The Journal of Urology

This Month in Adult Urology

William D. Steers — 2010-07-21

Tollefson et al (page 925) from Rochester, Minnesota question the need for frequent monitoring of patients with low risk prostate cancer. To defend this practice, data from the records of 2,219 patients undergoing surgery between 1994 and 2004 were analyzed using a definition of low risk as prostate specific antigen (PSA) less than 10, pathological stage T2c or less and Gleason score 6 or less with negative lymph nodes and negative margins. Only 142 patients experienced biochemical failure within the study end points. The risk of biochemical failure decreased with increasing duration of the PSA-free interval. Patients at 1, 3 and 5 years had cumulative biochemical failure rates of 1.8%, 4.2% and 6.3%. For patients with undetectable PSA at 5 years biochemical failure rates at 10 years were essentially 0. The risk of biochemical failure was proportionate to the PSA-free interval in low risk patients. The authors suggest that PSA measurements at 2 years would capture the majority of low risk cases that progress.

This Month in Pediatric Urology

H. Gil Rushton — 2010-07-21

In the first of 2 reports members of the AUA Vesicoureteral Reflux (VUR) Guidelines Panel describe meta-analysis of data extracted from 131 articles in the literature (page 1134). The purpose of the panel was to determine outcomes related to evaluation and treatment of children older than 1 year with VUR, evaluation and treatment of infants younger than 1 year with VUR, and treatment of children with VUR and bladder/bowel dysfunction (BBD). Risk factors for renal cortical scarring were identified, including the frequency of urinary tract infections (UTIs), increasing grade of VUR and presence of BBD. The efficacy of continuous antibiotic prophylaxis could not be established based on current data nor could the lack of efficacy recently reported in prospective clinical trials due to numerous limitations of these studies. The presence of BBD affected spontaneous VUR resolution rates, risk of febrile UTIs and renal scarring, risk of postoperative UTI and rate of cure following endoscopic therapy. Based on evidence and expert opinion, statements were graded based on the degree of flexibility in application. Guidelines were proposed for initial and followup evaluation, nonoperative and operative management, and long-term followup based on relative risk levels.

This Month in Investigative Urology

Karl-Erik Andersson — 2010-07-21

Chromogranin A (CHGA) has been used as a candidate marker for diagnosis and prediction of the prognosis of prostate cancer. Endothelins (ETs) exert paracrine and autocrine effects through cell-surface receptors, and are known to influence cellular processes such as angiogenesis, cellular proliferation, tissue repair and development. Ma et al (page 1182) from Japan investigated the clinical significance of CHGA polymorphism, and CHGA and ET-1 expression in prostate cancer.

Introduction to the National Urology Research Agenda: A Roadmap for Priorities in Urological Disease Research

Anthony J. Schaeffer, Michael Freeman, Leo Giambarresi — 2010-07-20

The American Urological Association Foundation launched an ambitious initiative to define national research priorities for the field of urology. This major effort was commissioned by the AUA Foundation Board of Directors to define urology research priorities provided by the urology research community, reverse the decline in urology research funding and progress, and promote an increase in urological disease research funding and activity. The end point is the creation of the AUA Foundation National Urology Research Agenda: 2010 (NURA) which will serve as a roadmap for articulating basic and clinical research as well as the research infrastructure priorities in urology, thereby promoting substantial improvements in patient care. There is a tremendous need for such an initiative and we have much to gain from this effort.

Approaches to Reconstruction of the Ureter

J. Christopher Austin — 2010-07-20

Stuck between a rock and a hard place is how a surgeon feels when faced with a ureteral defect that cannot be primarily repaired. If possible, first line therapy when reconstructing the ureter is to bridge the defect with the ureter. The use of this approach depends on the site of the injury (near the kidney, the mid ureter or below the pelvic brim). When the injury is below the pelvic brim, mobilization of the bladder with fixation via psoas hitch may allow for primary ureteral reimplantation, and if not possible a Boari flap can be used to bridge the gap.

