Introduction: Benign prostatic hyperplasia (BPH) is one of the most common urological conditions. When indicated, transurethral resection of prostate (TURP) is the gold standard therapy till now, but with numerous side effects, one of them is the retrograde ejaculation. Aquablation, a novel robotically controlled, waterjet based therapy, is proposed as a treatment for BPH-related LUTs. The main advantage is the preservation of antegrade ejaculation.
Aim of study: To evaluate the effectiveness of Aquablation technique in improving LUTS while maintaining antegrade ejaculation.
Materials & methods: The study included sexually active men with LUTs related to BPH and prostate volumes between 30 to 80 cm³. Participants were assigned to either the Aquablation or transurethral resection of the prostate groups without prior selection. We excluded Patients with previous prostate or bladder surgery, diabetic neuropathy, and those taking anticoagulants from the study. A standardized pre- and post-operative evaluation was conducted, which involved medical and sexual history, the international prostate symptom score (IPSS), physical examination, and measurement of post-void residual urine volume. The statistical analysis was done with SPSS software, using chi-square and F-tests.
Results: 126 patients were included in the study. Mean follow-up was 19 months (6-32 months). The groups were comparable in main characteristics. The improvement of LUTS after Aquablation was statistically and clinically comparable with the results of TURP. Antegrade ejaculation was preserved in the majority of patients after Aquablation. Postoperative complications in the form of Bleeding, reoperation, and urinary retention after catheter removal were comparable in both groups. The most common major complication after Aquablation was acute urinary retention. Hospital stay in patients in Aquablation group was significantly shorter in comparison to TURP group.
Conclusion: Aquaablation is a safe and effective modality for treating Patients suffering from BPH, especially those who want to preserve their ejaculatory function.

Correspondence to: Ahmed Yousef, Lausitzer Seeland Klinik Hoyerswerda, Hoyerswerda, Germany.
Email: ahmed0122@med.bsu.edu.eg

Aim: To assess the impact of the TilePro^TM software on surgical workflow and tumor localization by integrating real-time intraoperative ultrasound during robotic-assisted partial nephrectomy for endophytic medial renal tumors.
Methods: We are conducting an ongoing, prospective analysis of patients undergoing retroperitoneal roboticassisted partial nephrectomy for endophytic medial renal tumors. The procedure is performed using the da Vinci Xi surgical system with warm ischemia. The TilePro^TM software is used to display a real-time feed from a laparoscopic ultrasound probe directly on the surgeon’s console. We are collecting data on patient demographics, tumor characteristics, operative time, warm ischemia time (WIT), estimated blood loss (EBL), intraoperative ultrasound usage time, and postoperative outcomes, including surgical margin status and complications.
Results: To date, five patients have been enrolled in the study. The mean tumor size was 3.6 cm (range 2.9-4.5 cm). The average operative time was 250 ± 40 minutes, and the mean warm ischemia time was 13 ± 3 minutes. The average estimated blood loss was 200 ± 30 mL. The dedicated time for intraoperative ultrasound guidance for tumor localization and margin definition was an average of 10 ± 3 minutes. In all five cases, the tumor was successfully identified and resected with negative surgical margins. There were no intraoperative or major postoperative complications.
Conclusion: The integration of intraoperative ultrasound using the TilePro^TM software is a feasible, safe, and effective technique for robotic-assisted partial nephrectomy of endophytic medial renal tumors. It allows for precise realtime tumor localization and margin assessment without significantly prolonging operative time, contributing to excellent surgical outcomes.

