Newer Frontiers in Urology, Volume III

Use of Lasers in Upper Tract Urology: Technology, Applications and Future Directions

2026-01-27T10:01:14+00:00

Laser energy has revolutionised the treatment of pathology within the upper urinary tract. Lasers were first introduced into urology with early Nd: YAG and CO₂ systems, which were mainly used for coagulation and treatment of superficial urothelial lesions. Over subsequent decades, technological advances led to pulsed holmium: YAG and, more recently, thulium fibre lasers, enabling safe intracorporeal lithotripsy and precise soft‑tissue ablation throughout the urinary tract. They underpin flexible ureteroscopy and percutaneous nephrolithotomy for stone disease, enable organ‑preserving management of upper tract urothelial carcinoma and treat benign strictures. However, each platform has unique physical properties that influence its clinical utility. This chapter reviews laser physics, evolution of technology, and compares Ho: YAG with TFL, emphasising their mechanisms of lithotripsy, modes of operation, instrumentation and safety considerations. Clinical applications in stone fragmentation, tumour ablation and stricture incision are discussed, supported by contemporary evidence. We present a practical algorithm for laser selection and settings in upper tract endourology and highlight future directions, including pulse modulation, dual‑wavelength systems and integration with digital ureteroscopy. Understanding the capabilities and limitations of lasers is essential for urologists to optimise outcomes while minimising complications.

Evidence-based Approaches to Male Infertility: Current Standards and Future Directions

2026-01-27T10:05:47+00:00

About 13–15% of couples have male infertility, a multifactorial condition that contributes to roughly half of all reported cases of infertility globally. Its aetiologies include genetic, endocrine, anatomical, infectious, immunological, environmental, and idiopathic causes. Genetic abnormalities, dysregulation of the hypothalamic-pituitary-gonadal axis, varicocele-associated oxidative stress, previous cryptorchidism, genital tract infections, and antisperm reactions are the main causes of its pathogenesis, which disrupts spermatogenesis and sperm transport.

Oxidative stress and hormonal imbalance are common routes shared by environmental pollutants, obesity, heat exposure, and lifestyle variables. Dopamine agonists for hyperprolactinemia; gonadotropin therapy with hCG and FSH in hypogonadotropic hypogonadism; varicocele repair in men with palpable varicoceles and abnormal semen parameters; avoidance of exogenous testosterone or anabolic steroids in men pursuing fertility; and selective oestrogen receptor modulators like clomiphene and tamoxifen in idiopathic oligozoospermia with suboptimal testosterone.

Although there is still little data based on guidelines, antioxidants, including CoQ10, L-carnitine, and vitamins C and E, may lessen oxidative stress. The results of severe oligozoospermia and azoospermia have been transformed by assisted reproductive technologies like IVF and intracytoplasmic sperm injection, which are complemented by surgical methods, including orchiopexy, repair for blockage, and sperm retrieval procedures. Probiotic manipulation of the gut-testis axis, stem cell transplantation, immunomodulators, and nutraceuticals are emerging topics that hold promise for the future. To maximise reproductive results for men and couples, management ultimately calls for a customised, evidence-based, multidisciplinary approach that incorporates established therapies, emerging research, and guideline recommendations.

Clinical Integration of Artificial Intelligence in Urology with a Focus on Temporal Deep Neural Networks for Emphysematous Pyelonephritis

2026-01-27T10:09:12+00:00

Artificial intelligence (AI) is transforming urology by facilitating quick, data-driven analysis in diagnosis and treatment. This chapter explores core AI concepts and their applications in urological conditions like kidney stones, bladder cancer, prostate cancer, and benign prostatic hyperplasia (BPH). Examples of models (such as convolutional neural networks and support vector machines) used in urology are used to teach general AI approaches (machine learning and deep learning). Automated MRI prostate cancer diagnosis (AUC ~0.96), ureteroscopic stone identification (CNN ~90% accuracy), and bladder tumour segmentation are significant achievements.

Additionally, the chapter highlights issues with dataset heterogeneity, sample size, and selection bias while briefly discussing the types of datasets used in AI-driven urology research, including imaging, clinical, and longitudinal data. A case study of an emerging multi-task deep neural network (t-MTDNN) for the prediction of emphysematous pyelonephritis (EPN) is included. Feature descriptions (SHAP) are provided for the t-MTDNN architecture and workflow, and its clinical impact and performance metrics are analysed.

In conclusion, the strengths and challenges of AI models are compared (Table 1) and prospective opportunities in AI-assisted urology are described with an emphasis on the therapeutic advantages (improved accuracy, efficiency) and limitations (data requirements, interpretability). Instead of replacing clinical judgement, urologists and healthcare organisations view AI as a clinical decision-support tool that can enhance workflow efficiency, support hospital-level adoption through interdisciplinary collaboration, and augment physician expertise.

