Journal of Clinical Urology

Aquablation is FDA and NICE approved for treating benign prostatic hyperplasia (BPH). In the UK, increasing surgical elective waiting lists have created the need for HIT list models. We present a tertiary centre experience using Aquablation within a HIT list framework and compare it to standard operating protocol (SOP).

A prospective cohort study was performed with 60 patients awaiting bladder outlet surgery. Ten patients were operated using HIT protocol and compared to 50 patients under SOP. We assessed differences in perioperative outcomes and complications, including postoperative follow-up.

There was a significant decrease in IPSS from 24.92 to 5.93 (p = 0.001) and 93% ejaculation preservation. A significant difference in postoperative Hb decrease was observed, with HIT = 5.3 g/L vs SOP = 12.3 g/L (p < 0.05). No blood transfusions were needed. Operative times were similar, with the HIT group having a median of 56 minutes and the SOP group 59 minutes.

Our analysis demonstrates that the introduction of Aquablation in a tertiary centre is feasible for managing moderately enlarged prostate glands (80–150 ml). The implementation of a dual operating theatre HIT list using a single Aquabeam robotic system appears to be a viable strategy for increasing surgical capacity. While initial results suggest comparable perioperative outcomes to standard operating protocol, further studies with larger cohorts are required to assess the long-term safety and broader applicability of this approach.

3

Non-muscle invasive bladder cancer (NMIBC) is traditionally managed with transurethral resection of bladder tumour (TURBT) and intravesical therapy. Although effective, TURBT carries morbidity, particularly in frail or comorbid patients. Outpatient transurethral laser ablation (TULA) is an emerging alternative with fewer complications. However, national data on patient selection and practice patterns are limited. This survey provides a contemporary overview of TULA use in the United Kingdom.

A structured questionnaire was distributed to UK urologists, assessing current TULA practice, selection criteria, and barriers to service delivery.

Responses were received from 105 urologists. Of these, 60 (57%) reported performing TULA, averaging 348 procedures annually. Indications included low-grade, small (<1 cm) superficial recurrences, and primary treatment in patients unsuitable for TURBT due to comorbidities. Additional considerations were anticoagulated patients and challenging lesion sites, such as the bladder dome. Reported limitations included technical challenges with lesion visibility during flexible cystoscopy, difficulties at the bladder neck, and service constraints related to funding and laser equipment availability.

TULA is a promising treatment for carefully selected NMIBC cases, particularly in frail populations. Standardised selection criteria, prospective monitoring of outcomes, and establishment of a national registry are required to guide safe practice, inform clinical guidelines, and support equitable service provision.

Level 4 cohort study

Robotic pyeloplasty (RP) has emerged as a preferred surgical approach for treating pelviureteric junction obstruction (PUJO) in adults. While comparisons with open and laparoscopic pyeloplasty (LP) are established in paediatric populations, adult data remain limited. This study aims to compare clinical outcomes of RP and LP in adults and evaluate the learning curve required to achieve proficiency in RP.

Retrospective data were collected for 94 consecutive patients undergoing either RP (n = 48) or LP (n = 46) by a single surgeon between June 2008 and June 2021. Variables analysed included demographics, operative time, hospital stay, complications, and postoperative renography findings. RP learning curve was assessed using operative time and analysed with the CUSUM method. Statistical analysis was performed using SPSS v28 and Kruskal–Wallis H test (p < 0.05 significant).

Mean operative time was significantly lower in the RP group (128.5 minutes) compared to the LP group (169 minutes; p < 0.01). Median hospital stay was shorter for RP (2 days vs 4 days; p < 0.01). Postoperative renography (available in 79% of patients) showed improved drainage in 81% of RP and 78% of LP patients (p = 0.46). Symptom resolution was achieved in 96% of RP and 89% of LP patients (p = 0.11). Thirty-day complication rates were 15% for RP and 22% for LP (p = 0.36). Operative time was analysed using the CUSUM analysis. Phase 1 plateaued at case 16 suggesting initial learning phase complete. Phase 2 with inflection of the curve occurred at case 29 suggesting true mastery.

