搜索结果：Current opinion in urology

This narrative review summarizes recent evidence (2023-2025) on the role of palliative care in urology. It focuses on utilization trends, access disparities, symptom burden, procedural palliative needs, and end-of-life (EOL) care in advanced genitourinary malignancies. PC utilization in genitourinary cancers is increasing. Inpatient palliative care use rose from 4.9 to 31.5% in renal cell carcinoma and from 5.9 to 19.0% in testicular cancer. Yet, integration into routine care remains inconsistent. Disparities persist, including lower palliative care utilization among certain ethnic groups and uninsured patients, and higher odds of receiving high-intensity EOL care among socioeconomically vulnerable populations. Symptom burden remains substantial, with up to 82% of patients reporting multiple symptoms. This underscores the need for more timely palliative care involvement and more standardized reporting. Communication gaps, particularly regarding prognosis and EOL preferences, highlight opportunities for urologists to engage more actively in initiating palliative care discussions. Procedural palliative needs, including malignant ureteral obstruction management, illustrate the direct impact of urologists in providing symptom-directed palliative care. Despite growing recognition of palliative care gaps remain in access, referral timing, and systematic assessment. Addressing disparities, enhancing interdisciplinary collaboration, and prioritizing prospective research will be essential to improve patient and caregiver-centered outcomes.

Environmental sustainability is increasingly relevant to urology, yet its structured integration into medical and specialty education remains limited. This review examines faculty and student perspectives on sustainability and evaluates current approaches to environmental sustainability in medical training. Current evidence demonstrates high awareness and strong willingness among urologists and trainees to participate in sustainability initiatives; however, institutional metrics and formal educational frameworks are lacking. Most documented activities are brief, elective, and primarily knowledge based. Data from urologic practice reveal considerable variability in emissions associated with imaging, endoscopic technologies, and perioperative workflows, highlighting the necessity for specialty-specific educational strategies. Integrating sustainability into clinical decision-making and quality improvement processes appears more effective than isolated lectures. Nevertheless, there is limited evidence linking training interventions to behavioral change and measurable environmental outcomes. Sustainability education in urology is evolving but fragmented. Faculty engagement, trainee involvement, and competency-based integration into operative workflows are essential for durable implementation within specialty training frameworks.

This review is timely due to the rapid integration of suction systems, automated irrigation, and intrarenal pressure (IRP) monitoring in flexible ureteroscopy (FURS). These technological advances are redefining fluid management from a passive supporting role to an active determinant of surgical safety and efficacy, necessitating a consolidated evidence-based overview for clinical practice. Contemporary literature highlights a paradigm shift driven by flexible and navigable suction ureteral access sheath (FANS), suction irrigation pressure autoregulating systems (SIPS) and real-time IRP monitoring. Key themes include the critical role of steady-state flow rates (>40-60 ml/min) in mitigating laser-induced thermal injury, the importance of the ratio of endoscope-to-sheath diameter (RESD) for optimizing fragment clearance and intrarenal pressure control, and the superiority of SIPS in maintaining "pressure-neutral" environments. In-vitro and initial in-vivo studies demonstrate that these technologies enable continuous laser lithotripsy, enhance stone-free rates, and reduce procedural complications. The integration of AI-driven SIPS with FANS marks a fundamental shift in endourologic fluid management. SIPS optimizes the suction irrigation ratio (SIR), enables steady-state flows >60 ml/min for continuous lasering, and reduces operator duty cycles. Increasing flow to 100 ml/min improves stone fragment extraction and ergonomics. With appropriate ratio of endoscope to sheath diameter and built-in safety alarms in SIPS, SIPS can mitigate high-IRP risks. Further research is needed to optimize settings for higher energy use.

This scoping review synthesizes contemporary evidence on the role of simulation, uro-technology and structured training curricula in shaping the next generation of endourologists, both inside and outside of the operating theatre. A broad range of simulation platforms - spanning low-fidelity benchtop models, virtual reality systems and high-fidelity hybrid simulators - have demonstrated validity in endourological training across ureteroscopy, percutaneous nephrolithotomy, transurethral surgery and laparoscopy, with several also showing skill transfer to the clinical environment. Proficiency-based progression curricula such as the Endoscopic Stone Treatment Steps 1 and 2, and the ENTRY project for transurethral bladder tumour resection, represent the current standard of structured competency-based training. Artificial intelligence is rapidly evolving and shaping simulation training by facilitating automated performance assessment and personalized, adaptive feedback. Simulation in paediatric endourology unfortunately remains a considerable gap. Endourological training is at a turning point in history where simulation and uro-technology are shifting the learning phase away from the operating theatre. Structured, PBP-based curricula with objective performance metrics offer the most robust framework for competency development and new technologies will help individualize the learning pathway, assuring proficiency is reached prior to clinical exposure. Several hurdles still need to be taken before this can be made widely available for all urological trainees.

