Paradigm shifts in urology Five decades of advances in uro-technology
Encouraging results with mRNA-based cancer treatment vaccines as monotherapy and in combination with checkpoint inhibitors have been obtained. Techn revolution in diagnostic imaging In the early 1970s, the use of ultrasound (US) as a means of creating images of the abdomen, small parts, and pelvis was introduced at radiology practice and medical literature. In 1972, computed tomography (CT) scan was established and only a decade later in 1982, magnetic resonance imaging (MRI) was on the stage. These diagnostic imaging modalities became so popular and necessary that nobody would understand current hospital practice and particularly urologic practice without them. In fact, even more than urine and blood testing, US has been incorporated in all urologic departments worldwide since the 1990s as the first clinical approach to diagnosis. Significant progress in computer equipment throughout the acquisition of a picture archiving and communication system (PACS) freed the technologists from film development, greatly enhanced productivity, and dramatically increased its use. This has also caused a stage shift in several malignancies including kidney cancer to low-stages, thus improving the therapeutic efficacy and ultimately, prognosis. In addition, PCa diagnosis was improved by both the advent of Prostate Specific Antigen (PSA) and the widespread use of US-guided prostate biopsy. The retaining of US technology in urology departments has enabled the integration of medical and surgical knowledge within urology, with office endoscopy and urodynamics as complementary diagnostic tools. Multiparametric MRI (mpMRI) has managed to change the paradigms on PCa detection and risk classification. Investigations to integrate morphologic and functional evaluation of the tissue were initiated in the 1980s, but again, more technological development was needed. It was not until 2012 that a common terminology for evaluating prostate MRI was established with the first version of Prostate Imaging Reporting and Data System (PI-RADS). Afterwards, image-guided targeted prostate biopsy improved diagnosis of PCa and consolidated alternative therapeutic approaches such as active surveillance and focal therapies. Although initially investigated for diagnosis of brain tumours, the clinical applications of positron emission tomography/computed tomography (PET/ CT) with radiolabeled choline in patients with prostate cancer was established in 2003. PET/MRI hybrid devices and new tracers such as [68Ga]- PSMA are under investigation in the diagnostic imaging of PCa. Organ transplantation achieved excellent results Solid organ transplantation is one of the most remarkable and dramatic therapeutic advances in medicine in the past 60 years. The field has progressed from what was a clinical experiment to a routine and reliable practice; it was not only clinically effective and cost-effective, but also life-saving. Some of the major milestones of this remarkable multidisciplinary clinical science evolution stems from the serial confluence of cultural acceptance, legislation that facilitates organ donation, technical advances in organ preservation, surgery, immunology, immunosuppression and the effective management of complications. The role of urologists involved in kidney transplantation has allowed the increase of living donor kidney transplants with minimal skin incision and the advent of laparoscopic-guided donor nephrectomy (Rosales 2010) has accelerated such practice. There is no doubt that minimally invasive technique in kidney transplant is helpful, and the robotic- assisted kidney transplant (RAKT) has been incorporated. Longer ischemia time is still controversial and the outcomes remain very dependent on individual surgeon expertise. However, it is anticipated that in the next decade, the integration of further digitization, ergonomic instrumentation, and AI within robotics will exponentially improve RAKT outcomes with an increase in costs.
