Gernot Ortner

Image guidance and data-driven support systems. These developments contribute to reproducibility and facilitate more tailored surgical approaches, while also indicating a gradual transition towards more structured and technology-supported workflows.At the same time, the definition of surgical success has broadened. While oncological control remains the primary objective, functional outcomes-particularly urinary Looking ahead, further changes may arise from the introduction of new robotic platforms and the increasing diversification of the surgical technology market. Greater competition may improve accessibility and potentially lower costs, thereby facilitating wider adoption. In this context, telesurgical concepts and teleproctoring may become increasingly relevant. Remote guidance and structured training pathways could help disseminate complex surgical techniques beyond specialized centers and may offer opportunities to expand access to advanced procedures in lower-resource settings.Nonetheless, such developments require careful evaluation. Issues related to training, quality assurance, infrastructure, and regulatory frameworks will need to be addressed to ensure that broader accessibility does not compromise patient safety or outcomes.The integration of new technologies into clinical practice should therefore be accompanied by rigorous assessment and ongoing multidisciplinary exchange.In summary, this Research Topic reflects the dynamic development of minimally invasive radical prostatectomy and illustrates how technological innovation, combined with an improved understanding of anatomy and physiology, continues to influence surgical practice. The contributions highlight the importance of a balanced approach that aligns technical progress with clinical judgment and interdisciplinary collaboration. Future developments will likely depend not only on further technological advances but also on the ability to integrate these innovations into safe, effective, and accessible patient care.

Objectives: To explore the rationale of unilateral extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) by external validation of a nomogram for unilateral ePLND (unilat‐NG) and comparison to the Briganti 2019 nomogram. Patients and methods: Patients with magnetic resonance imaging‐fusion biopsy and consecutive RP with bilateral ePLND were identified within an institutional database. The primary endpoint was the detection rate of lymph node invasion (LNI) contralateral to the prostatic lobe with adverse cancer characteristics. The performance of the unilat‐NG and the Briganti 2019 nomogram to detect contralateral LNI was assessed using descriptive analysis, the receiver operating characteristic curve–derived area under the curve (AUC), and multivariable logistic regression analyses. Results: Of the overall 406 consecutive patients, 68/406 (16.7%) presented with pathological (p)N1 disease at RP. The AUC for the unilat‐NG with a 1%, 2% and 2.5% cut‐off was 0.58 (95% confidence interval [CI] 0.53–0.63), 0.67 (95% CI 0.59–0.75), and 0.69 (95% CI 0.60–0. 77), respectively; compared to an AUC of 0.72 (95% CI 0.66–0.78) for the Briganti 2019 nomogram with a 7% cut‐off. Applying the unilat‐NG with a 2.5% cut‐off, contralateral ePLND could be omitted in 303/406 (74.6%) patients, misclassifying 10/406 (2.5%) patients with pN0 disease. Conclusion: The Briganti 2019 nomogram outperformed the novel unilat‐NG in contralateral LNI prediction. Yet, a significant proportion of patients undergoing unilateral ePLND would be falsely classified with pN0 disease using any of the nomograms. Therefore, bilateral ePLND should remain the standard of care if PLND is indicated.

Purpose To investigate the effect of pre-biopsy rectal swab and urine screening combined with a risk-adapted antibiotic treatment strategy on reducing post-biopsy infections (PBIs) following multiparametric magnetic resonance imaging (mpMRI)/ transrectal ultrasound (TRUS) fusion-targeted transrectal prostate biopsy (TRPBx). Methods 1119 Patients undergoing mpMRI-TRUS fusion TRPBx between June 2017 and February 2024 were included. Patients were screened for rectal extended-spectrum beta-lactamase (ESBL)/multi-resistant gram-negative (MRGN) and urinary pathogens. Standard-risk patients (rectal non-ESBL/MRGN-carriers) either received Cefuroxime (2017–2020) or Ceftriaxone (2020–2024) intravenously before biopsy. For high-risk patients (rectal ESBL/MRGN-carriers) intravenous Ertapenem was used. Patients with positive urine cultures received oral targeted prophylaxis. PBIs were the primary outcome of the study. We used uni- and multivariable logistic regression analysis (MLRA) to reveal predictors for the main outcome. Results Rectal ESBL/MRGN prevalence was 5.5%. For standard-risk patients, PBI-rates were 8.1% and 0.24% for Cefuroxime and Ceftriaxone (p < 0.0001), respectively. Only 1.7% of high-risk patients treated with Ertapenem developed PBI. On MLRA, Cefuroxime (OR 38.7, 95%-CI: 10.9–246), oral Ciprofloxacin (OR 103, 95%-CI: 10.8–994), other oral targeted antibiotics (OR 42.7, 95%-CI: 1.86–496) (reference Ceftriaxone, all p < 0.005) were significant predictors for PBI whereas Ertapenem (OR 7.30 95%-CI: 0.34–77.4, p = 0.11) was not. Conclusion By integrating rectal swab ESBL/MRGN and urine screening, we developed a tailored antibiotic treatment strategy, resulting in low PBI-rates following TRPBx. Carbapenem-based treatment of high-risk patients is crucial. Ceftriaxone should be considered for routine use in standard-risk patients as it offers very low PBI-rates.