Health policy and political decision-making increasingly shape reimbursement, technology access, workforce capacity, and research funding in urology. Despite these growing influences, many urologists receive little formal training in advocacy. This review is timely given ongoing reimbursement reform, regulatory shifts, cancer policy initiatives, and cross-border health legislation in both the United States and the European Union (EU). Recent literature highlights declining procedural reimbursement, workforce shortages, and regulatory barriers to innovation in the United States, alongside expanding EU-level influence in public health, data governance, research funding, and cancer screening policy. Case studies, including reform of vaginal estrogen labeling, Veterans' prostate cancer legislation, and EU prostate cancer screening recommendations, demonstrate how coordinated clinician advocacy can directly shape policy outcomes. Professional societies and policy offices increasingly serve as structured channels for specialty engagement. Advocacy is emerging as a core professional competency for urologists. Structured engagement at institutional, national, and supranational levels enables clinicians to align policy with clinical realities, promote equitable access, and safeguard innovation. Integrating policy literacy into urologic training may strengthen the specialty's ability to influence sustainable, evidence-based health systems.

The development of digital solutions has a direct impact on the modern understanding of the future of urology. Augmented reality is no exception. Specialists use it for intraoperative navigation, which positively impacts procedure metrics, especially in endoscopic surgery for stones. This review aims to determine the chronology of this technology's development and its current trends in endourologists' routine practice. In 2023-2025, studies confirmed the clinical benefits of augmented reality navigation, including reduced puncture time and decreased complication rates. At the same time, the development of intelligent systems with ultrasound/computed tomography (CT) fusion and deep learning has taken augmented reality from visualization to active optimization of the accuracy and safety of interventions. In retrograde surgery, spatial navigation and instrument tracking, complemented by cognitive-oriented and gaze-based systems, have become key areas of focus, paving the way for objective assessment of surgeons' visual strategies and personalized training. Augmented reality (AR) and mixed reality (MR) are rapidly transforming endoscopic surgery for urolithiasis: in percutaneous nephrolithotripsy (PCNL), these technologies have already reached clinical maturity as navigation tools, while in ureteroscopy (URS) and retrograde intrarenal surgery (RIRS), they are emerging as powerful cognitive and navigation platforms. Despite differences in current application scenarios, both trajectories converge toward a common goal: to make key stages of stone treatment measurable, reproducible, and less dependent on the individual experience of the surgeon. The integration of augmented reality with real-time visualization, artificial intelligence, and attention tracking systems is likely to redefine the standards of accuracy and quality in endourology in the coming years.

Sexual and gender minority (SGM) populations face persistent inequities in urological care, stemming from stigma, biased frameworks, and inadequate clinician training. This review synthesizes current evidence on SGM-specific urological needs and highlights the importance of equity-oriented approaches to improve clinical outcomes and patient experiences. Across the urological care continuum, SGM populations experience lower cancer screening uptake, delayed diagnosis, poorer treatment-related quality of life, and unmet survivorship needs compared with cisgender and heterosexual populations. Traditional equality-based clinical guidelines frequently fail to account for anatomical diversity, gender-affirming hormone therapy, prior gender-affirming surgery, and psychosocial contexts that influence access to care and outcomes. In transgender and gender-diverse individuals, inconsistent application of organ-based screening, limited guidance following gender-affirming surgery, and under-recognition of long-term urological morbidity exacerbate inequities. Sexual and reproductive health needs, including trauma-informed care, fertility preservation, and inclusive approaches to sexual function, remain insufficiently integrated into routine urological practice. These disparities are reinforced by gaps in clinician knowledge and competence, limited collection of sexual orientation and gender identity data, and restrictive sociopolitical contexts. Equitable urological care for SGM populations requires moving beyond uniform, equality-based models toward anatomy-aware, affirming, and patient-centered care. Integrating equity principles into urological practice, education, research, and institutional policies is essential to improving outcomes and quality of care for SGM populations.