Organization was created in 1948 to internationally coordinate epidemic response although its role appears to have declined in our modern, globalized world as we recently saw with the COVID-19 pandemic. In 1953, the structure of deoxyribonucleic acid (DNA), with its two entwined helices and paired organic bases was determined by Francis Crick (1916-2004) and James D. Watson (1928-) in Cambridge using X-ray diffraction and the mathematics of a helix transform. The discovery had a major impact on biology, particularly in the field of genetics, enabling later researchers to understand the genetic code and also the molecular basis of disease. The plastic surgeon Joseph Murray (1919-2012) performed in Harvard the first long-term successful kidney transplantation between monozygotic twins in 1954. The organ survived for eight years. The first successful kidney transplanted from a deceased donor using the immunosuppressive drug azathioprine was performed in 1962. For his efforts in the field, Murray was honoured with the Nobel Prize in medicine in 1990. “We are experiencing a high velocity in AI advancement; it can be found practically in all the technological elements that we use today.” The first laser (light amplification by stimulated emission of radiation) was built in 1960 by the engineer and physicist Theodore H. Maiman (1927-2007) at the Hughes Research Laboratories in California. The pivotal landmark upon which the solid bioethical foundations on which clinical research is based was the Declaration of Helsinki in 1964. Charles Huggins (1901-1997), surgeon and researcher from Ann Arbor was Nobel Prize laureated in 1966 for the discovery that hormones can be used to control prostate cancer (PCa). This was in fact the first proof that cancer could by controlled by drugs, and for that Huggins is often referred as the father of modern-era chemotherapy. Major developments after 1973 The significant paradigm shifts in urology within the last five decades can be summarised in several principles for genitourinary (GU) health improvement which will be discussed later. Some of these advances are anonymous and often depend on multidisciplinary collaboration; however, others are mainly based on titanic personalities that, after standing on the shoulders of giants, have been able to foresee and take the next steps of development. Serendipity, evolving techniques and improvements in equipment are the tools they used to build innovation. It is impossible to mention all the names involved in this race for excellence, but I will at least try to mention the milestones reached. Infectious diseases kept in check During the last decades, urinary tuberculosis has disappeared, and novel antibiotics have kept bacterial infections in check. However, new GU infectious diseases have emerged such as the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic in 1981 with the producing agent identified two years later. On the other hand, retroviral treatments have become a safe and effective tool to live with HIV infection.
Urologic surgery: Less invasive and more precise Progressive minimalization and technological improvement of flexible elements and laser technology have allowed the endoscopic access to the entire urinary tract. Cystoscopy (Nitze, 1877), ureteral catheterization (Albarrán, 1897), open nephroscopy (Rupel and Brown, 1941) and antegrade nephrostomy (Goodwin, 1955) were the first steps in endourology. However, it was not until the 1970s that innovation allowed full access to the upper urinary tract with the fundamental milestones of Teflon tubing (Takayasu, 1974), percutaneous nephrostomy for renal calculi extraction under radiological control (Fernström and Johansson, 1976), transurethral ureteroscopy (Pérez-Castro, 1979), extracorporeal shockwave lithotripsy (Chaussy, 1980) and flexible ureterorenoscope (Bagley, 1983) achieving full upper urinary tract access for stone clearance. A number of technological advances in equipment design with reduced calibre and wide-working channel allowed the simultaneous use of instruments and active deflection at the distal end. These were followed by high-definition digital imaging leading us to current standards. Pioneer applications of the laser in urology in the 1980s included the use of a CO2 laser for condylomata, photodynamic therapy for bladder carcinoma, pulsed-dye laser for urolithiasis and the Nd:YAG lasers for prostatic vaporization. The modern era of lasers in urology in the 1990s began with the use of side-firing fibres and their application in the treatment of benign prostatic hyperplasia (BPH). Thulium and Holmium lasers both for BPH surgery and lithotripsy have increased in popularity despite their cost. “In the years to come, we should be aware if we are applying critical thinking or paying too much attention to algorithms that make the clinical decisions for us.” The British urologist John Wickham (1927-2017) was the first to use the term “minimally invasive surgery” and attracted attention and criticism in 1987 when he predicted the paradigm shift in practical surgery. He stated, “Surgeons applaud large incisions and denigrate keyhole surgery. Patients, in contrast, want the smallest wound possible, and we at Britain’s first department of minimally invasive surgery are convinced that patients are right”. Doctors and patients alike became fascinated with laparoscopic surgery and the first laparoscopic nephrectomy (Clayman, 1991), cystectomy (Parra, 1992), prostatectomy (Schuessler, 1992), and partial nephrectomy (Winfeld, 1993) were performed. However, after these first successful