PURPOSE OF REVIEW:Despite the effective use of phosphodiesterase type-5 inhibitors, a considerable number of patients fail initial attempts to manage erectile dysfunction with these medications. We reviewed the literature describing recent advances and future directions, and propose new regimens to manage nonresponders. RECENT FINDINGS:Patient education, psychological interventions, lifestyle changes and treatment of comorbidities are associated with improved erectile function. The administration of testosterone replacement combined with phosphodiesterase type-5 inhibitors promotes beneficial effects on erectile function in hypogonadal men. Combination of two different phosphodiesterase type-5 inhibitors at the same time is a promising approach, especially in individuals with more severe forms of erectile dysfunction, without increasing the incidence of adverse events. Although intracavernosal injection and penile prosthesis implantation are traditional and established therapeutic options to restore erectile function in refractory cases. Recent advances in medicine have expanded the therapeutic panorama, with emerging regenerative approaches, showing promising potential to restore erectile function. SUMMARY:The choice of the best strategies should be individualized according to the preferences of the patient and his sexual partner based on the advantages and disadvantages of the various options. Therefore, shared decision-making with the patient is strongly encouraged.
PURPOSE OF REVIEW:Circumcision remains one of the most commonly performed urological procedures worldwide. This narrative review discusses contemporary methods of circumcision, with emphasis on patient selection, conventional surgery, device-assisted circumcision, ShangRing, stapler devices, laser and energy-assisted techniques, wound closure, and special situations such as severe pathological phimosis and lichen sclerosus. RECENT FINDINGS:Recent literature has focused on adult phimosis management, modified conventional techniques, disposable circumcision devices, stapler devices, ShangRing, Alisklamp, Unicirc, Plastibell outcomes, laser circumcision, thermocautery, ultrasonic dissection scalpel and tissue adhesive closure. Devices generally offer shorter operative time, consistent excision and favourable cosmetic outcomes in selected patients. However, bleeding, oedema, retained rings or staples, ring-related discomfort, wound gaping and difficulty in severe pathological phimosis remain important considerations. SUMMARY:Conventional circumcision remains the most versatile reference technique against which newer methods are judged. Laser, ShangRing, stapler devices, tissue adhesive closure and other device-assisted techniques are useful adjuncts when matched appropriately to patient profile, foreskin pathology, surgeon experience and healthcare resources.
PURPOSE OF REVIEW:Cryptozoospermia, spermatozoa detectable only after centrifugation of the ejaculate, sits at the severe end of spermatogenic failure and is frequently misclassified as azoospermia. We review recent evidence on its accurate diagnosis and on optimizing the male to recover usable ejaculated sperm before defaulting to surgical retrieval. RECENT FINDINGS:Extended semen analysis reclassifies roughly one in five apparently azoospermic men as cryptozoospermic, and these men are genetically and prognostically distinct, with AZFc microdeletions strongly enriched. Hormonal therapy (selective estrogen receptor modulators, aromatase inhibitors, gonadotropins) helps a minority: eligibility is limited and benefit concentrates in normogonadotropic men, while men with azoospermia rarely respond. Microsurgical varicocelectomy improved semen parameters in about half of cryptozoospermic men with palpable varicoceles, frequently obviating surgical sperm retrieval. SUMMARY:Accurate diagnosis must precede management. In selected men, hormonal or surgical optimization can convert cryptozoospermia into an ejaculate adequate for assisted reproduction and spare an invasive retrieval, but the evidence remains largely observational and patient selection is paramount.