Correspondence to: Ahmed Yousef, Lausitzer Seeland Klinik Hoyerswerda, Hoyerswerda, Germany.
Email: ahmed0122@med.bsu.edu.eg

Background: Stress urinary incontinence (SUI) adversely affects women’s quality of life. While pelvic floor muscle training is first-line therapy, moderate to severe cases often require surgical intervention. The transobturator midurethral sling (TOT) is widely adopted due to quicker recovery, though concerns exist regarding mesh complications. Laparoscopic Burch colposuspension provides com- parable results to midurethral slings but is less commonly performed. Comparative data from Egypt are limited.
Objective: To compare the efficacy, safety, and patient-reported outcomes of laparoscopic Burch colposuspension versus TOT in Egyptian women with SUI.
Methods: In this randomized clinical trial, 52 parous women with SUI were randomized 1:1 to undergo laparoscopic Burch colposuspension (n = 26) or TOT (n = 26) between January 2021 and December 2023. Baseline evaluation included clinical, laboratory, imaging, and urodynamic assessments. The primary outcome was SUI resolution via cough stress test. Secondary outcomes included Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7) scores at 3, 6, and 12 months. Statistical comparisons were made between groups and over time.
Results: Baseline characteristics were similar, except for higher detrusor overactivity in the TOT group. Operative time was longer in the colposuspension group (P < 0.001). The colposuspension group had a significantly higher treatment failure rate (34.6% vs. 7.7%; P = 0.017) and greater need for reintervention (P = 0.025). TOT resulted in more sustained symptom relief and significantly lower UDI-6 and IIQ-7 scores at 6 and 12 months. Chronic pain locations differed between groups, and urinary tract infections were more common with TOT (P = 0.042).
Conclusion: Both procedures improved SUI symptoms, but TOT demonstrated superior long-term efficacy, lower failure rates, and sustained improvements in quality of life compared to laparoscopic Burch colposuspension. The only concern regarding TOT is about the long term complications.

Correspondence to: Mahmoud Farouk Abughanima, Assiut University, Assiut, Egypt.
Email: mahmoud12@aun.edu.eg

Introduction: This study aims to compare the efficacy and safety of autologous rectus fascia sling versus synthetic mid-urethral sling in treating female stress incontinence.

Material & methods: This prospective study involved 120 female patients with stress incontinence. Participants were equally divided into 2 groups: Group 1 (n = 60) received a synthetic transobturator tape (TOT) sling, while Group 2 (n = 60) underwent an autologous rectus sheath sling procedure. The groups were compared pre and postoperative as regard to results of Urogenital Distress Inventory-Short Form (UDI-6), operative time, postoperative pain scores, duration of indwelling urethral catheter, hospital stay, return to normal activity. A p-value of less than 0.05 was used to determine statistical significance.

Results: Our patients were normally distributed with no statistically significant differences in patients’ demographic data and comorbidities, mean hospital stay was longer and the return to normal activity was delayed in Group 2 compared to Group 1. The highest mean postoperative pain score was recorded in Group 2 with mean = (2 Â ± 0.9) and (5.4 Â ± 1.4) in groups 1 and 2, respectively. Also, there were statistically significant differences between groups 1 and 2 for operative time, hospital stay and UDI6 score result (after 1 year) with (100%) were “succeeded” In group 1. While in group 2, (86.7%) were “succeeded” and (13.3%) were improved.

Conclusion: The TOT procedure with synthetic sling demonstrated superior operative outcomes and fewer complications compared to that with autologous rectus sheath sling.

Correspondence to: Eman El Dydamony, Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt., Cairo, Egypt.
Email: Emanmohamed.8@azhar.edu.eg

Introduction: To systematically review and compare the clinical efficacy and safety of the Swiss LithoClast® Trilogy system against laser-based lithotripsy for percutaneous nephrolithotomy (PCNL).
Material & methods: This systematic review and metaanalysis was conducted following PRISMA guidelines and was prospectively registered in PROSPERO. A comprehensive search was performed in PubMed, Scopus, Web of Science, and Cochrane Library for studies that evaluated Trilogy versus Holmium:YAG or Thulium Fiber Laser lithotripsy in adult PCNL patients. The primary outcomes analyzed were the stone-free rate (SFR), lithotripsy rate, operative time, and postoperative complications. Statistical analysis was performed using Review Manager Software. Effect size was calculated as risk ratio (RR) for dichotomous data and mean difference (MD) for continu- ous data, using a random-effects model in cases of significant heterogeneity (I² > 50%).
Results: Four studies involving 260 patients were included in the qualitative synthesis. Pooled data showed that Trilogy lithotripsy resulted in a statistically significant higher stone-free rate compared to laser lithotripsy (RR = 1.24, 95% CI: 1.06-1.44; P = 0.005), with no heterogeneity observed (I² = 0%). The lithotripsy rate was also significantly faster in the Trilogy group (MD = 33.23 mm³/min, 95% CI: 13.55-52.91; P = 0.0009) based on a pooled analysis of two studies, again with no heterogeneity (I²= 0%). There were no statistically significant differences between the two groups in mean operative time (MD = 3.75 minutes; P = 0.42) or in the risk of postoperative complications (RR = 1.44; P = 0.47).
Conclusion: Trilogy lithotripsy demonstrates superior stone-free and lithotripsy rates when compared to laserbased systems for PCNL, without compromising operative time or overall safety. The findings suggest that the unique design of the Trilogy system, which combines ultrasonic and ballistic energy with integrated suction, facilitates more efficient stone fragmentation and removal, supporting its use as a viable first-line option for PCNL.

