Keywords: urology; advances; minimally invasive.
Urology is a relatively old specialty with a long history; at the same time, it is a rapidly developing emerging discipline. In recent years, due to the rapid development of various related disciplines such as medical genetics, medical immunology, molecular biology, genetic engineering technology, imaging science, computer multimedia technology and polymer biomaterials science, the basic research and clinical treatment of modern urology have entered a period of rapid development, and many breakthroughs have been made.
1.Minimally invasive urology progress
Minimally invasive urology in China started late compared with foreign countries, but with the deepening of communication between China and counterparts around the world and the continuous research in the field of minimally invasive technology, minimally invasive urology in China has made rapid progress and the gap with developed countries has been narrowing, and the proportion of laparoscopic surgery in urology in many hospitals in China has exceeded 50% of the total surgery. Minimally invasive urological surgery has been involved in most fields of urological surgery.
(1) LESS and NOTE
Laparoscopy has been widely used in urological surgery, and its surgical access has been gradually expanded from the abdominal cavity to the retroperitoneum. Laparoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are the result of the development and extension of minimally invasive techniques. The technology is a new type of minimally invasive surgery with endoscopy as the tool, which enters the abdominal cavity through the natural orifice such as stomach, vagina, colorectum and urinary bladder for treatment. Compared with traditional open surgery and laparoscopic surgery, its advantages are mainly reflected in no body incision, good cosmetic effect, low psychological trauma, light postoperative pain and fast recovery, etc. At present, minimally invasive surgery of abdominal cavity such as appendix, prostate, kidney and gallbladder has been performed through the natural orifice Minimally invasive surgery and examination of organs, but most treatment centers are currently stuck in the animal experimental stage, we have performed animal trials of transvaginal nephrectomy through natural orifices.
LESS minimizes the number of incisions in laparoscopic surgery, maximizes aesthetics based on the safe performance of surgery, has good postoperative recovery, reduces postoperative pain and has better cosmetic results, and has a wide range of application prospects. However, at this stage, LESS should continue to be performed in large medical centers by experienced laparoscopists to ensure patient safety. We have already carried out single-port laparoscopic renal cyst deprogramming, single-port laparoscopic nephrectomy and single-port laparoscopic paraganglioma resection, which are at the leading level in China. In fact, both LESS and NOTES try to cure the disease as much as possible while preserving the natural structure.
(2) 3D technology
With the development of image molding technology, modern communication technology and computer multimedia technology, etc., the application field of minimally invasive urology has been broadened, and 3D technology and robotics have been initially applied in urological laparoscopic surgery. the development of 3D technology gives more immersive feeling, and also makes medicine more realistic and accurate, reducing surgical complications and difficulty of surgery. Both 3D effect laparoscopic techniques, robotic imaging, and puncture methods of the prostate have introduced this magical technology. We have already tried 3D laparoscopic technology and are the first in China to perform 3D laparoscopic renal cyst decortication, nephrectomy, pyeloplasty and pheochromocytoma resection. The 3D image of the prostate is simulated by computer using a linear combination of spherical and harmonic functions through the 2D ultrasound image combined with the trans-perineal prostate 11 saturation puncture method to perform more accurate prostate puncture biopsy and tumor localization.
(3) Robotics
At present, there are three major robotic systems used in urology: the AESOP system, the ZEUS system and the DA VINCI system. The biggest advantage of the robotic system is that it can provide more than ten times magnification and perfect 3D stereoscopic vision, while eliminating the tremor of the surgeon’s hand through software processing to make the surgery more delicate. The clear images and good hand-eye coordination of the robotic system can reduce the fatigue of the surgeon and also allow remote surgery. At present, scholars in some domestic hospitals have been initially applied in the surgery of adrenal gland, kidney, ureter, bladder and prostate, especially in the laparoscopic radical prostate cancer surgery with obvious advantages.
(4) Intraoperative laparoscopic ultrasound technology
Laparoscopic intraoperative ultrasonography is a new diagnostic imaging technique that combines laparoscopic surgery and intraoperative ultrasonography, developed in recent years based on the rapid development of modern laparoscopic surgery. Laparoscopic ultrasonography is an ultrasound technique performed by scanning the tissue and organs under direct contact with the laparoscopic view. Laparoscopic ultrasound has been widely used in urology partial nephrectomy, laparoscopic radiofrequency ablation and other procedures, becoming an important auxiliary device to ensure the safety and accuracy of minimally invasive surgery, and has very important clinical application value and broad application prospects in minimally invasive urology diagnosis and treatment.
2.Progress of genitourinary system tumors
(1) Kidney cancer
With the increasing number of incidental kidney cancer, scholars at home and abroad advocate to perform kidney unit preserving surgery for early limited kidney cancer with small tumor size and low stage, especially when the tumor is located at the edge of kidney parenchyma. With the development of minimally invasive technology, laparoscopic radical nephrectomy and laparoscopic partial nephrectomy for renal cancer have gradually become routine operations in our hospital. Other treatment methods such as radiofrequency ablation and other new technologies are still in the clinical exploration stage.
