This review provides a comprehensive overview of difficult access in endourology. This focuses on anatomical factors that complicate endoscopic management of upper and lower urinary tract diseases and discussing strategies to manage these challenges. Advances in preoperative imaging, three-dimensional reconstruction, flexible digital ureteroscopes, suction-assisted ureteral access sheaths, thulium fibre laser technology, miniaturized percutaneous techniques, and image-guided navigation have significantly improved management in patients with complex anatomy. Improved understanding of congenital and acquired anatomical variations has facilitated individualized surgical planning. Difficult access is a major determinant of operative success and complications in endourology. Anatomical challenges—including narrow ureters, tortuous ureters, lower pole anatomy, calyceal diverticula, horseshoe kidneys, urinary diversion, obesity, spinal deformity, and previous surgery—require preoperative assessment and selective intraoperative strategies. This review summarizes current evidence, practical technical solutions, emerging technologies, and future directions to optimize access, improve stone-free rates, minimize complications, and enhance patient outcomes in complex endourological cases.
Nocturia is a highly prevalent symptom that affects multiple aspects of health. However, it is often underrecognized and undertreated, leading to problems both within the genitourinary system and systemically. The goal of this paper is to further characterize the pathophysiology behind the most common medical factors that contribute to nocturia by performing a focused literature review in a structured format. This will aid clinicians when evaluating and treating patients with nocturia. Based on expert opinion, we recognized six main common pathologies associated with nocturia: obesity, diabetes mellitus, hypertension, obstructive sleep apnea, benign prostatic hyperplasia, and lifestyle habits. Our literature review identified 49 articles including randomized controlled trials, observational studies, systematic reviews, and meta-analyses. Each condition has its own unique pathophysiology that is associated with the development of nocturia. These etiologies also present various ways upon which nocturia can be intervened. These six pathologies are the most common medical etiologies for nocturia based on expert opinion. This paper demonstrates the multifactorial nature of nocturia and highlights assessment and treatment strategies.
Treatments for voiding dysfunction secondary to benign prostatic hyperplasia (BPH) have evolved greatly but also attempted to recapitulate existing ideas. This review will detail the MISTs for BPH through three temporal lenses: past failures and their lessons, contemporary therapies with evidence bases and emerging technologies that are potential futures for minimally invasive BPH treatment. Newer minimally invasive surgical therapies (MISTs) either occupy a new technological niche or refine concepts used by earlier, unsuccessful BPH treatments. Historical permanent stents, balloon dilation, prostatic injection therapies, transurethral needle ablation, and transurethral microwave thermotherapy were limited by complications, inconsistent objective improvement, or high retreatment rates. Contemporary options, including prostatic urethral lift, water-vapor thermal therapy, and drug-coated balloon dilation, demonstrate improved symptom and flow outcomes in selected patients, while temporary nitinol devices and histotripsy continue to evolve. Contemporary devices frequently revisit earlier mechanical, thermal, or dilation-based approaches. Improved materials and delivery systems may reduce prior limitations, but they do not eliminate the need to demonstrate durable efficacy, acceptable retreatment rates, preservation of sexual function, and appropriate patient selection through high-quality long-term studies.
To examine the evidence on contemporary lasers and provide a practical framework for platform selection, parameter optimization, and thermal safety based on the principles of smart lithotripsy. Holmium: yttrium-aluminum-garnet (Ho:YAG) remains versatile for fragmentation and dusting, whereas thulium fiber laser (TFL) provides efficient fine-particle dusting with limited retropulsion. Pulsed thulium: YAG (p-Tm:YAG) shows an intermediate profile between Ho:YAG and TFL, but clinical evidence on lithotripsy outcomes is limited. Higher power settings with Ho:YAG may accelerate ablation, but have to be used carefully with high flow rates and access sheaths. For TFL, high-power settings have not been shown to shorten operative time or improve stone-free outcomes and may increase thermal risk. Future systems may incorporate stone recognition, composition prediction, and tissue protection. There is no ideal laser for every clinical scenario. Urologists should match the platform, settings, and treatment strategy to the intended endpoint, whether fragmentation with active extraction or dusting with passive clearance.
