Alfonso Santangelo

Objective: To systematically evaluate surgical outcomes of urethroplasty for bulbomembranous urethral strictures developing after endoscopic surgery for benign prostatic hyperplasia (BPH), focusing on patency, urinary continence, and erectile function. Patients and Methods: A pre‐registered systematic review (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD420261374244) was performed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) 2020 guidelines. PubMed and the Excerpta Medica database (EMBASE) were searched for observational studies reporting urethroplasty outcomes in ≥10 patients with post‐BPH bulbomembranous, membranous, or proximal bulbar strictures. Risk of bias was assessed using the Risk Of Bias In Non‐randomised Studies of Interventions (ROBINS‐I). Random‐effects meta‐analysis with logit back‐transformation and Hartung‐Knapp‐Sidik‐Jonkman correction pooled proportions of patency and urinary incontinence (UI), stratified by technique. Results: A total of 11 studies comprising 669 patients were identified, of which nine (417 patients) were included in the primary quantitative analysis. All studies were retrospective or prospective observational cohorts with moderate‐to‐serious risk of bias. Definitions of patency and continence were heterogeneous across studies. The overall pooled patency rate, predominantly defined as freedom from re‐intervention rather than objectively confirmed anatomical patency, was 90% (95% confidence interval [CI] 85–93%), with moderate heterogeneity ( Q = 11.22). Subgroup analysis by technique yielded patency rates of 87% (95% CI 76–93%) for ventral onlay buccal mucosal graft (BMG) (four studies), 94% (95% CI: 87–97%) for anastomotic urethroplasty (three studies), and 91% (95% CI 83–95%) for dorsal onlay BMG (one study). The pooled UI rate was 5% (95% CI 3–10%), with moderate heterogeneity ( Q = 11.38). Sensitivity analysis excluding studies incorporating simple prostatectomy cases (two studies) yielded consistent results. Erectile function data were insufficient for pooled analysis; the two studies reporting Sexual Health Inventory for Men scores documented no significant deterioration. Conclusions: Urethroplasty for bulbomembranous strictures following BPH surgery achieves high, heterogeneously defined patency—predominantly freedom from re‐intervention—with low de novo UI in experienced centres. The heterogeneous, non‐comparative evidence precludes technique‐specific recommendations; prospective, standardised studies are needed to refine patient selection.

Background: International guidelines recommend further diagnostic evaluation for patients with an elevated prostate-specific antigen (PSA; >4 ng/mL). However, real-world adherence to these recommendations remains poorly characterized. We aimed to quantify the proportion of patients receiving appropriate diagnostic work-up after an elevated PSA and to identify factors associated with adherence.Methods: We conducted a retrospective cohort study using the Epic Cosmos database (USA). Among 15,369,304 individuals undergoing PSA testing between 2017 and 2024, we included patients aged 40–75 years with at least 1 year of follow-up. Patients with prior prostate cancer, prostate MRI, or biopsy were excluded. The primary outcome was appropriate diagnostic work-up, defined as repeat PSA within 6 months and/or prostate MRI or biopsy within 12 months after an elevated PSA. Predictors included PSA level, age, race, Charlson Comorbidity Index, Area Deprivation Index, and ordering department. Findings: The final cohort included 1,002,947 patients. Overall, 49.1% received appropriate diagnostic work-up. Rates increased from 43.7% in 2017 to 55.5% in 2024. Patients receiving appropriate work-up had higher PSA levels (mean 5.5 vs 5.1 ng/mL; p<0.001) and were younger (mean 65 vs 66 years; p<0.001). They were more frequently White (73.1% vs 71.8%; p<0.001), had lower Area Deprivation Index (median 0.44 vs 0.46; p<0.001), fewer severe comorbidities (13.6% vs 14.5%; p<0.001), and were more often privately insured (39.1% vs 33.1%; p<0.001) and partnered (71.4% vs 67.9%; p<0.001). These associations were confirmed in multivariable analyses. Interpretation: In this large, contemporary cohort, approximately half of patients with elevated PSA did not receive guideline-concordant diagnostic evaluation. Despite modest improvement over time, substantial disparities persist, particularly across sociodemographic and clinical factors. These findings highlight an important gap in prostate cancer care and support the need for targeted strategies to improve adherence to diagnostic guidelines.Funding: None.