RP is a safe, effective procedure offering reduced operative time and hospital stay compared to LP, with comparable functional and symptomatic outcomes. A total of 29 cases are required to achieve proficiency in robotic pyeloplasty. These findings support the broader adoption of RP in adult urological practice.

IV.

To present our experience and outcomes in the surgical management of rectourethral fistula (RUF).

We retrospectively analysed data from 11 patients treated for RUF between 2015 and 2024. Patient demographics, aetiology, fistula complexity, surgical approach, and outcomes were reviewed.

The mean patient age was 29 years (range = 18–62). In 81% of cases, RUF resulted from road traffic accidents, and four patients had previously failed repairs. All patients underwent suprapubic catheter placement and faecal diversion before definitive surgery. Seven patients (63.6%) had a complex fistulas, while four had simple ones. The perineal approach was used in eight patients (72.7%), with a transpubic in two patients (18.18%) and cystectomy with ileal conduit diversion in one patient (9%). The gracilis muscle interposition flap was used in most cases. At a 1-year follow-up, no patients experienced per rectal leakage, and 81% had catheter removal by 3 months.

Our study demonstrates that with thorough evaluation and proper management, RUF closure rates can reach up to 100%. The pedicled gracilis muscle flap is highly effective for interposition in complex cases.

2c

To develop a functional prototype of a device capable of reliably applying drug-coated titanium seeds transurethrally into the bladder wall through a cystoscope, as part of a seed-based system for intravesical drug instillation to treat non-muscle invasive bladder cancer (NMIBC). This innovation addresses the limitations of current approaches, such as short drug dwell time in the bladder lumen and poor drug penetration into the bladder wall, while preserving the benefits.

An interdisciplinary collaboration between biomedical engineers and clinical urologists followed a rigorous design process with theoretical evaluation of various designs, resulting in the production of a prototype. This was tested for its ability to implant seeds into different materials (gelatin, bovine muscle tissue). Model-based application by a panel of urologists resulted in the refinement of the initial prototype. The optimized prototype was finally tested in an ex vivo pig bladder model.

A functional prototype combining a reusable user interface component and a single-use component was successfully produced. In this cystoscopy-based approach, the seeds stored at the distal end of the device are applied to the bladder wall using a proximal trigger/plunger mechanism. We demonstrated efficient and accurate seed implantation in bladder-mimicking models and in an ex vivo porcine bladder experiment.

We developed a device that provides proof-of-concept for the feasibility of transurethral intravesical seed application using the working channel of a flexible cystoscope. With further refinement of the design and adequate validation of corresponding drug-coated seeds, this device would be suitable for testing in patient bladders.

Not applicable

To assess the detection of tumour markers in the cyst fluid of residual cystic non-seminomatous germ cell tumours disease post chemotherapy at the time of retroperitoneal lymph node dissection (RPLND) and assess the correlation with pre-treatment serum markers.

In this prospective study (May 2018–July 2023), cystic fluid was aspirated from residual masses during RPLND in 24 patients. Tumour markers alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH) were measured and correlated with serum markers and histopathology.

Twenty-four out of 26 (92.3%) cystic teratoma cases showed elevated AFP, HCG, or both in cystic fluid despite normalised serum markers post chemotherapy. No significant correlation was observed between serum and cystic fluid marker levels. One benign case showed no detectable cystic markers. Cystic tumour marker levels were independent of primary testicular tumour histology.

Cystic fluid tumour marker analysis at the time of post-chemotherapy RPLND frequently demonstrated elevated AFP and/or HCG in teratoma, even when serum markers were normal. There could be a role for assessment of cyst fluid tumour markers in patients with new cystic masses arising post RPLND to predict recurrence of teratoma. However, larger, multicentre studies including diverse cystic pathologies are needed to clarify the diagnostic accuracy and potential role of this approach in clinical decision-making.

2b

To evaluate the clinical utility of the Decipher genomic classifier in prostate biopsy specimens and its association with National Comprehensive Cancer Network (NCCN) risk stratification, metastatic outcomes, and racial differences.

