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Endoluminal procedures are widely used for male anterior urethral strictures (USs) because they are minimally invasive and easily accessible. However, their long-term success is modest, and repeated attempts may worsen the disease. The EAU panel updated its 2026 recommendations to clarify when these techniques are appropriate versus when surgical reconstruction should be pursued.

A structured search of Medline, EMBASE, and Cochrane databases (April 2022–April 2025) was conducted, including systematic reviews, comparative studies, and cohorts with at least 20 patients and 12 months of follow-up. Recommendations were developed using GRADE principles.

Direct vision internal urethrotomy (DVIU): Cold-knife DVIU is best suited for primary, short (<2 cm), single, nonobliterative bulbar strictures. Patency is highly variable (8–77%), and most recurrences happen within a year. Compared with urethroplasty, DVIU consistently shows lower patency and worse functional outcomes (e.g., the OPEN trial showed fewer reinterventions with urethroplasty). It can also salvage short, veil-like recurrences after urethroplasty. Stricture length is the strongest predictor of failure. The complication rate is around 6.5%, including erectile dysfunction (ED) (~5%), with greater risk in penile strictures.

Laser ("hot-knife") DVIU: No clear superiority exists between laser and cold-knife approaches; complication profiles differ slightly (more bleeding with cold knife, more retention and dysuria with laser).

Single dilatation: Outcomes are similar to DVIU, with recurrence rates between 24% and 65%. Visually controlled dilatation is safer than blind technique.

Post-procedure strategies: Intermittent self-dilatation (ISD) modestly reduces recurrence but often impairs quality of life. Adding intraurethral corticosteroids improves stabilization (77% vs. 64%). Intralesional agents like mitomycin C or PRP show promise but lack robust evidence. Temporary urethral stents extend patency but carry high complication rates and complicate later reconstruction.

Drug-coated balloon dilatation (DCBD): The paclitaxel-eluting Optilume balloon is a promising salvage option for recurrent short bulbar strictures, with around 78% retreatment-free survival at two years and 72% at five years. Adverse events are typically mild, although paclitaxel may persist in semen for up to six months.

Endoluminal treatments are safe and useful in carefully selected men but provide limited long-term cure. Repeated procedures risk worsening the stricture, so management should be individualized, with timely referral for urethroplasty when appropriate.

Retrograde intrarenal surgery (RIRS) has become a leading approach for treating upper urinary tract stones, supported by progress in endoscopic instruments and laser platforms. Fluoroscopy plays a central role during the procedure by guiding wire placement, sheath insertion, and navigation within the collecting system. Yet this reliance on imaging exposes both patients and operating staff to ionizing radiation, which carries cumulative risks. Stochastic effects, in particular, have no defined safe threshold and can theoretically raise the long-term risk of malignancies. The ALARA ("As Low As Reasonably Achievable") concept therefore underpins all radiation-reduction efforts in endourology.

The authors searched PubMed, Cochrane, EMBASE, Web of Science, and ClinicalTrials.gov for publications between January 2000 and July 2025 dealing with fluoroscopy reduction during RIRS. Twenty-nine studies were retained for analysis using PRISMA methodology, with bias evaluated through the RoB 2 tool for randomized trials and the Newcastle–Ottawa Scale for non-randomized work. Complications were uniformly recategorized using the Clavien–Dindo system.

Preoperative planning: Reviewing imaging in advance, displaying it during surgery, and using structured pre-fluoroscopy checklists substantially lower radiation doses. Kokorowski and colleagues documented a 67% drop in fluoroscopy time and an 88% reduction in dose-area product after introducing such a checklist, while Greene's team reported an 82% decrease in fluoroscopy time without added complications. Optimal patient placement, weight-adjusted dose settings, low C-arm tube positioning, and laser-guided centering all contribute to minimizing exposure.