Correspondence to: Hamza Mohamed, Faculty of Medicine, Assiut University, Assiut, Egypt.
Email: Hamza.Ahmed00099@med.aun.edu.eg

Aim: To assess the awareness, attitudes, and practices related to environmental sustainability among urologists and to explore targeted interventions, educational initiatives, and policy recommendations to enhance sustainability in urological practice while maintaining high standards of patient care.
Methods: A focus group defined objectives and methodology. Ethical approval was obtained (NEU IRB: 22425), and the study was registered on ClinicalTrials. gov (NCT06723574). A two-stage approach was adopted: a cross-sectional survey among EAU Section Office and working group members to assess sustainability awareness and practices; followed by a single-round structured consensus statement among a subset of senior EAU individuals to validate key findings and inform practical recommendations. While referred to as a ‘consensus statement’ in this manuscript, this process did not follow formal Delphi or multi-round consensus methodology.
Results: A total of 83 participants completed the first step survey, and 26 of 32 individuals responded to the consensus statement (81% response rate). High environmental awareness was reported (61.4%), with 49.3% considering sustainability in instrument use. Respondents showed high importance on implementing environmentally sustainable practices in the operating room, with 83.2% agreement rate. Institutional support was emphasized (70.9% strongly agreed), alongside making sustainability training mandatory in both residency and continuing education (87.5%). Workshops and institutional training about sustainability in urologic practice were highly supported (66.8%).
Conclusion: While awareness of sustainability is high among urologists, implementation is hindered by cost concerns, limited support, and inadequate tracking. Future efforts should focus on policy, collaboration, and costeffective solutions to enable systemic change.

Correspondence to: Atınç Tozsin, Trakya University School of Medicine, Department of Urology, Edirne, Turkey.
Email: atinctozsin@gmail.com

Aim: To evaluate the histopathological and functional effects of pirfenidone (PFD) at two doses and compare its efficacy with tadalafil (TAD) in an experimental rat model of Peyronie disease (PD).
Methods: Forty-two male Sprague-Dawley rats were randomized into five groups: Control, PD, Tadalafil 5 mg/ kg/day (TAD), Pirfenidone 30 mg/kg/day (PFD30), and Pirfenidone 300 mg/kg/day (PFD300). PD was induced by intratunical TGF-β injection. Treatments were administered orally for four weeks. Erectile function was assessed using maximal intracavernosal pressure (MICP)/mean arterial pressure (MAP) ratio. Histopathological evaluation included hematoxylin-eosin (H&E), Masson trichrome, and picrosirius red staining to assess fibrosis severity, collagen/smooth muscle ratio, and collagen type III/type I ratio.
Results: The TAD group showed the highest mean BICP value (6.5 ± 2.3), while the lowest mean was in the PFD300 group (2.0 ± 1.8), with a significant difference (P = 0.016). The mean MICP/MAP ratio was highest in the PFD300 group (1.09 ± 0.40), lowest in the TAD group (0.73 ± 0.53), with no significant differences (P = 0.363). Mild fibrosis predominated in the control group (75%), while severe fibrosis was observed in 87.5% of the PD group (P < 0.0001). In the TAD group, fibrosis was mild or moderate (75% and 25%, respectively). The PFD300 group showed a higher proportion of mild fibrosis (37.5%). All treatment groups had significantly lower collagen/ smooth muscle ratios than the PD group. For the collagen type III/type I ratio, significant reductions were seen only in the TAD and PFD300 groups. Among all treatments, the lowest collagen/smooth muscle ratio was in the TAD group, while the lowest collagen III/I ratio was seen in the PFD300 group, this was not statistically significant.
Conclusion: These findings contribute to the growing body of evidence supporting antifibrotic strategies in PD and warrant further long-term studies to evaluate the sustained efficacy, optimal dosing of pirfenidone in PD.

