Petros Sountoulides

Background: Active surveillance (AS) represents a cornerstone of personalized medicine in uro-oncology, offering an individualized management strategy for low- and selected favourable intermediate-risk prostate cancer that aligns treatment intensity with patient-specific risk profiles; however, real-world adherence data from southern European academic centres remain scarce. This study aimed to evaluate AS discontinuation rates, reasons for transition to active treatment, and quality of life (QoL) in a single-centre Greek university hospital cohort. Methods: This is an observational retropective cohort study of patients enrolled in an AS protocol at the First Department of Urology, Aristotle University of Thessaloniki, between October 2016 and July 2022. Treatment-free survival (TFS) was estimated using Kaplan–Meier analysis. Associations between AS discontinuation and age at diagnosis, PSA level, and Charlson Comorbidity Index (CCI) were explored using univariable and multivariable Cox proportional hazards regression. QoL, erectile function, and anxiety were assessed cross-sectionally in patients remaining on AS using SF-12, IIEF-6, STAI-6, and MAX-PC. Results: Thirty-six patients were included (32 low-risk; 4 favourable intermediate-risk), with a median age of 69.5 years, median PSA of 6.92 ng/mL, and median CCI of 3. After a median follow-up of 24 months (IQR 21–45), 19 patients (52.8%) transitioned to active treatment; the median time to treatment was 21 months (IQR 17–34). Among the 10 patients with a known reason for discontinuation, 6 (31.6% of all discontinued) showed histopathological or clinical disease progression, 3 (15.8%) had a PSA increase alone, and 1 (5.3%) transitioned due to urinary symptoms; the reason was unknown in 9 cases (47.4%). In exploratory Cox regression, PSA ≥ 7.0 ng/mL was the only factor with complete documented output significantly associated with transition to active treatment (univariable HR 3.70, 95% CI 1.35–10.1, p = 0.011; multivariable HR 3.93, 95% CI 1.42–10.9, p = 0.008). Cross-sectional QoL assessment in 10 patients remaining on AS demonstrated median scores above established population norms for SF-12 and below clinical anxiety thresholds on STAI-6 and MAX-PC. Conclusions: In this single-centre cohort, AS discontinuation occurred early and at a rate higher than that of established international programmes, consistent with the institution’s initial AS experience. Higher PSA at diagnosis was the only factor with complete analytical documentation to be significantly associated with earlier transition.

Introduction/Background: Large-volume benign prostatic hyperplasia (≥80 mL) requires complete anatomical removal of the adenoma. Robot-assisted or minimally invasive simple prostatectomy (RASP/MISP) and anatomic endoscopic enucleation of the prostate (AEEP) have both emerged as minimally invasive alternatives to open simple prostatectomy, but their comparative perioperative performance in very large glands remains incompletely defined. Objective: To systematically review and quantitatively synthesize the perioperative outcomes and complications of RASP/MISP versus AEEP in the surgical management of large-volume BPH. Methodology: Following PRISMA 2020, PubMed, Embase, Scopus and the Cochrane Library were searched from inception to 7 June 2026 for randomized and non-randomized comparative studies of RASP/MISP versus AEEP in men with mean or median prostate volume ≥ 80 mL reporting at least one perioperative or functional outcome and at least one Clavien–Dindo grade ≥ III complication. Continuous outcomes were pooled as mean differences (MD) and dichotomous outcomes as risk ratios using random-effects models (REML with Knapp–Hartung adjustment); heterogeneity was assessed with I². Risk of bias was evaluated with the Newcastle–Ottawa Scale and ROBINS-I, and certainty of evidence with GRADE. Publication bias and leave-one-out sensitivity analyses were performed where the number of studies permitted. Results: Five comparative cohort studies published between 2017 and 2025 were included, comprising 271 patients treated with RASP/MISP and 998 treated with AEEP. AEEP was associated with a significantly shorter catheterization time (pooled MD 5.95 days; 95% CI 1.98–9.92; p = 0.014) and a shorter hospital stay (pooled MD 2.73 days; 95% CI 1.07–4.39; p = 0.010), both with high heterogeneity (I² 99.0% and 96.1%, respectively). Perioperative hemoglobin drop tended to favor AEEP without reaching significance (pooled MD 0.65 g/dL; 95% CI −0.33 to 1.63; p = 0.103), and transfusion risk was lower but not statistically significant (pooled RR ≈ 0.46; 95% CI 0.18–1.15). PSA reduction was substantial and broadly equivalent between techniques. Functional outcomes (IPSS, QoL, Qmax, PVR) improved comparably with both approaches. Leave-one-out analyses confirmed that the catheterization and length-of-stay advantages of AEEP were robust, and no evidence of publication bias was detected. Certainty of evidence was low to moderate, reflecting the observational designs. Leave-one-out analyses indicated that the catheterization and length-of-stay differences were not driven by any single study; publication bias could not be assessed reliably because fewer than ten studies contributed to any outcome. Certainty of evidence was low to moderate, reflecting the observational designs, the small number of studies, and substantial between-study heterogeneity, and the findings should be regarded as hypothesis-generating. Conclusions: In large-volume BPH, AEEP and RASP/MISP achieve comparable functional improvement and adenoma debulking, but AEEP offers superior perioperative efficiency, with markedly shorter catheterization and hospital stay and at least comparable safety. RASP/MISP remains a valuable option where robotic infrastructure is available but high-volume enucleation expertise is lacking. These findings, drawn from observational evidence of low-to-moderate certainty, support AEEP as the more resource-efficient minimally invasive option for very large glands and underline the need for randomized comparative trials.

