Current Opinion in Urology最新文献

Purpose of review: Prostate cancer (PCa) is the most common malignancy in men. While prostate-specific antigen (PSA) screening aids early detection, its low specificity leads to unnecessary biopsies and overdiagnosis of low-grade cancers. Blood- and urine-based biomarkers are proposed by clinical guidelines to better identify patients with elevated PSA that can safely avoid more intensive testing (e.g. imaging, biopsy). The current article aims to provide clinicians and researchers with a contemporary assessment of prostate cancer biomarker tests.

Recent findings: This review focused on prebiopsy blood- and urine-based biomarker tests that are commercially-available and included in clinical guidelines. A systematic search identified 955 studies, of which 14 were published in the past 18 months (July 2023-January 2025) and reported performance metrics for clinically significant PCa (csPCa, defined as grade group ≥2). The literature revealed that blood- [Prostate Health Index (PHI), 4Kscore, and IsoPSA] and urine-based tests [SelectMDx, ExoDx IntelliScore (EPI), and MyProstateScore (MPS, MPS2)] maintained high sensitivity for csPCa while significantly reducing unnecessary biopsies performed relative to PSA-based testing. Furthermore, available data suggest that biomarkers can inform the need for biopsy in patients with equivocal (PI-RADS 3) mpMRI.

Summary: Commercially-available, noninvasive biomarker tests consistently outperformed PSA and PSA-based risk calculators for detection of csPCa. Clinical use of these tests appears to substantially reduce the proportion of unnecessary biopsies performed, while maintaining detection of the vast majority of significant cancers.

Purpose of review: Numerous scope-related innovations have taken place in the field of endourology. The presented analytical review is aimed at studying the technical innovations of the single-use digital flexible ureteroscopes. In November 2024, a comprehensive search was done for information on latest disposable flexible digital ureteroscopes, as well as their various unique characteristics. A thorough examination was conducted for image qualities; sizes and channels; and deflection capabilities. Furthermore, supplementary features about the latest advances were assigned to a separate group including 'Unique' solutions. Using the last search query, various innovations in flexible ureteroscopy in general were also searched and sorted into appropriate groups.

Recent findings: Modern single-use flexible digital ureteroscopes are characterized by advanced technologies for transmitting light and images, miniaturization, as well as by a number of unique solutions that were previously characteristic only of semi-rigid or fiberoptic endoscopes. These include features such as integrated buttons for data recording, self-locking mechanism, separate ports, rotating shaft, direct-in-scope suction, pressure monitoring, enhanced tip control and customizable settings.

Summary: Since their introduction in urology, endoscopes have undergone many changes, as illustrated by the example of single-use flexible digital ureteroscopes. The imaging quality has improved, the dimensions of both the distal tip and shaft have decreased, with over 15 manufactures producing and distributing these scopes. A lot of new additional new features are likely to enhance the efficacy and safety of ureteroscopic procedures.

Purpose of review: To review the current risk and prognostic stratification systems in localised prostate cancer. To explore some of the most promising adjuncts to clinical models and what the evidence has shown regarding their value.

Recent findings: There are many new biomarker-based models seeking to improve, optimise or replace clinical models. There are promising data on the value of MRI, radiomics, genomic classifiers and most recently artificial intelligence tools in refining stratification. Despite the extensive literature however, there remains uncertainty on where in pathways they can provide the most benefit and whether a biomarker is most useful for prognosis or predictive use. Comparisons studies have also often overlooked the fact that clinical models have themselves evolved and the context of the baseline used in biomarker studies that have shown superiority have to be considered.

Summary: For new biomarkers to be included in stratification models, well designed prospective clinical trials are needed. Until then, there needs to be caution in interpretation of their use for day-to-day decision making. It is critical that users balance any purported incremental value against the performance of the latest clinical classification and multivariate models especially as the latter are cost free and widely available.

Purpose of review: This narrative review provides an overview of the use, differences, and clinical impact of current methods for kidney stone volume assessment.

Recent findings: The different approaches to volume measurement are based on noncontrast computed tomography (NCCT). While volume measurement using formulas is sufficient for smaller stones, it tends to overestimate volume for larger or irregularly shaped calculi. In contrast, software-based segmentation significantly improves accuracy and reproducibility, and artificial intelligence based volumetry additionally shows excellent agreement with reference standards while reducing observer variability and measurement time. Moreover, specific CT preparation protocols may further enhance image quality and thus improve measurement accuracy. Clinically, stone volume has proven to be a superior predictor of stone-related events during follow-up, spontaneous stone passage under conservative management, and stone-free rates after shockwave lithotripsy (SWL) and ureteroscopy (URS) compared to linear measurements.

Summary: Although manual measurement remains practical, its accuracy diminishes for complex or larger stones. Software-based segmentation and volumetry offer higher precision and efficiency but require established standards and broader access to dedicated software for routine clinical use.

Purpose of review: This review presents the latest research in tissue-based genomic testing in localized prostate cancer (PCa). Here we explore the current and most commonly used genomic assays, their clinical applications, current challenges, and the future of genomic testing.

Recent findings: The management of localized PCa has evolved with the integration of genomic assays, offering a more personalized approach to risk stratification and treatment decision-making. Traditional clinical markers such as PSA levels and Gleason scores are often insufficient in capturing clinically significant cancer due to disease heterogeneity.

