Aug. 18, 2025
In this interview, Arpeet Shah, MD, considers some of the advancements and challenges that the field of urology will face in the coming year. Shah is a urologist at Associated Urological Specialists, which is a part of Solaris Health. In clinical practice, Shah does a combination of general urology as well as urological oncology.
Link to Ezisurg
This transcript was AI generated and edited by human editors for clarity.
One of the biggest trends shaping urological research, as well as care in , [will be] a shift toward precision-based care, where we're tailoring diagnosis and treatment to the individual patient. One example of this is in prostate cancer detection, where we see tools like IsoPSA or other adjunctive tests, which have emerged as game-changers in the diagnostic process. IsoPSA, for example, is a blood test that goes beyond traditional PSA [prostate-specific antigen] testing and detects structural changes in the PSA that are linked to cancer. This allows us to better distinguish benign conditions from clinically significant prostate cancers, thus reduc[ing] the need for unnecessary biopsies and [allowing us to] focus interventions for patients who need them the most.
If you look at things beyond prostate cancer, there are precision-based approaches for bladder cancer and kidney cancer. All of these are improving our ability to detect diseases earlier and develop treatment plans that minimize overtreatment and [adverse] effects.
The work force challenges in urology are multifaceted and mirror broader trends in health care, but there are unique aspects to our field of urology. There are concerns with the growing demand of urological care in terms of an aging population. We have increasing prevalence of prostate cancer, kidney stones, and BPH [benign prostatic hyperplasia], and we're seeing a significant mismatch between the number of practicing urologists and the patient population. This is leading to longer wait times and limits access to timely care, particularly in rural and underserved areas.
This problem only gets worse when you look at recruitment and retention. Urology is a very in-demand specialty. A recent study [found that] it’s one of the most demanding specialties in medicine, with potentially 8 jobs available per applicant. Being able to recruit urologists is a real challenge for practices. This also gets worse when you look at the retirement of urologists. The average age of a practicing urologist is in the upper 50s. We're not training enough urologists to fill the gaps that are coming with the increased retirements. As a result, we have many practices exploring different ways to optimize team-based care, [such as] leveraging APPs [advanced practice providers] to help meet patient and practice needs.
We've already seen quite significant advancements in diagnostic imaging, but I think they will continue to revolutionize how we diagnose patients faster, more precisely, and less invasively. For example, we already use multiparametric MRI, and it's pretty widespread. But if you include the addition of AI driven imaging analysis to improve our ability to detect cancers earlier and with greater accuracy, it's a really interesting concept.
We’ve focused a lot on oncology, but there's many non-invasive urinary pressure flow [devices] such as UroCuff, which are allowing us to objectively determine the significance of patients' BPH diagnosis and allow us to be less invasive compared with traditional urodynamics testing. There are a lot of new diagnostic testing coming out that will help us care for our patients better.
Biomarkers are a game-changer in the early detection of urological conditions like prostate cancer and kidney cancer.
For example, in prostate cancer, biomarkers like IsoPSA or 4K scores, or urinary biomarkers like ExoDX or Select MDX are helping us better stratify patients based on their risks. This allows us to reduce unnecessary biopsies and focus on identifying clinically significant cancers.
In kidney cancer, there are emerging blood-based and urine-based biomarkers, which are showing some promise to detect tumors at earlier stages, even sometimes before they're visible on imaging. These advancements mean we're moving towards a more personalized approach in screening and surveillance.
There are several novel therapies and immunotherapies that are related to more advanced forms of bladder and kidney cancer, and these are transforming the way we treat these conditions. For example, in bladder cancer, we're seeing significant advancements in antibody drug conjugates and checkpoint inhibitors, which are providing more effective options for patients with advanced or metastatic disease. We're seeing similar novel therapies in kidney cancers. Looking forward, I think the focus is on improving response rates and durability of these treatments and figuring out what combination of treatments and in what order we should deliver all these new therapies that are coming to market.
AI is hitting all parts of health care delivery. It’s going to have an impact on how we approach diagnosis, treatment planning, and other forms of patient care. If you look at one of the more immediate ways that AI will have an impact, there are AI-powered imaging tools that help improve the accuracy of diagnostic imaging conditions like prostate cancer, kidney stones, or urothelial carcinoma. These systems can analyze imaging data faster and more precisely than ever, as well as identify subtle abnormalities that might be missed by the human eye. This ultimately helps us diagnose disease earlier and with greater confidence.
