic reviews, meta-analyses, and clinical trials focusing on the surgical treatment of localized prostate cancer, were selected. The review begins with the history of prostatic surgery, chronicling its evolution through laparoscopic and, ultimately, robotic approaches. It highlights how improved visualization and new technologies have led to better functional outcomes and preservation of structures while maintaining oncological safety. A specific focus is placed on the technical evolution of robot-assisted radical prostatectomy, new robotic platforms, and the role of focal therapy as an ultra-minimally invasive technique for localized disease. Conclusions: Robot-assisted radical prostatectomy represents the current reference surgical technique for localized prostate cancer. However, it is crucial to acknowledge RALP’s elevated cost and the need for further long-term, randomized data to establish definitive oncological equivalence compared to non-surgical options. Full article

Background/Objectives: Bulkamid^® (Axonics, Irvine, CA, USA) is a non-particulate polyacrylamide hydrogel used in the treatment of urinary incontinence. While its effectiveness is well-documented in female stress urinary incontinence (SUI), there is limited data on its role in male stress urinary incontinence, particularly post-prostatectomy incontinence (PPI). This study evaluates the efficacy of Bulkamid as a primary or adjunctive treatment for male PPI. Methods: A retrospective chart review was conducted on male patients who developed PPI and underwent Bulkamid injections between 2016 and 2021. Data collected included pre- and post-procedure pad usage, the volume of Bulkamid injected, prior and subsequent incontinence treatments, and patient-reported satisfaction. Bulkamid was injected transurethrally in four quadrants near the vesicourethral anastomosis using a rigid cystoscope. Results: Twenty-one men with a history of radical prostatectomy (six open and fifteen robotic), including four who received adjuvant radiotherapy, were included. Fifteen underwent Bulkamid injection as a primary treatment, with five (33%) requiring repeat injections due to initial improvement. Eight (54%) subsequently underwent an AdVance XP^® sling placement, while two (13%) required no further treatment. Six patients received Bulkamid as an adjunct to prior incontinence surgery, with 80% of post-sling patients reporting improved continence. Bulkamid was less effective in men with detrusor overactivity or prior radiation. Conclusions: Bulkamid demonstrated a higher success rate as an adjunct to the AdVance XP sling, with 80% of men experiencing improved continence. As a primary treatment for PPI, success was modest, with only 33% achieving improvement, often requiring repeat injections or conversion to a sling. Bulkamid presents a low-risk option for select male PPI patients, particularly those with prior sling placement, but durability and long-term effectiveness remain concerns. Full article

Background/Objectives: To develop an automated American Joint Committee on Cancer (AJCC) staging system for radical prostatectomy pathology reports using large language model-based information extraction and knowledge graph validation. Methods: Pathology reports from 152 radical prostatectomy patients were used. Five additional parameters (Prostate-specific antigen (PSA) level, metastasis stage (M-stage), extraprostatic extension, seminal vesicle invasion, and perineural invasion) were extracted using GPT-4.1 with zero-shot prompting. A knowledge graph was constructed to model pathological relationships and implement rule-based AJCC staging with consistency validation. Information extraction performance was evaluated using a local open-source large language model (LLM) (Mistral-Small-3.2-24B-Instruct) across 16 parameters. The LLM-extracted information was integrated into the knowledge graph for automated AJCC staging classification and data consistency validation. The developed system was further validated using pathology reports from 88 radical prostatectomy patients in The Cancer Genome Atlas (TCGA) dataset. Results: Information extraction achieved an accuracy of 0.973 and an F1-score of 0.986 on the internal dataset, and 0.938 and 0.968, respectively, on external validation. AJCC staging classification showed macro-averaged F1-scores of 0.930 and 0.833 for the internal and external datasets, respectively. Knowledge graph-based validation detected data inconsistencies in 5 of 150 cases (3.3%). Conclusions: This study demonstrates the feasibility of automated AJCC staging through the integration of large language model information extraction and knowledge graph-based validation. The resulting system enables privacy-protected clinical decision support for cancer staging applications with extensibility to broader oncologic domains. Full article

Robotic-assisted radical prostatectomy (RARP) has emerged as a leading surgical approach for localized prostate cancer in many centers worldwide. Leveraging minimally invasive techniques and advanced visualization, RARP has demonstrated benefits in perioperative and functional outcomes, and at least comparable, if not better, oncologic control relative to open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). This review summarizes the current evidence on the efficacy, safety, and functional outcomes associated with RARP and discusses its role in contemporary prostate cancer management. Full article

