Biochemical recurrence (BCR) after primary treatments for prostate cancer (PC) is an extremely heterogeneous phase and at least a stratification into low- and high-risk cases for early progression in metastatic disease is necessary. At present, PSA-DT represents the best parameter to define low- and high-risk BCR PC, but real precision medicine is strongly suggested to define tailored management for patients with BCR. Before defining management, it is necessary to exclude the presence of low-volume metastasis associated with PSA progression using new-generation imaging, preferably with PSMA PET/CT. Low-risk BCR cases should be actively observed without early systemic therapies. Early treatment of low-risk BCR with continuous androgen deprivation therapy (ADT) can produce disadvantages such as the development of castration resistance before the appearance of metastases (non-metastatic castration-resistant PC). Patients with high-risk BCR benefit from early systemic therapy. Even with overall survival (OS) as the primary treatment endpoint, metastasis-free survival (MFS) should be used as a surrogate endpoint in clinical trials, especially in long survival stages of the disease. The EMBARK study has greatly influenced the management of high-risk BCR, by introducing the concept of anticipation and intensification through the use of androgen receptor signaling inhibitors (ARSIs) and ADT combination therapy. In high-risk (PSA-DT ≤ 9 months) BCR cases, the combination of enzalutamide with leuprolide significantly improves MFS when compared to leuprolide alone, maintaining an unchanged quality of life in the asymptomatic phase of the disease. The possibility of using ARSIs alone in this early disease setting is suggested by the EMBARK study (arm with enzalutamide alone) with less evidence than with the intensification of the combination therapy. Continued use versus discontinuation of enzalutamide plus leuprolide intensified therapy upon reaching undetectable PSA levels needs to be better defined with further analysis. Real-world analysis must verify the significant results obtained in the context of a phase 3 study.

Background: Contrast-enhanced ultrasound (CEUS) is a diagnostic tool that is gaining popularity for its ability to improve overall diagnostic accuracy in bladder cancer (BC) staging. Our aim is to determine the cumulative diagnostic performance of CEUS in predicting preoperative muscle invasiveness using a comprehensive systematic review and pooled meta-analysis. Methods: A systematic review until October 2023 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Patients with BC suspicion were offered CEUS before the transurethral resection of the bladder tumor (TURBT). The diagnostic performance of CEUS was evaluated based on non-muscle-invasive bladder cancer (NMIBC) vs. muscle-invasive bladder cancer (MIBC) confirmed at the final histopathological examination after TURBT. The outcomes were determined through pooled sensitivity, specificity, pooled positive likelihood ratio (PLR+), negative likelihood ratio (PLR−), and area under the summary receiver operating characteristic (SROC) along with their respective 95% confidence intervals (CI). Results: Overall, five studies were included. In these studies, a total of 362 patients underwent CEUS prior to TURBT. The pooled sensitivity and specificity were 0.88 (95% CI: 0.81–0.93) and 0.88 (95% CI: 0.82–0.92), respectively. SROC curve depicted a diagnostic accuracy of 0.94 (95% CI: 0.81–0.98). The pooled PLR+ and PLR− were 7.3 (95% CI: 4.8–11.2) and 0.14 (95% CI: 0.08–0.23), respectively. Conclusions: Our meta-analysis indicates that CEUS is highly accurate in the diagnosis and staging for BC. Beyond its accuracy, CEUS offers the advantage of being a cost-effective, safe, and versatile imaging tool.

Single Port (SP) surgery is the most relevant surgical innovation of the past six years. Few data are available on the advantages and disadvantages of SP Robotic-Assisted reconstructive urology. In the present systematic review, we summarize the results of available literature exploring the feasibility of SP reconstructive urological procedures and comparing the SP and Multi Port (MP) approaches. The MEDLINE, EMBASE and Cochrane Library Databases were systematically searched for articles evaluating outcomes of SP robotic-assisted pyeloplasty, ureteral reimplantation, Boari Flap, fistula repair, bladder diverticulectomy and vaginoplasty. After meticulous study selection, we conducted a meta-analysis to compare perioperative and postoperative outcomes of SP and MP robotic-assisted pyeloplasty (SP-RP and MP-RP). Regarding ureteric reimplantation, Boari Flap, bladder diverticulectomy, fistula repair and vaginoplasty, we underwent a structured narrative synthesis, since meta-analysis was not feasible due to heterogeneity or insufficient study numbers. The meta-analysis included a total of six retrospective cohort studies and 202 patients. SP-RP demonstrated significantly lower Estimated Blood Loss (EBL) (SMD − 0.45, 95%CI − 0.80 to − 0.09, p = 0.01, I ² = 0%) and better cosmetic results (MD 1.83, 95%CI 0.98–2.68, p < 0.001). The mean length of hospital stay was shorter for patients submitted to SP-RP, but the difference did not reach significance (SMD = − 0.68, 95%CI − 1.43 to 0.07, p = 0.08, I ² = 80%). There were no significant differences in terms of complication rates, operative times, success rate and renal function increase between the two approaches (p > 0.05). Respectively, a total of four, one, two, one and two articles evaluating robotic-assisted SP ureteral reimplantation, Boari Flap, bladder diverticulectomy, fistula repair, and vaginoplasty, were included for the final structured summary. The included studies consistently suggest the feasibility and safety of the SP approach, however, available evidence predominantly consists of small retrospective series or individual case reports, and statistical validation is not possible. SP-RP has been successfully described, with possible advantages in terms of shorter hospital stays, better pain control and cosmetic results. Although successful cases of other major reconstructive urological procedures are reported in the literature, the available evidence remains limited and of low quality. Hopefully, the encouraging findings regarding SP-RP will increase the popularity of the SP robotic system among reconstructive urologic surgeons and the availability of more robust data.