Health equity has emerged as a priority in urology, as disparities in access to care and health outcomes are driven by social, structural, and geographic factors. Women living in rural communities represent a particularly vulnerable population, given the high prevalence of chronic urologic conditions that impact quality of life and require longitudinal management. Conditions such as urinary incontinence, overactive bladder, recurrent urinary tract infections, and pelvic organ prolapse are common among women yet remain under-recognized and undertreated in rural settings. Rural women face multiple, interrelated barriers to urologic care, including geographic isolation, workforce shortages, limited health infrastructure, financial constraints, and sociocultural factors influencing care-seeking behavior. These barriers contribute to delayed diagnosis, persistent symptom burden, and diminished quality of life. Careful initiatives including telemedicine, mobile outreach, workforce development, and policy reform may help to reduce these inequities over time. This review examines disparities in women's urologic health in rural settings, focusing on the epidemiology, key barriers to care, and consequences of inequity. Emerging strategies to improve access and outcomes for rural women to improve care delivery are highlighted. Advancing health equity will ultimately require coordinated efforts across clinical practice, health systems, and policy domains.

Elevated intrarenal pressure (IRP) during flexible ureteroscopy (fURS) and retrograde intrarenal surgery (RIRS) is increasingly recognized as a key driver of infectious and inflammatory complications. Novel devices integrating real-time pressure monitoring and active suction have been developed to address this modifiable risk factor. This review evaluates emerging intelligent pressure-controlled systems and examines whether they represent the future standard in endourological practice. Intelligent pressure-controlled ureteral access sheaths (IPC-UAS) and related suction-assisted platforms incorporate continuous IRP sensing with automated feedback mechanisms to maintain renal pelvic pressure within predefined safety thresholds. Observational studies report stone-free rates ranging from 80% to 96%, comparable to or exceeding conventional fURS and, in selected cases, minimally invasive percutaneous nephrolithotomy. Importantly, postoperative fever and sepsis rates appear consistently reduced, with several large series reporting near-zero sepsis incidence. Additional benefits include improved visualization, enhanced fragment clearance, shorter hospitalization, and potential expansion of ureteroscopic indications to larger stones and high-risk populations such as solitary kidneys or infection-prone patients. Current evidence, although predominantly retrospective, suggests that real-time IRP monitoring and automated pressure control improve safety without compromising efficacy. Standardization of measurement techniques and high-quality randomized trials are required to confirm clinical benefit and cost-effectiveness. Nevertheless, intelligent pressure-regulated systems align with the broader evolution toward data-driven, feedback-controlled endourology and may represent an important step toward safer intrarenal surgery.

Structural racism is increasingly recognized as a fundamental driver of racial and ethnic health disparities, yet it remains insufficiently addressed in research. This review examines persistent disparities in urologic outcomes across malignant and benign conditions and highlights the role of upstream inequities and policies that shape care. The literature links structural racism to inequities across several domains, including screening policy and guideline implementation, referral patterns, subspecialty access, insurance design, and neighborhood-level factors such as redlining and environmental toxin exposure. In prostate cancer, race-neutral screening guidance contributes to delayed diagnosis and worse outcomes for black men. In bladder and kidney cancers, disparities persist in timeliness and quality of management, including delayed diagnoses and guideline discordant care. For benign conditions, particularly nephrolithiasis, benign prostatic hyperplasia (BPH), and prolapse disease, structural factors are associated with delays to definitive treatment, differential pain management, and variable access to advanced surgical care. Structural racism should be treated as a causal determinant in urologic outcomes research and targeted with upstream interventions. Clinically, standardizing pathways, improving equitable access to specialty care, and auditing guideline concordant treatment can reduce avoidable disparities. Advancing rigorous methodology and testable frameworks is essential to identify and disrupt structural mechanisms of racial inequity in urologic outcomes.

Urinary tumor DNA (utDNA) has emerged as a promising noninvasive biomarker that may complement or reduce the need for cystoscopies in the diagnosis, surveillance, and treatment monitoring of urothelial carcinoma. Unlike plasma circulating tumor DNA (ctDNA), which is heavily diluted by hematopoietic cell-derived DNA, utDNA originates directly from tumor cell shedding into urine and often appears at higher concentrations, improving molecular detection. While there is an increasing number of publications using utDNA with promising results, most of these studies were developed from a laboratory perspective, making it difficult to find a direct clinical application. This review aims to apply a clinical perspective for potential daily practice use of utDNA testing. This review summarizes the most recent literature on the potential clinical use of utDNA for diagnosis, follow-up, and response to treatment in nonmuscle-invasive bladder cancer, muscle-invasive bladder cancer, and upper tract urothelial carcinoma. There is accumulating evidence on the potential use of utDNA for the diagnosis of urothelial carcinoma in the bladder as well as in the upper tract, while preliminary studies show promising results with sensitivities around 80-90% and specificities 90-100%, further research is needed.