Beyond imaging, AI is enhancing clinical decision-making. We have machine learning algorithms that can help analyze large data sets to predict patient outcomes, stratify risk, and even suggest personalized treatment pathways. For example, in prostate cancer management, AI can integrate data from biomarkers, genomic testing, and imaging studies to guide toward a more targeted intervention.
We're also seeing AI become more integrated in robotic surgery as well as predictive analytics. For example, PROCEPT Aquablation is now utilizing AI to determine treatment planning. We're going to see AI touch all forms of technology to make surgery more precise and safer, outcomes more predictable, and care more efficient.
If you look at AI in terms of workflow, it can help with clinical documentation and integrating with live patient encounters, allowing the physician to spend more time with the patient rather than on all of the administrative tasks. There's going to be a lot of advancements that AI brings to health care, but it's crucial that we ensure these advancements are implemented thoughtfully, with an emphasis on improving patient outcomes and maintaining the clinician-patient relationship at the center of all of it.
We're in the golden age of BPH therapy. There are many therapies, surgical procedures, and MISTs [minimally invasive surgical therapies] that are in line. What's more remarkable from a global level is that all of these new technologies for BPH—whether you're talking about Aquablation or FloStent or Rezūm or PAE [prostatic artery embolization]—are bringing awareness to the issue and getting patients and providers off the bench, getting them to be more proactive in treating BPH earlier in the disease state before there's a real compromise to bladder health. Even more than the techniques and technologies that are coming down the pipeline, I'm most excited about the more widespread use of objective diagnostic testing to tell us how severe of an issue BPH is to the health of a patient. We know things like IPSS [International Prostate Symptom Score], although important, are extremely subjective and do not tell us the whole story. The use of objective testing in urology, specifically in bladder and prostate health, allow the provider and the patient to make a better decision.
I say this to everybody, but the analogy to cardiology is really important. You don't go to a cardiologist and have them give you a survey on how your heart is feeling. They determine your cardiac care based on objective testing, whether it's an echocardiogram, a stress test, or something else. Urologists need to move away from just survey-based questionnaires to more objective measurements of bladder and prostate health to determine what needs to be done.
Robotic nowadays represents the gold standard for numerous surgeries. Its use is transversal to several medical specialties and its diffusion is constantly growing all over the world.
What is meant by the term “robotic surgery”: “A computer-controlled manipulator with artificial sensing that can be reprogrammed to move and position tools to carry out a range of surgical tasks” (1).
Two types of robotic systems are currently available; indeed, they can be OFF-LINE (FIXED PATH SYSTEMS) if they perform precise movements based on pre-programmed imaging studies obtained before surgery or ON-LINE (MASTER-SLAVE SYSTEMS) in which the robot replicates the surgeon’s movements in time real within the operating range and the Da Vinci robotic system falls into this second category (2).
In this review of the literature, we will try to highlight what have been the peculiarities in the development of robotic surgery in urology from the beginning till today and trying to identify what are its future prospects.
A non-systematic literature review was performed using the PubMed/Medline electronic search engine using the following terms: “robotic surgery” or “development of robotic surgery” or “single site surgery” or “single port surgery”.
Articles in English and of urological interest relating to single-site robotic surgery with a dedicated platform were selected.
In the late s, after the statements of President George H. W. Bush to want to bring man to Mars, a series of technological innovations followed. A group of researchers developed a stereoscopic 3D viewing display unit called the head-mounted display (HMD) (3). Later researchers from the Stanford Research Institute (SRI) together with a military surgeon developed a system for instrument telemanipulation (4). Unfortunately, these technological innovations were not technically ready for telepresence surgery, however, the contemporary development of laparoscopic surgery led to the development of a robotic system that could be applied to it. This aroused the interest of the United States Department of Defense which financed a research project for the development of a robotic system capable of delivering first aid to wounded soldiers on the battlefield [Defense Advanced Research Projects Agency (DARPA)] (5).
Starting from the early s two main private industries (Computer Motion and Intuitive Surgical) brought the technical-scientific innovations necessary for the final development of the robotic system used today.
Computer Motion Inc. initially developed an Automated Endoscopic System for Optimal Positioning (AESOP) that used voice-controlled commands to provide hands-free intraoperative maneuvering.
Later, with the use of funding obtained from DARPA, they developed a robotic system called Zeus capable of reproducing the surgeon’s movements (2).
In , the Intuitive Surgical company was founded, which, after a few prototypes, developed the surgical system known as Da Vinci. This system, unlike previous prototypes that involved anchoring the robotic arms to the operating table, consisted of a patient-side cart, a stereoscopic vision, and an advanced master manipulator system. In the first robotic cholecystectomy was performed in Brussels using the “Mona” prototype (6). Subsequently, myocardial revascularization interventions were performed in Germany in (7).
