782666

review-article2018
TAU0010.1177/1756287218782666Therapeutic Advances in UrologyDE Bernstein and BS Bernstein

Therapeutic Advances in Urology Review

Urological technology: where will we be in

Ther Adv Urol

2018, Vol. 10(8) 235­–242

20 years’ time? DOI: 10.1177/

https://doi.org/10.1177/1756287218782666
https://doi.org/10.1177/1756287218782666
1756287218782666

© The Author(s), 2018.

Reprints and permissions:
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Darryl Ethan Bernstein and Brett Sydney Bernstein journalsPermissions.nav

Abstract:  Since prehistoric times, our understanding of urology has rapidly expanded. Whilst
primitive urologists began by using urine as a therapeutic substance, modern urologists may
find themselves removing a kidney remotely by driving a robotic arm, with seven degrees of
movement, while using image overlay-augmented reality. This review provides an insight into
the potential status of urological technology in 20 years’ time, assessed through an analysis
of developments in imaging, diagnostics, robotics and further technologies. A particular
emphasis is given to the promising fields of minimally invasive techniques, nanotechnology
and tissue engineering, which likely hold the key to a new era for urology.

Keywords:  diagnostic tools, future technology, imaging, robotics, urology

Received: 20 December 2017; revised manuscript accepted: 23 May 2018.

Introduction
Since prehistoric times, urology has fascinated
humans, from observing urine and its potentially
healing properties, to the utilization of reeds to
alleviate bladder obstruction.1 Thousands of
years later, armed with an increased knowledge of
anatomy and medicine, urological practice is at a
stage where the majority of effort is put towards
producing technology that offers a minimally
invasive, individualized and targeted approach to
treating disease.
This paper seeks to identify, in this rapid evolu-
tionary stage, where urological technology will be
by 2038. Herein, imaging and diagnostics, robot-
ics and new, upcoming technology will be consid-
ered. However, as urology is a field at the forefront
of research and innovation, it is only possible to
provide a glimpse into current developments.2
Imaging and diagnostics
In 20 years’ time much will have changed in imag-
ing and diagnostics, including both an improve-
ment in the scope of current technology, and the
utilization of new techniques currently under
development. Narrow band imaging (NBI) is just
one of these new techniques, using specific blue
and green wavelengths in endoscopy to enhance
mucosal detail.3 NBI has a greater ability to detect Correspondence to:
Darryl Ethan Bernstein
cancerous tissue compared with the currently University College London
prevalent white-light cystoscopy, with research Medical School, 74 Huntley
Street, London, WC1E
finding that the use of NBI in transurethral resec- 6BT, UK
tion of bladder tumours reduced tumour recur- darrylbernstein@doctors.
org.uk
rence.4 Whilst this imaging may benefit those
Brett Sydney Bernstein
with nonmuscle invasive bladder cancer, it may Royal Free Hospital,
have further ramifications for other urological London, UK
b.bernstein@nhs.net
cancers.
The use of magnetic resonance imaging (MRI) in
diagnosis will also be improved through pioneer-
ing nanotechnology, including the attachment of
magnetic nanoparticles to specific targets, such as
lymph-node metastases, which can then be visu-
alized on MRI.5 In addition, MRI has been found
to be significantly better than prostate-specific
antigen (PSA) measurements in the follow up of
patients after focal therapy for prostate cancer.6
Furthermore, through multi-parametric imaging,
MRI–ultrasound fusion in prostate biopsy is
showing great promise with real-time ultrasound
imaging to better sample the prostate to improve
Gleason score.7,8 In the future, with the possible
reduction in cost of MRI scans, these techniques
may become more widely utilized.
Recent advances in MRI technology have also
yielded the 7 Tesla MRI, which boasts a major