Behavioral Interventions for Incontinence and Other Urinary Symptoms: More Than Pelvic Muscle Exercises

Gianna Pace — 2010-07-20

Urinary incontinence (UI) is far more common in women than in men and its prevalence increases with age. UI, urgency, overactive bladder symptoms, cystitis and urinary tract infections are frequently diagnosed in the female population, and have been estimated as occurring in 5% to 69% of women. The prevalence of male UI ranges between 1% and 39% with urge urinary incontinence the predominant subtype, although the relative proportion shifts toward stress urinary incontinence with increasing age. UI impacts the lives of men and women with detrimental effects on social, professional and recreational activities as well as on sexual health. As described in this issue of The Journal in articles by Soda et al (page 1000) and Wing et al (page 1005), it may also encourage adaptive changes in the behavior of those affected such as prophylactic urination, urination on first desire and fluid restriction.

How Should We Report Incontinence After Radical Prostatectomy?

Andrea Cestari, Lorenzo Rigatti, Giovanni Lughezzani, Giorgio Guazzoni — 2010-07-20

Despite improvements in surgical techniques, urinary incontinence (UI) is not uncommon after radical prostatectomy (RP) and may dramatically worsen the quality of life of a patient who has been successfully cured of prostate cancer. The real incidence of post-prostatectomy UI remains unknown as it depends on various factors, namely the definition of UI, the methodology used to assess continence, the time of observation, the caregivers involved in followup and, most importantly, the subjective evaluation of continence status by the patient. Some patients are satisfied with their continence status although they require 2 pads daily, while others complain about severe incontinence if they lose a drop during a Valsalva maneuver. Therefore, a proper objective evaluation of post-RP UI is essential not only to properly evaluate incontinence itself but also to evaluate the ability of new surgical techniques or postoperative treatments to improve or hasten continence recovery.

Long-Term Outcomes in Male Patients With Sex Development Disorders—How are We Doing and How Can We Improve?

Richard S. Hurwitz — 2010-07-20

The treatment of the severely undermasculinized male has always been difficult and, at times, agonizing. In the past it was common to recommend gender conversion when the phallus was small and unresponsive to hormonal stimulation. Now even with a small and nonresponsive phallic structure there is greater reluctance to recommend gender conversion for fear that in utero brain masculinization by testosterone has already occurred and that gender conversion could lead to gender dysphoria. The dilemma remains whether to convert the severely undermasculinized male to a female or to hope for the best, maintaining male sex of rearing with masculinizing genitoplasty on a small penis. Will he be happy, function normally and be well-adjusted as an adult? Other options include observation or phalloplasty, even at an early age. How do we advise the parents? What information can our disorder of sex development (DSD) teams provide to help them confront this overwhelming situation and make an informed decision? Can we present evidence-based information about likely functional and psychological outcomes? How successful have we been in treating these patients in the past and what will future treatments hold?

Contemporary Management of Renal Tumors With Venous Tumor Thrombus

2010-07-20

Purpose: Renal cell carcinoma with intravenous tumor thrombus remains one of the most intriguing and challenging topics in urological oncology. With better understanding of the biology of intravascular tumor invasion and improvements in overall survival, the surgical and medical treatment of these patients is being completely redefined.Materials and Methods: We performed a MEDLINE® search for relevant articles on renal cell carcinoma with intravenous tumor thrombus.Results: We describe the staging systems, prognostic factors and surgical techniques involved in the management of renal cell carcinoma with intravenous tumor thrombus. We also review long-term survival of local, advanced and metastatic renal cell carcinoma with tumor thrombus invasion. Finally, we propose a clinical algorithm for the treatment of patients with renal cell carcinoma invading the venous system.Conclusions: Management of a kidney cancer tumor invading the venous system should now consider the primary biology and natural behavior of a given tumor in that specific patient rather than only focusing on the level and extent of venous invasion. Treatment must be individualized for every patient based on performance status, tumor biology and risk of surgery.

