European Association of Urology

To evaluate the effect of intraoperative administration of 1g of tranexamic acid (TXA) on perioperative and postoperative outcomes in patients receiving antithrombotic therapy undergoing endoscopic enucleation of the prostate (EEP). This multicenter, prospective, observational study included 932 patients across 30 centers (December 2024-June 2025). Patients were divided into four groups based on TXA use and continuation or discontinuation of blood thinners during EEP. The primary endpoint was bleeding complications within 30 days, defined as a composite of transfusion, clot retention, bleeding requiring restart of continuous bladder washout (CBWO), or surgical reintervention to control hemostasis. Multivariable Logistic regression analysis identified independent predictors of bleeding complications. There were 534 patients in Group 1 (stopped blood thinners, no TXA given), 316 in Group 2 (on blood thinners, no TXA given), 69 in Group 3 (stopped blood thinners, TXA given), and 13 in Group 4 (on blood thinners, TXA given). Median total operative time was longest in Group 2 (88min [IQR 70-127]) and shortest in Group 3 (55min [IQR 39-69]). Hemostasis time was shortest in TXA groups (p < 0.001). Transfusions occurred in 0.6-7.7% and surgical reinterventions in 0.6-7.7% across groups (p < 0.001). At 3 months, urinary symptoms and continence were comparable. On multivariable analysis, TXA reduced the odds of bleeding complications (OR 0.17, p < 0.001), while ongoing anticoagulant therapy (OR 2.93, p = 0.01), dual therapy (OR 4.31, p < 0.001), and longer operative time (OR 1.01, p < 0.001) increased the odds. Intraoperative TXA might mitigate perioperative bleeding and potentially protect patients at higher hemorrhagic risk.

While some patients with metastatic renal cell carcinoma (mRCC) may experience an indolent disease progression and could benefit from deferred systemic therapy (ST), including active surveillance (AS) or metastasis-directed therapy (MDT), the evidence on its oncological efficacy and safety are still not well-established. We aimed to provide an overview of the available evidence on oncological outcomes of patients with mRCC undergoing deferred ST. A systematic review of the literature was conducted in August 2024 using the PubMed, Scopus, and Embase databases to identify prospective and retrospective studies evaluating AS or deferred ST for patients with mRCC (PROSPERO ID: CRD42024579021). The co-primary outcomes were ST-free survival (ST-FS) and overall survival (OS). A random-effects model was used for quantitative analysis. We identified 15 eligible studies including 2,912 patients. Of these, 4 were prospective (n = 589 patients) and 11 were retrospective (n = 2,323 patients). The estimated 1-, 2-, 3-, 4-, and 5-year ST-FS rates (n = 1,070) were 74%, 54%, 49%, 43%, and 37%, respectively. The estimated 1-, 2-, 3-, 4-, and 5-year OS rates (n = 2,872) were 96%, 89%, 80%, 71%, and 69%, respectively. Key limitations at a study-level included selection bias, unmeasured confounding, and variability across deferred ST/AS protocols, including the indications for metastasis-directed therapy. Moreover, most studies used tyrosine kinase inhibitors as ST. The proportion of patients receiving MDT, including metastasectomy or stereotactic body radiation therapy, ranged from 14 to 100%. Deferring ST by AS or MDT was associated with favorable oncological outcomes in carefully-selected patients with mRCC, highlighting the potential value of this approach in the contemporary multidisciplinary management of mRCC. Considering the limitations of available evidence and the lack of data on the oncological efficacy and safety of deferred ST for mRCC in the immune-oncology era, our review calls for further research in this field.

To compare the stone retropulsion of an artificial model of urinary stones in vitro using the new holmium:yttrium aluminium garnet (Ho:YAG) laser generator with a very low peak power pulse modulation mode (Quanta Magneto Technology™; Quanta System, Samarate, Italy) and thulium fibre laser (TFL). The following laser energy settings were used: 0.2 J-50 Hz, 0.4 J-25 Hz, 0.8 J-12 Hz, 1.5 J-6 Hz, and 2 J-5 Hz. A 5 × 5 × 5 mm cubic artificial stone was placed on two perpendicularly aligned metal rulers to create a V-shaped cross-sectional rail submerged in a tank filled with 0.9% saline solution, with the laser fibre in contact with the stone. The laser was activated for 5 s. Stone retropulsion was captured by a camera and assessed using video tracking software. Five repetitions were performed for each setting. Descriptive statistics investigated differences between the two lasers in stone retropulsion distance and speed at selected time points (0.35, 1, 3, and 5 s) and over the first second following laser activation. Comparable stone retropulsion distance and speed were observed between 'Magneto' and TFL according to tested high-energy settings. Magneto exhibited lower mean stone displacement at selected time points (all P < 0.02) and lower mean retropulsion speed over the first second following laser activation (all P < 0.01), when compared to TFL at low-energy settings (0.2 and 0.4 J). Although Ho:YAG lasers are generally associated with greater stone retropulsion compared to TFL, Magneto exhibited a retropulsion performance similar to TFL. Further research is needed to clarify the retropulsion dynamics observed with Magneto at low-energy settings.