This manuscript provides a narrative review of techniques of neurovascular reconstruction during robotic-assisted laparoscopic radical prostatectomy (RALP). Historic techniques of neurovascular reconstruction, including autologous nerve grafting and neurorrhaphy, have been shown to be feasible in patients in early pilot studies. More recently, perinatal tissue allografts have been studied, with studies supporting earlier recovery of potency or continence. We review historic experimental techniques which are less frequently employed, including nerve grafting and end-to-end nerve anastomosis. More recently, perinatal tissue allograft wraps placed over the neurovascular bundles (NVB) have been demonstrated to be feasible, requiring minimal additional operative time. Existing studies demonstrate earlier return to potency or continence for men with good preoperative function. While further prospective research is needed to validate these findings, this represents a feasible method which may accelerate recovery for men undergoing RALP.
This review focuses on intravesical recurrence (IVR) of upper tract urothelial carcinoma (UTUC). We explore epidemiology, risk factors, mechanisms of tumor cell seeding, molecular pathways, genetic predispositions, and related factors of UTUC. Diagnostic techniques, strategies managing disease and reducing recurrence, as well as controversies and challenges in UTUC management are discussed. By synthesizing the latest research findings, this review aims to provide a comprehensive understanding of UTUC IVR which can guide clinical practice and future research efforts.
Large-scale databases have become an essential resource in urologic oncology, enabling the generation of real-world evidence across broad and diverse patient populations. This narrative review aims to summarize the contribution of population-based cancer registries, hospital-based clinical registries, and administrative healthcare databases to the understanding and management of prostate, bladder, renal, and other genitourinary malignancies. Over the past decade, large database studies have provided key insights into cancer epidemiology, treatment patterns, outcomes, and healthcare disparities. These data sources complement randomized clinical trials by capturing routine clinical practice at a population level. Major findings include shifts in cancer incidence and mortality, increased adoption of active surveillance in low-risk prostate cancer, and greater use of nephron-sparing approaches in renal cell carcinoma. In addition, large-scale analyses have highlighted disparities related to patient demographics, institutional volume, and access to care. They have also contributed to evaluating the real-world effectiveness and safety of established therapies, particularly in populations often underrepresented in clinical trials. Despite their strengths—particularly large sample sizes and enhanced generalizability—big data studies remain subject to important limitations, including residual confounding, coding variability, and limited availability of granular clinical and biological information. When interpreted with appropriate methodological rigor, these observational data provide valuable evidence to support clinical decision-making, inform guideline development, and identify gaps in care. Continued improvements in data quality, analytical methods, and integration with emerging technologies are expected to further strengthen the role of real-world data in advancing urologic oncology.
Prostatic artery embolization (PAE) has emerged as a minimally invasive treatment for a spectrum of prostatic conditions. Supported by a growing body of randomized and observational evidence, PAE now occupies an established role in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) and is increasingly applied for refractory prostatic bleeding and hematospermia. A structured review of PubMed, Google Scholar, and MEDLINE was performed with priority given to studies published from 2020 onward, including randomized controlled trials, prospective multicenter studies, large observational cohorts, and current guideline statements. Outcomes of interest included technical success, symptom improvement, urodynamic parameters, postvoid residual volume, hematuria resolution, retreatment rates, and adverse events. For BPH-related LUTS, PAE produces meaningful and durable symptom improvement. However, it consistently demonstrates inferior urodynamic outcomes and higher long-term retreatment rates compared with transurethral resection of the prostate (TURP) and holmium laser enucleation. PAE’s advantages include lower periprocedural risk in medically high risk patients and early preservation of sexual and continence-related function. For refractory prostatic bleeding — including BPH-related, malignant, and post-procedural etiologies — retrospective and prospective series consistently report high technical success and clinically meaningful hemostasis, supporting its use in patients who are poor surgical candidates or who have failed transurethral surgery. Evidence for PAE in refractory hematospermia is limited to small case series and remains investigational. PAE is a safe, guideline-recognized treatment option for BPH that offers meaningful symptom relief with a favorable safety profile, though with less durable outcomes than transurethral surgery. It serves as a clinically valuable salvage or palliative option for refractory prostatic bleeding. Patient selection, shared decision-making with urology and interventional radiology, and realistic counseling about durability are essential to optimizing outcomes.