Correspondence to: Atınç Tozsin, Trakya University School of Medicine, Department of Urology, Edirne, Turkey.
Email: atinctozsin@gmail.com

Introduction: Absence of antegrade ejaculation is one of the drawbacks of transurethral resection of the prostate (TURP) in sexually active men. This study aimed to assess the effectiveness of preserving the urethral mucosa around the verumontanum and at the prostatic apex in maintaining antegrade ejaculation and improving early postoperative continence in patients undergoing TURP.
Material & methods: A randomized controlled trial was conducted at a tertiary care center involving patients scheduled for TURP. Participants were randomly divided into two equal groups: Group A (control) underwent conventional TURP, while Group B received an ejaculationsparing modification of the procedure. Postoperative follow-up over three months focused on voiding outcomes and the preservation of antegrade ejaculation.
Results: The study included 106 patients, with both groups demonstrating similar improvements in voiding parameters. Antegrade ejaculation was preserved in 83% (44 patients) of Group B compared to 18.9% (10 patients) in Group A, a difference that was highly statistically significant (P < 0.001). Early postoperative urge urinary incontinence was significantly lower in Group B (5.7%) than in Group A (20.8%) (P = 0.02). Other perioperative outcomes were also analyzed and compared between groups, with no statistically significant difference.
Conclusion: The ejaculation-sparing TURP technique used in this study significantly improved the preservation of antegrade ejaculation (83% success rate) and reduced early postoperative urge incontinence, suggesting it is a promising approach for maintaining functional outcomes after TURP.

Correspondence to: Ahmed Maher Higazy, Ain Shams University, Cairo, Egypt.
Email: ahmedmaherhigazy@gmail.com

Introduction: Ectopic insertion of a duplex ureter is a rare congenital anomaly that may go unrecognised until radical prostatectomy as in the case we present. Intraoperative identification is critical to avoid complications such as urine leakage, misdiagnosis as bladder or anastomotic injury, or the need for open conversion. We present a case of successful robotic management of this anomaly encountered during prostatectomy.
Material & methods: This video presents the case of a 63-year-old man undergoing RALRP for Grade Group II prostate cancer. Intraoperatively, a right-sided ectopic ureter was identified based on a sudden gush of urine from the posterior bladder neck. The ureter was cannulated with a nylon thread attached to a metal clip for orientation. Controlled spatulation was performed, and the ureter was incorporated into the bladder wall using three stay sutures. A sensor guidewire was inserted retrogradely through a 16 Fr Council-tip Foley catheter, followed by successful JJ stent placement into the ectopic ureteric orifice. Urethrovesical anastomosis was completed robotically as standard.
Results: The ureter was preserved without the need for reimplantation or open conversion. A watertight anastomosis was confirmed intraoperatively. Postoperative cystogram at 2 weeks showed no leakage. The JJ stent was removed after confirming a patent ureteric orifice, and PSA at 6 weeks was undetectable.
Conclusion: Early recognition of ectopic ureter during RALRP allows for successful robotic management without compromising urinary drainage or oncological safety. This case highlights a reproducible technique for safe handling of intraoperatively discovered ectopic ureters during robotic prostatectomy.