Since the implementation of targeted therapy regimens in 2006, treatment options for metastatic renal cell carcinoma have undergone striking changes and have dramatically increased the proportion of progression-free survival for patients receiving these systemic treatment options. The most commonly used targeted agents today are sunitinib and sorafenib. Other agents such as mTOR kinase inhibitors have been used as second-line agents where first-line targeted drug therapy has failed and are currently undergoing relevant clinical trials.
(2) Bladder tumors
In China, bladder tumors are the most common tumors of the genitourinary system. Photodynamic diagnostic techniques can detect in situ cancer and microscopic tumors that are not easily detected by the naked eye, resulting in a significantly higher diagnosis rate of superficial bladder tumors and more thorough surgical removal of tumor tissue.
The surgical approach for invasive bladder cancer is transitioning from traditional open surgery to laparoscopic surgery or robot-assisted laparoscopic surgical approach. Radical cystectomy is still the most effective treatment for recurrent, multiple, in situ and high-grade invasive bladder cancer. Various urinary diversions of the urinary storage bladder after resection, such as ileal cystectomy and in situ controlled bladder, have led to a significant reduction in postoperative complications and a significant improvement in the quality of life of patients compared to the past.
The position of chemotherapy in the comprehensive treatment of bladder cancer has been further strengthened. Preoperative neoadjuvant chemotherapy can achieve the purpose of stage reduction, reduce the rate of positive incision margin and reduce recurrence, and adjuvant chemotherapy can reduce the postoperative recurrence rate and improve the long-term survival rate of patients.
(3) Prostate tumor
The incidence of prostate cancer in China is on the rise due to the popularity and screening of prostate-specific antigen PSA. Laparoscopic radical prostate cancer treatment has been commonly performed in China and is gradually replacing open radical prostate cancer treatment, but in economically developed countries, robotic-assisted laparoscopic radical prostate cancer treatment has become the trend. Brachytherapy has the same efficacy as open and laparoscopic radical prostate cancer treatment, but for a broader population and with significantly lower surgical risk, especially for urinary incontinence.
As the mainstay of androgen deprivation therapy for prostate cancer, gonadotropin-releasing hormone (GnRH) analogs are now available in a new 3M dosage form, which is more convenient to inject once every 3 months and allows for faster testosterone suppression, lower testosterone levels, and significantly faster PSA decline, with persistent efficacy.
Many miRNAs in prostate cancer can make it easy for cells to escape apoptosis. A notable example is miR-21. This important miRNA is upregulated in a variety of tumors and exerts an anti-apoptotic mechanism through the P53 pathway. From the data, at least 10 miRNAs may be associated with apoptosis evasion, including those with multiple targets and miRNAs present in the feedback system. this suggests that miRNAs regulate cell proliferation, apoptosis and senescence. In studying the expression levels of miRNAs associated with hormone-sensitive and hormone-resistant cells, the investigators found that modulation of these miRNAs in the in vivo setting by assaying the expression levels of prostate-specific antigens altered cellular responsiveness to dihydrotestosterone and contributed to a decrease in cellular androgen dependence. In clinical terms, miRNAs hold promise as biomarkers because their structure and size make them immune to RNAase attack, thereby delaying degradation. miRNAs in cancer may be the most exciting development in new therapies. miRNA analysis and selective targeting could enable personalized treatment of various tumors.
(4) Adrenal tumors
The diagnosis and treatment of adrenal gland diseases is a major feature of our hospital. The Chinese Medical Association Urology Section has commissioned our urology department to edit the Chinese guidelines for the diagnosis and treatment of common adrenal gland diseases. The perioperative diagnosis and treatment of pheochromocytoma has significantly reduced surgical complications and mortality with the cooperation of related departments such as urology, endocrinology, cardiology, anesthesiology and ICU department. Laparoscopic pheochromocytoma resection and laparoscopic paraganglioma resection have gradually replaced open surgery.
3.Stone-related progress
(1) Ureteral flexible microscopy
The hottest topic in terms of new technological advances is ureteroscopy. As technology advances, more and more ureteral flexible scopes are using more sensitive and lower power CMOS chips, optical fibers are using digital fiber, and some flexible mirror lighting and imaging systems have been integrated. Some instruments and equipment used under the soft scope such as anti-injury entry sheaths, guide wires, mesh baskets and peripheral equipment such as endoscopic ultrasound have been further improved. These technological advances applied to the clinic have significantly expanded the therapeutic indications for flexible ureteroscopy. Together with the use of laser, flexible ureteroscopy is becoming more and more powerful in the management of stone diseases, and some special types of stones: such as embedded ureteral stones, stones in the lower renal calyces, pediatric stones, stones in the urinary receptacle after urinary flow diversion, horseshoe kidney stones, stones in the diverticulum of the renal calyces, and medullary spongy kidney stones can be treated by flexible ureteroscopy.
