We have just read a Letter to the Editor from @nickva1, @alison_tree, @piet_ost that carries an implication of dishonesty, and unfaith, deliberately distorting the facts in order to criticize and mislead readers to truly understand the article .

“Oncological Outcomes Following apy for Treatment of Nonmetastatic Prostate Cancer in the United Kingdom: An Updated Analysis of 3477 Patients from the Prospective HEAT and ICE Registries”

We firmly oppose their behavior. Our forthcoming analysis will clarify the actual content and specifically identify how they have twisted the information.

@LondonProstate1 ,@AJWLight @IP_London

@drshchaudhry @Mohamedendourol @uroksarica @JustineShi_js @DocGauhar @StefaniaFerret @Endo_Society @endouro @peepeeDoctor @Urologeman @Endo_Sec_Eua Suction is the integral part of reusable #MIP sheath by @KARLSTORZUro. Look up all publications of our #TRUST group on #MIP and #towerofbabel @TheodorosTokas Udo Nagele David Schilling pubmed.ncbi.nlm.nih.gov/25833660/
#minimalivasivePNL available since 2005.

Tomorrow, the results of the VOLGA trial will be presented and discussed during the "game-changing" session at #EMUC26

Read my thoughts and questions below

Basically:
🔹 Why did twice as many control patients decline surgery?

🔹 Why was cystectomy delayed beyond 12 weeks control patients?

🔹 Why did so few receive EV after recurrence?

@OncoAlert @Uroweb

beyondtheabstracturology.substack.com/p/volga-a-clea…

The Great Betrayal

Cristiano Ronaldo has officially retired from international football 🇵🇹

He retires with the most caps in international football (234) and most goals in international football (146) 🐐

After prostate surgery, MASTER found that sling and artificial sphincter procedures improved leakage symptoms, although most men still reported some incontinence.

Ref: doi:10.1016/j.eururo.2021.01.024
#UrinaryIncontinence #Urology

#PROTEUS Substudy Design and Three-Year Event-Free Survival Endpoint.
Mary-Ellen Taplin, MD joins @neerajaiims to discuss the PROTEUS substudy, randomizing 400 high-risk localized prostate cancer patients 3:1 to prostatectomy alone versus six months of apalutamide and ADT, more months of apalutamide and ADT. #WatchNow on UroToday > bit.ly/4z8V2Fu @DanaFarber

Correction to our earlier post: Wymer, Lehner et al. found HoLEP was most cost-effective for BPH in 30–80 and 80–150 cc prostates using a decision model. Patient preferences may change rankings.

@vidit_sharma_ @SocietyofBPD

doi.org/10.1016/j.urol…

Continuing on with added context:

The reason this one paper matters so much is its recency. EviCore has, for many years now, deemed LDRT for OA as medically necessary.

To reverse course means new information must have become available between their last version and this one.
s published in September 2025, which means it technically predates the guidelines from February 2026 covering LDRT, but...we'll just say EviCore didn't find it in time for those guidelines.

Unfortunately, it's not "new" data to justify this reversal, it's just a meta-analysis. But it has a convenient conclusion (if you're an insurance company).

Alright, we can skip over the publishing Round Robin AI Ring the authors have going and just head right to the first graphic. Table 1.

So, Table 1, second column. Several of the study design labels are incorrect - RCTs listed as cohort, retrospectives listed as RCTs, etc.

Ultimately, not SUPER problematic.

But uh, the next column is. The number of patients for each study in the third column.

Those are not anywhere close to the patient populations actually used in those studies. The difference is severe (Hermann 2021 is listed as 160, actual is 25; Keller 2013 is actually over a thousand, listed as 120, etc).

Well that's not good.

And then we get to "Duration of Complaints". Somehow, mysteriously, all of these studies enrolled patients with 9.5-11.1 years of symptoms prior to treatment.

Obviously...wildly incorrect as well.

But the best are the final two columns which are outcomes. Second to last is pain, last is function.

It sure is weird that, for a meta-analysis claiming LDRT has no effect, that each and every study allegedly used in their analysis ALL show an improvement in pain and functional status.

Now, normally I would expect a meta-analysis to conclude positive treatment effect if, you know, each and every included study showed a benefit in multiple domains.

Obviously...those results aren't what the original manuscripts themselves concluded (because, for example, they might have measured outcomes completely differently...).