Correspondence to: Asem Abdelrahman, Resident Radwan Alokour, Cambridge University Hospitals, Cambridge, United Kingdom.
Email: mr.asemfathy@gmail.com

Aim: To compare clinical outcomes, procedural efficiency, complication rates, and learning curves of holmium laser enucleation of the prostate (HoLEP) versus bipolar enucleation (BipoLEP), as part of the initial EEP implementation in Algeria.
Materials and methods: A retrospective study performed at the department of urology, university hospital of Oran, from December 2024 to April 2025. Sixty patients with symptomatic BPH were enrolled, half underwent HoLEP, and 30 underwent BipoLEP, all procedures performed by two surgeons. HoLEP comprised laser enucleation followed by morcellation whereas BipoLEP involved enucleation with direct bipolar resection. Demographic data, perioperative variables (operation time, tissue-weight of enucleated tissue, haemoglobin drop, duration of catheterization and hospital stay) as well as occurrence of complications (graded after Clavien-Dindo) were registered. Functional outcomes (IPSS, Q_max, QoL, PVR) at 1 and 3 months. We applied Welch’s t-test to analyze quantitative data, and Fisher’s exact test for qualitative data (P < 0.05). Results: Preoperative characteristics were similar. HoLEP achieved greater enucleated tissue weight (40.4 g vs. 31.5 g, P = 0.0083), lower hemoglobin drop (0.81 vs. 1.32 g/dL, P = 0.0003), and higher retrieval efficiency (6.60 vs. 2.79 g/min, P < 0.0001). No transfusions were needed in HoLEP versus three in BipoLEP. HoLEP showed longer operative time (157 vs. 139 min, P = 0.0593), with four staged in the HoLEP group procedures indicating a steeper early learning curve. Functional recovery and complication rates were similar, with most events being minor (Clavien I–II).
Conclusion: Both HoLEP and BipoLEP are safe and effective for BPH surgery. HoLEP offers superior hemostasis, efficiency, and tissue removal at the cost of longer operative time. BipoLEP remains a valuable, accessible alternative with a smoother learning curve and similar functional outcomes. The choice between techniques should be guided by surgeon experience, equipment availability, and individual patient considerations.

Correspondence to: Mohamed Elamine Berraho, University Hospital of Oran – Department of Urology, Oran, Algérie.
Email:medaminebrh2020@gmail.com

Introduction: Recurrent pelvi-ureteric junction obstruction (PUJO) poses significant surgical challenges, particularly in young adults with previous failed pyeloplasty. Robotic surgery offers enhanced precision and visualization, making it ideal for complex redo cases. This video highlights a re-do robotic Scardino vertical flap pyeloplasty in a 25-year-old male with persistent PUJO following a prior pyeloplasty.
Aim: To demonstrate the feasibility and technical nuances of performing a re-do robotic pyeloplasty using a Scardino vertical flap approach in a patient with significant adhesions and distorted anatomy.
Methods: The patient was positioned in right lateral decubitus. A Hasson technique was used for the 12 mm assistant port, followed by pneumoperitoneum and insertion of four 8mm robotic ports. After careful dissection of dense adhesions around the renal pelvis and ureter, intraoperative indocyanine green (ICG) dye was injected through a nephrostomy to delineate anatomy. A small crossing vein was identified, clipped, and divided. A vertical incision was made in the renal pelvis, with ureteral spatulation distal to the strictured segment. A wide-based ureteral flap was fashioned from the redundant pelvis, rotated and sutured to bridge the ureteric defect, creating a spiral flap. An 8/24 ureteric stent was inserted. The anastomosis was completed using 4/0 Biosyn. A drain was placed, and ports were closed.
Results: The procedure was completed robotically without intraoperative complications. The nephrostomy was removed under fluoroscopy post-operatively. The patient was discharged on postoperative day one. The ureteric stent was removed at 8 weeks. He remains asymptomatic and is awaiting a follow-up renogram at 3 months.
Conclusion: Re-do robotic pyeloplasty using a Scardino vertical spiral flap is a safe and effective option in com- plex PUJO cases. The robotic approach enhances precision, facilitates dissection in scarred fields, and allows for tailored reconstructive techniques to optimize outcomes.

