Written By: Anna Chiara Corriero
Anglia Ruskin School of Medicine
Medicine is an ever-evolving field: every day we discover new diseases and fight relentlessly to cure them. Just look at 2020: a cluster of pneumonia cases were reported by the Wuhan Municipal Health Commission in China on the 31st of December 2019. The following day, the WHO had set up the Incident Management Support Team that would investigate and help with this disease (1). In one year, we have given a name to this infectious disease, we have enclosed our communities to protect our most vulnerable members and finally, we are on the verge of developing multiple vaccines to eradicate COVID-19.
Most advancements in medicine, however, do not get as much celebration and fame as the COVID-19 vaccine has gotten. Some of these unsung advances happen in the field of Urology whereby the main focus is on the diagnosis and management of surgical and medical diseases of the urinary-tract system in both male and female patients as well as on the diseases that affect the male reproductive organs.
Let’s take a look at the predictions that were made regarding urological advancements in this decade by analysing the paper “Urovision 2020” written in 2015 by Venkatramani and comparing it with our reality in 2020.
1) Management of urolithiasis
Patients with kidney stones suffer from common pain that can frequently recur even after initial management. The pain is unilateral and most commonly located in their flank; often it travels “loin to groin”. Previously, kidney stones were managed with opioids (2), but due to the contraindications for patients with kidney injuries, the side effects caused by opioids such as vomiting (3), as well as the highly addictive nature of opioids, urologists are trying to move away from prescribing these drugs. Non-steroidal anti-inflammatory drugs and paracetamol have therefore become the drugs of choice for patients with an acute episode of pain due to stone colics as they are considered overall better analgesics than opioids (4).
The recurrence of the disease and the lack of complete disintegration of a stone in a single session of shockwave lithotripsy is still an issue in 2020. Despite its non-invasive characteristic, extracorporeal shock wave lithotripsy is losing popularity amongst urologists as many of them have not been sufficiently successful with the procedure. This is thought to be due to the guideline principles that are often poorly applied (5).
Recent reviews show a rise in use of endourologic techniques in the management of stones (6), just like the “Urovision 2020” paper predicted. While for stones bigger than 1 cm, shockwave lithotripsy, stereoscopic retrieval and percutaneous nephrolithotomy can all be performed (7), shockwave lithotripsy is not preferred due to the evidence of fragmentation and complication following the procedure (8). Percutaneous nephrolithotomy is also often disregarded as this leads to multiple complications including blood transfusions (6). As a result, stereoscopic retrieval with an endoscopic procedure seems to have gained more recognition and popularity.
As the paper analysed in this article suggests, there are many uses for robotics in surgical aspects of urology. Now more than ever, onco-urological cases in particular are often managed with robotic technology, from prostatectomies to cystectomies and partial nephrectomy.
While we always notice the pros of minimally invasive surgery, which is often done through keyholes therefore leaving less wounds and scars on patients, the cons of this practice are less obvious. Nonetheless, they are important to consider. For example, it might take longer to perform these procedures as sometimes, due to the limited visual fields, they might need to be converted to open procedures. They are also quite costly- however, the monetary cost is greatly out-weighted by the benefits of the procedure given by the keyhole incisions. Keyholes lead to less blood loss, lower risk of infection and quicker recovery time, which all contribute to a shorter hospital admission for the patients (9). The reduction in admission time, apart from being efficient from an economical point of view, leads to huge benefits in patients who will be overall more satisfied with the procedure and be able to go back to the comfort of their homes sooner. It might be argued that the costs of the procedure should not be taken into consideration if there is an improvement in patient care and wellbeing.
Another downside of robotic surgery is that often surgeons are not able to “feel” or practice. This has been hugely changed by the use of virtual reality, whereby often surgeons can train for surgeries and learn how to visualise the operating field with virtual reality boxes (10). There are boxes of any type and many of them are extremely affordable and have got a variety of uses in medicine, from medical education and their uses in virtual Objective Structured Clinical Examinations, to the applications of Virtual Reality to the management of autism, memory loss and chronic pain.
While most research still concludes that improvements are needed to reach optimum use of all these technologies, we are on the right path to implement new techniques which will only lead to further advancements in patient care (11). Some authors have suggested that with the fusion of robotic surgery and virtual and augmented reality, machines that operate automatically might be created (12). However, machines will never be able to have that human touch that makes such a difference to patient care. Technology is only as good as the people operating it, therefore we should not only rely on its advancements but keep training ourselves as well, to be the best physicians we can be and deliver the best possible care.
3) Imaging and diagnostic tests
For what concerns the advancements in Imagining and tests, two main suggestions are brought forward by the author: improvements in narrow band imaging as well as advancements in the use of MRIs.