Objectives: To prospectively evaluate the influence of multiparametric magnetic resonance imaging (mpMRI) quality, as assessed by the Prostate Imaging Quality (PI‐QUAL) score, on diagnostic accuracy in men undergoing prostate biopsy after external mpMRI at a tertiary referral center. Materials and Methods: From June 2024 to July 2025, a total of 246 consecutive patients referred for prostate biopsy after external mpMRI were prospectively enrolled. All patients underwent systematic biopsy with targeted biopsy when indicated. External mpMRI scans were centrally reviewed by expert uro‐radiologists blinded to clinical and pathological data. Image quality and lesion grading were reassessed using PI‐QUAL v2 and Prostate Imaging Reporting and Data System (PI‐RADS) v2.1. Accuracy for clinically significant prostate cancer (csPCa; International Society of Urological Pathology [ISUP] grade ≥2) was assessed using receiver operating characteristic–derived area under the curve AUC before and after review, stratified by PI‐QUAL (1–2 vs 3). Results: Median age and prostate‐specific antigen (PSA) were 66.5 years (interquartile range [IQR] 61–73) and 6.6 ng/mL (IQR 4.8–9.7), respectively, and csPCa was detected in 128 patients (52%). After review, 49 (20%), 113 (46%), and 84 (34%) mpMRI scans were classified as PI‐QUAL 1, 2, and 3, respectively. The proportion of indeterminate PI‐RADS 3 findings was 27% for PI‐QUAL 1, 15% for PI‐QUAL 2, and 8% for PI‐QUAL 3. PI‐QUAL 3 scans demonstrated greater diagnostic accuracy than PI‐QUAL 1–2 (AUC 0.79 vs 0.66, P = 0.01). Central review improved csPCa detection in both PI‐QUAL 1–2 (AUC 0.63 vs 0.78, P < 0.01) and PI‐QUAL 3 (AUC 0.77 vs 0.89, P < 0.01) scans. Conclusions: High‐quality mpMRI achieved approximately 15% higher diagnostic accuracy for csPCa and were associated with a lower prevalence of indeterminate findings than were low‐quality MRI scans; centralized expert review reclassified nearly half of PI‐RADS assessments. These findings support upfront high‐quality mpMRI acquisition and PI‐QUAL–based quality control to optimize diagnosis and reduce unnecessary procedures.

Introduction: Giant retroperitoneal liposarcomas (GRPLs) are rare tumors that often reach considerable size before diagnosis due to their indolent growth and deep anatomical location. Surgery represents the only potentially curative treatment, yet recurrence rates remain high. While histological subtype is a recognized predictor of recurrence, the prognostic role of tumor size, particularly in giant tumors, remains controversial. This study evaluates the impact of tumor size and histological subtype on recurrence risk in a literature-based retrospective cohort. Materials and Methods: Data were extracted from a literature-based database of GRLPs published between 2004 and 2023. Only tumors >20 cm treated without positive surgical margins were included; patients receiving adjuvant therapy or with missing follow-up were excluded. Histological subtype (well-differentiated vs. other) was the main variable of interest. Recurrence-free survival (RFS) was defined as the primary endpoint and estimated using the Kaplan–Meier method. The association between histological subtype and recurrence risk was evaluated using a Cox proportional hazards model. A sensitivity analysis was performed to explore the potential interaction between tumor size and histological subtype. Results: Our final cohort yielded a total of 81 patients, of whom 47 (58%) had a well-differentiated GRLPs. The median tumor size was 38 cm and median follow-up was 16 months, with 24 recurrences observed. At 24 months, RFS was higher in well-differentiated tumors than in other histological subtypes (81% vs. 41%). In multivariable Cox analysis, histology was independently associated with recurrence risk (HR 3.2, 95% CI 1.28–8.17, p = 0.01), whereas tumor size showed no association with recurrence. Interaction analysis confirmed no differential effect of tumor size across histological subtypes. Conclusions: In this literature-based cohort of GRLPs treated with surgery, histological subtype independently predicted recurrence, whereas tumor size showed no prognostic value, either overall or within individual histological subtypes.

Prostate cancer (PCa) screening has long relied on PSA testing, a strategy that has shaped diagnostic pathways for decades but remains limited by substantial overdiagnosis and downstream overtreatment. As screening practices evolve, the relevance of historical evidence must be reconsidered in the context of contemporary diagnostic workflows that now incorporate imaging, refined biopsy techniques, and risk-adapted management. This narrative review examines the transition from PSA-only screening toward modern, risk-adapted early detection strategies. We synthesize evidence supporting the integration of mpMRI, refined biopsy techniques, and active surveillance (AS) as key components of contemporary screening pathways aimed at improving the detection of clinically significant disease while minimizing unnecessary interventions. Particular emphasis is placed on second-line MRI-based approaches, which consistently reduce the number of avoidable biopsies and enhance the diagnostic precision. In addition, we review the role of blood-based and genomic biomarkers in pre-biopsy risk stratification, discussing established tools within a unified framework of individualized screening. The review also contextualizes very recent regulatory developments, including the FDA approval of a novel structure-based PSA assay, as part of the ongoing evolution of biomarker-supported screening rather than a paradigm shift. Overall, this article provides a timely synthesis of mature randomized evidence and emerging diagnostic innovations, offering a clinically grounded perspective on how PCa screening is being reshaped toward more personalized and harm-aware strategies.