Benign prostatic hyperplasia (BPH) is a highly prevalent urological condition in aging men, contributing to lower urinary tract symptoms (LUTS) and reducing the quality of life. The increasing burden of BPH underscores the need for preventive strategies targeting modifiable risk factors. This review examines the evidence on the association between physical activity (PA), exercise, and BPH risk, aiming to determine whether these two forms of activity exert different effects on BPH pathogenesis. A literature search was conducted in multiple databases to identify human studies evaluating the association between PA or exercise and the risk of developing BPH and/or LUTS. A total of 19 studies were included: 17 observational studies, one meta-analysis, and one two-sample Mendelian randomization study. Among the six studies evaluating exercise, four reported a protective effect against BPH development, while two found no significant association. Moderate-intensity exercise appeared to confer greater protection than high-intensity exercise. Of the 14 studies assessing PA, seven reported a protective effect, with most indicating that high-intensity PA provided the greatest benefit. Two studies yielded mixed results, while five found no significant association between PA and BPH risk. Although moderate-intensity exercise and moderate-to-high PA appear to reduce BPH risk, evidence remains inconsistent. Future research should prioritize randomized controlled trials with standardized protocols, clearly defined outcomes, and objective assessment of dose–response effects to elucidate underlying mechanisms. Such approaches are critical to clarify the role of exercise and PA in BPH prevention and to inform clinical and public health recommendations.
Obstructive sleep apnea syndrome (OSAS) is increasingly recognized as a multisystem disorder with important effects on the lower urinary tract, including overactive bladder (OAB). Although the association between OSAS and OAB has been widely investigated, most available evidence originates from male populations, whereas women remain underrepresented despite distinct hormonal, anatomical, and pelvic floor characteristics. Unlike previous reviews that primarily focused on OSAS and nocturia or predominantly male populations, this review specifically highlights female-related pathophysiological mechanisms, emerging clinical evidence, and their potential implications for the evaluation of women with OAB. Recent evidence supports a significant association between OSAS and OAB through multiple interacting mechanisms, including intermittent hypoxia, autonomic nervous system dysregulation, increased atrial natriuretic peptide secretion, circadian rhythm disruption, systemic inflammation, and oxidative stress. Emerging studies suggest that female-specific factors such as menopause, estrogen deficiency, and pelvic floor dysfunction may further amplify bladder symptoms. In addition, treatment of OSAS, particularly with continuous positive airway pressure, has been associated with improvement in OAB symptoms, supporting a potentially modifiable relationship. Current evidence demonstrates a consistent association between OSAS and OAB, although a causal relationship has not yet been established. Recognition of OSAS as a potential contributing factor, particularly in women with refractory OAB or prominent nocturia, may improve clinical evaluation and support a more comprehensive multidisciplinary approach. Further prospective studies focusing on female populations are needed to clarify causal mechanisms and determine which patients are most likely to benefit from targeted screening.
The advent of the Intuitive da Vinci single-port (SP) robotic system represents a pivotal evolution in minimally invasive urologic surgery, offering enhanced dexterity, improved surgical ergonomics, and reduced patient morbidity. This review is designed to provide a comprehensive evaluation of current literature regarding the feasibility, efficacy, cost considerations, and clinical applications of the SP platform across various benign urologic surgeries including pyeloplasty, ureteral reconstruction, donor nephrectomy, renal auto-transplantation, partial cystectomy, and simple prostatectomy. The review also analyzes current limitations of the robotic platform including a narrower range of available instruments, diminished instrument grip strength, and a steeper learning curve. Across these procedures, the SP system demonstrates comparable operative outcomes when compared to multi-port (MP) and open approaches. The SP system also has notable advantages in postoperative analgesia, incisional cosmesis, and hospital length of stay. The system’s low-profile design and ability to maintain an extraperitoneal approach confer distinct benefits in patients with complex surgical histories or hostile abdomens. Although the SP platform incurs higher disposable instrument costs, overall expenditures are mitigated with decreased hospital length of stay and reduced postoperative care requirements. As surgical experience and technological refinements progress, the SP robotic platform is anticipated to achieve broader integration in benign urology. Overall, SP robotic surgery offers a safe, effective, and patient-centered alternative to established minimally invasive techniques with the potential to further optimize perioperative outcomes and redefine the standard of care in contemporary urologic practice.