HER-2/neu Expression in Prostate Adenocarcinoma: A Systematic Review and Meta-Analysis

2010-07-20

Purpose: HER-2/neu has been linked to the clinical progression of hormone independent prostate cancer. We performed a meta-analysis to investigate the prognostic impact of HER-2/neu over expression in patients with prostate adenocarcinoma, and its correlation with other pathological and clinical variables.Materials and Methods: We searched the MEDLINE®, Embase®, CancerLit® and ASCO® abstract databases for published studies of HER-2/neu protein expression in primary prostate cancer tissue with a median followup of greater than 2 years and data on survival in patients with and without HER-2/neu over expression. We separately analyzed studies reporting HER-2/neu soluble receptor levels in patients with prostate cancer.Results: We included 38 articles with a total of 5,976 patients. The overall RR of death in those with HER-2/neu over expression in the primary tumor was 1.63 (95% CI 1.47–1.82, p <0.0001). In the presence of over expression the recurrence RR was 1.87 (95% CI 1.59–2.21, p <0.0001). High HER-2/neu extracellular domain levels also correlated with death (RR 2.01, 95% CI 1.21–3.35, p = 0.007) and recurrence (RR 1.74, 95% CI 1.41–2.15, p <0.0001).Conclusions: There is a consistent association of HER-2/neu over expression and Gleason less than 7 with a higher RR of death and recurrence in patients with prostate cancer. Further clinical trials should test the hypothesis that HER-2/neu is a marker of a clinically worse outcome in patients with prostate cancer and a potential target for therapy.

Emergence and Spread of Drug Resistant Neisseria gonorrhoeae

Takashi Deguchi, Keita Nakane, Mitsuru Yasuda, Shin-ichi Maeda — 2010-07-20

Purpose: The emergence and spread of Neisseria gonorrhoeae with resistance to oral antibiotics have led to difficulty in treating gonorrhea. We review drug resistance in N. gonorrhoeae with a particular emphasis on resistance to fluoroquinolones, cefixime and azithromycin.Materials and Methods: Literature selected from peer reviewed journals listed in MEDLINE®/PubMed® from 1943 to 2009 and from resources cited in those articles was reviewed comprehensively.Results: Due to the spread of fluoroquinolone resistant N. gonorrhoeae fluoroquinolones are no longer recommended for the treatment of gonorrhea. The emergence of N. gonorrhoeae with a mosaic penicillin-binding protein 2 associated with oral cephalosporin resistance has threatened cefixime treatment for gonorrhea. Emergence of N. gonorrhoeae with high level resistance to azithromycin has also been documented. However, injectable antibiotics (sepctinomycin and ceftriaxone) retain their activity against N. gonorrhoeae. To monitor drug resistance in N. gonorrhoeae several national and international programs have become functional.Conclusions: Oral regimens for the treatment of gonorrhea are limited. At present to our knowledge ceftriaxone is the most reliable and available agent for the treatment of gonorrhea. To prevent the further emergence and international spread of drug resistance, and allow for the selection of appropriate treatments, a comprehensive global program is needed including surveillance for drug resistance in N. gonorrhoeae and collection of patient epidemiological data. Clinicians should effectively treat patients with gonorrhea, always being conscious of local trends of drug resistance in N. gonorrhoeae, and should perform culture and antimicrobial susceptibility testing in those with persistent gonorrhea after treatment.

Prospective Clinical Trial of Preoperative Sunitinib in Patients With Renal Cell Carcinoma