This review outlines a pathology-driven framework that integrates morphology, immunophenotype, and molecular profiling to inform personalized treatment strategies in renal cell carcinoma (RCC), particularly with immunotherapy and tyrosine kinase inhibitors (TKIs). Systemic therapy for RCC has progressed from cytokine-based regimens to VEGF-targeted TKIs and, more recently, immune checkpoint inhibitors (ICIs), alone or in TKI combinations, resulting in improved survival. Yet, reliable predictive biomarkers remain an unmet need. Programmed death-ligand 1 (PD-L1) expression, while biologically relevant, offers limited clinical utility, as ICI responses occur in both PD-L1-positive and -negative tumors. Tumor microenvironment features (e.g., T-effector and myeloid inflammation signatures) and genomic alterations (e.g., PBRM1 , BAP1 , SETD2 ) provide biological and prognostic insights, but have inconsistent predictive value. Pathology remains essential for accurate histologic classification, grading, and assessment of adverse features such as sarcomatoid changes and necrosis. Molecular profiling is increasingly helpful in non-clear cell RCC, guiding targeted therapies in subtypes such as MET-driven papillary RCC. Emerging tools (liquid biopsy, spatial transcriptomics, and AI-assisted pathology) offer minimally invasive monitoring, refined immune profiling, and multiparametric biomarker integration to advance precision oncology in RCC.

Urethral complications remain a major source of morbidity following gender-affirming genital surgery, particularly in the setting of masculinizing procedures requiring urethral lengthening. This review summarizes recent advances in the epidemiology, prevention, and reconstructive management of urethral complications, with a focus on principles relevant to reconstructive urologists. Urethral complications are uncommon after feminizing genital surgery but occur frequently following masculinizing surgery, with pooled rates of strictures and fistulae approaching 50% after phalloplasty. Recent studies emphasize the heterogeneity of these complications, highlighting the importance of timing, anatomical location, and surgical technique. Improved classification systems, such as the Montréal classification, aim to standardize reporting. Preventive strategies - including careful patient selection, expectation management, hair removal protocols, optimized flap design, tissue interposition, and staged reconstruction - are increasingly recognized as critical but remain underreported. Reconstructive management must be individualized, as outcomes are influenced by tissue vascularity and prior interventions. Staged urethroplasty appears to offer the most durable results for complex strictures, while prolonged urinary diversion may allow conservative resolution of selected fistulae. Urethral complications after masculinizing gender-affirming genital surgery are common and complex. Emphasis on prevention, standardized reporting, and individualized reconstructive strategies is essential to improve long-term urinary outcomes.

Personalised medicine has rapidly reshaped the management of urothelial carcinoma, driven by advances in tumour genomics, immune profiling and targeted drug development. This review is timely as multiple biomarker-driven therapies have recently entered routine clinical practice across disease stages, necessitating an integrated appraisal of how precision approaches should be applied and sequenced in contemporary care. Key advances include the expanding role of immune biomarkers beyond PD-L1, such as tumour mutational burden and DNA damage response alterations, to refine the use of immune checkpoint inhibitors. FGFR3 alterations represent the first validated genomic target in urothelial carcinoma, with FGFR inhibitors now established treatment options. Antibody-drug conjugates targeting Nectin-4 and HER2 have demonstrated substantial clinical activity, redefining treatment paradigms in both first-line and refractory settings. In parallel, circulating tumour DNA has emerged as a powerful dynamic biomarker for minimal residual disease detection and adjuvant treatment selection. Urothelial carcinoma has transitioned into a biomarker-driven disease, enabling more precise, biologically informed treatment decisions. Integrating genomic, immunologic and liquid biopsy biomarkers will be essential to optimise patient selection, treatment sequencing and toxicity management, and represents a critical direction for future research and clinical practice.

Kidney stone disease (KSD) is heritable and genetic testing is becoming increasingly relevant to its management. However, it is unclear who should be offered genetic testing and what these investigations should entail. This review gives an overview of the existing evidence and future directions. In highly selected cohorts, genetic testing for monogenic disease can yield high diagnostic rates. These diagnoses can facilitate genetic counselling, familial testing, and targeted medical therapies.Our understanding of the role of rare intermediate effect size and common low effect size genetic variants is evolving. The clinical utility of polygenic risk scores and genetic sequencing in unselected cohorts remains uncertain. Genetic testing for monogenic KSD is advised in individuals with a strong family history and with recurrent stones. There is a need for large-scale studies, including in urology settings, to determine optimal criteria for patient selection in real world settings. Further research is required to define the role of genetic testing, including polygenic risk scores, in risk prediction, personalised management, and disease recurrence.