journals.sagepub.com/home/tau 235
Therapeutic Advances in Urology 10(8)
improvement in diagnostic technology over the
current 1.5 and 3 Tesla models. Through ena-
bling an increased spatial resolution and enhanced
vessel signal, the system allows for superior diag-
nostic quality, providing more accurate identifi-
cation of abdominal pathology, such as in the
prostate.9 Enhanced detection of prostate cancer
recurrence has also become possible through the
identification of the prostate-specific membrane
antigen (PSMA) expressed by almost all prostate
cancers.10 This antigen is hoped to allow replace-
ment of the currently used 18F-flurocholine posi-
tron emission tomography (PET)/computed
tomography (CT) by 68Ga-PSMA-11 PET/CT,
which is noted to be superior in identifying pros-
tate cancer recurrence and extra prostatic dis-
ease.11 Furthermore, recent studies suggest that
due to its high sensitivity and specificity, there
may be added benefit in the use of 68Ga-PSMA-
PET/CT in primary staging for metastatic
spread.12 It is hoped that through a multicentre
prospective clinical trial, 68Ga-PSMA-PET/CT
can be directly compared with conventional scans
to better understand if the method has improved
diagnostic ability in primary staging, with subse-
quent positive effect on patient management.13
In addition to PET/CT, current studies suggest
that the PSMA PET/MRI offers even further
advantages by identifying lymph-node metastases
that would have been missed on CT.14 This
method of PSMA PET/MRI has been seen to be
particularly useful when PSA levels are low,
showing a high detection rate for locally recurrent
disease.15 In addition, PSMA has further thera-
nostic applications in local salvage therapy, such
as in the use of lutetium-177-labelled PSMA
(177Lu-PSMA), which directly treats prostate
cancers with the added benefit of a reduction in
side effects.16 Beyond local therapy, treatment
with 177Lu-PSMA has also been seen to have high
response rates in patients with PSMA-avid meta-
static prostate cancer that is castration resistant.17
However, more research and study is required
before this practice becomes regularly used, and it
is likely that in the next two decades more specific
ligands will be found to enable a more personal-
ized treatment approach for all, potentially acting
as a key to theranostic urological advancement.
Beyond imaging, ‘tumour markers’ are likely to
become more sophisticated. Two recently found
markers for monitoring oncological burden are
serum microRNA and circulating tumour cells
(CTCs). CTCs, first identified by Ashworth,
236 journals.sagepub.com/home/tau
have recently been found to best predict patient
survival in metastatic castration-resistant prostate
cancer, with low levels indicating a good progno-
sis.18,19 Furthermore, through genomic analysis of
the cells, CTCs have utility in the identification of
specific therapeutic targets for tumours.20 In
addition, the specific microRNA, miR-371a-3p,
is a novel biomarker recently found to be both
sensitive and specific for testicular germ-cell
tumours, more so than the blood tests currently
used in diagnosis.21,22 These tumour markers, as
well as the newly found ability of dogs to smell the
urine of patients to identify prostate cancer, high-
light the potential ease of screening and monitor-
ing of patients in the future and helping
‘personalized medicine’ based on genomics to
flourish.23
Robotics
Urology pioneers progression in the field of robot-
ics. Robotics has been adopted because of it being
minimally invasive, providing 3D vision, allowing
magnification of fields of view and providing
enhanced precision and dexterity.24 However,
well-documented problems in current robotics
include the external clashing of instruments, lack
of haptic feedback and difficulty in maintaining
triangulation around the surgical field. Thus, a
new single-port platform has been adapted for use
in robotics, utilizing only one entry site into the
patient. This single port can accommodate a
camera and multiple robotic instruments, whilst
only requiring one arm of the da Vinci robotic
system (Intuitive Surgical Inc., Sunnyvale, CA,
USA). Furthermore, the instruments within the
port have an elbow joint, providing increased
intracorporeal triangulation for better dexterity.24
In a clinical trial on 19 patients, this single-port
technique proved to be successful.25 Further
improvements to current robotics that may be
seen include hydraulic manipulators with built-in
sensors to improve tool precision, and Firefly®
technology (Firefly Technology, Winchester,
UK) to better guide tumour resection in a partial
nephrectomy.26,27
New robotic procedures are also likely to be
implemented in the future. In an effort towards
complete tumour removal without incision and
scattering, novel procedures may include a robotic
en bloc resection for nonmuscle invasive transi-
tional cell carcinoma, as well as a robotic radical
prostatectomy with a perineal approach.28–30 In
addition, future advances in robotics such as the