Short Tube and Big Challenges: Diagnostic Approach, Urodynamic Evaluation, and Modern Reconstructive Techniques in Female Urethral Stricture Disease

2026-01-27T10:25:55+00:00

Background: Female urethral stricture disease (FUSD) is an uncommon yet increasingly recognised cause of bladder outlet obstruction (BOO) in women that has long been obscured by heterogeneous definitions and overlap with “female urethral syndrome”. Women typically present with mixed lower urinary tract symptoms (LUTS) such as thin stream, hesitancy, straining, prolonged voiding, incomplete emptying, dysuria, and recurrent urinary tract infection, most often alongside frequency, urgency, nocturia, or incontinence.

Methodology and diagnostic approach: Diagnosis rests on a synthesis of clinical examination, uroflowmetry and post-void residual urine estimation, imaging, and endoscopy. Video-urodynamics is reserved for dilemmas separating BOO from detrusor underactivity.

Surgical management: Endoscopic dilation or direct vision internal urethrotomy (DVIU) is widely accessible but provides only short-term relief with high recurrence, especially after repeated procedures. Definitive management is reconstructive. Technique selection flap-based (vaginal or labial) versus graft-based (buccal or lingual oral mucosa, vaginal or labial mucosa) is guided by stricture site, length, tissue quality, and aetiology. Dorsal onlay buccal mucosal graft (BMG) urethroplasty, exploiting the vascular support of the clitoral cavernosal tissues and reducing fistula risk, has become the workhorse for many mid and proximal strictures. Ventral inlay/onlay approaches are valuable for distal disease or limited dorsal exposure, and double-face grafting is reserved for obliterative or recurrent cases.

Outcomes: Contemporary series consistently demonstrate ≥80% success with substantial improvements in flow and residual volumes, high satisfaction, and preserved continence. Risk factors for failure include longer strictures, prolonged symptom duration, multiple prior dilations, and lichen sclerosus.

Conclusion: This review systematises the diagnostic algorithm, urodynamic evaluation and modern reconstructive techniques for FUSD, addressing a critical gap in the literature and advocating the need for prospective, multi-centre trials with standardised definitions and quality of life endpoints.

Applied Risk Scoring in Acute Pyelonephritis: Evidence, Implementation, and Future Directions

2026-01-27T10:29:14+00:00

Acute pyelonephritis (APN) spans a broad severity spectrum from uncomplicated febrile illness to emphysematous pyelonephritis with shock, creating a persistent need for reliable, bedside risk stratification. This chapter synthesises evidence on physiologic, disease-specific, and imaging-based scoring tools. It shows how to assemble them into a practical, layered pathway that improves triage, timing of imaging, and source control decisions. We review general sepsis scores (SIRS, SOFA, qSOFA, NEWS2) for early physiological surveillance; APN-specific clinical models for bacteremia prediction at first contact; global severity tools (Pitt Bacteremia Score, Charlson Comorbidity Index) for comorbidity and mortality profiling; and radiologic frameworks led by the Huang–Tseng CT classification for emphysematous pyelonephritis. Particular attention is given to a modified NEWS2 (mNEWS2) tailored for EPN, which retains original variables but re-bands risk and identifies scores ≥15 as a decisive high-risk delimiter linked to ICU need, nephrectomy, and mortality. We appraise biomarkers that add dynamic signal pro-calcitonin for bacteremia likelihood, lactate for occult hypoperfusion, and presepsin as an emerging adjunct and show how trends over 24–72 hours refine escalation or de-escalation. The chapter translates these elements into an implementation pathway: screen with NEWS2 or qSOFA; obtain early pro-calcitonin and lactate; expedite ultrasound or CT when red flags exist (diabetes, obstruction, acute kidney injury); apply APN specific bacteremia models to support admission and empiric coverage; and, in confirmed EPN, pair CT class with mNEWS2 bands to set thresholds for ICU, drainage, and early nephrectomy if non-responding. Special populations, such as those with diabetes, elderly or frail patients, transplant recipients, and those with obstruction, are addressed with lower action thresholds. Finally, we outline emerging opportunities for precision risk prediction, including machine learning classifiers to refine early bacteremia detection, radiomics-enhanced CT to integrate imaging features with clinical data, and transparent validation standards, moving APN care from static scores to adaptive, multimodal, precision risk prediction. The result is a clinician-facing roadmap that accelerates antibiotics, imaging, and decompression, reducing preventable harm across care systems.

