The 2021 AUA Annual Meeting showcased the torrid pace of technology-driven innovations in urology with 30 abstracts in the “imaging and radiology” category and 56 in the “technology and instrumentation” category. Themes included using machine learning methods and the application of standard and novel imaging modalities to optimize cancer detection, as well as using novel surgical techniques to improve outcomes. Over 30 abstracts discussed surgical skill improvement, with a focus on utilizing virtual reality and other simulation technologies. Though we regretfully cannot cover every meritorious presentation, we discuss select abstracts that highlight these noteworthy trends.

Novel Applications of Ultrasound

Micro-ultrasound uses higher frequencies to improve image resolution over traditional ultrasound devices. In a small case series, transrectal micro-ultrasound compared favorably to magnetic resonance imaging (MRI) in detecting pathology-confirmed prostate cancer lesions (MP22-09). Another study demonstrated the feasibility of ultrasound-tomography, an acoustic 3D imaging modality, for prostate cancer detection in ex-vivo models (MP22-17). These proof-of-concept studies highlight the potential for ultrasound to again be used as a low-cost, point-of-care tool to help manage prostate cancer.

Novel uses for ultrasound technology in benign urology were also reported. One group demonstrated that contrast-enhanced ultrasound (CEUS), which uses a microbubble contrast agent, was superior to fluoroscopy in detecting ureteral drainage in patients undergoing endoscopic stone management (PD10-01). The authors hypothesized that CEUS could be used to more accurately determine the need for post-lithotripsy stent placement. Other authors used CEUS to assess urethral strictures and reported it to be more accurate than retrograde urethrography (PD10-12). Another study found that traditional ultrasound was noninferior to computerized tomography urogram for the detection of suspicious lesions in low risk microhematuria patients (PD10-07). These studies suggest ultrasound modalities may be a valuable alternative to imaging modalities that expose patients to ionizing radiation.

Deep Learning in Cancer Detection

Deep learning models for MRI-detected prostate cancer have traditionally been hampered by incomplete or inaccurate pathology-confirmed ground truth labels. One study aimed to overcome this by co-registering MRI images with annotated whole mount pathology slides to directly correlate radiological and histological features on a pixel-by-pixel basis (PD10-01). Their model demonstrated excellent cancer detection performance and highlights the potential for machine learning methods to help enhance MRI interpretation.

Similarly, other authors used deep learning models to distinguish benign renal masses from renal cell carcinoma (PD41-02). Their model incorporated both imaging and clinical information to achieve promising discriminatory performance. Notably, the model enhanced diagnostic accuracy in patients who had undergone negative or nondiagnostic renal mass biopsy, suggesting radiomics may have a role in reducing the overtreatment of indolent or benign masses.

Surgical Skill Improvement

Several presentations this year examined creative ways to improve technical surgical skills among trainees. One multicenter randomized control trial examined the utility of surgical simulation to improve resident performance of ureterorenoscopy (PD58-04). The authors found that trainees exposed to simulation had better overall proficiency scores with faster skill acquisition during subsequent surgical procedures in patients. A creative way of promoting more widespread use of surgical simulation is the use of gamification through the creation of team-based competitions. These authors showed that participating in a robotic surgery simulation league could improve resident engagement and proficiency with surgical simulation (PD58-06). Residents also reported subjective improvement in surgical confidence and autonomy. Work exploring the use of high-fidelity surgical simulators was also presented, including a mixed-reality laparoscopic simulator that incorporates haptic feedback and real-world obstacles into virtual simulations. This added realism can more accurately mimic adverse events such as uncontrolled bleeding or bowel injury. Together, these presentations highlight the growing focus on improving technical skills prior to entering the actual operative setting.

Other strategies to improve surgical outcomes were also investigated. One study analyzed room traffic, external communication, and other intraoperative distractions in relation to adverse operative events (MP10-02). Another examined the use of 3D anatomical visualization platforms, such as the Da Vinci® Iris®, and found that users were able to more quickly and accurately understand patient anatomy compared to using traditional 2D viewing platforms (PD41-11). Ergonomics were also of particular interest in several presentations that examined economy of motion and posture during laparoscopic, robotic and microsurgery (PD58-11, PD41-07, PD58-05). While these studies are still preliminary, they may yield important improvements in historically overlooked, but important, aspects of surgery.

New Devices/Techniques

Several new devices were introduced this year, including a multi-resolution foveated laparoscope which allows for simultaneous wide angle and zoom views for better field of vision (MP10-04). A novel pneumo-cystoscope with a laparoscopic instrument channel was introduced as well (MP10-03). The authors demonstrated this scope in a small series of bladder tumor resections using a supersonic scalpel in a bladder pressurized with carbon dioxide. Other surgical advancements include intraoperative near-infrared fluorescence (using Firefly®) of the prostatic neurovascular bundles to facilitate nerve-sparing procedures during robotic-assisted radical prostatectomies (MP10-07). The authors report safely identifying all neurovascular bundles in their cohort of 207 patients, resulting in significantly improved postoperative erectile function.

A large collection of presentations featuring procedures performed with the Da Vinci Single Port robot were also presented, including extraperitoneal kidney transplantation (V08-08), extraperitoneal radical prostatectomy (V08-10), bilateral pyeloplasty (V08-06), inguinal lymph node dissection (V08-05), radical cystectomy with intracorporeal creation of neobladder (V08-01) and ipsilateral transureteroureterostomy (V08-07). However, the true patient and system-level benefits of the single port platform over established surgical approaches requires further study of its economic impact and incremental effectiveness.