Socio-economic status and geographical location contribute to disparities in localized prostate cancer (PCa) treatment. We examined the impact of area of deprivation index (ADI) on initial treatment type for localized PCa in a North American cohort. We performed a retrospective analysis of patients diagnosed with localized PCa treated within the State of Michigan, between 2010 and 2022, with available ADI-data. The latter was assigned based on residential census block group, ranked as a national deprivation percentile. Patients were categorized into three treatment groups: radical prostatectomy (RP), radiation therapy (RT) and "other" treatment. Using the multinominal logistic regression, we assessed ADI impact on treatment choice. After excluding patients without cT, ISUP-grade and/or PSA, we stratified by D'Amico risk-classification and repeated the regression analysis in each subgroup. The cohort consisted of 46,481 patients. Among those, 17.7% were Non-Hispanic Black men. Regarding treatment, 21,152 (45.51%) patients underwent RP, 9,713 (20.89%) received RT and the remaining 15,616 (33.59%) underwent "other" treatments (OT). Median (IQR) National ADI Percentile was 58 (38 - 79) and it was 55 (37 - 76), 62 (41 - 83), and 59 (38 - 82) for the patients treated with RP, RT, and other, respectively (p < 0.0001). At multivariable analysis, ADI was significantly associated with the type of received treatment. For each 10 unit increase in ADI, patients were 3% more likely to receive RT and 2% less likely to receive a RP, compared to 'other' treatment (OR, 1.03, 95% CI, 1.02-1.04; p <0.001) and (OR, 0.98, 95% CI, 0.97-0.99; p <0.001), respectively. When stratified by D'Amico risk classification, among patients with known PSA, grade, and stage (25,571 patients), 6,976 (27.28%) were Low Risk, 12,329 (48.21%) were Intermediate Risk and 6,266 (24.50%) were High Risk. At multivariable analysis, for each 10 unit increase in ADI percentile, low risk patients were 7% more likely to receive RT compared to other treatments (OR, 1.07, 95% CI, 1.04-1.10; p <0.001). While among intermediate and high risk PCa patients, each 10 unit increase in ADI was associated with 4% and 6% decreased likelihood of receiving RP, respectively, compared to other treatments (OR, 0.96, 95% CI, 0.95-0.98; p = 0.001) and (OR, 0.94, 95% CI, 0.91-0.97; p <.001). Patients living in developed areas were more likely to receive RP, while those living in the most disadvantaged areas received higher rates of RT. Understanding neighborhood influence on initial localized PCa treatment is essential in guiding interventions and reducing disparities.

Background: Esophageal achalasia increasingly affects elderly patients, in whom frailty and comorbidity complicate management and heighten procedural risk. Minimally invasive Heller–Dor myotomy remains the reference surgical treatment, while the advent of robotics has renewed interest in its potential advantages. Whether these refinements translate into meaningful benefits for older adults remains unclear. This gap is clinically significant given the distinct physiological vulnerabilities of older adults. Methods: A narrative review of the literature was conducted to examine current evidence on robotic Heller–Dor myotomy for achalasia, with specific focus on its applicability in elderly and frail patients. Comparative studies between robotic and laparoscopic approaches were analyzed and integrated with available data on achalasia management in older individuals. Results: Robotic Heller–Dor myotomy demonstrates equivalent efficacy to laparoscopic surgery, with reduced mucosal perforation rates, improved ergonomics, and comparable operative times once the learning curve is achieved. However, no published series has specifically analyzed outcomes in geriatric cohorts. Available evidence from laparoscopic studies confirms that surgery remains safe and effective in geriatric patients, suggesting that the precision of robotics could potentially further enhance safety and recovery in this subgroup. Conclusions: Robotic Heller–Dor myotomy represents a promising evolution of minimally invasive therapy for achalasia, potentially aligning technological refinements with the physiological needs of older adults. Prospective studies incorporating frailty assessment, patient-centered outcomes, and cost analyses are required to determine its true value and guide evidence-based use in the aging population.