One of the most exciting changes in our field over the past 2 decades has been in the delivery of urologic oncology care. Just like shock wave lithotripsy and percutaneous surgery radically changed clinical practice in stone disease, so too has laparoscopic and robotic surgery shifted urologic oncology practice to a minimally invasive approach in almost every oncologic disease site. Additionally, with evolution of image-guided surgery and ablative techniques, thermal ablation for select small renal masses is now considered part of guideline-based care while the evidence to support focal therapy for the treatment of prostate cancer continues to mature. Lastly, the use of MRI-fusion and transperineal prostate biopsies has improved diagnostic accuracy and patient care.

In concert with evolution in surgical care, parallel innovations in radiation oncology, as well as dramatic increase in chemotherapeutic options, targeted therapies, immunotherapies, biomarkers, and genomic testing among others, have resulted in a more thoughtful and multidisciplinary approach to delivering patient-centered care.

These transformational changes in the practice of urologic oncology have also had significant implications on training. At the residency level, robotic surgery training, exposure to multidisciplinary clinics, and tumor boards have become the norm. However, because of the ever-changing landscape in urologic oncology and the ever-present challenge for learners to achieve technical proficiency in new surgical techniques, there will always be a need for postgraduate training. Taking prostate cancer as an example, the Accreditation Council for Graduate Medical Education and Urology Residency Review Committee require a minimum of 30 prostate cancer cases to graduate,¹ arguably a low bar to define proficiency, much less expertise. Moreover, according to the 2022 AUA Census, 30% of urologists practice in academic medical centers and 76.7% of respondents who perform radical prostatectomy utilize robotics.² Also, 66% responded that oncology and 39.8% responded that robotics is an area of their subspecialization. Taken together, these findings support efforts to improve urologic oncology training and enhance practice standards for both academic and community-based urologists.

Since its founding in 1983, the Endourological Society has established itself as an international association whose mission is to innovate, discover, and disseminate new technologies worldwide that shape the future of our dynamic field. This year we celebrate 40 years of innovation, spanning endourology and stone disease, oncology, benign prostatic hyperplasia, female pelvic medicine, reconstructive urology, pediatric urology, and more. Surgical discoveries that have been rooted in our Society include shock wave lithotripsy, laser technologies, percutaneous therapies, laparoscopy, robotic surgery, image-guided therapies, advanced imaging, and artificial intelligence. Furthermore, the Society of Urologic Robotic Surgeons (SURS) and the Focal Therapy Society (FTS) were formally incorporated under the umbrella of the Society in 2009 and 2019, respectively. These 3 societies came together with the goal of influencing and implementing the development and dissemination of innovative oncologic techniques to enhance patient care.

In 2010, the Society recognized that not all fellow trainees aspire to the same career path, with some interested in academic pursuits and others interested in advancing their skills to provide novel treatments for their patients in a community-based setting. Some wanted to pursue basic science, while others had a more technology-driven focus, both of which are valuable patient-focused motivations. Furthermore, we remained cognizant that potential family responsibilities and financial burdens, including the rising debt load of our learners,³ could influence their choice in duration of fellowship training. This spectrum of motives to pursue advanced training provided the basis for incorporating flexibility into our fellowships by establishing 1-year, along with the traditional 2-year, fellowship tracts. The offering of multiple tracts of different duration and focus was to meet the needs of all candidates and their varied interests and future practice aspirations. This model was also in line with the international nature of our Society, serving the interests of international programs as well as fellows visiting from abroad. Currently there are 71 fellowship programs (56 North American and 15 International) that are recognized by the Society, including both 1- and 2-year tracts in 3 specific categories: (1) endourology including stone disease and benign prostatic hyperplasia therapies, (2) laparoscopy/robotic surgery in cluding thermal ablation, and (3) combined programs. Certificates are granted appropriate to each unique tract. Over the past decade, we witnessed a 2.5-fold increase in the number of fellows (56 fellows in 2023) with a predilection for 1-year over 2-year training programs as well as strong interest in the combined tracts.

This past year, our Society created the RSMIUO (Robotic Surgery and Minimally Invasive Urologic Oncology) fellowship tract as an additional option for candidates seeking fellowship certification within the Society. While the Society’s laparoscopic and robotic surgery fellowships have consistently provided high-quality, advanced training in minimally invasive surgery since their inception, this new tract was created in recognition of the multidisciplinary nature of a modern urologic oncological practice, where the majority of laparoscopic and robotic urological procedures are performed. In line with our goals to provide our fellows with many options to enrich their ability to care for urologic cancer patients, this new tract equips them with a broad and comprehensive training curriculum so as to provide their patients with the most advanced, multidisciplinary care. The Society has always been committed to high-quality training, ensuring that strict criteria be met for fellows to achieve their goal of mastering specialty care in areas of endourology and minimally invasive surgery. With input from SURS and FTS, expectations for the new RSMIUO tract were set for both the fellow applicant and the host training program with regards to (1) following a common core curriculum (ie, core knowledge outline, video lecture series), (2) attendance of multidisciplinary clinics and conferences at the host institution with specific rotations in medical oncology, radiation oncology, uroradiology, and uropathology, (3) a research commitment with a publication requirement of a least 1 published article in oncology, and (4) attendance of the joint annual SURS/FTS meeting. In addition, a surgical case requirement of at least 150 laparoscopic/robotic oncology cases was established, including at least 30 upper and 30 lower tract cases as well as 12 ablation cases. Provided the rigorous structure and case requirements could be achieved, both 1- and 2-year fellowships were considered acceptable, with the 2-year fellowship program largely focused on additional academic and research pursuits. In 2023, 16 programs met criteria and were approved.

Offering flexible options for fellowship training has been highly successful for our international Society as well as our fellows. Our mantra has been to maintain rigorous clinical and educational requirements across all of our fellowships, with less focus on a mandatory time commitment and more on competency-based training based upon each fellow’s unique goals. In the end, it is our belief that there are many strategies to train the next generation of fellows to achieve competence in urologic oncology, contribute meaningfully to our field, and enhance patient care respective to their career aspirations.