Correspondence to: Moaz Fathy Ismail Abdelrahman, East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom.
Email:moazfathy0@gmail.com

Background: Renal cell carcinoma with fibromyomatous stroma (RCC-FMS) is a rare tumor characterized by clear cells, seen within a fibro-leiomyomatous stroma. Initially listed as a provisional entity in the 2016 WHO classification, its status has evolved, with the 2022 WHO classification noting its overlap with clear cell papillary RCC and clear cell RCC, suggesting it may represent a distinct molecular subtype. Mutations in the TSC1, TSC2, MTOR and ELOC (TCEB1) pathways have been proposed in its pathogenesis.
Case presentation: We report two cases of RCC-FMS in adult patients aged 46 and 39 years, each presenting with incidentally discovered renal-confined masses. Both patients underwent partial nephrectomy. In one case, contrast enhanced CT identified a cortical, exophytic, upper pole mass, RENAL score 7, initially suspected to be a fat poor angiomyolipoma. The second case involved a 5.5 cm exophytic lower pole mass, less than 4mm from the collecting system, RENAL score 8.
Results: Grossly, both tumors were solid, and solid-cystic measuring 2.9 cm and 5.5 cm, in maximum diameter, respectively. Histologically, they demonstrated clear cells in tubulopapillary, nested, and cystic arrangements within a prominent fibromyomatous stroma with thick-walled blood vessels. Immunohistochemically, tumor cells were diffusely positive CK7, CA IX, CD10 and vimentin, and negative for GATA 3 and CD117. Desmin highlighted the leiomyomatous stromal component. Both tumors were staged as pT1a.
Conclusion: RCC-FMS is a rare renal neoplasm with distinct histomorphological and immunohistochemical fea- tures, distinguishing it from clear cell RCC and clear cell papillary RCC. These cases support the notion that RCC_FMA may represent a separate diagnostic entity. Further molecular studies and larger case series are needed to better define its classification and biological behavior.

Correspondence to: Samar El Achy, Alexandria Faculty of Medicine, Alexandria, Egypt.
Email: samarelachy@gmail.com

Introduction: Current EAU and AUA guidelines recommend percutaneous nephrolithotomy (PNL) as the firstline treatment for renal stones > 20 mm, particularly staghorn calculi, due to high single-session stone-free rates (SFR). However, PNL is invasive, requires prone positioning, and carries risks such as bleeding, adjacent organ injury, and prolonged recovery. Advances in flexible ureteroscopy (fURS), high-power holmium lasers, and ureteral access sheath technology may enable comparable clearance rates for large and complex stones with lower morbidity.
Objective: To evaluate the feasibility, efficacy, and safety of fURS as a primary treatment for staghorn stones, and to assess whether the current 2 cm size threshold between PNL and RIRS should be reconsidered.
Methods: Between January 2022 and January 2025, we retrospectively reviewed 10 consecutive patients with complete or partial staghorn calculi who underwent fURS as the sole treatment modality at our center. All procedures were performed under general anesthesia using a 14 Fr ureteral access sheath and high-power holmium:YAG laser. Staged procedures were performed when necessary. Stone-free status was defined as no fragments > 4 mm on follow-up imaging (KUB/ultrasound) at 3 months. Results: The mean patient age was 58 ± 4.5 years, with 6 males and 4 females. The mean stone burden was 3.53 ± 0.41 cm (range 3.0–4.1 cm), and the mean stone density was 1245 ± 448 Hounsfield units (HU). Six patients had complete staghorn stones and four had partial staghorn stones. Single-session SFR was 70% (7/10), and the final SFR after ≤ 2 sessions was 90% (9/10). The mean operative time per session was 181 ± 40 minutes. Seven patients required one session, two patients required two sessions, and one patient underwent three sessions. No major complications (≥ Clavien III) occurred; two patients developed transient postoperative fever, and no transfusions or adjacent organ injuries were recorded. Hospital stays ranged from 1 to 3 days (mean 1.9 ± 0.8 days).
Conclusion: Flexible ureteroscopy achieved high clearance rates with minimal morbidity in staghorn stone cases traditionally managed by PNL. These results support considering RIRS as a first-line treatment option for selected patients and suggest the need to refine current size-based guideline thresholds.

Correspondence to: Hossam Ismail, LSK Hoyerswerda, Germany.
Email: Drismailhossam@gmail.com