2010-07-20

Purpose: Sunitinib is an approved treatment for metastatic renal cell carcinoma. We performed a prospective clinical trial to evaluate the safety and clinical response to sunitinib administered before nephrectomy in patients with localized or metastatic clear cell renal cell carcinoma.Materials and Methods: Patients with biopsy proven clear cell renal cell carcinoma were enrolled in the study and treated with 37.5 mg sunitinib malate daily for 3 months before nephrectomy. The primary end point was safety.Results: In an 18-month period 20 patients were enrolled. The most common toxicities were gastrointestinal symptoms and hematological effects. Grade 3 toxicity developed in 6 patients (30%). No surgical complications were attributable to sunitinib treatment. Of the 20 patients 17 (85%) experienced reduced tumor diameter (mean change −11.8%, range −27% to 11%) and cross-sectional area (mean change −27.9%, range −43% to 23%). Enhancement on contrast enhanced computerized tomography decreased in 15 patients (mean HU change −22%, range −74% to 29%). After tumor reduction 8 patients with cT1b disease underwent laparoscopic partial nephrectomy. Surgical parameters, such as blood loss, transfusion rate, operative time and complications, were similar to those in patients who underwent surgery during the study period and were not enrolled in the trial.Conclusions: Preoperative treatment with sunitinib is safe. Sunitinib decreased the size of primary renal cell carcinoma in 17 of 20 patients. Future trials can be considered to evaluate neoadjuvant sunitinib to maximize nephron sparing and decrease the recurrence of high risk, localized renal cell carcinoma.

Surgical Management of Bilateral Synchronous Kidney Tumors: Functional and Oncological Outcomes

Matthew N. Simmons, Ricardo Brandina, Adrian F. Hernandez, Inderbir S. Gill — 2010-07-20

Purpose: We evaluated renal functional and oncological outcomes after sequential partial nephrectomy and radical nephrectomy in patients with bilateral synchronous kidney tumors.Materials and Methods: A total of 220 patients treated from June 1994 to July 2008 were included in the study. Estimated glomerular filtration rate, and overall, cancer specific and recurrence-free survival were assessed.Results: Patients underwent sequential partial nephrectomy (134), partial nephrectomy followed by radical nephrectomy (60) or radical nephrectomy followed by partial nephrectomy (26). Final estimated glomerular filtration rate after bilateral surgery was 59, 36 and 35 ml/minute/1.73 m2 in these 3 groups, respectively (p <0.001). The order in which partial nephrectomy and radical nephrectomy were conducted did not affect functional outcomes. Overall survival of patients with bilateral cancer was 86% at 5 years and 71% at 10 years, cancer specific survival was 96% at 5 and 10 years, and recurrence-free survival was 73% at 5 years and 44% at 10 years. Overall survival was decreased in patients with tumors larger than 7 cm (p = 0.003). Patients with postoperative stage III or greater chronic kidney disease had decreased overall survival due to noncancer causes (p = 0.007).Conclusions: Patients treated with sequential surgery for bilateral synchronous kidney tumors have 5 and 10-year oncological outcomes comparable to those of patients with unilateral kidney cancer. Decreased overall survival was significantly associated with tumor size larger than 7 cm and postoperative stage III or greater chronic kidney disease. Nephron sparing surgery should be conducted for all amenable bilateral kidney masses given the negative impact of renal functional decline on overall survival.

Pretreatment Neutrophil-to-Lymphocyte Ratio as an Independent Predictor of Recurrence in Patients With Nonmetastatic Renal Cell Carcinoma

Yoshio Ohno, Jun Nakashima, Makoto Ohori, Tadashi Hatano, Masaaki Tachibana — 2010-07-20