Background: To compare the costs of open retropubic radical prostatectomy (RRP), robotic-assisted radical prostatectomy (RALP), intensity-modulated radiation therapy (IMRT), low-dose brachytherapy (LDBT), stereotactic body radiotherapy (SBRT), cryotherapy (Cryo), and high-intensity focused ultrasound (HIFU) for low/intermediate-risk prostate cancer (PCa), from the healthcare system perspective. Methods: This retrospective, IRB-approved study compared the costs and charges of primary treatment options for localized PCa at Duke University Hospital between January 2018 and December 2019. We identified cases by querying the relevant disease, procedural, and charge codes from Duke Finance. Consecutive cases with NCCN high-risk disease, prior treatment, or missing institutional financial information were excluded. Costs were calculated from the point at which the treatment option was selected until the last treatment session (SBRT and IMRT) or hospital discharge (other modalities). All modalities except RRP were considered technology-intensive. Results: A total of 552 patients with a mean age of 65.0 years met the inclusion criteria. NCCN risk categories included 85 (13%) low, 218 (41%) favorable-intermediate, and 249 (46%) unfavorable-intermediate risk cases. RALP, RRP, Cryo, and HIFU were single-session treatments, whereas IMRT, SBRT, and LDBT were delivered over multiple sessions. IMRT and SBRT were the most expensive modalities, followed by RALP, HIFU, LDBT, Cryo, and RRP. The number of sessions (ρ = 0.55, p < 0.001) and being technology-intensive (ρ = 0.58, p < 0.001) were significantly correlated with treatment costs. Conclusions: In this cohort of PCa patients, treatment costs were highest for IMRT and SBRT, followed by RALP, HIFU, LDBT, Cryo, and RRP. The number of treatment sessions was a significant predictor of higher costs. Full article

Purpose of Review: In approximately 10–15% of patients with prostate cancer (PCa), pathological lymph node metastases (pN1) are detected at radical prostatectomy (RP). The aim of this review is to describe the various treatment options for pN1 patients, with a focus on the most recent evidence reported in the literature. Evidence Synthesis: Due to the lack of prospective studies, several retrospective analyses were conducted according to different types of treatment. Most common strategies are represented by observation plus early salvage radiotherapy (RT) in case of PSA rising, adjuvant androgen deprivation therapy (ADT) alone, or adjuvant RT with or without ADT. Patients with pN1 disease and favorable disease characteristics (lower T stage and ISUP ≤ 2 at RP, <3 metastatic nodes at pathology) have a similar overall mortality risk if observed with PSA testing and eventual use of early salvage RT compared to patients directly treated with adjuvant RT with or without ADT. While conflicting results in terms of survival benefit were reported for the use of adjuvant ADT only, several studies showed an overall survival benefit in patients with pN1 disease treated with adjuvant RT when high-risk features (such as an increasing number of positive nodes, ISUP > 3) were detected at RP. Lastly, few studies analyzed the rate of adverse events following adjuvant ADT or RT, leaving the issue of treatment-related side effects still open. Summary: There is no clearly established standard of care for men with pN1 PCa, and disease characteristics should guide the choice of optimal post-operative management for these patients. Prospective data and clinical trials are clearly needed to define the most effective therapeutic strategy. Full article

Robotic-assisted surgery has gradually established its role in uro-oncological cases that demand a high level of precision, optimising surgeon ergonomics and decreasing fatigue whilst maintaining optimal clinical outcomes. With the novel Hinotori surgical robot (Medicaroid Corporation (Kobe, Hyogo, Japan)) launched in Japan back in 2019, it has now demonstrated its use case across various clinical series of different surgeries. We sought to narratively synthesise the initial feasibility of the Hinotori robotic system in urology. A systematic, comprehensive literature search was conducted across various databases from September 2024 to October 2024. Relevant keywords within the scope of this study were generated for a more accurate search. After exclusion and removal of duplicates, a total of nine articles were included for review. Among the included studies, one study reported data solely on radical prostatectomy for prostate cancer, two studies reported on robotic-assisted nephroureterectomy for renal tumours, two studies reported on partial nephrectomy performed for renal masses, two studies reported on radical nephrectomy carried out for renal malignancies and one study reported on robotic-assisted adrenalectomy for adrenal cancer. Lastly, one study collectively reported on outcomes pertaining to partial nephrectomy, partial nephrectomy, vesicourethral anastomosis and pelvic lymph node dissection in a porcine model, as well as partial nephrectomy, radical prostatectomy and pelvic lymph node dissection in cadavers. The current literature supports its non-inferiority to the well-established Da Vinci system, with no major drawbacks or concerns identified when comparing parameters such as intraoperative time, estimated blood loss (EBL), perioperative events (transfusions, conversion to open surgery), length of hospital stay and major postoperative complications. Future studies involving larger cohorts and more complex surgical cases are essential to further evaluate the efficacy and safety of the Hinotori system. The new Hinotori robotic system offers unique three-dimensional features as a non-inferior robotic platform alternative that has proven clinically safe thus far in its use. Larger scale studies and randomised trials are eagerly awaited to assess and validate more holistically its clinical utility. Full article