PURPOSE OF REVIEW:Severe male factor infertility is increasingly managed with surgical sperm retrieval, yet current noninvasive predictors cannot reliably distinguish men with retrievable focal spermatogenesis from those with global spermatogenic failure. This review evaluates epigenomic approaches, with emphasis on seminal plasma cell-free DNA methylation, for prediction of sperm retrieval in nonobstructive azoospermia. RECENT FINDINGS:Recent literature reinforces a persistent clinical limitation: conventional markers and multivariable models can inform risk, but they do not reliably distinguish focal spermatogenesis from global failure before surgery. At the same time, DNA methylation-based tissue-of-origin analysis and seminal plasma cell-free DNA (cfDNA) studies have created a new opportunity to measure sperm-associated molecular signal directly from the reproductive tract. Preliminary multisite clinical data suggest that sperm-derived cfDNA is best understood as a conditional biomarker whose meaning depends on endocrine and etiologic context. SUMMARY:Epigenomic liquid biopsy analysis of cfDNA in seminal plasma may add a biologically direct, noninvasive layer to NOA counseling. The key insight is not simply that sperm-derived cfDNA can be measured, but that its interpretation changes with FSH, genetics, histology and the differential diagnosis of azoospermia. Prospective validation is needed to determine whether this approach improves treatment counseling and surgical planning.
PURPOSE OF REVIEW:Despite several advancements in the surgical technique of robotic prostatectomy, urinary incontinence and sexual dysfunction remain as significant side effects. The purpose of this review is to compare and evaluate the various modifications during the robotic prostatectomy that can help improve both urinary and sexual function outcomes. RECENT FINDINGS:Surgical innovations such as Retzius-sparing, anatomical reconstruction, and various tissue preservation techniques demonstrate high recovery rates of urinary continence up to 90% within 12 months. However, postoperative sexual potency outcomes vary widely across techniques and remain largely influenced by preoperative patient factors. Approaches such as endopelvic fascia preservation and ultrapreservation show promising erectile recovery rates up to 80% at one year. It is reassuring that these technical modifications continue to maintain acceptable oncological safety while helping to improve functional outcomes. SUMMARY:We evaluated recent surgical innovations in robotic prostatectomy that can help improve both sexual function outcomes while maintaining oncological safety. Future studies should focus on head-to-head comparisons of these anatomical techniques through well designed prospective studies to establish superiority in functional recovery after prostatectomy.
Purpose of review Idiopathic male factor infertility remains a major reproductive health concern, presenting with abnormal semen parameters despite no identifiable anatomical, hormonal, genetic, infectious, or endocrine cause. Oxidative stress is recognized as a central mechanism, as excessive reactive oxygen species can impair sperm concentration, motility, morphology, mitochondrial function, and DNA integrity. This review evaluates antioxidant therapy, mainly, in idiopathic male factor infertility. Recent findings Current evidence suggests that selected antioxidants may improve several semen parameters. However, improvements in semen quality do not consistently translate into higher pregnancy or live birth rates. Evidence remains limited by small sample sizes, heterogeneous formulations, variable dosing, inconsistent outcome reporting, and inadequate oxidative stress testing. Summary Antioxidants may be useful as targeted adjunctive therapy for selected men with idiopathic abnormal semen parameters, suspected oxidative stress, or elevated sperm DNA fragmentation. However, routine empirical use in all infertile men is not supported by evidence given the heterogeneity of formulations and limited comparative evidence. Treatment should be individualized, time-limited, and guided by oxidative stress assessment when available. Importantly, supplementation should not delay surgical intervention or assisted reproductive technologies when indicated. Future studies should prioritize standardized protocols and live birth outcomes.
PURPOSE OF REVIEW:The evolution of radical prostatectomy has resulted in excellent oncologic outcomes; however, postoperative erectile dysfunction remains a clinical constraint. While oncologic control in focal therapy remains its main limitation, Menon Precision Prostatectomy, also referred to as Millimeter Precision Prostatectomy (MPP) was developed to bridge this therapeutic gap. The purpose of this review is to summarize the rationale, development, and future direction of MPP. RECENT FINDINGS:Advances in anatomical understanding have demonstrated that periprostatic innervation extends beyond the classical neurovascular bundles, with a complex network of autonomic fibers distributed along the prostatic capsule, Denonvilliers' fascia, and the seminal vesicle complex. MPP was designed to enhance the preservation of these nerve-rich structures. In its initial iteration, a unilateral thin rim of prostatic tissue and the ipsilateral seminal vesicle were preserved, whereas dissection on the tumor-bearing side followed the principles of standard radical prostatectomy. SUMMARY:Prospective studies demonstrated favorable oncologic outcomes with superior functional recovery compared to contemporary radical prostatectomy. However, the technically demanding subcapsular dissection raised concerns regarding generalizability. MPP Version 2 was developed as a modification of this concept. In this technique, the prostate is removed en bloc, while both seminal vesicles are preserved, thereby maintaining the integrity of their surrounding neural structures. This approach extends beyond prior seminal vesicle-sparing techniques, which were limited to partial preservation. MPP V2 is currently under clinical investigation, aiming to improve functional outcomes for patients undergoing prostatectomy.
