Editorial

With the incidence of urolithiasis increasing worldwide, the treatment of stone disease is one of the most prominent branches of urology. This field is characterized by the continuous introduction of new technologies and frequent innovations. In essence, urolithiasis therapy could be seen as the field that has distinguished urology from other surgical disciplines since the dawn of modern medicine. In recent years, significant improvements have taken place in operative urology. The introduction of miniaturized endoscopes, the advancements in visualization technology as well as in modern lithotripsy methods, such as extracorporeal shock wave lithotripsy (ESWL) and endoluminal laser lithotripsy are noteworthy examples. However, the question now arises, which areas in urinary stone therapy can be improved upon in the future? Have we already accomplished our goals in this field? How can we further shape its developments? In this issue of Current Opinion in Urology, various experts on urolithiasis and endourological technology present the most important aspects of current and future trends for the treatment of urinary stones. Over the past 30 years, there have been a number of innovative advances in the field of medical imaging. Modern techniques have significantly changed the face of clinical management for patients with urolithiasis. The introduction of noncontrast enhanced and dual-energy computed tomography has made treatment results more objective and paved the path for new emerging diagnostic and therapeutic strategies. The development of modern antibiotic stewardships comprising state-of-the-art prophylaxis has become a crucial subject in urolithiasis, particularly in an era of increasing antibiotic resistance. Single-dose antibiotics for minimally invasive surgeries have increasingly proven to be as effective as prolonged antibiotic courses. Recent evidence presented on this topic continues to support a risk-adapted minimal antibiotic usage approach to combat antimicrobial resistance. Two decades ago, ESWL dominated stone therapy and had disruptively replaced open surgery. Currently, the situation has changed toward endoscopy. Despite the decreasing role of ESWL in the treatment of urinary stones, we present current applications and developments as well as future trends in this technology and discuss the importance of this modality in urological practice. Laser therapy has revolutionized the treatment of urinary stones during the last decades. Newer generations of holmium lasers and modifiable adjustments in pulse energy, frequency, and length now permit the urologist to accurately select from various fragmentation methods and to determine the desired functionality throughout the surgery. Dusting, fragmenting, popcorning, and dustmenting have been incorporated in the urological jargon reflecting the diversity of lithotripsy methods available to the urologist nowadays. A new era of laser technology looms over the horizon with the newly introduced pulse sequence modulation and superpulsed thulium-based laser systems. Advancements in laser systems have also been accompanied by significant developments in ureteroscopy (URS). Robotic technologies and disposable digital flexible ureteroscopes are set to change the current hospital-based management of urinary stones. Real-time identification of stone composition with automated laser settings and computerized measurement of extractable fragments are some of the promising innovations making their way into this field. Furthermore, the miniaturization of percutaneous nephrolithotomy (PCNL) is currently a topic of debate receiving close attention. New size-reduced PCNL systems are equally effective as standard PCNL, and may offer significant advantages regarding pain, blood loss, and length of hospital stay. Previous mini PCNL drawbacks, such as longer operative times and lower stone-free rates, have recently been shown to be comparable to the standard approach and in consequence redefined the panorama of percutaneous treatment modalities. Ureteral stents have undergone tremendous modifications in their design and composition to maintain patency in the long-term while diminishing stent-related symptoms. A variety of novel stents have been recently introduced into clinical practice. Biodegradable, metallic, coated, and drug-eluting stents are among those discussed in this issue along with up-to-date data as to the most effective therapy to control related symptoms. Although laser therapy has largely displaced shock wave lithotripsy as the endourological treatment of choice, the management of residual stone fragments remains controversial. This issue presents current data on their clinical significance and innovative technologies to extract residual fragments to render patients truly stone free. Furthermore, we obtain a glimpse of how artificial neural networks and statistic-based predictions are gradually being adopted in practice to help urologists predict surgical outcomes and counsel patients in decision-making for secondary procedures. Artificial intelligence and big data algorithms are continuously being used for automated stone detection, analysis, and predictive assessment of clinical outcomes. However, there is considerable discrepancy between the enormous commitment of large private companies and the investments of public funds. The last review of this issue discusses how public nationwide registries may hold the key to safeguard healthcare data acquisition, processing, and storage. In summary, the current panorama of technological trends in the treatment of urolithiasis points to the endourological approach as the future of surgical stone management. Once the economic barrier is breached by making inexpensive flexible ureteroscopes more accessible, URS will be adopted at an even greater scale worldwide. It is likely new fields of therapy will emerge, stemming from the improvement of existing technologies and the merging of others. The importance of computer-based modalities such as artificial intelligence and big data analysis will very likely exponentially increase and strongly influence patients’ management. Overall, a variety of promising innovations are present on the horizon for the future of stone management. With this issue of Current Opinion in Urology we aim to provide the readership with a profound and specialized insight into these developments through 10 thematic review articles. Acknowledgements A.M. cordially acknowledges Rodrigo Suárez Ibarrola B.Sc., M.D. for his constant constructive comments and invaluable help in the preparation of this special issue for Current Opinions in Urology. Financial support and sponsorship None. Conflicts of interest A.M. – German Federal Ministry of Education and Research, Berlin, DE – research funding, German Association of Urology, Düsseldorf, DE – travel sponsoring, European Association of Urology, Arnhem, NL – travel sponsoring, Walter de Gruyter, Berlin, DE – royalties, RichardWolf GmbH, Knittlingen, DE – speaker's fee, KLS Martin, Tuttlingen, DE – advisor, Avatera medical, Jena, DE – advisor, Lisa laser OHG, DE – proctor, Schoelly fiberoptics GmbH, DE – advisor, Optimed GmbH, Ettlingen, DE – advisor.