Purpose: We investigated the prognostic significance of the neutrophil-to-lymphocyte ratio to predict recurrence in patients with nonmetastatic renal cell carcinoma.Materials and Methods: We retrospectively reviewed the records of 192 patients with nonmetastatic renal cell carcinoma (T1-4N0M0) who underwent nephrectomy between 1986 and 2000. Mean followup was 93 months (range 6 to 232) months. We assessed the prognostic value of the pretreatment neutrophil-to-lymphocyte ratio, and other clinical and laboratory parameters on univariate and multivariate analysis.Results: Presentation mode, tumor stage, C-reactive protein, lymphocyte count and the neutrophil-to-lymphocyte ratio significantly correlated with recurrence-free survival on univariate analysis. The recurrence-free survival rate in patients with a neutrophil-to-lymphocyte ratio of less than 2.7 was 93.7% at 5 years and 79.8% at 10 years, significantly higher than the 77.9% and 58.4%, respectively, in patients with a ratio of 2.7 or greater (p = 0.0205). Multivariate analysis revealed that T stage and the neutrophil-to-lymphocyte ratio were independent predictors of recurrence. The 10-year survival rate in patients at low risk (T2 or less and neutrophil-to-lymphocyte ratio less than 2.7), intermediate risk (T2 or less and ratio 2.7 or greater, or T3 or greater and ratio less than 2.7) and high risk (T3 or greater and ratio 2.7 or greater) was 82.0%, 63.6% and 33.0%, respectively, which were significantly different.Conclusions: An increased pretreatment neutrophil-to-lymphocyte ratio is an independent predictor of recurrence. The combination of T stage and the neutrophil-to-lymphocyte ratio can be used to stratify recurrence risk in patients with nonmetastatic renal cell carcinoma.

Editorial Comment

William C. DeWolf — 2010-07-20

These authors used preoperative inflammatory response parameters to gauge the probability of long-term nonrecurrence in patients who underwent surgery for RCC. The association between the inflammatory response and malignant progression is poorly understood. My first memories of the association came from experiments revealing that in newly hatched chicks given injections of Rous sarcoma virus tumors developed at the injection site and despite virus in the blood no other tumors were found. However, when a wound was made away from the primary tumor, another tumor developed at the wound site. It was eventually found that wound tumor development correlated with circulating virus and inflammation, and in this case transforming growth factor-β, and acidic and basic fibroblast growth factor could replace wounding in tumor development.

Voided Urine Fluorescence In Situ Hybridization Testing for Upper Tract Urothelial Carcinoma Surveillance

James R. Johannes, Eric Nelson, Marluce Bibbo, Demetrius H. Bagley — 2010-07-20

Purpose: Fluorescence in situ hybridization is gaining popularity for transitional cell carcinoma screening. We determined the accuracy of fluorescence in situ hybridization for identifying upper tract transitional cell carcinoma.Materials and Methods: A retrospective review of our upper tract transitional cell carcinoma database from 2005 to 2008 identified 35 patients with upper tract transitional cell carcinoma who submitted voided urine specimens for fluorescence in situ hybridization at commercial laboratory during a routine office visit. Each patient was evaluated endoscopically in the operating room within 3 months of sampling. Suspicious lesions were biopsied and treated. Transitional cell carcinoma in the lower or upper tract was proved by direct visualization, positive biopsy or upper tract cytology read as positive or highly suspicious for malignancy.Results: Of the patients 35 satisfied study inclusion criteria. A total of 67 fluorescence in situ hybridization specimens were submitted. Upper tract transitional cell carcinoma was identified on 51 operative evaluations, of which 23 showed concurrent bladder tumor. For all encounters the sensitivity of fluorescence in situ hybridization was 56% and specificity was 80%. Sensitivity for low and high grade lesions was 68% and 67%, respectively. Only upper tract tumors were noted in 28 patients, in whom there were 2 false-positive and 13 false-negative voided fluorescence in situ hybridization results. In these cases sensitivity was 54% and specificity was 78% compared to the 18% sensitivity and 100% specificity of bladder cytology. Sensitivity for low and high grade upper tract transitional cell carcinoma was 60% and 50%, respectively.Conclusions: Voided fluorescence in situ hybridization has become an adjunct for bladder transitional cell carcinoma surveillance. However, it has limited value for upper tract tumor surveillance.