Background and Objectives: Benign prostatic hyperplasia (BPH) is a progressive, androgen-dependent condition driven by dihydrotestosterone (DHT). 5α-reductase inhibitors (5-ARIs), including finasteride and dutasteride, target this pathway and provide disease-modifying effects. Materials and Methods: This narrative review summarizes evidence from randomized trials, meta-analyses, and observational studies evaluating the efficacy, timing, and safety of 5-ARIs in the management of LUTS due to BPH. Results: 5-ARI therapy reduces prostate volume by 18–28% and serum PSA by approximately 50% within 6–12 months. Landmark trials (MTOPS, CombAT) demonstrate significant reductions in acute urinary retention (AUR) and BPH-related surgery (>50% RR reduction). Combination therapy with α-blockers provides superior symptom control and greater prevention of clinical progression, particularly in men with prostate volume ≥ 30–40 mL or PSA ≥ 1.5 ng/mL. Early initiation of combination therapy improves long-term outcomes, while α-blocker withdrawal may be feasible in selected patients. Adverse events are mainly sexual, with emerging data suggesting a possible association with depression. Conclusions: 5-ARIs are central to BPH management, offering sustained clinical benefits and prevention of progression. Optimal outcomes depend on appropriate patient selection, early treatment in high-risk individuals, and individualized long-term strategies.

Background/Objectives: Urology residency training widely varies across countries, and evidence comparing residents’ experiences at an international level is limited. This study reports the results of an international survey of urology residents from different countries worldwide, aiming to characterize training environments, educational exposure, and trainee expectations across diverse healthcare systems. Methods: A 39-item online survey was administered to urology residents during the Société Internationale d’Urologie (SIU) Regional Meeting (Florence, November 2024), assessing demographics, training exposure, educational resources, workload, satisfaction, and career perspectives. The results were compared between trainees at different postgraduate years (PGYs) to explore associations for key outcomes. Results: Overall, 208 urology residents from 21 countries completed the survey. Most residents were actively involved in research (76.4%), although confidence in independent scientific production was moderate (significantly lower among junior trainees). Surgical exposure increased with PGY, with good experience in endoscopy but limited hands-on exposure and expected autonomy in laparoscopic, robotic, and major open surgery. Despite high overall satisfaction with urology, residents described heavy workloads, inconsistent access to structured teaching and international fellowships, and a long-term shift in career expectations toward private practice. Conclusions: Urology residents worldwide report high engagement in research, strong satisfaction with their specialty choice, and interest in international mobility. Nonetheless, persistent disparities in surgical exposure, research confidence, workload, and gender representation highlight the need for competency-based curricula, structured mentorship, and improved training organization to promote equitable and high-quality urology education globally.

Introduction: Convective water vapor thermal therapy (WVTT, Rezum™) is an established minimally invasive surgical technique for men with LUTS secondary to benign prostatic hyperplasia (BPH). Despite increasing adoption, patient selection, peri-procedural management, technical execution, and training remain heterogeneous. We conducted a live modified Delphi consensus to define pragmatic, expert-driven recommendations for WVTT practice in Italy. Materials and methods: A 10-member steering committee screened the literature and drafted candidate statements across eight predefined domains. A live modified Delphi process was conducted with 22 Italian urologists. Panelists voted using a four-level response scale; justifications were required for any response other than full agreement. Statements below the predefined consensus threshold were discussed, reformulated when appropriate, and re-voted. Consensus was defined a priori as ⩾75% full agreement. Results: Twenty-six statements were voted. Consensus was achieved for 21/26 (80.8%) statements. Five statements did not reach consensus: routine preoperative cystoscopy (72.8%), routine semen culture (31.8%), restricting general anesthesia to selected cases/early learning curve (50.0%), continuation of antibiotics for the entire catheterization period (68.2%), and mandatory “complete” follow-up at 6 months (72.7%). Two items underwent iterative reformulation and re-voting: prostate volume ⩽ 80 cm ³ (77.3% → 100%) and supervision during the initial learning curve (31.8% → 61.9% → 90.5%). Conclusions: This live Delphi consensus provides practice-oriented guidance for WVTT and defines areas of strong expert agreement alongside persistent evidence gaps. The findings support standardized adoption of WVTT within defined indications while prioritizing future research on peri-procedural protocols and follow-up pathways.