PURPOSE OF REVIEW:Self-assembling peptide (SAP) hydrogels represent a novel class of synthetic biomaterials with growing relevance in surgery. Among them, the ion-complementary peptide RADA16 has gained attention as an athermal, transparent, and biocompatible hemostatic agent. While its use is increasingly reported in multiple surgical specialties, evidence specific to urology remains fragmented. This review aims to summarize the physicochemical properties, mechanisms of action, and current clinical evidence for RADA16-based hydrogels, with a particular focus on urological applications. RECENT FINDINGS:RADA16 rapidly self-assembles into a transparent, extracellular-matrix-like nanofibrillar hydrogel upon exposure to physiological fluids, providing effective local hemostasis without reliance on the coagulation cascade. Preclinical and clinical data from other surgical fields demonstrate rapid bleeding control, favorable safety, and potential regenerative effects. Emerging urological evidence suggests that RADA16 is effective in managing hemorrhagic cystitis, radiation-induced hematuria, and bleeding during prostate surgery, including robot-assisted radical prostatectomy and benign prostate surgery. Beyond hemostasis, RADA16 may support wound healing and promotion of re-epithelialization. However, the current evidence base is limited by small sample sizes, lack of comparative studies, heterogeneous methodologies, and short follow-up. SUMMARY:RADA16-based hydrogels represent a promising adjunctive hemostatic option in urology, offering technical advantages such as transparency, absence of thermal injury, minimal swelling, and applicability in confined or high-risk settings. Robust prospective, comparative, and cost-effectiveness studies are required to define its definitive role in routine urological practice.
PURPOSE OF REVIEW:Transvesical single port (SP) robotic radical prostatectomy (RARP) represents a novel minimally invasive surgical technique that is regionalized to the confines of the bladder and promises enhanced perioperative outcomes with improved patient comfort. This review details the surgical techniques, patient selection, and a summary of recently published perioperative, oncological, and functional outcomes of the surgical approach. RECENT FINDINGS:Since its initial introduction in 2020, transvesical SP-RARP has been increasingly adopted, with early clinical experience demonstrating favorable perioperative outcomes including reduced intraoperative blood loss, low complication rates, high rates of same-day discharges, and reduced postoperative pain. Comparative studies have also demonstrated the SP transvesical approach to offer significantly improved early urinary continence recovery with high rates of immediate continence, while maintaining comparable oncological outcomes and erectile function recovery, as well as providing effective surgical alternatives in patients with a hostile abdomen. SUMMARY:Leveraging the unique features of the purpose-built SP robotic platform, Transvesical SP-RARP represents a promising surgical approach featuring improved perioperative and functional outcomes, with enhanced patient comfort.
