Mauro Ragonese

Background/Objectives: Recently, the European Association of Urology (EAU) guidelines presented the EAU guidelines bot to assist urologists in the reading of the guidelines; however, to date, no external validation is available. The aim of our study is to assess the accuracy, completeness, and clarity of the guidelines bot in reading renal transplantation guidelines and clinical cases. Methods: A total of 103 questions derived from the recommendations included in the EAU guidelines on renal transplantation, together with 10 distinct clinical scenarios, were created. Each question and clinical case was submitted to the EAU guidelines bot, and the corresponding responses were independently evaluated by two expert urologists in terms of accuracy, completeness, and clarity. Each domain was scored using a 5-point Likert scale. In cases of disagreement between the two reviewers, a third urologist was consulted. Accuracy, completeness, and clarity were analyzed for the clinical cases and per chapter and grade of recommendation for the questions. Results: Overall, 103 questions were generated. Regarding accuracy, 101/103 responses (98%) were classified as accurate, corresponding to scores of 4–5, whereas 2/103 responses (2%) showed fair accuracy, corresponding to a score of 3. No responses were considered inaccurate, defined as a score of 1–2. In terms of completeness, 101/103 responses (98%) were judged to be complete, with scores of 4–5, while 2/103 responses (2%) were rated as fairly complete, with a score of 3. No responses were classified as incomplete. With regard to clarity, 102/103 responses (99%) were considered clear, corresponding to scores of 4–5, whereas 1/103 response (1%) was rated as fairly clear, with a score of 3. No responses were deemed unclear. No significant differences were observed when comparing responses related to strong versus weak recommendations. For the clinical scenarios, 8/10 responses (80%) were rated as accurate, with scores of 4–5, while 2/10 responses (20%) showed fair accuracy, with a score of 3. Regarding completeness, all 10 responses (100%) were classified as fairly complete, corresponding to a score of 3. Finally, in terms of clarity, 8/10 responses (80%) were judged to be clear, with scores of 4–5, whereas 2/10 responses (20%) were rated as fairly clear, with a score of 3. Conclusions: The EAU guidelines bot represents an accurate tool for renal transplantation. Besides some occasional inaccuracies the bot is an excellent tool for urologists, especially to clarify doubt about the EAU guidelines. At the same time, it can give good support when facing a clinical case.

Background: Elderly and frail patients undergoing surgery for urological cancer have increased vulnerability to postoperative complications, delayed recovery, and functional decline. The da Vinci Single-Port (SP) platform may reduce surgical stress by enabling regionalized extraperitoneal, retroperitoneal, or transvesical access through a single incision. Objective: The objective was to provide a narrative review of the comparative evidence on da Vinci SP versus conventional multi-port (MP) robotic surgery in elderly or frail urological cancer patients. Methods: A structured search was performed to identify comparative studies reporting outcomes in patients defined as elderly by chronological age (≥65 years) or as frail by a validated frailty index. Findings are reported separately according to the vulnerability construct that was actually measured. Because of procedural and methodological heterogeneity, a narrative synthesis was performed, and the risk of bias was appraised qualitatively along the domains of the ROBINS-I tool. Results: Only three retrospective comparative studies are currently available: two on robot-assisted radical prostatectomy (one in patients aged ≥65 years and one in patients stratified by the 5-item modified frailty index) and one on robot-assisted partial nephrectomy in patients aged ≥65 years. Across these studies, SP surgery was associated with fewer early postoperative complications, shorter length of stay, and more favourable recovery-related endpoints, and in the frailty-stratified study the apparent protective effect increased with frailty burden. All estimates are those published by the original authors, are reported descriptively, and were not pooled. Importantly, in none of the three studies was the SP platform compared with MP surgery performed through the same access route: SP procedures were predominantly extraperitoneal or retroperitoneal and MP procedures were predominantly transperitoneal, so the effect of the platform cannot be separated from that of the access route. Conclusions: The available data are compatible with a reduction in early perioperative morbidity after SP robotic surgery in selected elderly or frail urological cancer patients, particularly when the platform enables extraperitoneal or retroperitoneal access. Because this evidence rests on three retrospective studies at serious risk of bias, the findings are preliminary and hypothesis-generating rather than confirmatory. Prospective studies incorporating geriatric screening, validated frailty metrics, patient-reported recovery, cost-effectiveness, and long-term oncological outcomes are needed.