There is no consensus on whether to ligate or preserve uncomplicated vascular access (VA) after kidney transplantation (KT), as International Guidelines do not address this issue. Enhanced survival rates of kidney grafts may elevate the risk of cardiac morbidity and mortality due to prolonged exposure to the hemodynamic effects of arterio-venous fistulas (AVF). Although VA ligation reduces left ventricle (LV) mass, its impact on cardiovascular (CV) morbidity or mortality is unclear. High-flow VAs can complicate KT patients, and immunosuppressive medication may increase these complications. Despite preserving VA for future hemodialysis (HD) use, central catheters are used in nearly two-thirds of patients. Detecting transplant patients who can undergo AVF ligation and reconstruction when returning to HD allows for flexible decision-making with a multidisciplinary approach, personally tailored to patients at their discretion. Therefore, an algorithm involving Doppler ultrasound and cardiac evaluation is advisable.

This study aimed to evaluate the perioperative safety and functional outcomes of high-power holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) and long-term indwelling urinary catheter (IUC) use, with a specific focus on the impact of catheter duration on postoperative outcomes. A retrospective analysis was conducted on 380 patients who underwent HoLEP between 2016 and 2022, stratified into two groups based on catheter duration: long-term (≥ 28 days; Group 1) and short-term catheterization (Group 2). Demographic, intraoperative, and follow-up data were collected. Functional outcomes, including International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), and post-void residual (PVR), were assessed preoperatively and during follow-up at 3 and 12 months. Both groups demonstrated significant and sustained improvement in voiding function and symptom scores following HoLEP. Although perioperative metrics, such as operative time, hospital stay, and catheter removal time, were comparable, Group 1 had longer enucleation times (p = 0.02). No difference in postoperative complication rate was noted. At 3 months, Group 2 exhibited superior symptom relief (IPSS: 10 vs. 12, p = 0.01), though Qmax and PVR were similar. No patients in either group required re-catheterization postoperatively. By 12 months, functional outcomes converged between groups. Multivariate analysis showed that catheter duration predicted poorer symptomatic recovery one year after surgery (OR 0.786, p < 0.001). HoLEP is effective and safe for patients with BPH and preoperative catheterization. However, prolonged catheterization negatively impacts early symptom recovery. Early surgical intervention should be considered to optimize long-term outcomes and prevent catheter-related complications.

The treatment landscape for metastatic hormone-sensitive prostate cancer (mHSPC) is evolving rapidly. Real-world data (RWD) are essential to understand actual treatment use and outcomes. This study aimed to describe treatment trajectories and clinical outcomes in a large, multicenter RWD cohort under the PIONEER project. Eight European and US databases (2016-2020), including electronic health records, insurance claims, primary care data, and cancer registries, were standardized to the Observational Medical Outcome Partnership Common Data Model. Patients diagnosed with mHSPC and those receiving treatment were identified. The compared and analyzed outcomes included treatment switch, symptomatic progression, adverse events, and death. In total, 107 438 patients with mHSPC were identified, and 67 909 received treatment. Most of the patients received androgen deprivation therapy (ADT) monotherapy (69.4%), followed by ADT + an androgen receptor pathway inhibitor (ARPI; 15.2%), ADT + chemotherapy (14.0%), and triplet therapy (1.2%). The use of ARPIs increased over time. ADT + ARPI showed the highest persistence (53.8%) and a 5-yr switch-free survival rate of up to 72.3%. ADT monotherapy had 5-yr switch-free survival rates of 21.3-58.6% and adverse event-free survival rates of 64.7-81.2%. Addition of an ARPI improved switch-free survival (24.1-72.3%) but lowered adverse event-free survival (55.2-82.7%). Chemotherapy-based and triplet therapies showed variable results without consistent survival benefit. Limitations include residual confounding, inconsistent adverse event reporting, and possible data overlap. This is the largest RWD study of systemic mHSPC treatment. Despite evidence, ADT monotherapy remains the most used first-line therapy. Increased use ADT + ARPI is associated with better persistence and improved outcomes in the real-world setting, supporting its broader adoption in clinical practice.

Machine learning algorithms are occupying a larger space in medical and urology applications. However, typical medical physicians are not trained on these technologies and do not master the possibilities offered by these tools, to imagine their applications in the medical field. This manuscript is indented to be a guide in the use of machine learning in different urology applications, and to demystify the available machine learning and artificial intelligence algorithms. This manuscript reviews some of their applications and potential applications to the medical and urology field. Multiple works are published on the use of machine learning in urology, with performance demonstrated to be noninferior to human experts on multiple occasions. However, the major part of the machine learning publications in urology applications are concentrated on diagnosis and/or prognosis. Advanced machine learning algorithms based on agentic artificial intelligence, able to perform decisions and causality-based treatment optimization, are rarely put to use in urology. The democratization of advanced machine learning technologies in the medical fields can accelerate the adoption of these techniques, and potentially improve the patient care through relevant suggestive decision making. This work aims to demystify the machine learning tools for medical applications, facilitate decision making and adoption of the correct tools for the correct applications, and places a roadmap for the future of machine learning in the enhancement of patient care in urology.