On May 23, , Binder and Kramer performed the first robotically-assisted laparoscopic radical prostatectomy (8).
In Intuitive Surgical acquired Computer Motion and assumed a monopoly on robotic surgery. Since then, the food and drugs administration has approved 5 generations of Da Vinci systems for use in urology.
Simultaneously with the development of robotic surgery, laparoscopic surgery has also undergone considerable development over the years. In fact, the two techniques have had a parallel development influencing each other with the technological improvements introduced in one or the other. From the first laparoscopic experience published in by Schuessler et al. (9), there has been a notable development also with regard to conventional laparoscopic surgery with the introduction of HD 3D optics, dedicated instruments for haemostasis and motorized laparoscopic instruments to have greater degrees of mobility in the space. Even in conventional laparoscopy, there has been a tendency to minimize the surgical approach with the introduction of minilaparoscopy and single-port laparoscopic surgery (LESS) (10).
If you are looking for more details, kindly visit urology instruments evolution.
The first systems introduced in the early s were the Da Vinci system and the Da Vinci S system initially developed for coronary surgery but also used for urological surgery. Starting from , Intuitive Surgical introduced the Da Vinci Si system by making some technological improvements such as HD video technology, finger-based clutch mechanism and indocyanine green fluorescence (Fire-Fly technology) as well as the possibility of being adapted to single-port surgery using the VeSPA system. In the Da Vinci Xi system was introduced featuring an 8-mm HD 3D camera and a slimmer robotic arm design as well as the ability to move the operating table while the robotic arms are connected which gave it the ability to be used in multi-quadrant surgery.
In the end, the Intuitive Surgical introduced the Da Vinci SP system which, by means of a telescope and flexible instruments, allows the triangulation of them within the surgical field while using a single port (11).
Some other companies have introduced robotic systems but none currently has the diffusion of the Da Vinci system in the world.
After the first surgery performed in May by Binder and Kramer, robotic surgery has had an exponential development and diffusion in the urological field and thanks to this rapid diffusion the urologic community missed the window of opportunity to test this novel approach within an evidence-based frame. In fact, in the first years since its introduction, only few comparative studies have been undertaken that compared robotic surgery with conventional laparoscopy and retropubic prostatectomy (12).
The first systematic review on studies comparing conventional laparoscopy, retropubic prostatectomy and robotic prostatectomy comes in by Ficarra et al., about 10 years after the introduction of robotic surgery. Their conclusions are not conclusive because, from the analysis they conducted, it emerges that conventional laparoscopy and robotic surgery approaches are correlated with lower blood losses and transfusion rates, but there are not sufficient criteria to prove the superiority of a surgical approach compared to others (12).
Despite these fragile initial conclusions, the spread of robotic systems has continued exponentially to become the gold standard for some types of surgery.
In fact, almost all urological surgeries were performed with the use of robotic surgery. The spread of the robotic approach in urology has also led to the development of dedicated surgical techniques that are difficult to replicate with conventional laparoscopic surgery or open surgery. In Galfano et al. published their initial experience with Retzius sparing surgery and, to date, this method remains the prerogative of the robotic assisted surgical approach (13).
However, we can identify some limitations to robotic surgery. As identified by Cacciamani et al., some of these may be related to the characteristics of the tumor (size and surgical complexity), others to intrinsic characteristics of the patient which in some cases may lead to contraindicating the robotic approach from an anesthetic point of view (14).
The patient’s position in Trendelenburg or on the side and the need for a pneumoperitoneum can lead to changes in hemodynamics, respiratory dynamics, and intracranial pressure. All aspects that must be taken into consideration during the planning of the intervention (15).
Since , robotic-assisted single-site laparoendoscopic surgery (R-LESS) has been proposed as a further technical evolution in the urological field. The first series of R-LESS in urology was described by Kaouk et al. on three patients describing a radical prostatectomy, a pyeloplasty and a radical nephrectomy. These procedures were performed using the Da Vinci S robotic system through a single-port multi-channel platform (16).
However, the early robotic systems did not have a thin arm design and this caused numerous instrument clashing (17).
To overcome this inconvenience, the use of GelPort was introduced which allowed a better triangulation of robotic tools by decreasing arm clashing (18).
In the following years, further technical advances were introduced that allowed a further improvement in robotic docking and instrument triangulation. On the one hand, the introduction of a new multi-channel laparoscopic port with associated curved cannulae that allowed robotic instruments, equipped with flexible ends, to be crossed at the level of the fascia (VeSPA system). On the other, an improvement of the software able to eliminate the “reverse handedness effect”. That is, the need to maneuver the left instrument with the right hand and vice versa (19).