Background/Objectives: Recently the European Association of Urology (EAU) guidelines presented the EAU Guidelines bot to assist urologists in the reading of the guidelines; however, there is a lack of up-to-date external validation. The aim of our study is to assess the accuracy, completeness, and clarity of the guidelines bot in urethral strictures. Methods: A total of 117 questions based on the EAU urethral strictures guidelines recommendations were developed. Each question was input to the EAU guidelines bot and the response was assessed by two expert urologists to assess the accuracy, completeness, and clarity. Moreover, 10 simple clinical cases were input. A 5-point Likert scale was used as a score and, in case of discrepancies, a third urologist was queried. Accuracy, completeness and clarity were assessed per chapter and per grade of recommendation. All questions and answers were recorded in an Excel file. Results: Overall 117 questions were developed. In terms of accuracy, 111/117 (95%) were defined as accurate (scores 4–5), 4/117 (3%) presented a fair accuracy (score 3), and 2/117 (2%) were deemed not accurate. In terms of completeness, 93/117 (80%) were defined as complete (scores 4–5), 22/117 (19%) presented a fair completeness (score 3), and 2/117 (2%) were deemed not complete. Finally, in terms of clarity, 104/117 (89%) were defined as clear (scores 4–5), 13/117 (11%) presented a fair clarity (score 3), and 0/109 (0%) were deemed not clear. When comparing strong and weak recommendations, no differences were recorded. Overall the answers to simple clinical cases were in line with the guidelines with good accuracy, completeness and clarity scores. Conclusions: The EAU guidelines bot represents an accurate tool for urethral stenosis guidelines. Some fine-tuning is needed to improve readability and clarity.

Background and Objective: Liquid biopsy has transformed the management of advanced prostate cancer, yet its clinical role in non-metastatic disease remains uncertain. Conventional biomarkers such as PSA, imaging, and pathology have limited ability to capture minimal residual disease and biological aggressiveness. The objective of this review was to critically evaluate the current evidence on circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA) in non-metastatic prostate cancer, focusing on feasibility, prognostic value, and potential clinical applications. Methods: A narrative review of PubMed-indexed original studies evaluating liquid biopsy in clinically localized or non-metastatic prostate cancer was performed. Eligible studies included patients treated with curative-intent local therapy or experiencing biochemical recurrence without radiologic metastases. Study designs were predominantly prospective or retrospective observational cohorts. Liquid biopsy analytes included CTCs and ctDNA assessed from peripheral blood plasma using EpCAM-based enrichment, targeted next-generation sequencing, whole-genome sequencing, or ultra-sensitive tumor-informed assays. Primary outcomes included detection rates, associations with clinicopathologic features, biochemical recurrence, metastasis-free survival, and overall survival. Key Findings and Limitations: Across 11 studies, CTC detection using EpCAM-based platforms was infrequent in localized disease and biochemical recurrence and showed limited prognostic value (10–11% in preoperative settings). In contrast, ctDNA was detectable in a minority of patients but consistently identified biologically aggressive disease and a higher risk of recurrence when present, particularly using tumor-informed ultra-sensitive assays. Limitations include low detection rates, heterogeneous methodologies, small sample sizes, and predominantly exploratory study designs. Conclusions and Clinical Implications: Currently, its most promising application is not broad screening, but as a selective, biology-driven tool for detecting minimal residual disease and refining risk assessment. CtDNA acts as a biological risk modifier, potentially guiding the escalation or de-escalation of adjuvant therapy. However, prospective biomarker-driven trials are required to validate these strategies before routine clinical implementation.