Telelap ALF-X (Intuitive Surgical Inc.) improve
upon the artificial da Vinci surgical environment
by increasing situational awareness of surgeons
through the use of 3D glasses, as opposed to
enveloping the surgeon’s face, whilst also provid-
ing haptic feedback technology.31
Robotics is likely to become available to all patient
cohorts, contributed in part by the expiration of a
number of intellectual property patents, and thus
a reduction in costs.32 In addition, as highlighted
from a recent review on 65 children, robotics is
gaining increased acceptance in paediatric urol-
ogy. Despite obvious challenges due to the smaller
and more complex anatomy, technical manoeu-
vres, such as decompression of the bladder, can
be learnt to overcome these obstacles.33
The future of robotic urological surgery is excit-
ing and will improve postoperative outcomes and
patient satisfaction28 However, it demands greater
complexity in terms of structural needs, staff and
technology, and therefore must be constantly
scrutinized.34 In addition, robotic surgery has not
been proven to be better than laparoscopic sur-
gery in many procedures such as radical nephrec-
tomy, indicating that more improvements still
need to be made, particularly in a healthcare sys-
tem with limited resources.35
Minimally invasive technology
In an age where techniques are being refined to
offer reduced infection rates and length of hospital
stay, minimally invasive treatments will surely
become increasingly used over the next 20 years.
For example, current data on cryotherapy ablation
in prostate cancers that uses precise mapping and
biopsy has been promising, although more trials
are still required.36 It is likely that computer and
robotic-assisted methods will help revolutionize
cryotherapy and take it to new heights.37 In addi-
tion, the method of radiofrequency ablation
(RFA) for renal cancer has been seen to be safe
and effective, especially for those patients in which
surgery will not be tolerated.38 RFA also offers the
advantage of better outcomes, compared with par-
tial nephrectomy, whilst preserving more renal tis-
sue.39 Importantly, however, RFA has not been
seen to be suitable for all tumours, with lesions
greater than 5 cm having a high failure rate; future
advances will likely improve upon this.38,40
A final ablative treatment to be considered
is high-intensity frequency ultrasound (HIFU),
journals.sagepub.com/home/tau 237
DE Bernstein and BS Bernstein
which may become of use in salvage therapy for
prostate cancers that recur following radiother-
apy.41 This method reduces complications associ-
ated with salvage prostatectomy, whilst conferring
good clinical outcomes. The procedure will likely
be benefited, over the next 20 years, by the use of
simultaneous imaging such as ultrasound, a pro-
cess that provides real-time quality feedback on
the HIFU procedure.41,42
It is also clear that minimally invasive techniques
hold the future for the management of urolithia-
sis, with a notable increase in the use of ureteros-
copy and percutaneous nephrolithotomy
(PCNL), and a concurrent reduction in the use of
open surgery over the past few years.43 In addi-
tion, it is likely that these current techniques will
be further improved upon, with methods such as
the concurrent use of the Uro Dyna-CT (Siemens
Healthcare Solutions, Erlangen, Germany),
which creates real-time cross-sectional and three-
dimensional images that help to improve the
PCNL process, whilst also conferring improve-
ments in stone-free rates after the procedures.44
Furthermore, the PCNL process has evolved
since its conception in 1976.45 As well as the
aforementioned advancements imaging will likely
add to the technique, many companies have
allowed for miniaturization of the equipment
used, which has helped to reduce complication
rates, whilst providing an increased ability to
access difficult stones in all populations.46–48
Thus, in the next two decades it is likely that these
miniaturized PCNL techniques will hold the key
to stone management.
A new age
With benign prostatic hyperplasia and obstruc-
tion becoming more prevalent in our increasingly
ageing population, it is becoming increasingly
important to find improved treatment tech-
niques.49 Possible new techniques of manage-
ment, which have the potential to replace
transurethral resection of prostate (TURP) and
open prostatectomy, are holmium laser enuclea-
tion of the prostate (HoLEP) and thulium vapo-
nucleation. Both these methods have shown equal
clinical efficiency and safety in treating benign
prostatic obstruction.50 Furthermore, recent
studies suggest that modified HoLEP with pres-
ervation of urethral mucosa may allow for patients
to leave hospital within the day, thus further
improving patient standards of care.51 It is
Therapeutic Advances in Urology 10(8)
however noted, that although current operative
time with thulium vaponucleation compared with
TURP is longer, it is hoped that with time tech-
nique refinement can occur.52 One additional
management technique to be considered for
benign prostatic hyperplasia is prostate artery
embolization. This promising method, which
involves the therapeutic occlusion of arteries sup-
plying the prostate, has been seen to be a safer
alternative to minimally invasive methods such as
HoLEP, and can be performed as an outpatient.53