Despite these technological innovations, R-LESS surgery remained bound to some intrinsic limits such as external clashing, loss of triangularization of the instruments and poor accessibility for the assistant that made it a surgical technic under development (20).
To overcome these drawbacks, our group, while waiting for a robotic platform dedicated to single site surgery, introduced the use of a hybrid R-LESS which involved the use of a home-made multiport and with an additional standard robotic trocar (21).
More recently, Intuitive Surgical’s introduction of a robotic platform dedicated to single-port surgery has led to further development of R-LESS. First the SP999 system and then the SP system made it possible to articulate the robotic instruments, produced through a single-port access, within the operating field, allowing them to be triangulated correctly (22).
Although it is a very recent technology, some preliminary experiences have been presented in the literature that document the feasibility of some major urological interventions, including radical prostatectomies (23-26), radical cystectomy (26,27), partial nephrectomy (26,28) and ureterocystoneostomy (26,29) (Table 1).
Long-term oncological and functional outcomes are not yet available and require more follow-up.
The SP is a recent and very promising technological innovation. It combines the already consolidated advantages of robotic surgery such as optical magnification, the abolition of tremor and the possibility of using endowrist® manipulators with a further step in minimally invasive surgery. This actually leads to less postoperative pain, a lower chance of hernia and a better cosmetic result.
With the development of a dedicated platform, the initial drawbacks associated with the use of a standard platform adapted to single-port surgery, such as external and internal clashing and loss of triangularization, have been reduced.
All the instruments pass through a single door of 2.5 cm in diameter and within the operating field acquire the triangularization necessary to improve the workspace and reduce clashing between the endowrists.
In fact, the endowrists designed for SP surgery have been equipped with two movable joints, a wrist that allows the rotation of the instrument and an elbow that allows it to flex within the operating field in order to obtain a correct positioning within the same.
Thanks to these technological advances, single-port surgery takes on the characteristic of multi-quadrant surgery. However, the need to obtain a triangularization of the instruments within the operating field raises the need to have a suitable distance between the entry point of the instruments and the anatomical target. Lenfant et al. in identified 10 cm as the minimum distance between the entry point of the instruments and the anatomical target. In case it is not possible they also proposing, as an alternative solution, to obtain a sufficient distance between the instruments and the anatomical target, using the Gelpoint System to allow you to expand the work space in order to start the triangulation of the instruments outside the abdominal cavity. They called it floating docking technique and involves the positioning of the GelSeal cap and the robotic trocar 8 cm above the skin, then using the wound retractor (Alexis®) as a tunnel to allow for an adequate pneumoperitoneum (30).
However, the structural changes introduced at the robotic system and instrumentation level have entailed some limitations regarding the field of view and the maneuverability of the instruments in terms of rotation, force and range of action, partly bypassed by the introduction of a virtual visual overlay called “Navigator” able to show the surgeon the position of the robotic instruments even if they are outside the visual field (26).
In studies in the literature, the single-port robotic system has proved feasible and safe, although in small cases series. Re-evaluating the development of robotic surgery, with each innovation, it aroused great enthusiasm, leading to a great diffusion of the method before having randomized clinical trials that confirmed the effective improvement of the technique compared to the gold standard. The urological community should not miss the second chance to be able to evaluate an emerging technique based on comparative clinical studies.
In evaluating the development of a method, a fundamental part is linked to the cost analysis of the same. In relation to robotic surgery, a lot has been said about it. This analysis consists of many aspects, not only related to hospitalization and the costs of the operating room, but also to the patient’s reintegration into society and the possible emergence of postoperative complications. For this reason, Bijlani et al. in analyzed the cost impact of robotic surgery and concluded that despite the higher initial costs, this method allows the health system to save by affecting early discharge, fewer complications and a faster return to work (31).
Single-port robotic surgery represents an important technological innovation. It has been shown to be feasible and safe even in major surgery. However, it requires randomized controlled comparative clinical trials to evaluate perioperative and long-term outcomes.
Funding: None.
Provenance and Peer Review: This article was commissioned by the editorial office, AME Medical Journal, for the series “New Frontiers and Technologies in Urology”. The article has undergone external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10./amj-20-166/coif). The series “New Frontiers and Technologies in Urology” was commissioned by the editorial office without any funding or sponsorship. GM served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of AME Medical Journal. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
For more vessel sealing deviceinformation, please contact us. We will provide professional answers.
If you are interested in sending in a Guest Blogger Submission,welcome to write for us!
All Comments ( 0 )