In a recent multicenter analysis of 454 patients undergoing post-prostatectomy salvage radiotherapy, the open surgical approach, as opposed to minimally invasive surgery, emerged, unexpectedly, as the strongest predictor of acute gastrointestinal and genitourinary toxicity. Patients treated with laparoscopic or robotic prostatectomy experienced significantly lower rates of ≥grade 2 toxicity compared to those who had undergone open retropubic surgery, irrespective of total dose, treatment margins, or radiation delivery platform. This finding, which to our knowledge has not been previously reported, raises the hypothesis that surgical technique leaves a lasting biological imprint on irradiated tissues. Drawing on current knowledge in radiobiology, cytokine signaling, wound healing, and pelvic dosimetry, we explore potential mechanisms by which open surgery may create a more hypoxic, inflamed, and fibrotic microenvironment, thereby amplifying radiation damage. We further discuss how target volume margins may biologically interact with this tissue state to increase normal tissue exposure. This Perspective aims to provide a conceptual framework for understanding this unexpected association, highlighting its clinical relevance for individualizing margins, counselling high-risk patients, and designing future studies at the interface of surgery and radiation oncology. This paper does not introduce additional patients or statistical models; instead, it offers an in-depth clinical and mechanistic interpretation of previously published ICAROS findings. Full article

Since its development in 1904, radical prostatectomy (RP) has remained a fundamental surgical option in the management of localised prostate cancer. Over time, continuous advancements in surgical techniques have improved oncological outcomes while reducing functional complications. This narrative review explores the evolution of RP, depicting its progression from the traditional open approach to minimally invasive laparoscopic and robotic-assisted techniques. Key developments in RP techniques, including nerve-sparing, bladder neck-sparing and Retzius-sparing techniques as well as enhanced perioperative management, have contributed to reduced postoperative complications, namely incontinence and erectile dysfunction. Additionally, technological innovations such as augmented reality, utilising indocyanine green for improved visualisation of prostatic boundaries and illuminare-1 to easily identify nerves intraoperatively, artificial intelligence, and novel molecular imaging technologies such as PSMA PETs for improved margin assessment are shaping the future of RPs. Despite these advancements, challenges persist, including a steep learning curve associated with newer techniques, disparities in access due to cost considerations, and a lack of standardised outcome measures across different surgical approaches. This review provides insight into current trends, ongoing challenges, and future directions that may further refine surgical precision, enhance patient safety, and improve long-term treatment success in prostate cancer management. Full article

Background: This study aimed to develop a predictive model for acute gastrointestinal (GI) and genitourinary (GU) toxicity in prostate cancer patients treated with salvage radiotherapy (SRT) post-prostatectomy, using machine learning techniques to identify key prognostic factors. Methods: A multicenter retrospective study analyzed 454 patients treated with SRT from three Italian radiotherapy centers. Acute toxicity was assessed using Radiation Therapy Oncology Group criteria. Predictors of grade ≥ 2 toxicity were identified through Least Absolute Shrinkage and Selection Operator (LASSO) regression and Classification and Regression Tree (CART) modeling. The analyzed variables included surgical technique, clinical target volume (CTV) to planning target volume (PTV) margins, extent of lymphadenectomy, radiotherapy technique, and androgen-deprivation therapy (ADT). Results: No patients experienced grade ≥ 4 toxicity, and grade 3 toxicity was below 1% for both GI and GU events. The primary determinant of acute toxicity was the surgical technique. Open prostatectomy was associated with significantly higher grade ≥ 2 GI (41.8%) and GU (35.9%) toxicity compared to laparoscopic/robotic approaches (18.9% and 12.2%, respectively). A CTV-to-PTV margin ≥ 10 mm further increased toxicity, particularly when combined with extensive lymphadenectomy. SRT technique and ADT were additional predictors in some subgroups. Conclusions: SRT demonstrated excellent tolerability. Surgical technique, CTV-to-PTV margin, and treatment parameters were key predictors of toxicity. These findings emphasize the need for personalized treatment strategies integrating surgical and radiotherapy factors to minimize toxicity and optimize outcomes in prostate cancer patients. Full article