Purpose To introduce and illustrate a novel urethral reconstruction technique—the ‘urethral hammock-technique’—and to assess its impact on early postoperative continence following laparoscopic radical prostatectomy (LRP). Methods 119 patients who underwent LRP between January 2020 and May 2022 (hammock group: n = 43, control group: n = 76) were included in the study. The primary outcome was continence (zero pads or max. one security pad) at 1, 3, and 6 months following surgery. Secondary outcomes were operative time, complications, and histological findings. Univariate and multivariate regression analyses were performed to reveal predictors for continence. p values < 0.05 with a two-sided 95%-confidence interval were considered statistically significant. Results Baseline characteristics were comparable among both groups. The number of patients achieving complete continence in both the hammock and control groups at various time intervals was: 4 weeks 37.2% (16/43) vs. 19.2% (14/73) (p = 0.047); 3 months 60.5% (26/43) vs. 37.3% (28/75) (p = 0.021) and 6 months 72.1% (31/43) vs. 60.3% (44/73) (p = 0.23), respectively. Adjusting for bladder neck preservation status and age, the hammock technique was a significant predictor for continence for the 4-week (OR 0.33, 95% CI 0.13–0.83, p = 0.019) and 3-month (OR 0.28, 95% CI 0.12–0.66, p = 0.004) interval but not for the 6-month interval (OR 0.64, 95% CI 0.27–1.5, p = 0.31). Operative time, complication rates, time till catheter extraction and histological findings were comparable between both groups (all p > 0.05). Conclusions The hammock technique is a simple and reproducible technique to improve early postoperative continence for at least 3 months following surgery. However, these promising results warrant confirmation through a randomized controlled trial.

Background: Multiparametric Magnetic Resonance Imaging (mpMRI)-based targeted biopsy has shown to be beneficial in detecting Clinically Significant Prostate Cancer (csPCa) and avoiding diagnosis of Non-csPCa (ncsPCa); however, its role in the treatment of biopsy-naïve patients is still under discussion. Methods: After identifying predictors for the diagnosis of csPCa via Multivariate Logistic Regression Analysis (MLRA), a propensity-score (1:1 nearest neighbor) matched comparison was performed between a Systematic-Only Biopsy (SOB) cohort and a mpMRI-based Combined (systematic + targeted) Biopsy (CB) cohort from two tertiary urologic centers (SOB: Department of Urology, University General Hospital of Heraklion, University of Crete, School of Medicine, Heraklion, Crete, Greece; CB: LKH Hall in Tirol, Austria). Only biopsy-naïve patients were included in the study. The study period for the included patients was from February 2018 to July 2023 for the SOB group and from July 2017 to June 2023 for the CB group. The primary outcome was the diagnosis of csPCa (≥ISUP 2); secondary outcomes were overall cancer detection, the added value of targeted biopsy in csPCa detection, and the reduction in ncsPCa diagnosis with CB compared to SOB. To estimate the Average Treatment effect of the Treated groups (ATT), cluster-robust standard errors were used to perform g-computation in the matched sample. p-values < 0.05 with a two-sided 95% confidence interval were considered statistically significant. Results: Matching achieved well-balanced groups (each n = 140 for CB and SOB). In the CB group, 65/140 (46.4%) patients were diagnosed with csPCa compared to 44/140 (31.4%) in the SOB group (RR 1.48, 95%-CI: 1.09–2.0, p = 0.01). In the CB group, 4.3% (6/140) and 1.4% (2/140) of csPCa cases were detected with targeted-only and systematic-only biopsy cores, respectively. In the CB group, 22/140 (15.7%) patients were diagnosed with ncsPCa compared to 33/140 (23.6%) in the SOB group (RR = 0.67, 95% CI: 0.41–1.08, p = 0.1). When comparing SOB to CB (ATT), the marginal OR was 0.56 (95% CI: 0.38–0.82, p = 0.003) for the diagnosis of csPCa and 0.75 (95% CI: 0.47–1.05, p = 0.085) for the diagnosis of overall cancer (≥ISUP 1). Conclusion: The CB approach was superior to the SOB approach in detecting csPCa, while no additional detection of ncsPCa was seen. Our results support the application of mpMRI for biopsy-naïve patients with suspicions of prostate cancer.

Purpose To identify laser settings and limits applied by experts during laser vaporization (vapBT) and laser en-bloc resection of bladder tumors (ERBT) and to identify preventive measures to reduce complications. Methods After a focused literature search to identify relevant questions, we conducted a survey (57 questions) which was sent to laser experts. The expert selection was based on clinical experience and scientific contribution. Participants were asked for used laser types, typical laser settings during specific scenarios, and preventive measures applied during surgery. Settings for a maximum of 2 different lasers for each scenario were possible. Responses and settings were compared among the reported laser types. Results Twenty-three of 29 (79.3%) invited experts completed the survey. Thulium fiber laser (TFL) is the most common laser (57%), followed by Holmium:Yttrium–Aluminium-Garnet (Ho:YAG) (48%), continuous wave (cw) Thulium:Yttrium–Aluminium-Garnet (Tm:YAG) (26%), and pulsed Tm:YAG (13%). Experts prefer ERBT (91.3%) to vapBT (8.7%); however, relevant limitations such as tumor size, number, and anatomical tumor location exist. Laser settings were generally comparable; however, we could find significant differences between the laser sources for lateral wall ERBT (p = 0.028) and standard ERBT (p = 0.033), with cwTm:YAG and pulsed Tm:YAG being operated in higher power modes when compared to TFL and Ho:YAG. Experts prefer long pulse modes for Ho:YAG and short pulse modes for TFL lasers. Conclusion TFL seems to have replaced Ho:YAG and Tm:YAG. Most laser settings do not differ significantly among laser sources. For experts, continuous flow irrigation is the most commonly applied measure to reduce complications.

Purpose To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications. Methods After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified. Results Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely. Conclusions Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse’s and generator settings’ physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.