PURPOSE OF REVIEW:Focal therapy has emerged as a potential treatment option that may provide similar oncological outcomes with fewer complications for low-risk to intermediate-risk prostate Cancer (PCa) compared to standard management. Our aim is to describe recent clinically studies utilizing focal therapy - specifically high-intensity focused ultrasound (HIFU), cryotherapy, irreversible electroporation (IRE), focal laser ablation (FLA), and microwave - for localized PCa. RECENT FINDINGS:Recent studies demonstrate that HIFU achieves high rates (81-96%) of treatment-free survival up to 36-48 months, with noninferior salvage therapy-free survival rates when compared to radical prostatectomy. Cryotherapy demonstrates similar efficacy regardless of lesion location. FLA shows 80-84% clinically significant (cs)PCa-free rates at 12-36 months. IRE achieved 71-84% negative in-field biopsy at 12 months with stable urinary and sexual function. Microwave ablation demonstrates 81-90% csPCa-free rates at 12 months with 100% complete necrosis on histopathology. Current surveillance includes novel PI-FAB and TARGET scoring systems, with high specificity and high NPV for in-field recurrence. SUMMARY:Focal therapy represents a promising option for localized prostate cancer, with recent studies supporting favorable short-term oncologic control and preserved functional outcomes across modalities, with novel surveillance methods available following focal therapy treatment.
PURPOSE OF REVIEW:Horseshoe kidney (HSK) is a renal congenital abnormality characterized by the fusion of the lower poles of both kidneys via an isthmus. In robotic assisted surgery, HSK presents challenges due to its atypical anatomy, including aberrant vasculature and restricted renal mobility, complicating operative planning and execution across urologic surgeries. This review investigates the feasibility of robotic assisted surgery in HSK, aiming to address the unique surgical considerations the abnormality poses. RECENT FINDINGS:A targeted literature review was conducted using PubMed as the central database. Search terms included "horseshoe kidney," "robotic," and "case report." Results were limited to studies published between 2020 and 2026. A total of 18 studies met the search criteria, including case reports and case series. Across procedures including radical and partial nephrectomy, nephroureterectomy, and pyeloplasty, robotic assisted surgery was demonstrated as feasible with favorable perioperative outcomes. SUMMARY:Robotic assisted surgery is a safe and effective surgical approach for patients with HSK. Success was credited to extensive preoperative planning and case-specific, tailored intraoperative strategy. Key techniques included the preoperative use of 3D-CT reconstructive imaging for vascular mapping, selective patient positioning to increase exposure of target anatomy, and the use of indocyanine green to control blood supply intraoperatively.
PURPOSE OF REVIEW:To achieve pregnancy, men with azoospermia must currently undergo a testicular procedure to retrieve sperm for intracytoplasmic sperm injection (ICSI). However, sperm are successfully retrieved only ~50% of the time. Recently, isotretinoin administration has been investigated as a means of increasing sperm production in azoospermic men. This review explains the rationale for isotretinoin use and will update readers on the results from early studies of isotretinoin treatment of male infertility. RECENT FINDINGS:Pilot studies suggest that isotretinoin treatment for 3-6 months may improve sperm production to the point of reliable ejaculated sperm in up to one quarter of men with azoospermia. Notably, response rates differ by histological sub-type, with 25-40% of men with maturation arrest exhibiting improvement, while men with Sertoli-cell only syndrome do not appear to benefit. A recent case series found that in men with cryptozoospermia, sperm production can be stimulated to levels that allow for ICSI using ejaculated samples in about half of men, thus obviating the need for testicular sperm retrieval procedures. SUMMARY:Isotretinoin therapy may improve sperm production in a subset of men with severe infertility. A fuller understanding of which men will benefit from isotretinoin will require larger studies.
Purpose of review Artificial intelligence (AI) is emerging as a promising tool for sperm detection in men with azoospermia and cryptozoospermia, conditions in which rare spermatozoa can be difficult and time-consuming to identify. This review summarizes recent advances in AI-assisted sperm detection and their potential clinical applications. Recent findings Recent studies demonstrate that deep learning-based systems can improve the speed and sensitivity of sperm detection in both testicular tissue and ejaculate samples. AI-assisted image analysis has reduced search times and improved detection rates compared with conventional manual evaluation. Emerging technologies include augmented reality platforms that support embryologists during sperm searches and AI-integrated microfluidic systems capable of sperm detection and isolation. Early clinical data suggest these approaches may enable sperm recovery in patients previously considered sperm-negative by conventional methods. Summary AI-assisted sperm detection has the potential to improve efficiency, reproducibility, and access to fertility treatment for men with severe male factor infertility. Although further validation is required, ongoing advances in AI, imaging, and microfluidics may transform the diagnosis and management of azoospermia and cryptozoospermia.