We retrospectively reviewed 88 patients with prostate adenocarcinoma who underwent Decipher testing on diagnostic biopsy tissue between 2021 and 2023. Clinical variables, Decipher risk categories, and NCCN risk groups were compared using chi-square, t-test, analysis of variance (ANOVA), and logistic regression to assess their association with distant metastasis.

Decipher risk categories showed moderate concordance with NCCN classification (Phi = 0.46, p < 0.001). Forty-five percent of patients were Decipher low risk, 30% intermediate risk, and 25% high risk. During follow-up, seven patients (8%) developed distant metastasis; four had high-risk, two intermediate-risk, and one low-risk Decipher scores. Decipher high-risk classification was more common among African American patients than Caucasian patients (44% vs 19%, p = 0.04). The receiver operating characteristic (ROC) curve showed moderate discriminative performance (area under the curve (AUC) = 0.70).

Decipher testing on prostate biopsy specimens provides prognostic information beyond NCCN classification and may help identify biologic differences across racial groups, supporting its integration into personalized risk assessment.

3

Chronic venous insufficiency (CVI) and associated lower limb edema are common conditions that can contribute to nocturia and nocturnal polyuria (NP), adversely affecting patients’ quality of life and sleep. This study aimed to investigate the prevalence and correlation of urinary symptoms, including daytime frequency, nocturia, and NP, among patients with CVI and their impact on sleep quality.

A prospective cross-sectional study involving 53 patients with CVI recruited from two tertiary hospitals between June 2023 and January 2024 was conducted. Patient demographics, clinical characteristics, and urinary symptoms were assessed via standardized questionnaires, including the International Consultation on Incontinence Questionnaire (ICIQ) and the Pittsburgh Sleep Quality Index (PSQI). The correlation analysis was performed to evaluate the relationship between urinary symptoms and sleep quality.

The majority of participants were female (86.8%) and overweight (43.4%), with a median age of 46 years. The daytime urinary frequency ranged from 1 to 10 times per day, with a median bother scale of 3.64 (1.0–5.0). Nocturnal urination was reported by 50.9% of the participants, with 32.1% waking up twice and 18.9% waking up three times per night. No significant correlations were found between urinary symptoms and specific demographic factors. However, significant associations were observed between urinary symptoms and sleep disturbances, with higher ICIQ scores correlated with poorer sleep quality (r = −0.290, p = 0.035) and increased bother scale indicating greater sleep impairment (r = 0.570, p < 0.001).

This study highlights the prevalence and impact of urinary symptoms on sleep quality among patients with CVI. While no specific demographic correlations were identified, urinary symptoms were significantly associated with sleep disturbances, suggesting that targeted interventions may be beneficial to improve symptom management and enhance overall patient well-being in this population. Further research is warranted to explore effective treatment strategies tailored to the complex interplay between the CVI, urinary symptoms, and sleep quality.

Not applicable

We report on the outcomes following holmium laser enucleation of the prostate (HoLEP) and/or prostate artery embolization (PAE) for patients with catastrophic haematuria secondary to prostatic bleeding.

A retrospective review of all patients receiving HoLEP and/or PAE between April 2023 and 2025 for prostatic bleeding was performed in our tertiary centre. We report on outcomes following intervention.

Eleven patients were included with prostate volumes > 100cc: seven received HoLEP, three PAE and one received HoLEP after PAE. Median (interquartile range [IQR]) time from admission to procedure was 6 days (4–11) and 11 days (7–13) for HoLEP and PAE, respectively. All patients had successful resolution of haematuria; median time from procedure to resolution was 1 day (1–2) and 1 day (1–1), and median length of stay was 10 days (8–14) and 13 days (8–17), for HoLEP and PAE respectively. Six patients required transfusion during admission, median (IQR) pre-operative Hb drop was 14 g/L (5–21) and successful trial without a catheter was performed on all patients. One patient developed a hospital-acquired pneumonia; another required an urgent HoLEP following PAE for ongoing haematuria on day 8.

Within our unit, urgent HoLEP and PAE are complementary management options for patients with intractable bleeding from significantly enlarged prostates. Timely intervention prior to the procedure is vital in the safe management of such patients.

Dietary and lifestyle modifications can reduce kidney stone (KS) recurrence rates. This study evaluated Irish general practitioners’ (GP) knowledge and practices in dietary management to reduce KS recurrence.