To review recent evidence on effective mentorship practices in urology fellowship training, with emphasis on mentorship qualities, structured programs, and equity considerations. While few studies have examined mentorship specifically within urology fellowship, available evidence suggests that effective mentorship is dynamic and characterized by accessibility, alignment with mentee goals, and reciprocal engagement. Access to formal mentorship may reduce burnout and improve trainee well-being. Structured surgical mentorship programs have been associated with shortened learning curves and successful surgical outcomes. Diversity-focused initiatives have demonstrated success in improving representation in urology, yet disparities in mentorship access remain for women and underrepresented groups. Mentorship in urology fellowship can improve trainee well-being, foster career development, and support equitable representation. Collaborative efforts across subspecialty societies to expand structured mentorship models and establish standardized evaluation may strengthen training outcomes and reduce disparities in mentorship access and quality.
This review critically evaluates recent literature from the past five years concerning the management of lower urinary tract symptoms (LUTS) in patients with multiple sclerosis (MS), highlighting advances in understanding disease mechanisms, diagnostic strategies, and therapeutic options. LUTS can affect up to 90
Lower urinary tract symptoms (LUTS) may precede or accompany the other symptoms of neurologic disease and may be the presenting clinical manifestations of central, peripheral, or autonomic nervous system dysfunction. In clinical practice, urologists are often the first specialists to evaluate these patients, potentially before underlying neurologic disease has been identified. Early recognition of neurologic contributors to LUTS may help prevent diagnostic delay. This review aims to provide a symptom-based framework that highlights common urologic presentations associated with underlying neurologic disease, along with urodynamic findings of concern, to support earlier recognition of neurological disease in patients presenting with LUTS. Recent work has characterized neurologic diseases associated with LUT dysfunction using disease-based frameworks. Despite this, gaps persist in routine urologic evaluation, including inconsistent screening for neurological symptoms and limited incorporation of focused neurologic history and examination. Certain urodynamic patterns are increasingly recognized as suggestive of neurological pathology but are not consistently interpreted within this context. Barriers to timely neurologic evaluation, including limited specialist availability and prolonged wait times, further contribute to diagnostic delay. As a result, there is growing recognition of the need for urologists to identify clinical features within LUTS presentation that should prompt consideration of neurologic disease, though practical strategies for integrating these insights into routine care remain limited. A symptom-based framework for evaluating LUTS can enhance early detection of neurologic disease in urologic practice. Urologists and pelvic health specialists should have a broad understanding of what clinical characteristics associated with LUTS should trigger concern for underlying neurological disease and should always consider neurological disease in the differential diagnosis. This review provides a practical, clinically oriented overview of neurologic disease in LUTS assessment, including guidance on screening questions, initial testing considerations, urodynamic interpretation, and referral, particularly in the settings with limited neurology access. Algorithms are provided to facilitate early recognition of occult neurological disease within routine urologic practice.
The global incidence of urolithiasis has risen in recent decades. Emerging evidence suggests that higher ambient temperatures are linked to an increased risk of kidney-stone-related events, including acute renal colic, likely through physiological mechanisms such as increased urinary calcium excretion and greater supersaturation of calcium oxalate and calcium phosphate. This study aims to systematically review existing evidence on the relationship between ambient temperature and urolithiasis risk. Of 892 records identified, 46 studies met the inclusion criteria for the systematic review, and 16 were included in the meta-analysis. Most studies reported a positive association between higher ambient temperatures and increased kidney stone-related events, with seasonal peaks occurring during summer months in the Northern Hemisphere and from December to March in Australia. Considerable heterogeneity was observed in exposure definitions, meteorological data sources, outcome ascertainment, and lag structures. Reported effect estimates ranged from RR 1.10 to 2.54. Meta-analysis showed that higher ambient temperature was associated with an increased risk of urolithiasis presentation (pooled RR 1.31, 95
This review examines the modern role of open partial nephrectomy (OPN), indications for this surgical approach, and outcomes associated with the open technique in the era of robotic surgery. Robotic-assisted partial nephrectomy (RAPN) now predominates for small renal masses and is increasingly applied to larger and more complex masses. Across multiple comparative series and meta-analyses, RAPN offers equivalent oncologic control and functional preservation compared to OPN, while demonstrating reduced perioperative morbidity. Nonetheless, OPN remains valuable for tumors in hostile or re-operative fields, certain hereditary syndromes, solitary kidneys when cold ischemia is preferred, and settings without reliable robotic access. Declining open case exposure during training raises concerns about maintaining surgical competency. OPN remains an important option when use of the approach provides improved surgical exposure, ischemia management, intra-operative safety, or feasibility of nephron sparing. A pragmatic, surgeon-experience–based approach that prioritizes oncologic control, parenchymal preservation, and patient safety best serves individualized care. OPN is relevant in the robotic era for select clinical scenarios including hostile operative fields, hereditary kidney cancer syndromes, solitary kidneys requiring cold ischemia, and resource-limited settings. RAPN and OPN offer equivalent oncologic control and renal functional preservation in most comparative series. Many of these series also show that RAPN demonstrates reduced perioperative morbidity; however, these findings should be contextualized with the selection bias inherent in retrospective data from high-volume centers. The decline in open surgical training raises legitimate concerns about maintaining OPN competency in the next generation of urologists; training programs must ensure adequate exposure through simulation, mentorship, and selective case allocation. Surgical approach should be individualized based on tumor complexity, patient factors, surgeon experience, and institutional resources, with the goal of maximizing oncologic control and nephron preservation.