Oh and I totally forgot the column that somehow claims each included study miraculously enrolled 38-44% males. All of them.

Crazy!

The one outlier is the final study, Fazilat-Panah et al, 2025.

If you look at the history of this Hammadeh paper, it was submitted originally in March 2025 and accepted in July 2025.

The Fazilat-Panah paper was published online in March 2025.

Obviously, Hammadeh and friends couldn't have included the Fazilat-Panah paper with their original submission - they wouldn't have known about it.

So one of the reviewers (hard to imagine this paper had reviewers, but whatever) must have asked them to include this newly published paper as a revision.

But that Fazilat-Panah paper is excellent: it's a double-blind sham-controlled RCT showing a tremendous benefit of LDRT.

Thus, when Hammadeh plugged that paper in and re-ran his AI tool...that's what caused the the calculated I² to be a massive 96%.

My assumption is the AI tool hallucinated much of the original data towards "no benefit". But when this Fazilat-Panah paper data was included after the fact with the real results - the heterogeneity went off the rails.

No paper should be published with an I² of 96%.

So, I assume no reviewer actually read this paper after it was re-submitted as a revision. Then the editors rubber-stamped the AI trash, and boom!

@evicorehc and their AI scraping algorithm programmed to find any and every reason for denial uncovered this gem and here we are today.

Who doesn't love science and medicine in 2026?

(probably the suffering patients getting treatments denied don't love it, but EviCore hasn't ever cared about that before, and neither has @SpringerNature)

@StrijbosMichielte it in their statistics plan.
This substudy aimed to enroll ~ 400 patients to generate 120 events.
With this number of events, the trial would only achieve about 66% statistical power, which was below the desired threshold.
Therefore, just in case, the investigators plawith an additional ~200 patients from the main study to raise the overall statistical power to 80%.

However, in reality, after a median follow-up of approximately 3 years, the number of events reached 207, that is far exceeding the original projection of 120 events.
So, this substudy achieved adequate statistical power without the need for the planned pooled analysis. Then the primary analysis is conducted only in the 408 patients.

RT @scoffonecesare:

Recommended reading materials prior to second opinions…. @dr_coops @uroegg @VickersBiostats @OtisBrawley (and of course the PCF new diagnosis pdf).

🚨 PSMA PET/CT complements mpMRI for selecting #FocalTherapy candidates with #prostatecancer 🚨

👉Our group’s new paper, out today in @jnmnews

👥 112 men, biopsy GG ≤3, unilateral disease, PSA <20, PSMA PET + mpMRI before RP
📊 Diagnostic accuracy study, reference standard who🔬 Outcome: detecting ineligibility for focal therapy (EPE, SVI, multifocal/bilateral, any GG>3)

✅ 69% were actually ineligible on whole-mount, incl 17% w/ GG>3
✅ Sensitivity for ineligibility: PET + MRI 83% vs MRI 70% vs PET 53% (P<0.001 vs PET)
✅ MRI more sensitive for EPE (77 vs 32%), PET more specific (90 vs 58%)

⚠️ Adding PET dropped specificity to 26%; per 100 pts, ~9 more true exclusions but ~7 candidates falsely excluded

🎯 Adding PSMA PET to mpMRI catches more adverse pathology at the cost of specificity for focal candidacy

🔗 doi.org/10.2967/jnumed…

@urotoday @UrologyTimes @PCF_Science @CalaisJeremie @CzerninJohannes @StevenSRaman_MD @wayne_brisbane @uroegg @UclaUrology @CedarsSinai

Should high-risk prostate cancer go straight to surgery? PROTEUS finally offers a head-to-head answer: preoperative apalutamide + ADT vs prostatectomy alone 👇

cslide.ctimeetingtech.com/esmo2026/atten…

LBA53 - Perioperative apalutamide (APA) plus androgen-deprivation therapy (ADT) with radical ic lymph node dissection (RP + PLND) vs RP + PLND alone in patients (pts) with high-risk localized or locally advanced prostate cancer (HR LPC/LAPC): PROTEUS substudy

PROTEUS’s prespecified open-label substudy randomized 408 patients with high-risk localized or locally advanced #ProstateCancer 1:3 to perioperative apalutamide plus ADT or immediate radical prostatectomy plus lymphadenectomy alone.

