Chloe Shu Hui Ong

Lutetium-177-PSMA-617 (Lu-PSMA) radioligand therapy (RLT) is established in metastatic castration-resistant prostate cancer (mCRPC), with regulatory approvals based on the VISION and TheraP trials. Subsequent trials have extended the evidence to taxane-naive mCRPC (PSMAfore) and demonstrated that combining Lu-PSMA with enzalutamide yields a significant overall survival benefit over enzalutamide alone (ENZA-p). However, higher and more homogeneous PSMA expression in treatment-naive disease, combined with lower tumor burden and preserved bone marrow reserve, provides a biological rationale for deploying RLT earlier in the disease course. In metastatic hormone-sensitive prostate cancer (mHSPC), the Phase III PSMAddition trial reported improved radiographic progression-free survival when Lu-PSMA was added to standard androgen deprivation therapy (ADT) plus androgen receptor pathway inhibitor (ARPI), and the Phase II UpFrontPSMA trial demonstrated enhanced biochemical responses with Lu-PSMA induction before docetaxel. In oligometastatic and oligorecurrent disease, the BULLSEYE and LUNAR trials have shown progression-free survival benefits, raising the possibility of deferring androgen deprivation therapy and its associated morbidity. Meanwhile, next-generation radionuclides, including actinium-225 (WARMTH) and the dual beta-Auger emitter terbium-161 (VIOLET), are entering clinical development to address the radiobiological limitations of Lutetium-177. This review synthesizes the evidence for PSMA-targeted radioligand therapy across the prostate cancer disease continuum and discusses patient selection, treatment sequencing, and the access and cost-effectiveness considerations that will shape adoption in earlier disease settings.

Introduction: To compare the clinical outcomes and complication rates of convective water vapor energy ablation (Rezum ^® ) and prostatic urethral lift (Urolift ^® ). To identify predictive factors for treatment failures in both treatments. Materials & Methods: Prospective clinico-epidemiological data of patients who underwent Urolift ^® or Rezum ^® in a single institution for benign prostatic hyperplasia (BPH) was collected. The choice of intervention depended on the preference of the patients after patient-centric discussions. Results: From October 2019 to October 2022, 86 patients underwent Rezum ^® , and 62 patients underwent Urolift ^® . Rezum ^® involved a longer indwelling catheter duration (12.38 ± 5.548 vs 1.39 ± 3.010 days, p < 0.001) compared with Urolift ^® . Rezum ^® was associated with more complications compared with Urolift ^® (36 [41.9%] vs 10 [16.1%] cases, p < 0.001). Rezum ^® had more cases of hematuria (17 [19.8%] vs 4 [6.5%] cases [ p = 0.022]) and urinary tract infections (27 [31.4%] vs 3 [4.8%] cases, p < 0.001) compared with Urolift ^® . There were no significant differences in Clavien–Dindo Grade 3–5 complications between the interventions. Urolift ^® was associated with higher reoperation rates (5 [8.1%] vs 0 [0%] cases, p = 0.010) compared Rezum ^® . Rezum ^® had higher anticholinergic usage rates compared with Urolift ^® post-operation (22 [25.6%] vs 8 [12.9%] cases, p = 0.024). Both interventions showed improvement in the International Prostate Symptom Score (IPSS), quality of life score, and peak velocity flow over the 2 years with no significant difference between the two. Based on receiver operating characteristic curve, preoperation IPSS ≥16 had 95.7% sensitivity and 38.4% specificity to predict the probability of treatment failures after the interventions. Conclusions: There was no difference in clinical outcomes of patients who underwent Rezum ^® and Urolift ^® . However, patients who had undergone Rezum ^® faced more minor complications and more required anti-cholinergic medications. Lastly, physicians should note that patients with IPSS ≥16 would unlikely benefit from either intervention.