Background/Objectives: To assess the incidence and factors associated with urethral stricture following monopolar transurethral resection of the prostate (mTURP) and open simple prostatectomy (OSP) over a 21-year period. Methods: We conducted a retrospective cohort study of adult male patients insured by Clalit Health Services in Israel, who underwent either mTURP or OSP at multiple centers. Key baseline characteristics, including age, body mass index (BMI), socioeconomic status, Charlson comorbidity index score, and the incidence of urethral stricture, were collected. Postoperative urethral strictures were identified using the ICD-10 code N35.9 (urethral stricture, unspecified). Results: Between January 2000 and December 2021, 54,872 patients underwent simple prostatectomy across 29 hospitals, with 43,525 (79%) undergoing mTURP and 11,347 (21%) undergoing OSP. The median age of patients undergoing mTURP was 73.6 years, while those undergoing OSP had a median age of 72.1 years (p < 0.0001). The incidence of urethral strictures was 1.15% (500) following mTURP and 0.538% (61) following OSP, with an incidence rate ratio (IRR) of 2.139 (p < 0.0001). On multivariable analysis, factors associated with the development of urethral stricture included the type of procedure (HR = 2.349, 95% CI: 2.081–2.653, p < 0.0001), older age at surgery (HR = 1.012, 95% CI: 1.007–1.018, p < 0.0001), higher Charlson Index score (HR = 1.128, 95% CI: 1.109–1.148, p < 0.0001), and lower BMI (HR = 0.990, 95% CI: 0.982–0.999, p = 0.027). Conclusions: Our study highlights a higher incidence of urethral stricture following mTURP compared to OSP. Additionally, older age and a higher Charlson comorbidity index were associated with increased risk of stricture development postsurgery. Full article

Background: Prostate cancer is a major cause of cancer-related mortality among men, with approximately 15% of newly diagnosed patients having pelvic lymph node metastasis (PLNM). For this reason, PLNM identification before localized PCa treatment would significantly impact treatment planning, clinical judgment, and patient outcome prediction. Radiomics has gained popularity for its ability to predict tumor behavior and prognosis without invasive procedures. Magnetic resonance imaging (MRI) is widely used in radiomic workups, particularly for prostate cancer. This study aims to predict lymph node invasion in prostate cancer patients using clinical information and mp-MRI radiomics features extracted from the suspicious nodule, prostate gland, and periprostatic adipose tissue (PPAT). Methods: A retrospective review of 85 patients who underwent mp-MRI at our radiology department between 2016 and 2022 was conducted. This study included patients who underwent prostatectomy and lymphadenectomy with complete histological examination and previous staging mp-MRI and were divided into two groups based on lymph node status (positive/negative). Data were collected from each patient, including clinical information, radiomics, and semantic data (such as tumor MRI characteristics, histological tumor details, and lymph node status (LNS)). MRI exams were conducted using a 1.5-T system and were used to study the prostate gland. A three-year resident manually segmented the prostate nodule, prostatic gland, and periprostatic tissue using an open-source segmentation program. A random forest (RF) machine learning model was developed and tested using Chat-GPT version 4.0 software. The model’s performance in predicting LNS was assessed using accuracy, precision, recall, F1 score, and area under the curve (AUC) receiver operating characteristic (ROC), with sensitivity and specificity evaluated using DeLong’s test. Results: Random forest demonstrated the best performance in prediction considering features extracted from DWI nodules (67% of accuracy, 0.83 AUC), from T2 fat (78% of accuracy, 0.86 AUC), and from T2 glands (78% of accuracy, 0.97 AUC). The combination of the three sequences in the nodule evaluation was more accurate compared with the single sequences (88%). Combining all the nodule features with gland and PPAT features, an accuracy of 89% with AUC near 1 was obtained. Compared with the analysis of the nodule and the PPAT, the whole-gland evaluation had the best performance (p ≤ 0.05) in predicting LNS when compared with the nodule. Conclusions: Precise nodal staging is essential for PCa patients’ prognosis and therapeutic strategy. When compared with a radiologist’s assessment, radiomics models enhance the diagnostic accuracy of lymph node staging for prostate cancer. Although data are still lacking, deep learning models may be able to further improve on this. Full article