Developments in MRI-targeted prostate biopsy Purpose of review MRI-targeted prostate biopsy may be an attractive alternative to systematic biopsy for diagnosing clinically significant prostate cancer. In this narrative review, we discuss the new developments that have occurred in the advancement of MRI-targeted prostate biopsy, over the past 24 months. Recent findings MRI-targeted biopsy offers enhanced diagnostic accuracy, when compared with the current standard of care of systematic transrectal ultrasound-guided (TRUS) biopsy, by decreasing the overall number of biopsies needed, maintaining or improving significant prostate cancer detection, and reducing the detection of clinically insignificant prostate cancer. The necessity of combining systematic prostate biopsy with MRI-targeted biopsy is still debated. The use of MRI--ultrasound fusion systems for lesion-targeting is promising for optimizing significant cancer detection, but recent evidence suggests that additional cognitive biopsy cores are still useful in detecting additional cancers. Summary MRI-targeted biopsy in selected men with positive MRI offers a number of benefits over systematic biopsy in all men, and as such, may emerge as the new standard of care for the diagnosis of clinically significant prostate cancer.

Promise of PET imaging in prostate cancer: improvement or waste of money? Purpose of review Prostate cancer is a high prevalence malignancy whose management is a major challenge for clinicians worldwide. Molecular imaging, and in particular PET with computed tomography (PET/CT), is increasingly gaining importance in the work up and management of all prostate cancer patients. PET/CT remains, however, an expensive imaging modality and currently not reimbursed. Recent findings Although other PET tracers are available and have gained institutional recognition from regulatory agencies, prostate-specific membrane agents (PSMA)-based PET/CT tracers have demonstrated the highest sensitivity and specificity for prostate cancer, outperforming any other PET radioligand to date. Regardless of the clinical scenario (staging, biochemical recurrence, therapy response assessment in advanced prostate cancer) PSMA PET/CT scans have become common practice in countries allowing for use outside of controlled clinical trials because of the overwhelming evidence demonstrating the extremely high sensitivity of this imaging modality in identifying prostate cancer lesions. This evidence can make PSMA PET/CT appealing for clinicians and lead to unnecessary scanning with limited supporting evidence. Summary Our aim is to provide an update on the most recent literature available on PET-based imaging for prostate cancer and particularly PSMA PET/CT, offering an expert opinion on the data collected to provide clinicians with guidance on appropriateness and efficacy of PET-based imaging, in order to maximize clinical benefits and avoid waste of resources.

Frontiers of stone management Purpose of review The surgical tool-box for urinary stone disease is growing. In this review, we discuss recent developments in the surgical management of urolithiasis, with emphasis on tailoring the management to the individual patient, and attention to the quality of care. Recent findings Shockwave lithotripsy remains a popular noninvasive treatment option for patients, with new data emerging on how to improve treatment outcomes as well as its limitations. Next-generation holmium lasers are expanding the role of dusting techniques for ureteroscopy but further studies are needed to assess safety and clinical outcomes. Advances in miniaturization and patient positioning are propelling percutaneous renal stone surgery toward endoscopic combined intrarenal and simultaneous bilateral surgery for patients with complex stone disease. Summary Stone management will be increasingly personalized to the unique qualities of the patient, stone, desired outcome, and available expertise and technology. Future studies assessing the quality of stone surgery should incorporate objective metrics to better delineate the success and cost of the different techniques available.

The changing role of lasers in urologic surgery Purpose of review To summarize recent publications on the topic of laser in urology and explore new developments which may impact the future role of lasers in surgery. Recent findings Ho: Yttrium-aluminium garnet (YAG) laser with Moses technology allows less retropulsion during a lithotripsy, yet its efficacy needs to be tested in clinical trials. Data on the efficacy of this device for benign prostatic obstruction treatment is also pending. A new promising generation of laser systems – thulium-fiber (Tm-fiber) lasers – has been introduced. Tm-fiber has already been shown to be effective and well tolerated in endoscopic enucleation of the prostate and has demonstrated favorable outcome compared with Ho:YAG in preclinical lithotripsy studies. However, more studies are needed to better understand the use of this novel technology and elucidate its role within the armamentarium of available technologies. Summary Lasers remain an integral part of benign prostatic hyperplasia surgery and stone treatment and gain popularity in en-bloc resection of bladder cancer. Current efficacy of laser systems in prostate cancer ablation and their place in laparoscopy remain unclear, despite promising initial reports.

Biological and therapeutic advances in the pursuit of effective immunotherapy for prostate cancer Purpose of review The successful development of effective cancer immunotherapy, in particular immune checkpoint inhibitors, has changed the treatment paradigm of many tumor types. In light of the limited efficacy of checkpoint inhibitors demonstrated in recent clinical trials in refractory prostate cancer, this review highlights important recent and ongoing studies that are shaping the pursuit of effective immunotherapy for prostate cancer. Recent findings We review two overarching themes with respect to recent studies of prostate cancer immunotherapy: evolving therapeutic strategies and novel biological findings, including the landscape of predictive biomarkers of immunotherapy response. Summary Novel and combinatorial immunotherapy strategies are being implemented across the clinical spectrum of prostate cancer. Greater understanding of complex tumor-immune interactions and the determinants of therapy response in prostate cancer is an area of intense investigation, and will inform both translational and clinical immuno-oncology research in the field.