Background: Non-muscle-invasive bladder cancer (NMIBC) represents approximately 70–75% of newly diagnosed bladder cancers and is characterized by high recurrence rates despite guideline-based management. Chronic urinary retention and bladder outlet obstruction (BOO) have been proposed as under-recognized modifiers of NMIBC outcomes through prolonged exposure to urinary carcinogens, inflammation, and altered intravesical pharmacokinetics. This narrative review qualitatively synthesizes biological and clinical evidence linking BOO-related dysfunction with NMIBC behavior and explores the emerging, but preliminary, role of Holmium Laser Enucleation of the Prostate (HoLEP) as a functional adjunct in selected patients. Methods: A narrative review was conducted according to SANRA guidelines. PubMed/MEDLINE, Embase, and Scopus were searched (January 2000–October 2025) using predefined terms for NMIBC, BOO, urinary retention, and HoLEP. Two reviewers independently screened records, with disagreements resolved by consensus. Sixty-one studies met inclusion criteria. Results: Elevated postvoid residual (PVR) (>80–100 mL) and moderate to severe lower urinary tract symptoms (LUTS) were consistently associated with higher NMIBC recurrence rates, independent of tumor stage and grade, in heterogeneous cohorts. Retention correlated with reduced efficacy of Bacillus Calmette–Guérin (BCG) and mitomycin C, likely via uneven drug distribution and a chronically inflamed urothelium. Mechanistic data support a plausible link between BOO-related inflammation, barrier dysfunction, and tumor biology, although direct biomarker correlations with PVR or pharmacokinetic studies are lacking. HoLEP provides durable relief of BOO, reduces PVR, and improves LUTS. Limited retrospective data suggest an association between HoLEP and lower recurrence, but these observations are confounded and should be viewed as hypothesis-generating. Conclusions: Chronic urinary retention and BOO appear to be modifiable functional factors that may influence NMIBC recurrence and intravesical therapy performance. HoLEP is a promising option to optimize bladder emptying in carefully selected patients, but its oncologic impact remains unproven and should be considered hypothesis-generating pending prospective, risk-adjusted studies.

Background: Sexuality in women with muscle-invasive bladder cancer (MIBC) undergoing radical treatment represents a crucial aspect of their overall quality of life, which is increasingly recognized as a key component of patient-centered care and long-term well-being. This review aimed to analyze the available literature to provide a comprehensive overview of the effects of treatments on female sexual function. Methods: We included all qualitative and quantitative studies addressing sexual function in patients treated for MIBC. Excluded were narrative reviews, case reports, conference abstracts, systematic reviews, and meta-analyses. The included studies involved women undergoing either robot-assisted radical cystectomy (RARC) or open RC (ORC), often with nerve-sparing, vaginal-sparing, or pelvic organ-preserving techniques. Data on oncological and functional outcomes were collected. Results: A systematic review of 29 studies including 1755 women was conducted. RC was performed via robotic/laparoscopic approaches in 39% of cases and open techniques in 61%. Urinary diversions included orthotopic neobladders (48%), ileal conduits (42%), ureterocutaneostomies (3%), and Indiana pouches (7%). Radiotherapy, used in 6% of patients, was mainly applied in a curative, trimodal setting. Sexual function was evaluated using various pre- and/or postoperative questionnaires, most commonly the EORTC QLQ-C22, FACT-BL, Bladder Cancer Index (BCI), LENT SOMA, and Female Sexual Function Index (FSFI). Radiotherapy was associated with reduced sexual function, though outcomes were somewhat better than with surgery. Among surgical approaches, no differences in sexual outcomes were observed. Conclusions: Further qualitative research is essential to better understand the experience of FSD after treatment. Incorporating both patient and clinician perspectives will be key to developing tailored interventions. In addition, efforts should be made to standardize the questionnaires used to assess female sexual dysfunction, in order to improve comparability across studies and ensure consistent evaluation.

Background/Objectives: Given the increasing interest in the predictive role of inflammation in oncology, we aimed to assess the association between inflammatory factors (IFs) and the histopathological characteristics of bladder cancer (BC). Our objective was to correlate some of these IFs with BC progression and recurrence, identifying possible new diagnostic tools. Methods: We retrospectively analyzed 285 patients (79.8% male, 20.4% female; median age 73) who underwent transurethral resection of the bladder (TURB) between January 2016 and January 2022. The preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), pan-immune-inflammation value (PIV), systemic inflammation response index (SIRI), and standard clinical variables were collected one month before TURB and evaluated as predictors of recurrence and progression. Patients were stratified using the Youden Index and ROC analysis. Cox regression models were applied to identify independent predictors. Results: High-grade tumors were present in 74.6% of cases, and 34% were recurrent. Carcinoma in situ was found in 5%. After 72 months, 53% underwent radical cystectomy, and 13.7% died within 5 years. The optimal cutoffs were PLR 139, SIRI 1.12, PIV 248.49, NLR 2, SII 327. Smoking, primary MIBC, age, and lymph node status were significantly associated with recurrence. Elevated PLR correlated with recurrence and T2 progression (p = 0.004). Higher SIRI, PIV, and PLR levels were significantly associated with lymphovascular invasion and nodal metastasis (p < 0.05). PLR was linked to recurrence in tumors ≥ 3 cm post-BCG (p = 0.004); high SIRI predicted recurrence within 48 months (p = 0.05). Conclusions: High PLR and SIRI levels were associated with recurrence. Our findings support the emerging role of IFs in predicting BC outcomes and suggest their potential inclusion in future prognostic models.

