This week in Urology

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Welcome to This Week in Urology. This week we're covering 10 notable papers spanning treatment intensity in prostate cancer, risk and surveillance in bladder cancer, and infection and recurrence in endourology and stone disease. Let's dive in.

We start with prostate cancer, where two papers ask how much local and systemic treatment actually buys patients. In European Urology, Briganti and colleagues report the PROTEUS substudy, which randomized 408 men with high-risk localized or locally advanced disease, three to one, to radical prostatectomy alone or to prostatectomy wrapped in a year of apalutamide plus androgen deprivation, given as six cycles before and six after surgery [1]. Three-year event-free survival was about 63 percent with perioperative therapy against 41 percent with surgery alone, and the risk of an event fell by roughly sixty percent. Because the hazards were not constant over time, the authors added a restricted mean analysis, which estimated about eleven extra months free of events over the first three years. The need for subsequent therapy fell by about seventy percent, and metastasis-free survival improved when PSMA PET was counted, but metastasis-free survival on conventional imaging showed no difference. Severe adverse events were more common with the combination, at about 31 versus 22 percent. Some caveats matter here: the substudy was open-label, the comparator was surgery with no systemic therapy, and the primary endpoint leans heavily on biochemical failure. The authors, alongside the blinded main PROTEUS trial, conclude this supports perioperative apalutamide as an option for selected surgical candidates, though overall survival data are not yet in hand. At the other end of the risk spectrum, Falkenbach and colleagues in the World Journal of Urology used SEER data on about 220,000 men with intermediate-risk disease to estimate years of life lost against matched population controls [2]. Men treated with prostatectomy or radiotherapy showed no survival deficit, whereas men without local therapy lost about a fifth of a year on average. That gap widened among men diagnosed between 45 and 55, where untreated patients lost over a year, and men receiving radiotherapy lost about seven tenths of a year, while men undergoing prostatectomy showed no deficit. Unfavourable intermediate-risk disease without local treatment also carried a loss. This is registry data with obvious selection effects, so it reinforces rather than settles the case for local treatment in younger men and unfavourable disease.

Turning to bladder cancer, four papers span the pathway from first presentation through surveillance. In The Journal of Urology, Ryan and colleagues followed about 16,000 patients with hematuria in the All of Us research program and found evaluation was both infrequent and unequal [3]. Women received cystoscopy at roughly half the rate of men, for both microscopic and gross hematuria, with similar gaps for imaging and complete workup, and Hispanic patients with more severe microscopic hematuria had lower cystoscopy rates after adjustment for social determinants. The authors call for referral and guideline adherence interventions, and the gender gap echoes concerns about delayed bladder cancer diagnosis in women. Once a tumour is found, grading may need refinement. Simard and colleagues in BJU International centrally re-reviewed 321 primary Ta high-grade tumours and quantified the high-grade component [4]. The proportion of high-grade tissue did not predict recurrence, but thresholds of ten percent and above were associated with progressively worse progression-free survival, most clearly in patients not given BCG, while the current five percent threshold did not separate outcomes. This is retrospective and the authors ask for prospective validation, but it suggests that reporting the high-grade percentage could sharpen risk stratification. At the far end, Contieri and colleagues in the World Journal of Urology studied 793 patients who had cystectomy for clinically non-muscle-invasive disease across 23 centres [5]. Over a third of these patients were upstaged at final pathology. Among patients with confirmed non-muscle-invasive disease, two-year recurrence was about twelve percent, lymphovascular invasion roughly tripled the risk, pT1 stage roughly doubled it, and about a third of recurrences involved the remaining urothelium. The forward-looking risk halved between the two- and five-year landmarks, from about seven to about three percent, which the authors read as support for surveillance tailored to biology, time, and site. Finally, a systematic review by Miyajima and colleagues, also in the World Journal of Urology, examined BCG-induced granulomatous prostatitis across 47 mostly descriptive studies [6]. PSA above 4 occurred in about half of evaluable patients and often fell on its own, and PI-RADS 4 or higher lesions appeared in nearly nine in ten imaged cases, yet biopsy found cancer in only about eight percent. Grade reporting was too inconsistent to estimate clinically significant cancer, so the authors' suggestion of structured observation before immediate biopsy rests on low-quality evidence.

Our third theme is endourology and stones, where infection prevention and follow-up strategy both come under scrutiny. In the World Journal of Urology, Shiomi da Cruz and colleagues updated their meta-analysis of suction versus traditional ureteral access sheaths in retrograde intrarenal surgery, pooling 29 studies and about 5,600 patients, only four of them randomized [7]. Suction sheaths roughly halved residual fragments at both early and late assessment, cut fever by more than half, and roughly halved sepsis, without lengthening operative time. Septic shock was rare and the reduction was not statistically significant, and a post hoc signal favouring flexible-tip sheaths needs randomized confirmation. Certainty was moderate for stone clearance and fever, and low or very low elsewhere. Complementing this, Khondakar and colleagues in The Journal of Urology reviewed about 10,000 patients undergoing endoscopic procedures to ask whether all contaminated preoperative urine cultures are equal [8]. A positive culture nearly tripled the odds of postoperative urinary infection, and a polymicrobial culture containing at least one uropathogen raised the odds by about forty percent, whereas mixed skin flora alone carried no excess risk. Contaminated cultures were also associated with roughly doubled odds of readmission and ninety-day mortality. It is retrospective and relies on coded diagnoses, but it supports distinguishing these culture reports, with the authors suggesting repeat collection or speciation when a uropathogen is present. On longer-term follow-up, Geraghty and colleagues in BJU International built a virtual stone clinic from UK Biobank and All of Us data covering more than 25,000 patients and tested the European Association of Urology risk stratification [9]. Its ability to predict symptomatic events over five years was only modestly better than chance, decision curve analysis showed no benefit to risk-stratified follow-up, and the only useful predictor was two or more prior symptomatic episodes. The authors conclude their data do not support using the current criteria to guide follow-up, a direct challenge to guideline practice, though coded data may miss metabolic detail.

One functional urology paper rounds out the week. In European Urology Focus, Peyronnet and colleagues report one-year results from VENUS, a prospective European registry of women receiving the AMS 800 artificial urinary sphincter for stress incontinence due to intrinsic sphincter deficiency at 19 institutions in seven countries [10]. More than eighty percent of women were continent at one year, defined as no pads or a single security pad, with acceptable short-term device survival and manageable morbidity. As the first prospective multicentre data in this population it is a meaningful step, but without a comparator or long-term device outcomes the authors acknowledge its place in guidelines remains undefined.

If you only have time for one paper this week, make it the PROTEUS substudy in European Urology [1]. Together with the blinded main trial, it reopens the long-closed question of whether systemic therapy around prostatectomy improves outcomes in high-risk disease, while leaving overall survival and conventional-imaging metastasis benefit still unanswered.

That's your roundup for This Week in Urology. The full transcript and references are available on the episode page. See you next week.

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