Narrow band imaging (NBI)- an endoscopic imaging technique using specific blue and green wavelengths that highlights features of the mucosa- has been used for the past decade to distinguish benign lesions from malignant tumours (13). In 2016, narrow band imaging also showed the ability to give higher sensitivity results in cystoscopies compared to the most used and suggested white light cystoscopy. Lately, it has also been suggested that NBI technology could be used for transurethral resections of bladder tumours, leading to a decreased number of residual tumours and a decrease in the recurrence of tumours (14). More studies are required but the available literature is already incredibly promising with a 5.6% recurrence in the low-risk patients in the twelve months following NBI facilitated resection compared to the more traditional method of trans-urethral resection of bladder tumours which reports more than 27% cases of disease recurrence (15).
MRIs have indeed revealed themselves extremely useful particularly for what concerns the detection of prostate cancers. This has been seen through the prostate MR imaging study (PROMIS). This study has shown that MRIs have higher sensitivity for prostate cancer compared to ultrasound guided biopsies.
However, lower specificity of the former compared to the latter has emerged. The two have been combined whereby a prostate MRI followed by a guided biopsy have been performed on patients that presented with suspicious systemic symptoms of prostate cancer and this has led to a cost-effective path to diagnose the malignancy (16).
Talking about prostate cancer, an amazing modality of detection of the disease has been found in the radiolabeled prostate-specific membrane antigen PET. This has been applied to a number of stages in assessment of the malignancy, from initial staging, to treatment response and prognostication; it has shown great potential in the personalisation of care with regards to prostate cancer and in understanding the pathogenesis of the disease (17).
Nanotechnology and its applications are one of the most exciting and avant-garde applications of medicine and of course, the field of urology is not left out from this revolution. As Venkatramani suggested, the potential use of nanotechnology in urology is quite broad, encompassing drug delivery, diagnosis and treatment as well as possible disease prevention. Newer literature reports the use of pharmacological nanoparticles, particularly gold, both magnetic and polymeric, that have been used as new drug delivery methods in prostate cancer (18). In terms of other onco-urological diseases, nanotechnology has been applied to the management of renal and bladder cancer, where it has been used to avoid the effects of drug dilution in urine, therefore increasing the therapeutic effects of current drug regimens (19).
As suggested in “Urovision 2020”, another important application of nanotechnology has been found in regenerative medicine. The latest literature suggests that nanotechnology can be used for bladder reconstruction after malignant diseases; indeed, due to its nature, this technology would be able to mimic the smooth muscles found in bladder tissue through protein adsorption, cell adhesion, growth, and protein production (20).
The paper also mentions an artificial kidney; this is still in the works, but the shown animal results are promising and one can only hope that further research is carried out so that, with the help of pluripotent stem cells, we will be able to improve the renal function of patients currently suffering from end stage renal disease worldwide (21).
Despite the challenges that are faced in this field, as the lack of regulation of stem cell therapy and the slow progression of research, the many applications of stem cells in urology have been promising. Stem cell therapies have indeed been applied to erectile dysfunction issues as well as stress urinary incontinence (22), and this is all apart from what concerns the aforementioned bladder cancer and end stage renal disease or renal agenesis. Most literature suggests that further advancements, apart from facing these issues, should also make sure to tackle the cost effectiveness of these treatments and the overall improvement in the care given to the patient thanks to these treatments (22).
As always, it is exciting and encouraging to look back at the progress made in the urological field and in medicine in general. However, as Venkatramani suggested, we must never forget the emphatic side of medicine, the one that allows us to comfort a patient from person to person. All of the technological advantages which we witness or actively work towards must only make physicians better in the care delivered to their patients; this must remain the most salient point of a physician’s duty.
One can only look forward a 2030 “Urovision” update, where we will be able to sum up the most recent advancements in urology. Hopefully we will have seen an improvement in the management of common conditions like urolithiasis, with a procedure that increases the elimination of small fragments of stones, as well as more affordable robotic surgery equipment that will spread its use worldwide. We hope that these changes will be joined by further revolutions in imaging techniques, with the possible help of nanoparticles and lastly, that stem cell therapy will finally lead to strong, life-changing results for our patients.
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Rule A, Lieske J, Pais V. Management of Kidney Stones in 2020. Jama Insights. https://jamanetwork.com/journals/jama/fullarticle/2763484. Published 2020. Accessed December 9, 2020.
Pathan SA, et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. Lancet. Published 2016. 387: 1999. https://www.ncbi.nlm.nih.gov/pubmed/26993881. Accessed December 9, 2020.
Holdgate A, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane. Database Syst Rev, 2005: CD004137. https://www.ncbi.nlm.nih.gov/pubmed/15846699. Accessed December 9, 2020.
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