Background/Objectives: Urology residency training widely varies across countries and evidence comparing residents’ experiences at an international level are limited. This study reports the results of an international survey of urology residents from different countries worldwide, aiming to characterize training environments, educational expo-sure, and trainee expectations across diverse healthcare systems. Methods: A 39-item online survey was administered to urology residents during the SIU Regional Meeting (Florence, November 2024), assessing demographics, training exposure, educational resources, workload, satisfaction, and career perspectives. Results were compared be-tween trainees at different postgraduate year (PGY) to explore associations for key out-comes. Results: Overall, 208 urology residents from 21 countries completed the survey. Most residents were actively involved in research (76.4%), although confidence in in-dependent scientific production was moderate (significantly lower among junior trainees). Surgical exposure increased with PGY, with good experience in endoscopy but limited hands-on exposure and expected autonomy in laparoscopic, robotic, and major open surgery. Despite high overall satisfaction with urology, residents described heavy workloads, inconsistent access to structured teaching and international fellowships, and a long-term shift in career expectations toward private practice. Conclusions: Urology residents worldwide report high engagement in research, strong satisfaction with their specialty choice, and interest in international mobility. Nonetheless, persistent disparities in surgical exposure, research confidence, workload, and gender representation highlight the need for competency-based curricula, structured mentorship, and improved training organization to promote equitable and high-quality urology education globally.

The formation of kidney stones is a complex biologic process involving interactions among genetic, anatomic, dietary, and environmental factors. Traditional lithogenic models were based on urine supersaturation in relation to the activity of crystallization promoters and inhibitors. However, modern research has added new principles such as the “renal epithelial cell response” and the role of inflammation and oxidative stress leading to the development of a “multi-hit hypothesis”. A strong correlation between urinary stones and kidney damage has been well demonstrated by both cohort and case-control studies. The main contributors to chronic kidney damage associated with urinary stones include crystal deposition within the renal parenchyma, associated comorbidities, repeated obstructive and infectious episodes, as well as the potential adverse effects of stone removal procedures. Most hereditary stones may cause high urinary saturation levels promoting obstruction of the Bellini ducts and consequent glomerulosclerosis and interstitial fibrosis in the cortex. These include hereditary hypercalciurias, primary hyperoxalurias, cystinuria, adenine phosphoribosyltransferase (APRT) deficiency (associated with 2,8-dihydroxyadenine lithiasis) and xanthinuria. Complete distal renal tubular acidosis occurs in childhood and presents deafness, rickets, and a short life expectancy. The incomplete form usually manifests in adulthood, primarily with recurrent urinary lithiasis, and less frequently with nephrocalcinosis. In all stone formers stone analysis and a basic metabolic evaluation, including blood biochemistry, urine sediment examination, urinary pH and culture are mandatory, in contrast high-risk stone formers require a more specific metabolic evaluation, including a 24-hour urine sample to measure calcium, phosphate, citrate, oxalate, uric acid, magnesium, sodium and proteinuria. The morpho compositional analysis of kidney stones offers essential insights beyond merely identifying their predominant chemical component. This approach reveals key aspets of the stone formation, such as nucleation sites, crystal growth patterns, and the presence of specific lithogenic processes. The ideal analytical protocol combines stereoscopic microscopy (StM), scanning electron microscopy with energy-dispersive X-ray spectroscopy (SEM-EDS), and, when necessary, Fourier-transform infrared spectroscopy (FTIR). Recurrence prevention and managing residual fragments require complementary strategies such as lifestyle modifications, dietary interventions, and pharmacological therapies. Among pharmacological options, alkaline citrate salts, particularly potassium citrate, are widely used due to their ability to modify urinary chemistry and inhibit stone formation. Recently, novel molecules have been introduced into the management of renal stone disease. Phytate a naturally occurring polyphosphorylated carbohydrate, exibits a potent inhibitory effect on calcium salt’s nucleation, growth, and aggregation. Theobromine, another natural compound, has been shown to effectively inhibit uric acid crystallization. The co-administration of urinary alkalinizing agents, such as potassium citrate, alongside theobromine has been proposed as a therapeutic strategy to optimize uric acid solubility and to reduce the risk of excessive alkalinization and subsequent sodium urate precipitation. Struvite stones are caused by urinary tract infection with urease- producing microorganisms. Their treatment requires specific measures including complete surgical stone removal, short or long-term antibiotic treatment, to maintain urinary acidification to a pH below 6.2, and a urine volume of at least 2 litres/24 hours. L-methionine has been shown to effectively lower urine pH and the relative supersaturation of struvite. An essential aspect of medical management of urinary stone disease is treatment adherence, which depends on perceived benefit, treatment duration, and side effect profile. The side effects of citrate treatment are mild gastrointestinal disorders whereas thiazide diuretics tend to cause hypokalemia-related symptoms and less frequent metabolic and dermatologic side effects. Urease inhibitors for struvite stones and drugs used to enhance cystine solubility are more frequently associated with side effects. The use of smartphone applications can support patients by promoting adequate hydration, adherence to dietary recommendations, and compliance with prophylactic medication. Endoscopic techniques currently play a prevalent role in the removal of renal stones, while extracorporeal shock wave lithotripsy is today marginally used for specific indications. Different technical modalities can be used for percutaneous nephrolithotomy (PCNL), each with its own advantages and disadvntages (standard vs. mini, prone vs. supine, fluoroscopic vs ultrasound-guided). Flexible ureteroscopy or retrograde intrarenal renal surgery (RIRS) has extended its indications due to technological advancements in endoscopes and their accessories. The availability of new laser technologies (thulium fiber laser and pulse-modulated Ho:YAG laser) has enhanced stone fragmentation and dusting capabilities. However, their use exposes the renal parenchyma to high temperatures and pressures which could potentially contribute to renal damage. Factors influencing heat release include laser type and settings, exposure time, stone location, fiber-to-stone distance, irrigation volume and fluid circulation. Reduction of heat release can be achieved by limiting the laser settings to reasonable values or by improving fluid circulation with use of ureteral access sheaths, especially those navigable and equipped with suction. High intrarenal pressure is also closely associated with renal damage. Sustained high pressure or even pressure spikes may increase this risk, highlighting the importance of real-time pressure monitoring through sensors...

