Reviews & Analysis

The advent of molecular methods for the identification and characterization of the microbiome has led researchers to understand the role of the microbiota in various clinical conditions. Research by Cavarretta and colleagues has revealed the presence of microbial dysbiosis and its potential relationship with pathophysiology in the prostate tumour microenvironment. This finding could potentially enable future investigations that clarify the role of the microbiota in the development of prostate cancer and its future management, from a different perspective.

Undescended testis — known as cryptorchidism — is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer. The key factors that contribute to the occurrence of cryptorchidism remain elusive and a broad range of putative risk factors have been evaluated, but their plausibility is still in question.

Renal cell carcinoma (RCC) is largely percieved to be radioresistant, owing to the failure of several clinical trials involving fractionated radiotherapy. However, following the availability of new technologies, which enable the delivery of ablative doses of radiation, in fewer fractions, excellent responses have been observed among patients with RCC. In this Review, the authors describe the evidence supporting the use of ablative-dose radiotherapy, either alone, or in combination with other therapies in patients with RCC.

Life expectancy after primary treatment for localized prostate cancer is long, so the importance of functional outcomes and quality-of-life measures cannot be underestimated. Careful assessment of the data, with an emphasis on patient selection, definition of clinical significance, and length of follow-up duration, is essential.

Increased evidence that prostate-cancer-specific mortality can be reduced using serum PSA screening, in addition to the increasing role of active surveillance in reducing overtreatment underlies the revised USPSTF recommendation, which now supports selective use of PSA testing. However, this recommendation should not be interpreted as a license to return to the unthinking use of PSA testing of men between 50 to 70 years of age.

Kimura and colleagues describe the scientific background to the concept of personalized peptide vaccines and review clinical data on safety and efficacy of these treatments for urological cancers. They also provide a perspective on the future of peptide vaccines in urology.

Sepsis is an infrequent but serious adverse risk of transrectal ultrasonography-guided prostate biopsy. A new study evaluated whether the use of single-dose ertapenem, a broad-spectrum antibiotic, resulted in increased carbapenem resistance following biopsy. However, physicians need to carefully consider the risks of antibiotic resistance when balancing the benefit of broad-spectrum antibiosis against a 1% risk of sepsis.

Despite a rapid increase in the use of anticancer immunotherapy, our understanding of the mechanisms of action and the patients' responses remains limited. The discovery of immune inhibitory markers in the tumour microenvironment following immunotherapy should improve our understanding and might enable us to better apply combination therapies.

3D organoids are valuable tools for increasing understanding of disease biology. In this Review, the authors describe how successful application of organoids into urological cancer research can further our understanding of these diseases and provide preclinical cancer models to aid precision medicine.

Wu and Okeke review studies of the major validated scoring systems for outcomes of percutaneous nephrolithotomy, highlighting their performance in predicting stone-free rates and complications. They discuss the advantages and disadvantages of each system, provide suggestions for their applicability and propose requirements for a future unified scoring system.

The comparative efficacy of drugs for the management of overactive bladder syndrome (OAB) remains undefined. A new indirect treatment comparison demonstrates similar efficacy of mirabegron versus several antimuscarinic drugs and onabotulinum toxin A in a number of outcome measures. Head-to-head trials of these agents are still required to optimize the management of patients with OAB.

Advances in understanding of prostate cancer biology and improved treatment options have changed management of metastatic prostate cancer. Escape of the malignancy from the prostatic capsule no longer means that treatment is focused on limiting systemic spread, and data suggest that local treatment of the prostate is beneficial, even in men whose tumour has spread.

High levels of seminal oxidative stress lead to sperm DNA damage and male factor infertility. In this review, the authors describe the mechanisms of oxidative-stress-induced male factor infertility, and how lifestyle-related interventions might reduce levels of seminal oxidative stress, ameliorate infertility and potentially improve the health of the children of men with high levels of seminal oxidative stress.

Gender transition can substantially improve quality-of-life in individuals with gender dysphoria, and various surgical options are available for female-to-male (FtM) transition, including facial and chest masculinization, body contouring, and genital surgery. In this Review, the authors describe the management of these patients, with a particular emphasis on the surgical techniques used, and consider developments that might improve outcomes for FtM patients in the future.

Testosterone replacement therapy use has been increasing; however, a gap exists in patients' understanding of this therapy and its associated risks, and available online resources might not be bridging this gap. Action should be taken to provide patients with accessible credible information.

Endometriosis predominantly affects the reproductive organs but can also affect the urinary tract. The optimal therapeutic approach depends on the extent, depth, and location of these lesions. In this Review, the authors discuss the pathogenesis and optimal management of patients with urogenital endometriosis, describing the diagnostic challenges faced and surgical techniques used when managing patients with this disorder.

Leone et al. describe management strategies for patients with penile cancer and metastasis to regional lymph nodes. They review the prognostic factors, indications for lymphadenectomy, surgical techniques and the role of systemic chemotherapy, radiotherapy and new targeted and immunotherapeutic approaches.

The risk of urinary incontinence and other lower urinary tract (LUT) symptoms increases substantially with advancing age; however, such symptoms can emerge in otherwise healthy individuals. In this Review, the authors describe the changes in LUT physiology that take place during the ageing process, and whether or not these changes arise as a consequence of 'normal', healthy ageing, or unaddressed pathology.

A substantial number of women have pelvic floor dysfunction, resulting in urinary and/or faecal incontinence, often many years after vaginal delivery. In this Review, the authors describe the potential of regenerative medicine to repair and regenerate pelvic floor muscles and thus prevent, or ameliorate the symptoms of pelvic floor dysfunction.

Data from an immunohistochemical study reveal abundant expression of β₃-adrenoceptors on cholinergic nerves of the human urinary bladder. This finding suggests that the effects of β₃-adrenoceptor agonists on overactive bladder are not mediated simply through direct inhibition of bladder smooth muscle cell excitability, but might involve a more complex mechanism, including an inhibitory effect on cholinergic nerve terminals.