Fluoroless and fluoroscopy-free RIRS: Multiple cohorts have shown that abandoning or markedly limiting fluoroscopy is feasible in selected cases. Studies report stone-free rates ranging from roughly 70% to 98%, with low complication rates. The "sheathless and fluoroless" variant, beginning with semirigid ureteroscopy and proceeding over a guidewire, has yielded comparable outcomes. A 2024 randomized multicenter trial by Chung and colleagues found no meaningful differences in success, complications, operative duration, hospital stay, or retreatment between conventional and radiation-free RIRS. A 2021 meta-analysis covering 4029 patients similarly demonstrated equivalence, with only a 5% conversion rate to fluoroscopy-assisted technique. Suitable candidates have normal anatomy, well-localized stones, and ideally a pre-existing double-J stent, while patients with impacted calculi, strictures, or congenital anomalies should still undergo conventional fluoroscopic RIRS. Surgeons typically need around 50 prior cases of standard fluoroscopy-guided RIRS before transitioning safely.

Equipment optimization: Replacing continuous fluoroscopy (30 frames per second) with intermittent fluoroscopy at lower rates dramatically lowers exposure without harming outcomes reductions of around 30%–64% have been reported across endourological procedures. Collimation narrows the X-ray beam, cutting scatter and decreasing operator hand and thyroid exposure by up to 65%. The "last image hold" function lets surgeons review the prior image without re-irradiating the patient, while surgeon-controlled pedal use and stepping back when not imaging further limit unnecessary exposure.

Training and education: Formal radiation-safety training remains inconsistent across urology programs, and protective gear like leaded eyewear and gloves is often underused. Simulation-based training has reduced radiation exposure in interventional radiology and cardiology and may produce similar gains in RIRS, although it cannot replace mentor-led teaching.

Future directions: Real-time electronic dosimetry offers immediate feedback during surgery, and artificial intelligence is emerging as a tool for automated collimation, image enhancement at lower doses, and refining safety protocols.

Lowering radiation exposure during RIRS depends on a layered approach: thorough preoperative preparation with checklists, intraoperative use of fluoroless techniques and equipment optimization where appropriate, and ongoing training in radiation safety. The evidence supports the safety and effectiveness of these strategies in carefully chosen patients, although larger randomized trials remain necessary to standardize practice.

Robotic partial nephrectomy (RPN) is the recommended treatment for cT1–2 renal tumors, balancing oncologic effectiveness with kidney preservation. Despite refinements in technique, a substantial portion of patients still experience meaningful renal function decline after surgery. Two factors are thought to contribute: warm ischemia from hilar clamping and tissue damage from suturing the resection bed (renorrhaphy). To address these concerns, surgeons have explored off-clamp approaches, and more recently, sutureless (SL) techniques in which hemostasis is achieved through diathermocoagulation of the enucleation bed rather than parenchymal stitching. Until now, however, no high-quality randomized data has compared sutureless versus renorrhaphy approaches during purely off-clamp RPN (ocRPN).

The investigators carried out a single-center, single-surgeon, prospective randomized controlled trial at the Regina Elena National Cancer Institute in Rome, registered as NCT06846112. Adults with solitary cT1–2N0M0 renal masses suitable for elective nephron-sparing surgery were enrolled, while patients with solitary kidneys, prior renal surgery, multiple lesions, or imperative indications were excluded. A covariate-adaptive 1:1 randomization scheme was used to balance the two arms on age, sex, baseline kidney function, and tumor complexity. Pathologists assessing margins remained blinded to allocation, although surgeons and patients could not be blinded due to the surgical nature of the comparison. The primary outcome was Trifecta achievement at discharge defined as negative margins, absence of major (Clavien–Dindo ≥3) complications, and ≤30% drop in eGFR with noninferiority declared if the lower bound of the confidence interval for the between-group difference exceeded 10%.

All operations were performed by a single highly experienced robotic surgeon using a transperitoneal three-arm approach with the da Vinci Xi platform. The renal hilum was deliberately not dissected since no clamping was performed. After identifying the tumor and marking its borders, intra-abdominal pressure was briefly raised to 20 mmHg to facilitate enucleation along an avascular plane. Feeding vessels were progressively coagulated as encountered. In the SL arm, hemostasis was finalized through systematic monopolar diathermocoagulation of the resection bed, with oxidized cellulose applied near the calyceal system to limit thermal injury. In the renorrhaphy (RR) arm, single-layer cortical suturing was performed instead.