A cross-sectional online study of GPs in Ireland. The GP Knowledge of Kidney Stones Dietary Management questionnaire was hosted through the Qualtrics platform.

Of 70 GPs who participated most (75%) recognised dietary modification and increase in fluid (98%) as effective KS recurrence preventive measures. However, 53% were not confident in the role of diet with 45% reporting they never discussed diet in the context of KS. Only 31% reported utilising best practice advice to drink 2–3 L of fluid daily. There were no significant associations between years of experience and belief in the role of dietary and lifestyle modifications in the management of KS (χ² = 4.25, df = 2, p = 0.12), or the positive role of the reduction of protein in KS prevention (Fisher exact test = 0.48, p = 0.23).

The study identifies gaps in GP knowledge on dietary and lifestyle factors for KS recurrence. Targeted education for GPs may enhance patient counselling on prevention, which may be helpful in patient education around preventing recurrence of KS.

(LoBiondo-Wood & Haber 2022) = 4

Kidney stone disease is a growing global health problem, with increasing diagnostic challenges due to heterogeneous clinical presentations and imaging demands. This review aims to evaluate the role of artificial intelligence (AI) in imaging-based detection and assessment of urinary tract stones.

A systematic review was conducted by searching PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and Web of Science from database inception to May 2025 for studies evaluating AI-based imaging in the diagnosis of urinary tract stones. The search followed Preferred Reporting Items for Systematic reviews and Meta-Analyses literature search extension (PRISMA-S) guidance and used a Population, Intervention, Comparison, Outcomes and Study (PICOS) framework to identify eligible adult studies applying AI models to computed tomography (CT), ultrasound, or radiographic imaging, with expert interpretation as reference and diagnostic performance outcomes.

From 1142 records identified, 11 studies published between 2017 and 2025 met the inclusion criteria. Most studies used CT imaging and reported high diagnostic performance, with accuracies exceeding 90% in eight studies and reaching over 95% in several deep learning–based approaches, while ultrasound-based AI models also demonstrated strong performance with sensitivities and accuracies above 90%.

AI–based imaging demonstrates high diagnostic accuracy for urinary tract stone detection, particularly with CT. AI-enhanced ultrasound represents a practical and cost-effective alternative for implementation in resource-limited and rural settings.

2

To propose a surveillance approach for upper tract urothelial carcinoma (UTUC) recurrence in high-risk and very high-risk non-muscle invasive bladder cancer (HR NMIBC) patients.

Retrospective analysis in 2024 of 317 patients diagnosed with HR NMIBC in our centre between 2008 and 2018, including histology, CT urogram (CTU) frequency, radiation dose, UTUC recurrence, outcome, and risk factors for UTUC recurrence.

A total of 283 patients were included for analysis. Incidence of UTUC recurrence 5.7% (n = 16/283), with 3.5% (n = 10/283) undergoing nephroureterectomy. Mean time from initial diagnosis to UTUC recurrence is 5.2 years. At 5- and 10-year follow-up, UTUC incidence was 3.5% and 2.1%, respectively. No patients diagnosed with UTUC recurrence beyond 10 years. Patients underwent mean 2.2 surveillance CTU every 1.9 years, with 17.7 mSv mean radiation dose per scan. No significant increased risk of UTUC recurrence associated with carcinoma in situ (CIS) at diagnosis (χ² = 0.006, p value = 0.94). Risk of UTUC recurrence significantly increased in patients with recurrent HR NMIBC (27%) versus those without (4%) (relative risk = 7.12, χ² = 20.9, p value < 0.00001).

Consider surgical fitness and HR NMIBC recurrence status when determining duration of surveillance for patients. We propose biennial CTU in patients fit for nephroureterectomy, continuing up to 10 years if recurrent HR NMIBC, or up to 5 years if recurrence-free.

2b – Retrospective cohort study

Urologists are noting a surge in patients they see who are concurrently taking weight-loss injections, due to exponential rises in prescriptions of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for medical and aesthetic purposes. This study aims to summarise current evidence around GLP-1RAs by categorising their unintended benefits and side effects across common urological conditions that may have important ramifications within the field of urology.