Robotics in Indian Urology: Evolution, Clinical Applications and Future Direction

2026-01-27T10:32:27+00:00

Laparoscopy, by the 1990s, had become standard for many urological procedures, but it had intrinsic limitations: two-dimensional vision, limited instrument articulation, tremor, and surgeon fatigue, especially in deep pelvic dissections. Robotic systems were developed to overcome these barriers, offering new levels of precision and control. Robotic systems combine the minimal invasiveness of laparoscopic surgery with enhanced dexterity, three-dimensional magnified vision, tremor filtering, and ergonomic advantages that preserve surgeon precision over long operations. In this chapter, the study expands our understanding of robotics in Indian urology by tracing its evolution and technological developments, examining its clinical applications in both oncology and reconstructive surgery, exploring its advantages and limitations, reviewing training and credentialing, and outlining recent advances and future directions. Robotic technology has permeated nearly every subspecialty of urology. Although its initial appeal was confined to oncological surgery—especially prostate and kidney cancer—its role now extends to reconstructive, functional, and even pediatric urology. The combination of tele-robotics and indigenous cost-effective systems could make complex urological surgery feasible even in government hospitals serving semi-urban populations. Robotic platforms now integrate indocyanine green (ICG) fluorescence imaging, which assists in vascular mapping during partial nephrectomy, delineating renal vasculature and collecting systems. Indian surgeons increasingly use real-time fluorescence to ensure complete tumour excision while minimising ischemia.

Suction-Enabled Retrograde Intrarenal Surgery: Technical Principles, Physiological Rationale, and Evidence-Based Applications

2026-01-27T10:35:03+00:00

Background: Retrograde intrarenal surgery (RIRS) is a cornerstone for managing renal calculi <2 cm, yet it faces limitations including elevated intrarenal pressure, suboptimal stone clearance, and infectious complications. The integration of suction, particularly via Flexible and Navigable Ureteral Access Sheath (FANS), aims to mitigate these challenges. This chapter provides a critical appraisal of the role of suction in RIRS.

Methods: A synthesis of current literature and technical principles was conducted to evaluate the mechanisms, clinical outcomes, advantages, and limitations of FANS-assisted RIRS.

Results: FANS facilitates continuous outflow of irrigation fluid, stabilising intrarenal pressure and reducing the risk of pyelovenous backflow and sepsis. It enhances intraoperative visibility and may improve stone-free rates by actively evacuating fragments. However, these benefits must be weighed against increased costs, a learning curve, and a currently limited evidence base from large randomised trials.

Conclusion: Suction-assisted RIRS represents a significant technical advance, particularly beneficial in cases with enormous stone burdens, lower-pole stones, or infected systems. The decision to utilise suction—"to suck or not to suck"—should be individualised, as it is not a mandatory addition for all RIRS procedures but a valuable adjunct in select clinical scenarios.

Male Anterior Urethral Stricture Disease: Aetiology, Evaluation, and Modern Reconstructive Approaches

2026-01-27T10:37:26+00:00

Background: Male anterior urethral stricture disease is a challenging condition characterised by fibrotic narrowing of the urethra, most often in the bulbar or penile segments. It leads to obstructive voiding symptoms and significantly impacts quality of life. Definitive management requires surgical urethral reconstruction (urethroplasty), which offers far superior long-term success compared to repeated dilations or urethrotomies This chapter reviews the etiology, classification, and anatomy of anterior urethral strictures, and provides an in-depth discussion of urethral reconstruction techniques, including excision and primary anastomosis (EPA), substitution urethroplasty with buccal mucosa graft (BMG), penile skin flap urethroplasty, staged repairs, and perineal urethrostomy.

Methods: A comprehensive analysis of contemporary and classical literature was performed, incorporating landmark contributions (e.g. Barbagli, Kulkarni, Mundy) and recent series. Outcomes, indications, and complications of each reconstructive technique are summarised, and a comparative table is provided for quick reference.

Results: Short bulbar strictures (<2 cm) are effectively cured by EPA with success rates >90%. Longer or multiple strictures are managed with substitution urethroplasty using buccal mucosal grafts, which is now the standard augmentation tissue and yields durable success in ~85–95% of cases, depending on stricture length and location. Penile fasciocutaneous flap techniques (e.g. Orandi, circular flaps) can achieve comparable success to grafts in appropriately selected patients, though flap use has declined due to higher donor site morbidity (torsion, sacculation, etc.). Complex and lengthy strictures (particularly those due to lichen sclerosus) often require two-stage repairs to achieve a stable urethral calibre. Perineal urethrostomy is reserved as a salvage or permanent solution in refractory cases and offers excellent relief of obstruction with an acceptable quality of life.

Conclusions: Male anterior urethral strictures can be effectively reconstructed with a variety of techniques tailored to stricture characteristics. In experienced hands at high-volume centres, one-stage urethroplasty (anastomotic or substitution) achieves long-term cure in the majority of patients, with overall success rates exceeding 85–90%.

Buccal mucosa has become the graft of choice for augmentation. Proper patient selection and preoperative optimisation are crucial. Postoperatively, patients require structured follow-up with objective (uroflowmetry, ultrasound imaging) and subjective (symptom scores) assessments to detect and manage recurrences early. This chapter provides urologists with a detailed, evidence-based guide to contemporary urethral reconstruction, including technical pearls, expected outcomes, and management of complications.