reports, laparoscopic surgery remained unrealistic due to its difficulty and duration. Development of urologic laparoscopy was made technically feasible in several centres of excellence in France and Germany when large series were accumulated, and learning-curves were lowered at the end of the 1990s. Results of well-trained teams were comparable in terms of oncologic outcomes and sometimes better for improved functional outcomes. Single-port access, mini-laparoscopy, natural orifice transendoscopic surgery (NOTES) and hybrid techniques were the natural evolution of laparoscopy. Adoption of laparoscopic prostatectomy was hindered by the technical and ergonomic challenges over the vast open retropubic radical prostatectomy experience developed after Patrick Walsh (1938-), who popularized the technique of anatomic nerve-sparing radical prostatectomy for organ- confined PCa all over the world. The experience and outcomes achieved by a group of distinguished oncological surgeons in academic centres was another drawback for the generalization of the laparoscopic approach in the United States. However, this tendency changed with the introduction of da Vinci robotic surgical
Prof. Javier Angulo Clinical Department, Faculty of Medical Sciences, Universidad Europea, Madrid (ES)
javier.angulo@ universidadeuropea.es
Historically speaking, a 50-year span does not seem that long in terms of years. However, a span can also be a period of time separating two momentous dates or events during which something exists, functions, or happens. In this case, we look at the span between the first constituent assembly of the European Association of Urology (EAU) which took place from 3 to 4 July 1973 and the 38th Annual EAU Congress in Milan which will be held from10 to 13 March 2023. We are celebrating a half century of the EAU and how it has witnessed and influenced the development of urology across the globe. One clear indicator of this is the increase in membership from 259 to over 18,000 medical professionals. From cavern to metaverse Progress is moving extremely fast and undoubtedly, the engine of that change is technology. Considering that the year 2000 saw a rise in mobile phone technology, the increasing sophistication seen in computers and the Internet is also evident in Artificial Intelligence (AI). We are experiencing a high velocity in AI advancement; it can be found in practically all the technological elements that we use today. Current development of AI is led by four main factors: 1. Large amount of data available 2. Development of computing and information technology 3. Progress in the production of software 4. Knowledge and use of different strategies to solve problems such as random forest, neural networks, and deep learning. However the real question is, is AI the art of making programmes and machines that mimic and surpass the performance of biological beings in areas that require operations, specific skills, and simulate complex cognitive operations? If the answer is yes, we are probably still far from the limits of that metaverse. Of course, neither are we in the cavern of urology. On the shoulders of giants Before the EAU was established, urology was already more than surgery of the urinary tract. The very early steps for a modern medical discipline such as urology were possible, standing on the shoulders of giants. Henry Thompson (1820-1904), Felix Guyon (1831-1920), Maximilian Nitze (1848- 1906), Joaquín Albarrán (1860-1912), James Israel (1848-1926), Georges Marion (1869-1960), Leopold Casper (1859-1959), Alexander von Lichtenberg (1880-1949) and Antonio Puigvert (1905-1990) were some of the most outstanding giants in early European urology. They established the basis both for anatomic surgery, endoscopy, and the art of urologic consultation, understanding renal function, urinary infection, stone disease, and neoplasia. However, the world changed after the Great War and became more technology-focused rather than knowledge-based. Hugh Hampton Young (1870-1945) established the fundamentals of oncologic prostate surgery at the John Hopkins Hospital in Maryland and was the pioneer of urology in the United States. Reed Miller Nesbit (1898-1979) developed modern transurethral resection of the prostate in the 1950s through his brilliant improvement of the mechanism of the Stern-McCarthy resectoscope, a spring-loaded modification that allowed the surgeon to manipulate the instrument with one hand alone. Later, José Iglesias de la Torre (1904-1979) improved the resectoscope with simultaneous irrigation, suction and low intravesical pressure, as we use it today. The foundations for modern transurethral surgery had been lain. Most medical advances with direct application on modern urology came from social change and other health-related disciplines. The World Health
Bacterial resistance to antibiotics became a first-line sanitary problem, with the advent and spread of
extended spectrum beta-lactamase and carbapenemase producing pathogenic
enterobacteria. Vaccination for viral diseases has evolved, but there is still some need to improve immune control of common urinary pathogens and develop novel and better antiviral agents. In this regard, messenger ribonucleic acid (mRNA) vaccines first used to control the COVID-19 pandemic are a promising option for cancer immunotherapy. Technological advances have optimised mRNA-based vaccine stability, structure, and delivery methods. Multiple clinical trials are now enrolling patients with various cancer diagnoses.
European Urology Today
38
February/March 2023
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