This week in Urology

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This week: lesion-targeted ultrasound ablation for localised prostate cancer at one year, resection of the prostate before radiotherapy, and a new surgical robot tested head to head against an established platform.

Welcome to This Week in Urology. We're covering 10 papers this week: 3 in depth, 4 in brief, 3 quick signals.

In BJU International, Yli-Pietilä and colleagues report twelve-month results of a single-centre phase two IDEAL study of lesion-targeted transurethral ultrasound ablation, known as TULSA, as first-line treatment for MRI-visible localised prostate cancer [1]. They treated 59 men, most with Grade Group 2 disease. Eligibility was deliberately broad, with no exclusions for lesion size, location, multifocality or capsular contact. No Clavien-Dindo grade three or higher complications occurred within three months. Over the full year, two grade three events linked to urethral stricture or outlet obstruction occurred, and both resolved with intervention. At the twelve-month biopsy, 70 percent of men were free of Grade Group 2 or higher cancer in the treated field. Only about half of men were free of such cancer across the whole prostate. MRI was negative in most patients, and median PSA fell to about 1.3. Urinary and bowel function stayed stable, and just under three quarters of initially potent men kept their erections. The main limitations are the single-arm design and short follow-up. The study adds early safety and functional data in a less selected population, while the rate of cancer outside the treated field leaves oncological control an open question until comparative studies report.

Also in localised disease, The Journal of Urology publishes a multicentre retrospective cohort from Vrij and colleagues on planned transurethral resection of the prostate within nine months before external beam radiotherapy, in men with prostate cancer and lower urinary tract symptoms [2]. The cohort included 200 patients treated over a decade, with median follow-up of about two and a half years after radiotherapy. By three years, just over half of patients had a grade two or higher urinary adverse event, and about one in seven patients had a grade three or higher event. Symptom scores fell by around nine points on the International Prostate Symptom Score after resection and stayed at or below that level after radiotherapy. A larger target prostate volume was linked to a lower risk of severe urinary toxicity. A longer gap between resection and radiotherapy was linked to more moderate toxicity, which the authors attribute to confounding by indication. The design is retrospective with no comparison group, so it cannot show whether toxicity is higher or lower than with radiotherapy alone. The study adds a multicentre estimate of both the toxicity cost and the durable symptom benefit, and the authors conclude that resection is a feasible de-obstructive strategy before radiotherapy.

In the Journal of Endourology, Huang and colleagues report a randomized, single-blind non-inferiority trial comparing the Edge MP1000 surgical robot with the da Vinci Xi for robot-assisted radical prostatectomy [3]. The trial enrolled 80 men with clinically localised, mostly low to intermediate risk prostate cancer at three centres in China, split evenly between the platforms. The primary endpoint was surgical success, meaning completion of all planned steps without conversion to open or laparoscopic surgery. Every procedure in both arms succeeded, which met the prespecified non-inferiority margin. Operative time, docking time, blood loss, kidney function and length of stay did not differ significantly. Positive margins occurred in around five percent of men in each arm, and immediate continence was seen in roughly four in five men on both platforms. Adverse events were all grade one, and no device-related complications were reported. The limitations are a small sample, a wide twenty-point margin, an endpoint both platforms were expected to meet, and only twelve weeks of follow-up. This is randomized evidence on a newer platform, but the authors state it shows short-term feasibility and safety only, and does not establish oncological or functional equivalence.

Now, four in brief.

Staying with robotic platforms, World Journal of Urology publishes a single-surgeon retrospective cohort from Bubishate and colleagues comparing the da Vinci 5 with the da Vinci Xi in more than 2,200 radical prostatectomies, balanced with inverse probability weighting [4]. The newer system was associated with an operative time about three minutes shorter, of uncertain clinical relevance. It was also associated with faster continence recovery, with the rate of regaining continence about 45 percent higher. Complications, readmissions, potency recovery and biochemical recurrence did not differ. Follow-up was much shorter on the newer platform, and one high-volume surgeon limits generalisability. Unlike the randomized Edge trial, this is observational, and the authors call for prospective confirmation.

Also in World Journal of Urology, Anceno and colleagues pooled eleven studies with 648 men in a single-arm meta-analysis of radical prostatectomy without a prior biopsy, in men with high suspicion on MRI or PSMA PET [5]. Clinically significant cancer was found in about 94 percent of specimens, benign pathology in under one percent, and the pooled overtreatment rate was just under six percent. Positive margins occurred in about a quarter of cases. Yield was higher in biopsy-naive men than in men with a previous negative biopsy. Risk of bias was serious, mainly from verification bias, and there was no comparator arm. The authors conclude the approach belongs only in carefully selected patients at high-volume centres.

Two papers address metastatic urothelial carcinoma. In European Urology, Laukhtina and colleagues report a prospective single-centre phase two feasibility trial of nectin-4 targeted gallium DOTA-N188 PET CT against FDG PET CT, in 25 patients planned for enfortumab vedotin with pembrolizumab [6]. FDG generally showed higher uptake except in lymph nodes, and correlation between the tracers was weak. For the primary tumour, the nectin-4 tracer had a specificity of 86 percent against 57 percent for FDG, while FDG was more sensitive. Both tracers detected all distant metastases. With 25 patients and no link yet to treatment response, this is a feasibility result, and the authors say it is not ready to guide therapy selection.

In BJU International, Nakagawa and colleagues ran a post hoc analysis of THOR trial Cohort 1, covering 247 patients with FGFR-altered metastatic urothelial carcinoma treated with erdafitinib or chemotherapy [7]. Combining best response with six-month progression-free survival, erdafitinib shifted patients toward more durable phenotypes. Limited benefit was seen in under half of erdafitinib patients, against about three quarters of chemotherapy patients. Among responders, a response that did not last six months carried roughly a ninefold higher hazard of death in landmark analysis than a durable response. The analysis is exploratory and post hoc, and it suggests objective response alone does not fully capture benefit.

Three quick signals.

An EAU Endourology systematic review in the Journal of Endourology by Altunhan and colleagues covered eleven studies and 786 patients using pressure monitoring and suction technologies in flexible ureteroscopy [8]. Active pressure-control systems kept intrarenal pressure low, and a narrower access sheath was linked to much higher odds of elevated pressure. Mostly non-randomized studies and heterogeneous reporting precluded meta-analysis.

In Nature Reviews Disease Primers, Tzelves and colleagues review kidney stones, which affect about one in ten people and recur in about half of patients within five to ten years [9]. They describe minimally invasive treatment, with advances in laser fibres and suction technology, as improving outcomes. It is a narrative overview without new data.

In European Urology, Dinkelman-Smit and colleagues publish a consensus-based narrative review of male factor infertility [10], setting out pathophysiological, endocrine and phenotypic classification systems and the limits of semen analysis. They find hormonal and surgical treatments effective, with limited evidence for several add-on tests and empirical therapies. Without a systematic search, selection bias cannot be excluded.

Stepping back across this week's papers, much of the evidence on new prostate technology rests on early endpoints with short horizons. Platform comparisons and focal ablation studies report conversion, complications, early continence and early biopsy, while oncological durability remains unmeasured. Where randomization was used, the endpoint was one both arms were expected to meet. Where the sample was large, the design was observational and drawn from a single surgeon. Several reviews also found reporting too heterogeneous for pooled analysis.

If you only have time for one paper this week, make it the multicentre cohort of prostate resection before radiotherapy [2]. It addresses a common question in obstructed men heading for radiotherapy by quantifying the urinary toxicity that accompanies durable symptom relief, and it leaves open how that compares with radiotherapy alone.

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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