Of 374 screened patients, 248 were enrolled and randomly assigned. Intraoperative crossover happened in 18 cases 9 from each arm reflecting practical surgical adjustments rather than technique failures. Baseline characteristics were well matched, with median age 62 years, median tumor diameter 3 cm, and most lesions of low-to-intermediate complexity (88% with RENAL score below 10).

The Trifecta was reached in 93% of SL patients versus 95% of RR patients, with an absolute difference of 2.4% (90% CI: −7.4% to +2.6%), which fell within the prespecified noninferiority margin (one-sided p = 0.006). Operative time (around 65 minutes), hospital stay (3 days), hemoglobin drop, and acute kidney injury rates (1.6% in both arms) did not differ meaningfully. Blood transfusion was needed in only three SL patients and none in the RR group. Nine urinary fistulae developed across the entire cohort numerically more frequent in the SL arm but without reaching statistical significance and all were managed conservatively with temporary stenting. Notably, no pseudoaneurysms occurred in either group.

Renal function tracked similarly between groups at one month, three months, and twelve months, with both serum creatinine and scintigraphy-based GFR remaining stable. Surgical margins were negative in all patients, and Kaplan–Meier estimates showed 99% recurrence-free survival at one year regardless of technique.

The trial supports the idea that omitting renorrhaphy during off-clamp robotic partial nephrectomy does not compromise surgical quality, perioperative safety, or short-term kidney function. The anticipated functional benefit of avoiding cortical sutures suggested by experimental porcine data showing deeper ischemic injury from suturing compared with shallow thermal effects of coagulation was not clearly demonstrated here, possibly because most lesions were small and predominantly endophytic with limited tumor–parenchyma interface. The authors caution that results derive from a single high-volume center, with a surgeon who has performed over 1000 off-clamp procedures, which restricts how broadly the findings can be applied. Tumor complexity was generally low to moderate, follow-up was relatively short, and the study lacked statistical power for oncologic equivalence.

In skilled hands at a high-volume center, sutureless purely off-clamp RPN is a safe and effective alternative to renorrhaphy for selected cT1–2N0M0 renal tumors, with comparable surgical, functional, and early oncologic outcomes. Multicenter trials and longer follow-up are needed to identify which patients may benefit most from one approach over the other.

Testicular germ cell tumours (TGCTs) represent the most frequently diagnosed cancer in men between ages 15 and 35, accounting for nearly all malignancies originating in the testes. Roughly 55% are seminomas, 44% are non-seminomas, and the remainder consist of rare histological types. Treatment selection depends on multiple variables, including histology, clinical stage, tumor marker levels, IGCCCG prognostic group, and patient-specific factors. Therapeutic options span orchidectomy, retroperitoneal lymph node dissection (RPLND), radiation, and chemotherapy regimens most commonly bleomycin, etoposide, cisplatin, or carboplatin combinations.

Because cure rates for TGCTs are exceptionally high, the majority of patients survive long enough to encounter delayed adverse effects of therapy. Among the most concerning of these is the development of secondary malignant neoplasms, particularly secondary leukaemias. Although prior reviews have addressed second malignancies broadly, no previous synthesis had isolated leukaemia as a distinct outcome of interest. This study aimed to fill that gap by quantifying leukaemia risk among TGCT survivors treated with surgery, chemotherapy, or radiation, benchmarked against the general population.

The investigators conducted a systematic search across MEDLINE, EMBASE, and the Cochrane Library, supplemented by manual reference review, registering the protocol with PROSPERO (CRD42024618337) and reporting findings according to PRISMA 2020 standards. Eligible studies were peer-reviewed cross-sectional, cohort, case–control, or experimental investigations examining patients with primary TGCTs (seminoma or non-seminoma) who received surgery, radiation, or chemotherapy, and that reported quantitative effect estimates for secondary leukaemia versus the general population, with at least 5 years of median follow-up. Excluded were case reports, case series, abstracts, non-human studies, and studies in highly selected populations such as patients living with HIV.