Purpose: Endoscopic lithotripsy has become widely adopted worldwide and is considered the gold standard for managing upper urinary tract lithiasis. One of its possible complications is post-operative infection. We aimed to review available literature about the role of preoperative antibiotic prophylaxis and its indications. Methods: We performed a systematic search of the literature including “ureteroscopy”, “PNL”, “retrograde intrarenal surgery”, “antibiotic prophylaxis” and “sepsis” as keywords. Out of 760 relevant studies only 13 met our inclusion criteria: at least 10 adult patients (≥ 18 years old) diagnosed with kidney or ureteral stones; antibiotic prophylaxis described and reported; post-operative sepsis, UTI or SIRS assessed. Conclusions: Antibiotic prophylaxis strategies for stone surgery show different degrees of effectiveness depending on both the approach and the patient’s condition. Today’s evidence suggests that while routine antibiotic prophylaxis might not be necessary for all patients with sterile urine undergoing ureterorenoscopy and lithotripsy vs. percutaneous nephrolithotripsy, for those patients with positive preoperative urine cultures it is beneficial reducing the risk of postoperative infective complications.

Background: The Y chromosome (ChrY) is essential for male sex determination and spermatogenesis. However, recent studies have revealed its broader role in various physiological processes and disease susceptibility, including cancer. Methods: A comprehensive literature review was conducted using databases like MEDLINE, Scopus, Web of Science, and Google Scholar. The review included clinical and preclinical studies in animals and humans focusing on the role of LoY in urological tumors. Data on the frequency of LoY, its clinical implications, and underlying mechanisms were extracted and analyzed. Results: The evidence suggests that LoY is associated with an increased risk of urologic neoplasms, potentially serving as an early marker of genomic instability. Studies reveal that LoY in urologic cancers correlates with worse survival outcomes and may contribute to tumor progression. LoY may interfere with chromatin structure and epigenetic regulation, suggesting its role as a contributor to early tumorigenesis. Conclusions: LoY appears to be a structural aberration with unique biological and clinical relevance in urologic cancers, possibly serving as a biomarker for genomic instability. Further research is necessary to identify specific Y-linked genes affected by LoY, potentially informing targeted therapies and early diagnostic strategies for these cancers.

Testicular hemangioma is a rare benign vascular neoplasm originating from the inner layer of the tunica albuginea, predominantly affecting the pediatric population and often associated with hemangiomas in other organs. Histopathologically can be categorized into four types, including capillary, cavernous, papillary endothelial hyperplasia, and epithelioid (histiocytoid). We report a case of a 24-year-old presenting with left inguinal pain, diagnosed with an epithelioid (histiocytoid) hemangioma of the testis. Diagnostic evaluation included scrotal doppler ultrasonography, which revealed a small, hypoechoic formation with evident vascularization. Serum tumor markers were within normal limits. Surgical excision via testis-sparing surgery (TSS) was performed based on frozen section analysis. A literature review underscores the rarity of testicular histiocytoid hemangiomas. Advancements in diagnostic technique have improved the accuracy of diagnosis and allowed for more conservative surgical approaches, preserving fertility and minimizing long-term adverse effects. In conclusion, while testicular hemangiomas may present characteristic features on ultrasound, frozen section examination remains crucial in guiding surgical decision-making. TSS offers significant advantages over traditional excisional surgery, including reduced morbidity and preservation of cancer control, making it an essential option in the management of testicular hemangiomas, particularly in young patients concerned about fertility preservation.