Impact of Diagnostic Ureteroscopy on Intravesical Recurrence and Survival in Patients With Urothelial Carcinoma of the Upper Urinary Tract

2010-07-20

Purpose: We determined whether diagnostic ureteroscopy for upper urinary tract cancer affects intravesical recurrence and cancer specific mortality.Materials and Methods: In a retrospective, multi-institutional study we evaluated 208 patients undergoing nephroureterectomy for upper urinary tract cancer who had no perioperative systemic chemotherapy, history of invasive bladder cancer, distant metastasis or incomplete followup data. Of these 208 patients 55 who composed the study group underwent diagnostic ureteroscopy before nephroureterectomy while 153 serving as controls did not. We analyzed intravesical recurrence and cancer specific survival using the Kaplan-Meier method with the log rank test used to assess significance.Results: There was no significant difference between the 2 groups in patient characteristics or upper urinary tract cancer stage and grade while followup, and the proportion of multiple tumors and lymphovascular invasion positive tumors were significantly greater in controls. The 2-year bladder recurrence-free survival rate was 60.0% in the study group and 58.7% in controls. There was no significant difference in the intravesical recurrence rate between the 2 groups (log rank test p = 0.972). Estimated Kaplan-Meier cancer specific survival was 88.3% and 78.1% at 5 years in the study and control groups, respectively (log rank test p = 0.0687).Conclusions: Diagnostic ureteroscopy did not affect intravesical recurrence or cancer specific survival in patients with upper urinary tract cancer undergoing nephroureterectomy.

Stage pT0 at Radical Cystectomy Confers Improved Survival: An International Study of 4,430 Patients

2010-07-20

Purpose: We describe the cancer related outcome in patients with pT0 bladder urothelial carcinoma at radical cystectomy who did not receive preoperative chemotherapy in a large multicenter series. We also compared outcomes in patients with pT0 bladder urothelial carcinoma to those in patients with other stages and assessed the effect of clinical stage on outcome.Materials and Methods: We reviewed the records of 4,430 patients treated with radical cystectomy for bladder urothelial carcinoma without neoadjuvant chemotherapy at 12 centers in the United States, Canada and Europe.Results: Of the patients 228 (5.1%) had pT0 disease at radical cystectomy. Clinical stage was cTa or cTis in 13.6% and cT1 in 29.8% of these patients, and disease was muscle invasive (cT2-4a) in 56.2%. Metastasis developed to regional lymph nodes in 17 cases (7.5%). At a median 48.2-month followup 15 patients (6.6%) had died of bladder cancer. Five-year recurrence-free and cancer specific survival estimates were 89.7% (95% CI 85.3–93.1) and 93.1% (95% CI 88.9–95.6), respectively. Disease-free and cancer specific survival in pT0 cases was similar to that in pTa/pTis cases but significantly better than in pT1 or pT2 cases. On multivariate analysis increased disease recurrence and cancer specific mortality risks were significantly associated with lymph node metastasis (each p <0.001) and female gender (p <0.001 and 0.013, respectively).Conclusions: Although stage pT0 at radical cystectomy confers a benefit in survival, some patients experience disease recurrence and eventual death. Identifying these patients may help tailor postoperative decision making in patients with pT0.

Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors

Fray F. Marshall — 2010-07-20

J. Y. Dancer, L. D. Truong, Q. Zhai and S. S. Shen Department of Pathology, The Methodist Hospital and Research Institute and Weill Medical College of Cornell University, Houston, Texas

Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology

James E. Montie — 2010-07-22

R. Addeo, M. Caraglia, S. Bellini, A. Abbruzzese, B. Vincenzi, L. Montella, A. Miragliuolo, R. Guarrasi, M. Lanna, G. Cennamo, V. Faiola and S. Del Prete Oncologica Operative Unit S. Giovanni di Dio Hospital, Azienda Sanitaria Locale Napoli 3, Frattaminore, Naples, Italy

Socioeconomic Factors, Urological Epidemiology and Practice Patterns

David F. Penson — 2010-07-22

J. D. Kaye, L. Richstone, J. S. Cho, J. Y. Tai, J. Arrand and L. R. Kavoussi Smith Institute for Urology, North Shore-Long Island Jewish Health System, New York, New York

Diagnostic Urology, Urinary Diversion and Perioperative Care

Richard K. Babayan — 2010-07-23

R. S. Pruthi, M. Nielsen, A. Smith, J. Nix, H. Schultz and E. M. Wallen Division of Urologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Participation of Older Patients With Prostate Cancer in Medicare Eligible Trials