PURPOSE OF REVIEW:Elevated follicle-stimulating hormone (FSH) in primary hypogonadism is usually read as maximal but failing testicular stimulation, and affected men are often considered poor candidates for hormonal therapy. This is a hypothesis-generating narrative review rather than an evidence-based treatment recommendation. It re-examines that assumption and asks whether FSH bioactivity, rather than concentration alone, might shape the testicular response. RECENT FINDINGS:Circulating FSH is a mixture of glycosylation-dependent isoforms that differ in receptor-binding efficiency in experimental systems. Chronic gonadotropin excess can downregulate and desensitize the FSH receptor in animal and in vitro models. In principle, these mechanisms could combine to produce a state of functional FSH resistance, in which immunoreactive FSH is high while the effective signal in the testes is weaker. FSH suppression-associated rises in inhibin B, contemporary staged conditioning protocols, and stratification of hypergonadotropic men under the APHRODITE criteria are consistent with a strategy of temporary suppression before stimulation. SUMMARY:We outline the FSH reset hypothesis, in which a finite period of pituitary suppression reduces inefficient endogenous hormone and may allow receptor recovery before controlled recombinant FSH. We then present a stepwise treatment algorithm as a model for future investigation in selected men with spermatogenic failure. The hypothesis is speculative and remains unproven in prospective trials.
Purpose of review The single-port (SP) robotic platform has reshaped minimally invasive renal surgery, and the retroperitoneal low anterior access (LAA) approach has emerged as a versatile, increasingly favored technique. As adoption grows, surgeons need a detailed, anatomically grounded account of the operative steps and decision points unique to SP retroperitoneal partial nephrectomy, an account that current literature does not provide. Recent findings The advent of the da Vinci SP platform has reduced the influence of tumor location on surgical approach selection. Whereas anterior, posterior, hilar, and polar tumors often dictated whether a transperitoneal or retroperitoneal approach was chosen in multiport robotic surgery, contemporary SP series have demonstrated the feasibility of treating a broad spectrum of renal tumor locations through a retroperitoneal approach. The ability to work effectively within confined spaces allow access to anterior, posterior, hilar, upper-pole, and lower-pole masses from a single access site and patient position. These developments have expanded the applicability of retroperitoneal surgery and has facilitated its adoption among trainees and surgeons with previous transperitoneal experience. As a result, traditional paradigms that relied heavily on tumor location for operative planning are being increasingly reconsidered. Summary A retroperitoneal-first strategy with the SP platform simplifies access, shortens setup time, and broadens applicability across tumor locations, supporting its expanding role in nephron-sparing surgery. Comparative and long-term outcome data are still needed to refine patient selection.
Purpose of review Simulation-based surgical training (SST) has become an increasingly important part of contemporary urological education because of growing procedural complexity, patient-safety expectations, limited operative exposure, and the shift toward competency-based training. This review examines the current impact of SST in urology from the perspective of the European School of Urology (ESU) and the European Association of Urology (EAU) Endourology Section. Recent findings Available simulation modalities in urology include bench-top trainers, tissue-based and cadaveric models, virtual reality systems, and newer hybrid or 3D-printed platforms. Across major procedural domains, including basic endoscopic skills, transurethral surgery, laser enucleation, stone treatment, laparoscopy, and robotic surgery, simulation supports early familiarization, repeated practice, and more structured technical skills acquisition. However, the literature remains heterogeneous, and many studies still focus on simulator validation rather than higher level educational or clinical outcomes. Summary From the ESU and EAU perspective, the value of SST lies not in isolated model use, but in its integration into structured curricula supported by cognitive task analysis, expert consensus, validation, benchmarking, and staged assessment. SST should therefore be viewed as an important adjunct within progressive surgical training pathways.