Summary: Tissue-based genomic tests, such as Decipher, Oncotype DX (GPS), and Prolaris, have emerged as prognostic tools for assessing tumor aggressiveness and metastatic potential. Current evidence supports Decipher's prognostic capabilities with studies demonstrating risk stratification while further research is needed for Prolaris and GPS to solidify their role in PCa risk stratification. These assays are intended to guide therapeutic choices, reducing overtreatment in low-risk cases while identifying high-risk patients who may benefit from more aggressive or definitive intervention. Despite growing clinical adoption, challenges such as cost, disparities in access, and variability in physician utilization still remain. Further prospective studies and randomized trials are required to optimize clinical implementation and validate the long-term impact of genomic testing on PCa outcomes.

Purpose of review: Transurethral resection of bladder tumor (TURBT) remains the basis of bladder tumor diagnosis and an effective means of treating nonmuscle invasive bladder cancer (NMIBC). There are several limitations to this procedure: TURBT may cause free floating of malignant cells in the bladder and as a result re-implantation and early recurrence. Also, it does not allow the pathologist to define the correct spatial orientation of the specimen. The development of en bloc resection of bladder tumor (ERBT) has helped overcome the abovementioned key disadvantages of TURBT. However, many urologists doubt whether this approach is feasible for treating larger tumors.

Recent findings: In this review, it is shown that ERBT of large bladder tumor (>3 cm) is in fact a feasible and well tolerated method. Although there is a lack of comparative data proving its advantages over TURBT, en bloc in large tumor seems to result in better local cancer control (due to higher prevalence of detrusor specimen, lower need for re-TURBT), lower rate of relapse outside the resection area (due to lower risk of tumor cells circulation), and higher quality of pathology specimen.

Summary: Despite the skepticism of some surgeons, potential difficulties caused by larger tumor size may be overcome easily, and most agree that tumor size should not limit the implementation of the method in their daily practice.

Purpose of review: To examine association between high BMI, obesity, and kidney stone disease (KSD). For this, systematic review of empirical studies was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) guidelines. Cochrane Library, EMBASE, MEDLINE, CINAHL, AMED, Emcare, Clinicaltrials.gov, and WHO ICTRP were searched for English language population-based studies published from inception to October 2024, including adults aged at least 18 years reporting on high BMI, obesity and overweight, with incidence of KSD.

Recent findings: The search identified 943 records, of which 15 relevant articles with 97 645 participants and 17 158 cases in total were enrolled in the narrative synthesis. A high heterogeneity and imbalance were observed among baseline distribution of cohorts in most studies. Thirteen studies provided comparative data on stone occurrence in obese and nonobese participants, and on per-patient analysis, three studies demonstrated a lower risk (RR < 1; 95% CI: 0.78-1.03), four studies a higher risk (RR>1; 95% CI: 0.77-2.32), and six studies depicted similar risk (RR = 1; 95% CI: 0.94-1.06) of stone occurrence between the two cohorts.

Summary: Evidence in this study suggests an association between high BMI, being overweight, obesity, and increased risk of developing kidney stone disease. In the context of optimizing treatment, KSD should be considered a metabolic disease, with treatment to include dietary regimes, exercise intervention alongside pharmacotherapy to help reduce renal stone disease recurrence risk, alongside managing associated chronic diseases such as hypertension, type 2 diabetes mellitus, and coronary artery disease.

Purpose of review: Standardized definition of local recurrence after radical or partial nephrectomy is still lacking. Due to its rarity, data on natural history, oncological outcomes and prognostic factors are scarce and specific treatment recommendations cannot be made.

Recent findings: Surgery is still the preferred option to treat a local recurrence of renal cell carcinoma, with favorable survival outcomes. However, nonsurgical options like thermal ablation techniques may represent a valid alternative mainly in patients where a nephron-sparing treatment is imperative. Systemic therapy seems to have a limited role in this setting.

Summary: According to available data, surgical excision of local recurrence should be attempted whenever feasible. Alternatively, thermal ablation represents a reliable and repeatable option after partial nephrectomy, with low complication rate and good oncologic outcomes. However, the evidence comes mainly from limited, heterogeneous case series. Further high-quality studies are needed to properly define the most appropriate for each individual patient.

Purpose of review: This systematic review and meta-analysis investigate the toxicities of radioligand and radioisotope therapies - [ 177 Lu]lutetium-prostate-specific membrane antigen (PSMA) (Lu-PSMA), [ 225 Ac]actinium-PSMA (Ac-PSMA), and [ 223 Ra]radium-dichloride (223-Radium) - in metastatic prostate cancer. While previous studies have explored this topic, most failed to differentiate between treatment-emergent adverse events (TEAEs) and preexisting conditions, leading to inflated toxicity rates. By focusing exclusively on TEAEs, this study provides a more accurate and clinically relevant assessment.

Recent findings: This meta-analysis of 65 studies including 8706 patients identified haematotoxicities as the most frequent TEAEs across all therapies, affecting 10-20% of patients. Fatigue is a common nonhematologic adverse event in all treatments. Low grade xerostomia is specifically associated with Lu-PSMA and Ac-PSMA therapies, occurring in 30% and 84% of patients, respectively, while 223-Radium is uniquely linked to an increased fracture risk. Severe toxicities (Common Terminology Criteria for Adverse Events ≥ 3) are rare across all therapies. By clearly distinguishing TEAEs from baseline conditions, this study addresses a gap in the existing literature.

Summary: Severe TEAEs are uncommon across Lu-PSMA, Ac-PSMA, and 223-Radium therapies. Still, monitoring and managing specific toxicities to optimize the safety and tolerability of these therapies in clinical practice is mandatory, especially concerning xerostomia in Ac-PSMA therapy.