2010-07-20

Purpose: On June 7, 2000 President Clinton issued an executive memorandum directing Medicare payment for routine patient care in qualifying clinical trials. We estimated the proportion of older patients with prostate cancer who were examined as part of a qualifying clinical trial, and the association between participation and patient characteristics.Materials and Methods: We performed an observational study using the Surveillance, Epidemiology and End Results Medicare database to determine participation in qualifying clinical trials in a sample of 37,216 men 66 years old or older who were enrolled in Medicare and diagnosed with prostate cancer between September 2000 and December 2002.Results: Within 3 years of diagnosis 211 men (0.567%) received routine patient care in a qualifying clinical trial. These participants were more likely to be younger than 70 years (OR 1.687, 95% CI 1.27–2.24) and less likely to be less educated and reside in low income, metropolitan neighborhoods. White men were more likely to participate in clinical trials than nonwhite men but this association was not statistically significant (OR 1.426, CI 0.97–2.09). Participation varied significantly by registry site (0% to 1.2%) but not by tumor grade or stage, or prostate specific antigen status.Conclusions: Few older patients with prostate cancer participated in qualifying trials between 2000 and 2002. Those who participated were not representative of the general population of older patients with prostate cancer. Greater efforts are required to expand trial enrollment and decrease disparities in research participation.

Prostate Specific Antigen Velocity Does Not Aid Prostate Cancer Detection in Men With Prior Negative Biopsy

2010-07-20

Purpose: Prostate specific antigen velocity has been proposed as a marker to aid in prostate cancer detection. We determined whether prostate specific antigen velocity could predict repeat biopsy results in men with persistently increased prostate specific antigen after initial negative biopsy.Materials and Methods: We identified 1,837 men who participated in the Göteborg or Rotterdam section of the European Randomized Screening study of Prostate Cancer and who underwent 1 or more subsequent prostate biopsies after an initial negative finding. We evaluated whether prostate specific antigen velocity improved predictive accuracy beyond that of prostate specific antigen alone.Results: Of the 2,579 repeat biopsies 363 (14%) were positive for prostate cancer, of which 44 (1.7%) were high grade (Gleason score 7 or greater). Prostate specific antigen velocity was statistically associated with cancer risk but had low predictive accuracy (AUC 0.55, p <0.001). There was some evidence that prostate specific antigen velocity improved AUC compared to prostate specific antigen for high grade cancer. However, the small increase in risk associated with high prostate specific antigen velocity (from 1.7% to 2.8% as velocity increased from 0 to 1 ng/ml per year) had questionable clinical relevance.Conclusions: Men with prior negative biopsy are at lower risk for prostate cancer at subsequent biopsies with high grade disease particularly rare. We found little evidence to support prostate specific antigen velocity to aid in decisions about repeat biopsy for prostate cancer.

Value of Real-Time Elastography Targeted Biopsy for Prostate Cancer Detection in Men With Prostate Specific Antigen 1.25 ng/ml or Greater and 4.00 ng/ml or Less

2010-07-20

Purpose: We assessed the prostate cancer detection rate of real-time elastography targeted biopsy in men with total prostate specific antigen 1.25 ng/ml or greater and 4.00 ng/ml or less.Materials and Methods: Real-time elastography using an EUB 8500 Hitachi ultrasound system (Hitachi Medical, Tokyo, Japan) was done in 94 men with a mean age of 57.4 years (range 35 to 77) with increased prostate specific antigen between 1.25 ng/ml or greater and 4.00 ng/ml or less (mean 3.20, range 1.30 to 4.00) and a free-to-total prostate specific antigen ratio of less than 18%. Real-time elastography was done to evaluate peripheral zone tissue elasticity and hard areas were defined as suspicious. Targeted biopsies with a maximum of 5 cores were done in suspicious areas, followed by 10-core systematic biopsy. We analyzed the cancer detection rate of real-time elastography and systematic biopsy.Results: Cancer was found in 27 of 94 patients (28.7%). Real-time elastography detected cancer in 20 patients (21.3%) and systematic biopsy detected it in 18 (19.1%). Positive cancer cores were found in real-time elastography targeted cores in 38 of 158 cases (24%) and in systematic cores in 38 of 752 (5.1%) (chi-square test p <0.0001). The cancer detection rate per core was 4.7-fold greater for targeted than for systematic biopsy.Conclusions: Real-time elastography targeted biopsy allows prostate cancer detection in men with prostate specific antigen 1.25 ng/ml or greater and 4 ng/ml or less with a decreased number of cores compared with that of systematic biopsy.