However, before the therapy can be used as
standard, further patients will need to be studied
in future trials to better analyse complications
and clinical benefit.54
In addition, with chronic kidney disease becom-
ing more prevalent, it appears tissue regeneration
will be a cornerstone of the future. The combina-
tion of efforts in both tissue engineering and
regenerative medicine will likely be able to pro-
duce an artificial kidney in the near future.55 With
3D printers becoming more established, it is likely
that fabricated biomaterials will be produced,
though difficulties could arise due to the hetero-
geneous makeup of an organ.56 A further tech-
nique currently being studied in tissue
regeneration is that of the bladder acellular matrix
(BAM). This has the potential to improve surgi-
cal procedures that augment or substitute any or
all of the bladder, which have previously led to
complications such as stone formation, malig-
nancy and bacteriuria.57 The BAM, when seeded
with stem cells, acts as a scaffold for tissue gen-
eration and engineering, potentially revolutioniz-
ing options for the creation of a neo-bladder and
treating those with muscle invasive bladder can-
cer.58 Great advancement in stem-cell therapy in
urology is hoped for, but obstacles such as epige-
netic changes, immune reactions and infection
will need to be overcome.59
Likewise, nanotechnology will come to the fore-
front, aiding targeted therapies. Nanoparticles,
no larger than 1000 nm, have been loaded with
chemotherapeutic agents such as doxorubicin
with high efficiency, sustaining the effect of
chemotherapy in the body.60 In fact, nanoparti-
cles have been seen to enhance the chemothera-
peutic action of apoptosis in prostate cancer
cells.61 Moreover, it has been demonstrated that
nanoparticles are useful tools for gene therapy, as
they are more efficient and safer than their viral
vector counterparts in carrying genetic material
into cells.5,62
238 journals.sagepub.com/home/tau
With further regard to therapeutics it has also
been noted that nanoparticle-directed laser ther-
apy can result in directed tumour-specific abla-
tion in the prostate, with the aid of ultrasound
and MRI technology.63 Although current studies
have been limited in size, use of lasers has been
seen to be clinically safe and efficacious.64
However, more data will be required over the
coming years before this practice becomes
commonplace.
As well as in targeted medicines and therapies,
nanotechnology will also be key in the future for
much of urological equipment and imaging. For
example, a ureteric stent built with nanofibres
that degrade over time will help to reduce the
rates of inflammation and infection compared
with typical polyurethane stents.65 In addition,
the EnSealTM nanotechnology system (Ethicon
Endo-Surgery Inc., Cincinnati, OH, USA) has
been seen to reduce the drawbacks of diathermy
during laparoscopic surgery, through creating
haemostasis at lower temperatures, acting to
reduce damage to underlying structures.66 Finally,
nanotechnology has further enhanced MRI scan-
ning by being able to extravasate into the inter-
stitium of tumours, which can then be highlighted
on subsequent imaging scans, increasing the sen-
sitivity and specificity of carcinoma identifica-
tion.67 It is hoped that these advances will become
common practice in later years.
With this large body of new technology just
beyond the horizon, the training of the next gen-
eration of urologists is more important than ever.
Though currently simulators form a core part of
training,68 thanks to improvements in computing
power and interactivity, future simulators will
implement augmented reality and virtual reality.
This technology will be used in many ways, such
as utilizing medical imaging to create 3D simula-
tors for digital rectal examinations, or helping
surgeons better understand procedures.
Furthermore, technology will assist the develop-
ment of surgeons aiding operations from afar in
‘telesurgery’.69 Finally, it is noteworthy that cur-
rent advancements are being made in virtual con-
sultations, as well as the recording of consultations,
to further improve efficiency in the urological
profession.70–72
Conclusion
It is clear that urological technology will advance
in countless ways over the next two decades to

create a personalized medicine through which
each patient will receive targeted and specific
therapy with minimal side effects. However, it is
neglectful to not acknowledge that the advance-
ments in genetics and targeted therapy may signal
an end to many urological surgeries, such as
cytoreductive nephrectomies, which are falling
out of favour due to targeted therapies for kidney
cancer.
Whilst the prehistoric urologist may have had to
fend off a sabre-toothed tiger whilst treating his
patient, the challenge to urological professionals
of the future will be to utilize the technological
advances of the world, to complement the growth
in urological technology and better treat patients
who require their services.
Acknowledgements
Miss Helena Gresty, Urology Registrar at the
Royal Free Hospital.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
Conflict of interest statement
The author declares no conflict of interest in pre-
paring this article.
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