Objective: We aim to compare the stone-free rate (SFR), complications, and re-treatment rates in retrograde intrarenal surgery (RIRS) using a traditional suction ureteral access sheath (SUAS) with the more advanced flexible and navigable suction UAS (FANS). Materials and methods: Retrospective analysis was performed on patients who underwent RIRS using SUAS versus FANS across five institutions internationally as part of an audit. We analysed baseline and pre-operative characteristics such as stone location and density, intra-operative characteristics such as type of ureteroscope and laser, laser, and fluoroscopy time, as well as post-operative complications and residual fragments (RFs). Results: A total of 45 patients were included in each arm, with no significant difference in baseline characteristics. The commonest sheath size in the FANS group was 10–12 Fr (64.4%), while 11–13 Fr was preferred in SUAS (73.3%). Despite similar lasers (thulium fibre laser (TFL) and high-power holmium laser with MOSES), stone dusting (48.9%) and popcorning (95.6%) were carried out in FANS with minimal need for baskets (4.4%), while popcorning (64.4%) and basket extraction (40.0%) were required in SUAS. Although FANS had significantly longer operative times (65 minutes versus 55 minutes), it also had significantly higher rates of 100% SFR (80.0% versus 13.3%), and lower rates of clinically significant residual fragment (CSRF) (8.9% versus 53.3%), clinically insignificant residual fragment (CIRF) (11.1% versus 33.3%), and reintervention for CSRF (4.4% versus 37.8%). In addition, minor complications such as intra-operative oozing from mucosa not requiring intervention (8.9% versus 31.1%) and post-operative fever (11.1% versus 40.0%) were less common in FANS. On additional multivariate analysis, FANS was the only significant factor for higher SFR. Discussion and conclusion: The results of our study demonstrate that with its flexible and navigable tip, FANS proves advantageous over SUAS in terms of improving immediate SFR with negligible complications. By navigating the sheath into targeted individual calyces, fragments and dust are more successfully aspirated. FANS can therefore help to achieve the trifecta of high single-stage SFR, minimal minor and no major complications, and negligible reintervention rates. Level of evidence: Not applicable.

Introduction Androgen receptor targeted agents (ARTA) have increasingly been incorporated into treatment regimens for various stages of prostate cancer. Patients are living longer with prostate cancer, and thus have a higher cumulative exposure to the treatment and its accompanying side effects, especially those of cardiovascular disease. We aim to assess the differences in the incidence of cardiac-related adverse events after treatment of prostate cancer with ARTA versus placebo. Methods Three databases were thoroughly searched for relevant articles. The PICOS model was used to frame our clinical question, with which 2 independent authors went through several rounds of screening to select the final included studies. Meta-analysis was done using the Cochran-Mantel-Haenszel Method. Quality assessment was carried out with the Cochrane Risk of Bias tool RoB 2. Results The use of ARTA in prostate cancer increases the incidence of cardiac-related adverse events (RR: 1.56, 95% CI: 1.29–1.90, p < 0.00001), such as hypertension (RR: 1.69, 95% CI: 1.46–1.97, p < 0.00001), ischaemic heart disease (RR: 1.84, 95% CI: 1.36–2.50, p < 0.0001), and arrhythmia (RR: 1.38, 95% CI: 1.11–1.71, p = 0.004), although this did not manifest in an increased incidence of cardiac arrests/deaths (RR: 1.28, 95% CI: 0.87–1.88, p = 0.21). Discussion ARTA increases the risk of cardiac-related adverse events, hypertension, ischaemic heart disease and arrhythmia. Armed with this knowledge, we will be better poised to manage cardiac risks accordingly and involve a cardiologist as required when starting patients on ARTA.

Objective: To perform a systematic review and meta‐analysis to evaluate the impact of body mass index (BMI) on oncological (primary) and surgical (secondary) outcomes of patients who underwent nephrectomy, as obesity or high BMI is a known risk factor for renal cell carcinoma (RCC) and predictor of poorer outcomes. Methods: Studies were identified from four electronic databases from database inception to 2 June 2021, according to the Preferred Reporting Items for Systematic Review and Meta‐analysis statement. The review protocol was registered in the International Prospective Register of Systematic Reviews with the identification number: CRD42021275124. Results: A total of 18 studies containing 13 865 patients were identified for the final meta‐analysis. Regarding oncological outcomes, higher BMI predicted higher overall survival (BMI >25 vs BMI 25 vs BMI 2 : HR 0.60, 95% CI 0.50–0.73; BMI 25–30 vs BMI 30 vs BMI 25 vs BMI 2 : HR 0.72, 95% CI 0.63–0.82; BMI 25–30 vs BMI 2 : HR 0.59, 95% CI 0.42–0.82). Those with a lower BMI fared better in surgical outcomes, such as operation time and warm ischaemic time, although the absolute difference was minimal and unlikely to be clinically significant. There was no difference between groups for length of hospital stay, intraoperative or postoperative complications, blood transfusion requirements, and conversion to open surgery. Conclusion: Our study suggests that a higher BMI is associated with improved long‐term oncological survival and similar perioperative outcomes as a lower BMI. More research into the underlying biological and physiological mechanisms will enable better understanding of the effect of BMI, beyond mere association, on post‐nephrectomy outcomes.

Background: With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments and outline future directions and recommendations to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists. Methods: This study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy, RIRS, laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data were consolidated for analysis. Results: A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analyzed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS. Conclusion: Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.