Cytoreductive nephrectomy: does CARMENA (Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques) change everything? Purpose of review Over the past few years the treatment options for renal cell cancer (RCC) have rapidly evolved. Even in the setting of metastatic disease, a consistent component of treatment in RCC patients has been cytoreductive nephrectomy based on the results of research carried out over a decade ago. Despite huge shifts in systemic treatment modalities, cytoreductive nephrectomy continued to be recommended despite a lack of evidence for its use in metastatic RCC in those patients receiving state-of-the-art therapies. Recent findings To address the lack of evidence, two recent trials [Cancer du Rein Metastatique Nephrectomie et Antiangioge[Combining Acute Accent]niques (CARMENA) and SURTIME] sought to assess the role and sequence of cytoreductive nephrectomy in metastatic RCC patients receiving vascular endothelial growth factor-targeted tyrosine kinase inhibitor treatment. The results of one of these trials, namely CARMENA, demonstrated no benefit of cytoreductive nephrectomy when used in combination with the vascular endothelial growth factor-targeted tyrosine kinase inhibitor Sunitinib. However, with further developments in medical treatment and questions regarding the specific methods of the trial – do these results change everything for the role of cytoreductive nephrectomy? Summary While the results from CARMENA and SURTIME are not conclusive, they suggest that those patients with advanced disease requiring systemic therapy should indeed receive this first prior to any cytoreductive nephrectomy.

En bloc resection for nonmuscle invasive bladder cancer: review of the recent literature Purpose of review Conventional transurethral resection of bladder tumor (cTURBT) is the standard approach to the diagnosis and treatment of nonmuscle invasive bladder cancer. However, it suffers from inherent limitations such as insufficient assessment of resection depth and the need for intravesical tumor fragmentation that hampers histopathological evaluation. We summarize recent clinical data on en bloc resection of bladder tumor (ERBT), a method that promises to overcome these limitations. Recent findings The PubMed/Medline databases were searched for reports on ERBT focusing on trends in the last 2 years. ERBT provides greater resection quality, making up to 95% of detrusor muscle available for pathological evaluation. ERBT also allows detection of the muscularis mucosae thus facilitating T1 substaging. Available data demonstrate no significant difference in perioperative morbidity. No conclusions can be drawn on the impact of either modality on tumor recurrence and progression, as the available data is too underpowered. Summary ERBT is gaining acceptances as there is increasing evidence that it improves the quality of resected specimens. There seems to be no difference in perioperative morbidity between ERBT and cTURBT. The impact of ERBT on important endpoints such as recurrence and progression remains to be fully elucidated in further studies.

Artificial intelligence and robotic surgery: current perspective and future directions Purpose of review This review aims to draw a road-map to the use of artificial intelligence in an era of robotic surgery and highlight the challenges inherent to this process. Recent findings Conventional mechanical robots function by transmitting actions of the surgeon's hands to the surgical target through the tremor-filtered movements of surgical instruments. Similarly, the next iteration of surgical robots conform human-initiated actions to a personalized surgical plan leveraging 3D digital segmentation generated prior to surgery. The advancements in cloud computing, big data analytics, and artificial intelligence have led to increased research and development of intelligent robots in all walks of human life. Inspired by the successful application of deep learning, several surgical companies are joining hands with tech giants to develop intelligent surgical robots. We, hereby, highlight key steps in the handling and analysis of big data to build, define, and deploy deep-learning models for building autonomous robots. Summary Despite tremendous growth of autonomous robotics, their entry into the operating room remains elusive. It is time that surgeons actively collaborate for the development of the next generation of intelligent robotic surgery.

3D-printed models and virtual reality as new tools for image-guided robot-assisted nephron-sparing surgery: a systematic review of the newest evidences Purpose of review Nowadays, kidney cancer surgery has been focusing on a patient-tailored management, expanding the indication to nephron-sparing surgery (NSS). Starting from computer tomography images, 3D models can be created, allowing a never experienced before understanding of surgical anatomy. Once obtained the models can be printed or virtually visualized with the aid to assist the surgeon in preoperative planning and simulation or intraoperative navigation. The aim of this systematic review is to assess the preoperative and intraoperative impact of 3D printed and virtual imaging for robotic NSS. Recent findings Ten articles were found to meet the inclusion criteria and reviewed. An ‘intermediate’ score was assessed to the overall articles’ quality. A moderate/high risk of bias was recorded for all the studies. Summary 3D-printed models were considered to be more useful during both preoperative simulations and patients’ counseling. These models guaranteed a better comprehension of anatomical structures and surgical procedure. Costs and quality of the materials available represent the two main limits of this developing technology. Instead, in a virtual reality setting the preoperative planning was enhanced by using 3D virtual models in a mixed reality environment. Intraoperatively, the possibility to overlap the 3D model to real anatomy allowed augmented reality procedures. This technology is still a ‘newborn’ and is constantly evolving, expanding day by day the range of its potential applications.