Introduction: In recent years, due to the increasing life expectancy and the growing popularity of nephron sparing strategies (NSS), more elderly and frail patients are undergoing Robotic-Assisted Partial Nephrectomy (RAPN) for the treatment of localized Renal Cell Carcinoma (RCC). A Single Port Approach has demonstrated itself to reduce estimated blood loss (EBL), complication rates, and length of stay (LOS). In the present study, we aim to compare perioperative and postoperative outcomes of SP RAPN and Multi Port (MP) RAPN, with a focus on elderly patients. Materials and Methods: In the study, 293 cN0M0 RCC patients who underwent MP and SP RAPN performed at our institution from 2018 to 2024 were retrospectively reviewed. Clinical, demographic, patient, and tumor characteristics and perioperative variables were assessed across group A (<65 years old) and group B (≥65 years old) patients, as well as MP and SP cohorts. Subsequently, univariate and multivariate regression analyses were carried out, particularly for elderly patients, to evaluate the impact of selected preoperative and perioperative variables on the risk of 30-day postoperative complications. Results: Clinical and demographic characteristics were similar across the MP and SP cohorts of group A and group B. The SP cohort of both group A and group B demonstrated significantly higher rates of extraperitoneal access (75.9% vs. 26.6% for group A, p < 0.001 and 81.8% vs. 26.2% for group B, p < 0.001), shorter median operative times (186 [142.8–222] min vs. 190 [153–238] min for group A, p < 0.001 and 173.5 [143–228] min vs. 206 [178–237] min for group B, p < 0.001), and shorter median LOS (0 [0–1] days vs. 2 [1–3] days for group A, p < 0.001 and 0 [0,1] days vs. 2 [2–4] days for group B, p < 0.001). Moreover, for both groups, an SP approach required significantly longer median ischemia times (21 min [18–31] vs. 20 min [16–24] for group A, p = 0.02 and 24.5 min [20–28] vs. 19.5 min [16–26] for group B, p = 0.03). However, the SP cohort of group B, despite the lower rate of on-clamp procedures (63.4% vs. 90.5%, p = 0.03), demonstrated significantly lower median EBL (50 mL [31–142] vs. 100 mL [50–200], p = 0.03). At multivariate analysis, the SP approach was an independent predictor of lower 30-day postoperative complications (OR: 0.2, 95%CI 0.04–0.9, p = 0.04). Conclusions: In the present study, elderly patients undergoing SP RAPN did not demonstrate higher complication rates, EBL or hospitalization days compared to their younger counterparts. Moreover, an SP approach was found protective for 30-day postoperative complications. Our results suggest that SP RAPN is feasible and safe in older and frailer patients.

Contrast-enhanced ultrasound (CEUS) is an advanced imaging technique that integrates conventional US with the intravenous injection of specific US contrast agents (UCAs), combining the non-invasiveness of US with the higher accuracy of contrast-enhanced imaging. In contrast with magnetic resonance imaging (MRI), computed tomography (CT) and cystoscopy, CEUS has few contraindications, and UCAs are non-nephrotoxic agents that can be safely used in patients with kidney failure. CEUS is a well-established method for the detection of liver lesions and for echocardiography, and its indications are expanding. The updated 2018 WFUMB-EFSUMB guidelines have added the urinary bladder under non-hepatic applications of CEUS. The technique is able to distinguish between benign tissue, such as clots or hematoma, and malignant lesions by perfusing the mass with contrast agent. Thanks to the different perfusion rates of the various layers of the bladder wall, CEUS is also able to predict tumor invasion depth and stage. Despite that, current urological guidelines do not include CEUS as a plausible imaging technique for bladder urothelial carcinoma. The main reason for this omission might be the presence of scarce randomized evidence and the absence of large validated series. In this review, we describe the rationale behind the use of CEUS in bladder cancer and the added value of this imaging technique in the detection and staging of bladder lesions. In addition, we researched the available literature on the topic and then described the results of randomized clinical trials and a meta-analysis investigating the accuracy of CEUS in bladder cancer diagnosis and staging. The reported studies show that CEUS is a highly accurate diagnostic and staging tool for BC, reaching levels of specificity and sensitivity in differentiating between Ta-T1, or low-grade BC, and T2, or high-grade BC, that are comparable to those shown by the reference standard methods. Nonetheless, several limitations were found and are highlighted in this review. The aim of this study is to further validate and promote the use of CEUS as a quick, economic and effective diagnostic tool for this high-impact disease.

Background/Objectives: The da Vinci Single-Port (SP) system represents a recent evolution in robotic-assisted surgery, offering enhanced articulation and access through a single incision. The SP system was approved by the European Medicine Agency (EMA) in January 2024. Methods: This review synthesizes current clinical evidence on the feasibility, safety, and versatility of SP-assisted procedures across multiple surgical specialties to date based on a comprehensive literature search conducted through major databases (MEDLINE, EMBASE, and Cochrane) according to PRISMA and PICOS guidelines. Results: A total of 14 studies were included, highlighting that the SP platform has been successfully adopted in complex procedures such as cervical esophagectomy, radical prostatectomy, nephrectomy, gynecologic procedures, and wall surgery. Across indications, the SP approach is associated with reduced blood loss, shorter hospital stays, and low complication rates. On the other hand, limitations include restricted working space and the steep learning curve. Conclusions: Overall, the da Vinci SP platform expands the scope of minimally invasive surgery, but European centers lag behind international trends, particularly when compared to new, less-invasive techniques adopted in high-volume SP centers in the US. Urology remains the main field of application.