Comprehensive literature review using PubMed^®, MEDLINE^® and Google™ Scholar for relevant scientific articles published in English. Manual bibliography search and “related article” functions were employed to supplement original searches.

Current knowledge of the collateral impact of GLP-1RA on common urological conditions, such as erectile dysfunction (ED), UTIs, urolithiasis, urological malignancies and hypogonadism is conflicting and predominantly based on weak levels of evidence. Pubmed^® identifies 79 relevant studies relating GLP-1RA to the chosen common urological conditions. There are no randomised controlled trials (RCTs) dedicated to GLP-1RA whose primary outcome pertains directly to urological symptoms and/or sequelae.

GLP-1RA may exert clinically relevant effects across multiple urological domains; however, current evidence is insufficient to draw definitive conclusions. Long-term safety data are lacking. Urologists should remain vigilant while prospective, urology-focused RCTs are urgently needed.

Not applicable.

Multiparametric magnetic resonance imaging has reshaped prostate cancer diagnostics but is limited by cost, accessibility, and workflow complexity. High-resolution micro-ultrasound offers real-time lesion visualization and targeted biopsy capability as a potential complementary imaging modality.

A narrative review of the literature was conducted using PubMed and Embase from inception to March 2026. Search terms included “micro-ultrasound,” “MicroUS,” “29 MHz ultrasound,” “PRI-MUS,” “prostate cancer,” “clinically significant prostate cancer,” “biopsy,” and “active surveillance.” Priority was given to randomized trials, prospective comparative studies, systematic reviews, and meta-analyses.

Micro-ultrasound demonstrates high sensitivity for clinically significant prostate cancer, with randomized evidence from the OPTIMUM trial supporting noninferiority to magnetic resonance imaging–based diagnostic pathways. Prospective studies suggest that micro-ultrasound enables real-time lesion targeting and may detect clinically significant prostate cancer not identified by multiparametric magnetic resonance imaging, supporting a complementary role in combined diagnostic strategies. However, specificity and biopsy-avoidance capacity remain lower than those of multiparametric magnetic resonance imaging. In active surveillance, micro-ultrasound serves as an adjunct for targeted biopsy but does not replace MRI-based protocols.

Micro-ultrasound is a promising complementary imaging modality that enhances real-time targeting and workflow efficiency. Its primary role lies in integration within multimodal diagnostic pathways rather than replacement of multiparametric magnetic resonance imaging. Further multicentre validation and standardization are required to define its role in clinical practice.

Not applicable.

To evaluate outcomes in patients with body mass index (BMI) ⩾35 kg/m² undergoing robot-assisted radical prostatectomy (RARP), at a centre incorporating a dedicated High-Risk Preoperative Assessment Clinic (PAC) and surgical-anaesthetic multidisciplinary team (MDT) for complex patients.

Patients with BMI ⩾35 kg/m² (n = 50) undergoing RARP from August 2021 to July 2023 were compared to a random sample of patients with BMI <35 kg/m² (n = 186). Patient and cancer characteristics, perioperative, oncological and continence outcomes were compared.

A higher proportion of patients with BMI ⩾35 kg/m² were seen in High-Risk PAC and discussed in High-Risk MDT. Patients with BMI ⩾35 kg/m² had higher operating time (206 minutes vs 190 minutes, p = 0.035), estimated blood loss (300 mL vs 200 mL, p = 0.004) and incidence of ventilatory difficulties (15% vs 2.7%, p = 0.004). Postoperatively, there was no difference in unplanned PACU (post-anaesthesia care unit) admissions, postoperative complications, length of stay, readmissions, functional or oncological outcomes.

Our results support RARP as a safe and feasible option for treatment of prostate cancer in a well-selected cohort of patients with BMI ⩾35 kg/m², in a high-volume surgical centre employing robust pre-assessment by anaesthetists with experience in high-risk cases, and joint decision-making in a surgical-anaesthetic MDT.