Two independent reviewers screened studies and extracted data using the Covidence platform, with disagreements settled by consensus. Risk of bias was judged using the ROBINS-E tool, and certainty of evidence was rated with the GRADE framework. Random-effects meta-analyses—with inverse-variance weighting and Hartung-Knapp-Sidik-Jonkman confidence intervals where appropriate—were performed for treatment categories with more than two eligible studies. Heterogeneity was quantified through I² statistics, and prespecified subgroup analyses examined follow-up duration, treatment era, and tumor histology.

From 2,609 records, six retrospective cohort studies ultimately met inclusion criteria, encompassing 57,365 TGCT survivors and 163 secondary leukaemia events, with a weighted-mean follow-up of 12.8 years. Recruitment periods spanned 1943 to 2014.

For chemotherapy, five studies (15,375 patients, 43 leukaemia events) yielded a pooled standardized incidence ratio (SIR) of 5.77 (95% CI 1.35–24.62; p = 0.03), indicating a statistically significant elevation in leukaemia risk relative to the general population, with moderate-to-high heterogeneity (I² = 79%). For radiation therapy, four studies (22,988 patients, 81 leukaemia events) produced a pooled SIR of 2.55 (95% CI 0.70–9.32; p = 0.11), suggesting an elevated but not statistically significant excess risk, with substantial heterogeneity (I² = 77%). Only two studies reported on surgery alone, both showing SIRs below 1.8 with confidence intervals approaching unity, so no quantitative pooling was performed.

Subgroup analyses by follow-up duration, treatment era, and histology did not reveal statistically significant differences. A sensitivity analysis excluding high risk-of-bias studies attenuated the chemotherapy effect (SIR dropped to 3.74, 95% CI 1.29–10.91), while radiation estimates remained largely unchanged. The certainty of evidence was rated as moderate using GRADE for both modalities.

This is the first meta-analysis to specifically isolate secondary leukaemia as an outcome in TGCT survivors. The pattern observed elevated leukaemia incidence following chemotherapy, with smaller and statistically uncertain risk after radiation mirrors broader oncology literature on cytotoxic therapy. For instance, platinum-based regimens used in ovarian cancer have been associated with three- to four-fold increases in leukaemia risk, escalating to roughly eight-fold at higher cumulative doses. The current findings indicate that TGCT-directed therapies similarly produce a moderate-to-large relative increase, even though the absolute risk remains low.

Importantly, the excess risk appears to persist into the modern treatment era, despite reductions in cumulative drug exposure and treatment intensity. The typical latency period for therapy-induced leukaemia is around 5–6 years, with most events occurring within the first decade after treatment, although rare cases can emerge 15–20 years later.

The authors highlight several limitations: all included studies were observational, leukaemia events were rare leading to wide confidence intervals, granular details on chemotherapy regimens and radiation doses were largely unavailable preventing dose–response analysis, some cohorts were treated decades ago using outdated higher-intensity protocols, and nearly all data came from Western populations limiting global applicability.

Given that TGCT cure rates exceed 95%, balancing therapeutic effectiveness against long-term toxicity is increasingly important. Although routine bone marrow surveillance is not recommended for asymptomatic survivors, clinicians should maintain heightened vigilance for symptoms such as persistent cytopenias or unexplained fatigue, particularly during the first decade post-treatment. These data also reinforce the value of choosing surveillance over adjuvant therapy when oncologically appropriate for example, in stage I disease or following primary RPLND since avoiding unnecessary chemotherapy or radiation eliminates the small absolute leukaemia risk attached to those modalities. Nonetheless, when chemotherapy or radiation is clinically indicated, the absolute risk of secondary leukaemia is sufficiently low that it should not deter their use; instead, the findings should support informed shared decision-making and careful long-term survivorship care.

Chemotherapy administered for TGCTs is linked to a meaningful relative increase in the likelihood of developing secondary leukaemia, although the absolute likelihood remains modest. Radiation therapy shows a numerically elevated but statistically inconclusive association, and data on surgery alone are too sparse to allow firm conclusions. Future prospective and registry-based research is needed to determine whether contemporary, de-intensified TGCT regimens further reduce this late toxicity.

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