Clinical documentation continues to expand in volume and complexity, spanning outpatient encounters, inpatient summaries, patient-portal communications, and educational materials. These growing demands contribute to clinician burden and reduce time available for direct patient care. Artificial intelligence (AI) has emerged as a potential strategy to streamline documentation workflows. This review evaluates current AI applications in clinical documentation, with illustrative examples from urologic practice. Ambient AI scribes can capture the bulk of outpatient encounters and generate structured draft notes that clinicians edit rather than write de novo. Large language models have shown promise in assisting with inpatient documentation and discharge summaries, often producing drafts that are coherent, readable, and shorter than physician-authored text. AI tools can also simplify patient education materials and translate dense radiology reports into accessible language. Across these domains, however, studies consistently demonstrate that AI-generated content remains vulnerable to factual errors, omissions, hallucinations, and misaligned emphasis, reinforcing the need for clinician oversight. Overall, emerging evidence supports a complementary relationship between clinicians and AI. Used as supervised drafting aids rather than autonomous authors, AI tools have the potential to ease documentation burden and create more time for direct patient care without diminishing the clinician’s role in shaping the medical record.
The mainstay of surgical management for male stress urinary incontinence (SUI) for many years has been the male urethral sling and the artificial urinary sphincter. However, patients with pelvic radiation history are at increased risk for poorer outcomes. This review examines the surgical options for radiated men with SUI, how this history may affect outcomes, and surgical modifications which may optimize results. Male urethral slings demonstrate diminished success but may be considered in carefully selected radiated patients. The artificial urinary sphincter remains the gold-standard for radiated men though with increased risk of complications. Key technical modifications include conservative cuff sizing, selective transcorporal placement, and consideration of lower-pressure pressure-regulating balloons. Ongoing technological innovations may address the challenges in this patient population. Successful SUI management in radiated patients requires careful patient selection, consideration of technical modifications, and thorough patient counseling regarding anticipated risks and realistic expectations.
This review examines the evolution, mechanisms of action, clinical efficacy, and future directions of tibial nerve stimulation (TNS) in the management of overactive bladder (OAB). We sought to clarify how percutaneous (PTNS), transcutaneous (TTNS), and implantable (ITNS) modalities compare in efficacy, safety, durability, and practical application relative to other advanced therapies. Contemporary randomized trials, cohort studies, and meta-analyses demonstrate pooled response rates of approximately 60–80
This manuscript aims to provide an overview of the pathophysiology of voiding dysfunction, management goals, and treatment options for individuals with spina bifida in order to better assist providers caring for these patients and their families. Recent studies have demonstrated efficacy and safety of beta-3 agonists and onabotulinum toxin A as noninvasive options for management of neurogenic lower urinary tract dysfunction. Studies focusing on patient reported outcomes and health-related quality of life have raised greater awareness of patient goals and socio-environmental factors in the counseling of different treatment options. This review highlights the latest research on the management of voiding dysfunction in patients living with spina bifida. Better understanding of pathophysiology and new developments in non-invasive treatment options have substantially improved long-term durability and outlook for these patients. Future research should aim to identify patient and family goals to better manage expectations and quality of life for this lifelong condition.