3

Surgical management of bladder outflow obstruction (BOO) caused by benign prostatic enlargement (BPE) has proven challenging, with increased pressure on National Health Service (NHS) resources. Traditionally, transurethral resection of prostate (TURP) was performed requiring an average inpatient stay of 2–4 days. If complications occur, the patient’s stay in the urology ward is extended. Limited bed availability can result in the cancellation of elective surgeries. This continues to pose a challenge with the surge of COVID and respiratory infections during the winter season, resulting in a very limited bed availability. In recent decades, multiple new interventions for bladder outflow obstruction have emerged and proven safe and efficacious in multiple large studies. Our study’s aim was to demonstrate GreenLight Laser Prostatectomy’s (GLLP) feasibility as a ‘true’ day-case procedure.

Data collection for both GLLP and bipolar TURP was done as a retrospective observational cohort study in a single institution. Both cohorts underwent primary operation; primary GLLP cases were performed in 2021/2022, and primary bipolar TURP between 2023/2024. Greenlight laser prostatectomy was performed using the 180 W GreenLight XPS™ laser therapy system, and bipolar TURP using standard Olympus/Richard Wolf resectoscopes. Multiple preoperative, operative, and postoperative parameters were collected, with a primary focus on day-case discharge after the procedure.

A total of 180 patients underwent bladder outflow surgery, of which 90 patients (50%) had GLLP and the other 90 patients (50%) had TURP. The mean age for the GLLP group was 73.9 and for the TURP group was 71.9. We have observed a statistically significant difference in prostate volume between the two groups, with a mean volume of 98.9 cc for the GLLP group and 76.9 cc for the TURP group (p = 0.01). Even though prostates in the GLLP group were larger in size, the operation time was significantly shorter in the GLLP group, with a mean of 57.3 minutes, compared to 66.9 minutes for TURP (p = 0.01). In terms of hospital stay postoperatively, we observed a significant difference in the day-case discharge rate: 94.4% of patients in the GLLP group were discharged as day cases compared to only 4.4% in the TURP group (p < 0.001). Both the GLLP group (72 participants, 80%) and the TURP group (83 participants, 92.2%) achieved successful Trial to Void Without Catheter (TWOC), representing a significant difference in favour of TURP (p = 0.018). A survey regarding the patients’ experience was conducted with the operative and postoperative processes has shown that 71.1% of participants in the GLLP group were satisfied, compared to 51.1% in the TURP group, which was statistically significant in favour of the GLLP (p < 0.001).

Based on our observations, GLLP is a safe day-case operation with a good patient satisfaction rate and an acceptable success rate. It effectively addresses bladder outflow issues in hospitals with limited bed capacity. When implemented via a well-designed pathway, it can help reduce the waiting times in the NHS.

Not applicable.

To identify clinical, microbiological, and radiological factors associated with mortality in patients with emphysematous pyelonephritis (EPN) and to assess renal outcomes according to treatment strategy at a high-volume centre in Northern Mexico.

We conducted an ambispective cross-sectional study including 125 patients diagnosed with EPN between 2014 and 2024. Clinical, laboratory, and imaging data were collected. Disease severity was classified using the Huang-Tseng system. Patients were managed with medical therapy alone, minimally invasive intervention (MMI), or nephrectomy. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of mortality.

The mean age was 50.2 years, and 78.4% were women. Diabetes mellitus was present in 84.8% of cases. Escherichia coli was the most frequent pathogen (67.1%), and 34.2% of isolates were ESBL-producing. Overall mortality was 9.6%. On multivariate analysis, advanced age (OR = 1.08; 95% CI = 1.02–1.15; p = 0.008) and Huang-Tseng ⩾ 3b (OR = 5.68; 95% CI = 1.41–22.96; p = 0.015) were independent predictors of mortality. eGFR significantly improved after MMI (37.1→54.7 mL/min/1.73 m²; p < 0.001) and nephrectomy (21.5→59.2 mL/min/1.73 m²; p = 0.009), but not with medical therapy alone (p = 0.82).

Advanced radiological severity and older age were the strongest predictors of mortality in EPN. Minimally invasive management and timely nephrectomy improved renal function among survivors, highlighting the importance of early, individualised, and stepwise treatment guided by radiological staging and clinical stability.

III