Clinical Outlook

Androgen deprivation therapy (ADT) is the main treatment for advanced prostate cancer, but toxic effects can affect both physical and mental health. Awareness of these adverse effects cause some men to have reservations, leading to delay in, or refusal of, ADT. Specific counselling strategies and treatment approaches can help to manage these patients hesitant to ADT.

Hot flushes are among the most frequent and persistent adverse effects of androgen deprivation therapy for prostate cancer but remain under-recognized and often undertreated. Insights into KNDy-neuron-driven thermoregulatory dysfunction provide a strong mechanistic rationale for using neurokinin 3 and dual neurokinin 1 and 3 antagonists as a new non-hormonal treatment strategy.

Since 2019, computer-aided detection (CADe) has improved the adenoma detection rate in colonoscopy. CADe tools will emerge in cystoscopy, but the urological field lacks established performance metrics and CADe validation frameworks. Key lessons can be learnt from other endoscopic disciplines to guide the development and evaluation of artificial intelligence in cystoscopy.

Phase II trials have evaluated metastasis-directed therapy for oligometastatic and oligorecurrent prostate cancer and demonstrate that focused radiation is well tolerated and improves survival in selected patients, particularly when combined with androgen deprivation therapy. Phase III trials will optimize patient selection and refine combination treatment strategies.

Vaginal wall smooth muscle underpins pelvic support. In pelvic organ prolapse, smooth muscle cells are depleted and shift from a contractile phenotype to remodelling programmes, paralleling stress-induced switching in vascular disease. Defining trajectories and drivers could yield biomarkers and translatable, locally deliverable therapies to curb progression and recurrence.

Posterior nerve-sparing modifications during radical prostatectomy aim to improve preservation of the cavernous nerves and microvasculature to enhance postoperative erectile recovery. Current techniques for this are associated with varied functional outcomes and have a number of key anatomical and technical considerations.

Transrectal ultrasound-guided prostate biopsy is associated with limitations including high infection rates, sampling limitations and patient discomfort, which have led to the development of the transperineal approach. Randomized trials show that transperineal biopsy offers at least equivalent detection of clinically significant prostate cancer, providing robust evidence for a clinical practice change.

New evidence shows that NeuroSAFE, an intraoperative frozen section technique during radical prostatectomy, improves erectile function recovery. Traditional NeuroSAFE using frozen section analysis might not work for all centres, but new technologies for intraoperative margin assessment might facilitate more pragmatic alternatives during radical prostatectomy.

Urinary incontinence is a common sequela of robot-assisted radical prostatectomy and adversely affects quality of life. Advances in surgical technique preserve the pelvic anatomy to mitigate postoperative urinary incontinence. Pelvic-fascia-sparing techniques such as Retzius-sparing and hood with single-port or multi-port robotic approaches can improve outcomes.

Understanding of metastatic prostate cancer is mainly defined by macroscopic findings, but prostate-specific membrane antigen (PSMA) PET has increased sensitivity. PSMA⁺ serosal-based findings on the surface of the liver and other organs might not have the same implications when seen on PSMA PET versus conventional imaging. Awareness of this phenomenon is important in assessing whether treatment escalation is truly required.

Evidence of polypropylene mesh degradation has revealed particle accumulation in surrounding tissues, raising concerns about potential local and systemic immune responses. Associations between polypropylene degradation and autoimmune/autoinflammatory syndrome induced by adjuvants-like symptoms have been made, and vigilant clinical assessment is important, especially in patients with a predisposition for allergy or autoimmune diseases.

Autonomic dysreflexia is a sudden rise in systolic blood pressure observed in individuals with spinal cord injury at or above the sixth thoracic spinal cord segment, often triggered by stimuli from the urinary bladder, bowel or sexual organs. Autonomic dysreflexia can cause severe complications, including stroke or death. Cardiovascular monitoring during urological procedures is crucial, particularly for individuals with cervical spinal cord injury who are at the highest risk of developing autonomic dysreflexia.

The robot-assisted approach to radical prostatectomy has enabled same-day discharge. A substantial concern associated with this practice could be haemorrhage, but sound and thorough robot-assisted radical prostatectomy haemostasis surgical techniques that were introduced to prevent bleeding mitigate this phenomenon.

In March 2024, we convened a symposium to consider the state of the art regarding the mechanisms and management of congenital obstructive uropathy caused by bladder outlet obstruction, at which overarching themes emerged and opportunities for research were discussed to fill key knowledge gaps in achieving the best future for children with congenital obstructive uropathy.

Prostate cancer is often an indolent disease, and delays in treatment up to 6 months do not seem to affect cancer-free survival. Inadequate pre-treatment assessment and uninformed shared decision-making can lead to decision regret and disparities in receipt of treatments. Time is on our side to allocate sufficient time and resources to consider the most appropriate and individualized treatment decision in prostate cancer care.

Large language models are gaining increasing interest in the medical community; however, an important but overlooked aspect of their capacity is their ability to integrate with tools. This integration greatly extends their potential application in health care.

Currently, no consensus biomarker exists for predicting priapism associated with sickle cell disease. Biochemical and haematological parameters have been investigated, but they are limited by a lack of specificity and the need for pre-validated thresholds. Genetic biomarkers are a potential alternative for further consideration in future efforts.

Partial nephrectomy aims to provide both effective oncological management and renal function preservation. Surgical complications pertaining to the defect created during a partial nephrectomy include haemorrhage and urinary leak. We explore advances in techniques for managing the defect created during a partial nephrectomy (renorrhaphy).

For many years, PSA has been the most commonly used biomarker for prostate cancer screening and diagnosis. Although serum PSA measurement is highly sensitive, this biomarker has several limitations. Citrate, a molecule closely linked to the unique metabolism of prostate cancer, has the potential to be used as a complementary biomarker alongside PSA.

Inflammatory and fibrotic responses to polypropylene mesh led to the withdrawal of this practice for treatment of stress urinary incontinence and pelvic organ prolapse in women in some countries. Improved material testing has been urged. We report poor responses of polypropylene mesh to repeated mechanical distension and macrophage interrogation. These results from preclinical in vitro testing show the potential of this approach for testing and improving materials before their introduction into the clinic.