Current Opinion in Urology最新文献

Purpose of review: This review addresses the evolving role of metastasis-directed therapy (MDT) in the management of oligometastatic and oligoprogressive renal cell carcinoma (RCC). With advances in both surgical techniques and stereotactic ablative radiotherapy (SABR), it is timely to explore how MDT can improve patient outcomes in these distinct disease states. The review highlights the potential of MDT to delay systemic therapy and improve quality of life while noting the lack of randomized clinical trial data guiding its use.

Recent findings: Recent literature emphasizes the outcomes of MDT, including metastasectomy and SABR, in managing oligometastatic and oligoprogressive RCC. Key studies suggest that MDT may prolong progression-free survival and delay systemic therapy. SABR has demonstrated high local control rates and manageable toxicity, offering a less invasive alternative to surgery. Despite these findings, there remains uncertainty about MDT's long-term impact on overall survival due to the absence of prospective randomized trials.

Summary: MDT holds promise in treating RCC by offering symptom relief, improving quality of life, and potentially delaying systemic therapy. However, the long-term benefits, particularly regarding survival outcomes, remain unclear. Further research, including prospective trials, is needed to better define the role of MDT in clinical practice, particularly in the absence of clear guidelines for patient selection.

Purpose of review: Chemotherapy offers excellent long-term survival rates for men with clinical stage II germ cell tumours. However, in this predominantly younger population, chemotherapy is associated with long-term adverse effects. Primary retroperitoneal lymph node dissection (RPLND) may serve as an alternative treatment option, preserving oncological safety while potentially reducing adverse effects in men with limited retroperitoneal disease.

Recent findings: The rate of negative surgical specimens (pN0) in primary RPLND series varies between 4% and 16% in seminoma and 12-29% in nonseminoma, respectively. This suggests that early restaging, novel biomarkers, and/or percutaneous biopsies should be considered to minimize overtreatment. In stage II seminoma, three prospective RPLND series with follow-up periods ranging from 22 to 51 months report recurrence rates between 6% and 30%. In contrast, only retrospective data are available for stage II nonseminoma, with follow-up periods and recurrence rates yet to be fully defined. Following primary RPLND with confirmed viable cancer, adjuvant chemotherapy reduces recurrence risk. In cases of recurrence after primary RPLND, first-line chemotherapy remains a highly effective salvage option. Ongoing research is needed to identify risk factors for contralateral retroperitoneal disease to refine surgical templates and to determine predictors of recurrence, allowing for more personalized decisions regarding the use of adjuvant chemotherapy and follow-up strategies.

Summary: Men with clinical stage II germ cell tumours may benefit from RPLND due to its lower risk of long-term side effects. Chemotherapy is an effective salvage treatment if needed. Although RPLND is a safe and promising option, further studies are required to better understand relapse risks and to tailor treatment plans based on individual patient factors.

Purpose of review: Men face distinctive health-related challenges as a result of biological, behavioral, and sociocultural factors. In addition, the modern healthcare system does not offer men equal opportunities and options to ensure sex-specific access and delivery to health services. Men's health concerns are, indeed, often not addressed or even forgotten. In this review, we wanted to assess the impact of biology and sociocultural effects on sex-specific life-expectancy.

Recent findings: Globally, men have a shorter life expectancy than women. With a 5.8 years gender gap in the USA and 5.4 in the EU-27 (both in 2022). Cardiovascular disease, cancer, and accidents continue to represent the primary causes of mortality for both genders with all having disproportional preponderance in men. In recent years, there has been a notable decline in age-adjusted mortality rates related to cancer, while there has been an increase in deaths from accidental and intentional self-harm. Moreover, in the United States, men are more likely than women to develop and die from nonsex-specific cancers. As a result, men's poor health affects productivity, absenteeism, and employment.

Summary: The status of men in healthcare is complex. It is rooted in history, culture, and institutions. To address disparities, we need a comprehensive approach that includes policy reforms, sociocultural changes, and a fair and equitable public discourse. Grassroots and top-down strategies are needed to ensure a value-based societal healthcare system acknowledging the unique health needs of men.

Purpose of review: Following the COVID-19 pandemic, surgical wait times have surged, creating a backlog in elective urological procedures. This review aims to address the need to explore ambulatory care for penile and scrotal surgeries, which can offer benefits by shifting these procedures away from traditional inpatient settings.

Recent findings: Recent studies confirm the safety and efficacy of performing penile and scrotal procedures in an ambulatory setting using local anesthesia (LA) or loco-sedative techniques. Of 616 reviewed cases, over 90% of patients expressed high satisfaction with LA and reported minimal postoperative complications. Pain management advancements, particularly the use of liposomal bupivacaine, reduced the need for opioids postoperatively. Importantly, no intraoperative complications or hospital admissions were reported, and adverse events were managed conservatively. The data highlighted in this review supports a move towards outpatient surgeries as a safe alternative to inpatient care for select cases.

Summary: This review highlights the strong potential for ambulatory urological surgeries to alleviate surgical backlogs significantly, while reducing strain on hospital resources, and maintaining high levels of patient satisfaction. As evidence continues to grow on the safety, feasibility, and effectiveness of LA in office-based procedures, expanding ambulatory urological will be quintessential in modernizing patient care and reducing healthcare burdens.

Purpose of review: Oligometastatic prostate cancer (OMPCa) is an intermediary state between localized and disseminated metastatic disease that has historically been treated with androgen deprivation therapy (ADT) and more recently with additional systemic therapies in combinations. However, cytoreductive control of the primary tumor may offer an opportunity to control the disease and enhance the response from systemic treatment. In this review, the use of local therapy to the prostate including cytoreductive prostatectomy (CRP), whole pelvis radiotherapy (RT), and focal therapies will be evaluated in the treatment of patients with newly diagnosed OMPCa.