(2) Basic research
In basic research, α1 receptor antagonists (such as tamsulosin) can promote ureteral stone expulsion, and the sites of action of the drugs not only act on the ureter, but also the α1 receptors in the spinal cord are involved in the regulation of ureteral function, which can reduce the pressure in the ureter after obstruction. α1 receptor blockers’ stone expulsion effect, in addition to the peripheral sites, may also act through the spinal cord signaling system.
Progress related to abnormal voiding function
(3) Overactive bladder
Overactive Bladder (OAB) is a syndrome characterized by symptoms of urinary urgency and its prevalence in the population is underestimated. The current treatment drugs are mainly cholinergic receptor antagonists. The advent of the new drug Solifenacin Succinate Tablets has brought a boon to this group of patients, and its efficacy and adverse effects are superior to those of tolterodine.
(4) Diagnosis and treatment of prostate enlargement
As the aging of human society continues to emerge, the concern for lower urinary tract symptoms in elderly men is gradually increasing. The new urology guidelines should further standardize the diagnosis and treatment of lower urinary tract symptoms and benign prostatic hyperplasia. Transurethral resection of the prostate (TURP) is transitioning from the “gold standard” to an “optional” treatment, with plasma, holmium laser, green laser, and 2um laser all entering the field of prostate enlargement treatment. The laser has the same efficacy but is safer and is a minimally invasive approach.
4. Kidney transplantation
China has made remarkable progress in organ transplantation in recent years, and currently the most carried out in China is kidney transplantation. The 10-year survival rate of kidney transplant patients has exceeded 60%, and the longest survival time is more than 30 years. Kidney transplantation has become the most successful and fundamental clinical treatment for end-stage renal disease today.
The shortage of kidney source is the main obstacle to kidney transplantation, and increasing the source of kidney donor is a hot issue of common concern. In recent years, domestic scholars have done a lot of work on living relative donor kidney transplantation, formulated relevant laws and regulations to regulate the audit of kidney transplantation, and the momentum of living relative donor kidney transplantation has increased year by year.
(1) Laparoscopic donor nephrectomy
Minimally invasive surgical donor nephrectomy can reduce the surgical burden of the donor, and relevant studies have shown that laparoscopic nephrectomy taken for kidney transplantation in children and adults is safe for the recipient, and there is no significant difference in delayed graft kidney function and acute rejection within 6 months regardless of whether laparoscopic surgery or open surgery is used.
(2) Post-transplant tumors after renal transplantation
Studies have shown a 2- to 4-fold increase in the risk of malignancy after renal transplantation. Immunosuppressive therapy increases the incidence of cancer after transplantation; however, immunosuppression is not an independent risk factor for transplantation secondary to renal cell carcinoma. Several mechanisms have been postulated to be responsible for the transformation of donor-derived cells to malignancy. These include viral or oncogene transfection from the subject to the donor cells, which is subsequently enhanced by altered immune surveillance, chronic antigenic stimulation of the donor, and cellular aging of the donor.
5. Advances related to male science
Research in male erectile dysfunction has also made great progress with the application of effective oral drugs, especially inhibitors of nitric oxide/cyclic guanosine monophosphate signaling pathway induced PDE-5, such as sildenafil. However PDE-5 inhibitors are only effective in about seventy percent of human patients. Researchers in sexual medicine have made significant advances in understanding the physiological mechanisms of penile erection and the mechanisms by which the central nervous system and peripheral nervous system regulate sexual function. Scientists are conducting research on a more attractive ED treatment, namely gene therapy and stem cell therapy both as novel radical therapies for sexual function treatment. New drug therapies will dominate clinical practice in the next decade.
6.Progress related to specialty culture and so on
(1) Chinese urological disease diagnosis and treatment guidelines
Disease diagnosis and treatment guidelines are the summary of clinical experience. The Urology Branch of Chinese Medical Association takes Chinese evidence-based medicine as the main reference and collects domestic experts in related fields to write Chinese urological disease diagnosis and treatment guidelines, which will help standardize the diagnosis and treatment of urological diseases.
(2) Training for urology specialists
In order to promote the training of Chinese urological specialists, the Expert Committee for the Admission of Chinese Urological Specialists of the Ministry of Health started the pilot training of Chinese urological specialists in 2011. The study period is two years, and the study includes theoretical study, clinical skills simulation training and clinical residency or chief resident work.
7.Outlook and prospect
The continuous development of science and technology has brought greater opportunities and challenges to the ancient and emerging discipline of urology, and we need to challenge ourselves and innovate continuously to make our urology career progress continuously.