While robot-assisted surgery has rapidly expanded within reconstructive urology, debate persists regarding where it can be applied most effectively and where open surgery remains the more suitable option. The question is no longer whether robot-assisted reconstruction is feasible, but rather when it represents the most appropriate approach. Recent evidence indicates that both open and robot-assisted techniques achieve comparable short-term outcomes in the management of vesicourethral anastomotic stenosis, despite addressing a highly heterogeneous condition. Similarly, robot-assisted intracorporeal radical cystectomy offers no demonstrable advantage over open radical cystectomy with respect to key clinical outcomes. A notable emerging trend is the decline in continent urinary diversions, possibly reflecting the technical challenges of robot-assisted intracorporeal reconstruction and evolving institutional preferences. Open surgery remains the standard for perineal and external genital reconstructive procedures, whereas robot-assisted approaches are best suited for transabdominal reconstructions. Deep vesicourethral anastomotic stenoses involving the external sphincter should be managed through an open transperineal approach. Notably, during the decade of widespread robotic adoption, the rate of continent urinary diversions has declined significantly.

Population ageing is changing everyday urological practice. The number of older adults is increasing, and urology already treats a patient population that is, on average, older than the general population. Consequently, older adults with urolithiasis represent a core part of contemporary endourological practice. Given this, a focused review of the available evidence is valuable to inform clinical practice. A peak in stone disease can occur in older adults who may also be less likely to present with the classical features of renal colic. As such, delayed or missed diagnosis may carry greater clinical consequences. Although the literature remains relatively limited, ureteroscopy, shock wave lithotripsy, and percutaneous nephrolithotomy remain feasible options in appropriately selected older adults. In this group in particular, broader health associations merit consideration, as the presence of urolithiasis in older adults may reflect overall health status in later life. The burden of urolithiasis in older adults is increasing and now represents a routine component of everyday clinical practice. Clinical presentation may differ from that seen in younger "index" patients, and complications may have a greater impact on recovery and function. Management should therefore be individualized, taking into account comorbidity, frailty, functional status, and the patient's own priorities.

Ureteral stents are an integral part of daily urological clinical practice, but in case of ureteral stents inadvertently left in place or forgotten, they can lead to a range of complications. Managing retained DJ stents presents a complex challenge for urologists, involving various aspects such as surgery, legal implications, and financial factors both for the patient as for the health system. Ensuring proper follow-up of patients poses a significant challenge even in nowadays in everyday clinical urological practice as it involves efficient urologist-patient communication. In modern society, smartphones have become an essential part of daily lives, providing a convenient and reliable way to store and access information through certain applications. Is it the best way to go for stent tracking? We performed a systematic review of PubMed/Medline, EMBASE, Cochrane Library and Scopus and reference lists according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The tracking mechanisms include electronic medical records algorithms, mobile or chat applications, and computer-based applications. Prior to the implementation of a tracking system, hospitals experienced varying rates of stent loss or delayed removal, ranging from 0% to 13%. Through the implementation of a tracking mechanism, the occurrence of lost or delayed removal has been significantly reduced to 1%. Stent tracking systems have proven to be highly effective in reducing the incidence of delayed removal of ureteral stents. Nevertheless, the widespread applicability of these systems is limited due to their primarily tailored design for institutions, while before implementing their use as a standard of care, more solid data through randomized trials is needed.

Although urethral stricture is not highly prevalent, it remains a persistent reconstructive challenge due to its risk of recurrence despite advances in surgery. In parallel, experimental and translational research has expanded rapidly, particularly in animal modelling, fibrosis biology, and tissue engineering. This review highlights recent and clinically relevant developments in experimental and translational models of urethral stricture disease, with emphasis on reproducibility, biological relevance, and translational potential. Recent studies have refined experimental urethral stricture models by prioritizing standardization, reproducibility, and functional assessment. Human molecular profiling has improved understanding of fibrotic mechanisms and helped anchor experimental findings to clinical disease. Tissue engineering has shifted from passive structural replacement toward biologically active and adaptive biomaterials designed to modulate the regenerative microenvironment. While several approaches show promise in large animal models and early clinical studies, translation remains limited and heterogeneous. Experimental and translational research has generated important insights into urethral stricture disease and introduced innovative regenerative strategies. However, increasing experimental sophistication has not yet translated into clear clinical benefit. Approaches that combine reproducibility, functional relevance, and surgical practicality are most likely to impact future clinical practice, while cautious interpretation of early translational and clinical data remains essential.