PURPOSE OF REVIEW:The management of metastatic hormone-sensitive prostate cancer (mHSPC) has rapidly evolved into a complex landscape of doublet and triplet combination strategies. While treatment intensification was initially guided by clinical characteristics, growing insights into tumour biology are reshaping biomarker-driven decision-making algorithms. This review summarizes recent developments in mHSPC and incorporates new data presented at ESMO 2025 and ASCO GU 2026 within the current treatment landscape. RECENT FINDINGS:Phase III trials in the mHSPC presented at ESMO 2025 provide clinically relevant evidence supporting the earlier integration of biomarker-driven strategies, including poly(ADP-ribose) polymerase (PARP) inhibition in homologous recombination repair (HRR)-altered disease, protein kinase B (AKT) inhibition in PTEN-deficient tumours, and prostate-specific membrane antigen (PSMA)-targeted radioligand therapy. These approaches consistently improve radiographic progression-free survival (rPFS); however, overall survival (OS) data remain immature, and quality-of-life benefits are variable. The optimal treatment sequencing as well as patient selection remain to be defined. In parallel, phase II studies, presented at ASCO GU 2026, are hypothesis-generating and highlight emerging concepts such as intensified androgen receptor blockade and biomarker-guided treatment de-escalation. SUMMARY:Recent data reinforce the shift toward biomarker-driven management in mHSPC, but further maturation of clinical outcomes and careful balancing of efficacy and toxicity are required before broad clinical implementation.
PURPOSE OF REVIEW:Andrological disorders, including male infertility, hypogonadism, and sexual dysfunction, are often managed in adulthood despite their origins in early life. This review proposes the emerging concept of 'pediatric andrology', which integrates pediatric urology, endocrinology, and reproductive medicine, and aims to highlight its clinical significance from a life-course perspective. RECENT FINDINGS:Growing evidence suggests that common andrological conditions such as varicocele, cryptorchidism, and Klinefelter syndrome originate in childhood and have long-term implications for fertility and hormonal function. Advances in microsurgical techniques and assisted reproductive technologies, including microdissection testicular sperm extraction (micro-TESE), have improved reproductive outcomes even in severe cases. In parallel, recent guidelines emphasize the importance of early diagnosis, appropriate timing of intervention, and structured transition to adult care. However, controversies remain regarding optimal management strategies, timing of surgical intervention, and fertility preservation, particularly in adolescents. Environmental and lifestyle factors may also contribute to future reproductive health, although evidence is still evolving. SUMMARY:Pediatric andrology represents a novel interdisciplinary field that bridges pediatric urology and adult reproductive medicine. A life-course approach is essential to better understand the pathophysiology of andrological disorders and to optimize long-term outcomes. Establishing structured transition care and promoting collaboration across specialties will be critical for advancing this field and improving male reproductive health.
PURPOSE OF REVIEW:Kidney stones have a high heritability. More than 40 genes have been identified causing monogenic forms of kidney stone disease (KSD). Kidney stone formers with genetic variants implicated in monogenic forms of KSD often suffer from early onset, high recurrence rates, and chronic kidney disease. Some patients may also exhibit extrarenal disease requiring attention. RECENT FINDINGS:Recent analysis of KSD patients identified a likely monogenic cause in pediatric populations in 17-30% of participants while in adult unselected populations 2.7-8% had a positive finding. More patients carry single genetic variants in monogenic forms that are classically considered as autosomal recessive but may cause an intermediate genetic risk for the development of KSD possibly in interaction with environmental or lifestyle factors. Genome-wide association studies have identified additional risk loci associating with KSD. Their clinical relevance are currently investigated. Patients with recurrent kidney stone episodes may be at elevated risk of progressive chronic kidney disease. SUMMARY:Monogenic causes of KSD are prevalent in patients less than 25 years of age and in some patients with high-risk metabolic profiles. These patients should undergo genetic testing to enable a precise molecular genetic diagnosis and personalized therapy as well as family counseling and screening.