➡️Apalutamide plus ADT significantly improved event-free survival (median not reached vs 19.1 months; HR 0.38) and MFS (HR 0.49), and reduced the need for subsequent therapy at 3 years (35% vs 68%). Grade 3/4 adverse events were higher with apalutamide (30.7% vs 21.7%).

@Albert0Briganti, @EfstathiouEleni, @ProfHadaschik, @adamkibel_uro, @delataillealex, @marty_gleave

@OncoAlert 🚨 #LPCCC27
@Silke_Gillessen
@AOmlin
@ProfKHerrmann
@weoncologists

We should be noticed that this substudy was designed to fill a core evidence gap. Although the main PROTEUS study demonstrated that apalutamide + ADT + RP was superior to ADT + RP .

But, the problems is ADT + RP is not the current SOC for high-risk prostate cancer.
In reality, the SOC high-risk PCa is still RP only.
Therefore, a direct comparison between the PROTEUS regimen vs RP alone is needed to determine the true clinical value of this regimen. That’s the reason of this substudy.

If you understand the context of this substudy you will know the reason PSMA PET scheduling was not uniform between the two arms.
Because the treatment duration of the two groups differed .

The apalutamide + ADT arm underwent 1 year of systemic therapy (6 months neoadjuvant + 6 eas the control arm underwent RP alone.

That’s why, in the control arm, PSMA PET scans at 3 and 9 months after RP were added as active surveillance windows during the period of Apalutamide +ADT.
And at the 15-month post-RP time point, the imaging schedule became relatively aligned with that of the apalutamide arm (3 months after treatment apalutamide+adt completion).
Because this is a high-risk patient group, you cannot wait until 15 months post-operation to have the two imaging schedule scans synchronized.

It is true that the EFS results favoring apalutamide were substantially influenced by this asymmetric imaging schedule
However, this should be recognized as an unavoidable limitation of this substudy design, stemming from the difference in treatment regimens between the two arms rather than from methodology error.

With VOLGA results coming at #ESMO26, a summary of contemporary phase III perioperative trials in muscle-invasive bladder cancer.

⚠️ Different populations and designs—avoid cross-trial comparisons. VOLGA and EV-303 importantly include surgery-alone control arms without The next challenge: identifying who truly needs adjuvant ADC therapy—and who can safely avoid it.

#BladderCancer #GUOnc @OncoAlert @BladderCancerUS

@scserendipity1 @Kenrickng1 @TylerSbrt @alison_tree @DrSpratticus @_ShankarSiva nature.com/articles/s4139…

This may be of some use!

@TonyFeleflyree with you, Tony. For DASL Very High Risk N0 patients, the MFS-CI benefit is substantial and very robust (and a surrogate for OS). In addition to a group more enriched in Gleason 9-10 than Enzarad, our patients were enrolled in era replete with PSMA PET. How does that impact the enrolled group (even though it was not formally included in eligibility)?

There are two putatively localized settings where pts may not experience a significant MFS benefit from fixed duration ARPI intensification: 1) localized lower risk disease where metastatic potential is constrained and 2) localized by conventional imaging disease where PSMA PET reveals already extant mets. In the former, the metastatic cat may never get out of the bag; in the latter, it already is.

In the DASL era, a patient with CI neg/PSMA PET pos disease probably wasn’t enrolled. Investigators might not have viewed the arms in equipoise in that setting. They may have thought such patients needed ARPI intensification as SOC for OS purposes. We thus removed a patient population unlikely to realize an MFS benefit, since they already had Mets. This, in combination with enrolling higher grade gleasons, really enriched for the N0 population most likely to benefit. That’s why I would argue that in our PSMA PET era, DASL should have controlling weight in decision making regarding adding an ARPI in the N0 setting.

And for the RadOncs out there, with its favorable side effect profile, you might feel more comfortable take the initiative on prescribing Daro. #radonc

Cross-trial comparisons are a minefield, and periop MIBC is well mined: different staging, controls, event rules, path review. That being said, here comes the ultimate cross-trial comparison (Reviewer 2, look away). A week after VOLGA, a few questions keep nagging me.
1/9

🚨 More expensive technology ≠ Better clinical outcomes.

HoLEP: Standard Holmium vs. MOSES 1.0 vs. MOSES 2.0.

Other premium laser platforms may also fail to demonstrate meaningful clinical superiority despite their higher costs.