Recent findings: Retrospective studies have demonstrated that some patients with OMPCa may indeed benefit from CRP. With preliminary trials demonstrating that CRP is safe and feasible, there are several phase II and III trials that are currently underway to investigate the role of CRP among patients with OMPCa. Results from several clinical trials have demonstrated that RT and ADT may benefit patients with OMPCa. Lastly, the evidence for focal and cryotherapy remains limited and further clinical trials are required.

Summary: OMPCa is a unique disease state that may benefit from local therapy to the primary tumor. Further study is required to guide treatment selection and patient candidacy. Several trials specifically are awaited to better define the treatment options for patients.

Purpose of review: To provide up-to-date evidence and clinical guidance on the role of medical therapy in the context of hormonal imbalances affecting human spermatogenesis.

Recent findings: Compelling evidence has accumulated over the years regarding the role of gonadotropins, selective estrogen modulators, and aromatase inhibitors to either improve or restore spermatogenesis in men with hormonal abnormalities (e.g. hypogonadotropic/hypergonadotropic hypogonadism, hyperprolactinemia) or supraphysiologic levels (e.g. exogenous testosterone/anabolic steroid use). Despite the increasing number of studies being performed, most of the available evidence relies on small nonrandomized studies, mainly in men with hypergonadotropic hypogonadism or with history of exogenous testosterone/anabolic steroid use. As such, the efficacy of medical therapy is highly variable emphasizing the necessity of randomized clinical trials and individualized approaches.

Summary: This narrative review provides clinical guidance on medical therapies for male factor infertility based on the most up-to-date evidence, focusing on treatments for hormonal abnormalities (either hypogonadotropic or hypergonadotropic hypogonadism and hyperprolactinemia) and supraphysiologic levels (and exogenous testosterone/anabolic steroid use) to improve spermatogenesis.

Purpose of review: Muscle invasive bladder cancer (MIBC) is aggressive and requires radical cystectomy and neoadjuvant therapy, yet over 40% of patients face recurrence. The loss of the bladder also significantly reduces quality of life. Accurate staging, crucial for treatment decisions, is typically done through transurethral resection (TURBT), but inconsistencies in pathology affect diagnosis in 25% of cases. MRI is the most precise imaging method for evaluating local tumor invasiveness. This review discusses recent advances in MRI for staging MIBC and predicting responses to neoadjuvant therapy.

Recent findings: Vesical imaging - reporting and data system (VI-RADS) accuracy may improve if combined with ADC maps and tumor contact length, while a bi-parametric MRI approach without contrast could reduce side effects without losing diagnostic precision, though evidence is mixed. VI-RADS shows promise in predicting neoadjuvant therapy responses, and the new nacVI-RADS score is in development. Non-Gaussian diffusion-weighted imaging techniques and machine learning could enhance accuracy but need more integration with mpMRI. VI-RADS may assist in evaluating responses in bladder-sparing regimens. Urodrill, an MRI-guided biopsy, aims to replace diagnostic TURBT but needs more accuracy data.

Summary: MRI in MIBC is evolving, offering potential for accurate local staging and reduced side effects by avoiding TURBT. Predicting neoadjuvant treatment response could guide personalized treatment and bladder preservation. Larger trials are needed to validate these findings.

Purpose of review: This review explores the potential role of neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) for oligometastatic bladder cancer (OMBC) treatment. We focused on extrapolating evidence from studies including lymph node-positive only and metastatic bladder cancer to address the key challenges and therapeutic strategies for OMBC.

Recent findings: Current evidence for NAC and RC in OMBC is limited, with most data derived from studies in locally advanced bladder cancer. NAC has shown efficacy in downstaging and improving survival in patients with locally advanced disease, but its benefits in OMBC remain speculative. Additionally, diagnostic uncertainties, particularly regarding the inclusion of pelvic lymph nodes and the role of FDG-PET/CT, pose significant challenges to accurate staging and treatment decisions. Recent studies highlight the potential of metastasis-directed therapy, but uncertainties remain on patient selection and treatment protocols for OMBC.

Summary: There is need for prospective studies to evaluate neoadjuvant systemic treatments and RC specifically in OMBC. Moreover, resolving current diagnostic challenges is crucial to avoid undertreatment due to inaccurate staging. Until more concrete evidence emerges, changes to standard treatment protocols should be approached with caution and offered only within trials.

Purpose of review: This article aims to describe new developments in the field of nonobstructive azoospermia biology, diagnostics, biomarkers, and therapeutic strategies.

Recent findings: Recent studies have investigated the molecular underpinnings of cellular dysfunction that is contributing to spermatogenic dysfunction and findings suggest abnormalities across both somatic and germ cells. Biomarkers to predict the chances of sperm retrieval are being explored utilizing cell free (cf) DNA and RNA from various body fluids, in addition to a full range of transcripts and epigenetics within seminal fluid. Various approaches are being explored to optimize sperm identification from surgical specimens including microfluidic and machine learning approaches. Finally, approaches to regenerating sperm production from males with nonobstructive azoospermia are evolving to include various 3-dimensional culture techniques with integration of computational modeling.

Summary: The landscape of nonobstructive azoospermia biomarkers, molecular underpinnings, technological approaches to more reliably identify sperm and novel regenerative therapeutic strategies are likely to transform the field of male reproduction in years to come.