Urolithiasis is one of the most burdensome urinary tract conditions with a prevalence ranging from 1% to 20%. Approximately half of the patients experience a recurrence, while 10% face multiple stone episodes. Long before the advent of surgical treatment options, herbal therapy, or phytotherapy, had been used for both the prevention and management of urolithiasis. Recently, interest in phytotherapy has been rekindled due to the limitations associated with modern urolithiasis treatment, the limited options for conventional medical therapy, and the added cost of interventions for stones. While research on phytotherapy is still limited, it is ongoing and is yielding promising results. In order to capture the current trend in phytotherapy for urolithiasis, we performed a narrative review from data collected and synthesized from electronic databases, with a specific focus on randomized human studies. Our analysis revealed that the use of various herbal medicines and phytotherapy, either as mixtures or as sole plant extracts, in urolithiasis is on the rise and is mainly utilized as complementary therapy to conventional treatment. Although most studies demonstrate the effectiveness of phytotherapy in reducing stone size and facilitating stone expulsion, several questions regarding specific dosages, mechanisms of action, drug interactions, treatment duration, and types of stones that respond to phytotherapy remain unanswered. This review aims to summarize the current knowledge surrounding the role of phytotherapy in urolithiasis and to determine its role as a primary or complementary treatment alongside traditional treatment options. Ultimately, further research is essential to clarify the abovementioned unresolved issues, overcome the existing challenges, and optimize the best possible phytotherapy strategies and timing for dissolving specific types of stones with these regimens.

Urolithiasis is one of the most burdensome urinary tract conditions with a prevalence ranging from 1% to 20%. Approximately half of the patients experience a recurrence, while 10% face multiple stone episodes. Long before the advent of surgical treatment options, herbal therapy, or phytotherapy, had been used for both the prevention and management of urolithiasis. Recently, interest in phytotherapy has been rekindled due to the limitations associated with modern urolithiasis treatment, the limited options for conventional medical therapy and the added cost of interventions for stones. While research on phytotherapy is still limited, it is ongoing and is yielding promising results. In order to capture the current trend in phytotherapy for urolithiasis we performed a narrative review from data collected and synthesized from electronic databases, with a specific focus on randomized human studies. Our analysis revealed that the use of various herbal medicines and phytotherapy, either as mixtures or as sole plant extracts, in urolithiasis is on the rise and is mainly utilized as complementary therapy to conventional treatment. Although most studies demonstrate the effectiveness of phytotherapy in reducing stone size and facilitating stone expulsion, several questions regarding specific dosages, mechanisms of action, drug interactions, treatment duration, and types of stones that respond to phytotherapy remain unanswered. This review aims to summarize the current knowledge surrounding the role of phytotherapy in urolithiasis, as well as to determine its role as a primary or complementary treatment alongside traditional treatment options. Ultimately, further research is essential to clarify the abovementioned unresolved issues, overcome the existing challenges, and optimize the best possible phytotherapy strategies and optimal timing for dissolving specific types of stones with these regimens.