Fracture Types and Risk Factors in Men With Prostate Cancer on Androgen Deprivation Therapy: A Matched Cohort Study of 19,079 Men

2010-07-20

Purpose: Accumulating evidence shows that androgen deprivation therapy is associated with osteoporosis and fragility fractures of the spine, hip and wrist. One study suggested that androgen deprivation therapy may also be associated with nonfragility fractures in older men. Whether other clinical risk factors independently increase the risk of fractures is not certain.Materials and Methods: Using linked administrative databases in Ontario, Canada, we matched 19,079 men 66 years old or older with prostate cancer with at least 6 months of continuous androgen deprivation therapy or bilateral orchiectomy with men with prostate cancer who had never received androgen deprivation. Matching variables were age, prior cancer treatment, diagnosis year, comorbidity, medication, prior fractures and socioeconomic variables. Primary outcomes were a typical fragility fracture of the spine, hip or wrist and any fracture. Independent predictors of fracture outcomes were assessed with Cox proportional hazards models.Results: At a mean 6.47-year followup androgen deprivation therapy was associated with an increased risk of fragility fracture (HR 1.65, 95% CI 1.53–1.78) and any fracture (HR 1.46, 95% CI 1.39–1.54). Independent predictors of fragility and any fracture were increasing age, prior bone thinning medications, chronic kidney disease, prior dementia, prior fragility fracture and prior osteoporosis diagnosis or treatment (p <0.05).Conclusions: Continuous androgen deprivation therapy for at least 6 months is associated with an increased risk of fracture. Increasing age, prior osteoporotic fracture and dementia are important clinical factors that may warrant greater consideration of anti-osteoporotic therapy in these men.

Editorial Comment

Philip J. Saylor — 2010-07-20

ADT increases the fracture risk in men with prostate cancer. In men on ADT denosumab decreases the fracture risk and several bisphosphonates improve bone mineral density, a surrogate for fracture risk. Given a morbid problem and effective treatments, we must now work hard to accurately assess risk in individuals so that treatment can be given to those most likely to benefit.

Reply by Authors

2010-07-20

We agree that we need to move beyond BMD values alone to predict fracture risk. The WHO fracture risk algorithm (FRAX, www.sheffield.ac.uk/FRAX) is a step forward because it integrates major clinical risk factors as well as BMD to provide better prediction. However, in contrast to our findings, FRAX does not explicitly consider ADT except in the category of secondary osteoporosis and does not consider the presence of dementia as a risk factor for fracture. Whether men on ADT have similar risk factors predicting fracture risk compared to other men is not clear, and future studies are needed to examine this specifically. Meanwhile we agree that tools such as FRAX are definitely a step in the right direction.

Lifelong Yearly Prostate Specific Antigen Surveillance is Not Necessary for Low Risk Prostate Cancer Treated With Radical Prostatectomy

2010-07-20

Purpose: Many patients undergoing radical prostatectomy in the prostate specific antigen era have a low risk of recurrence. Aggressive postoperative prostate specific antigen surveillance is costly and anxiety provoking. In this study we investigate the need for yearly prostate specific antigen measurements in patients with surgically treated low risk prostate cancer.Materials and Methods: We identified 2,219 patients who underwent radical prostatectomy between 1994 and 2004 for low risk localized prostate cancer. Low risk was defined as prostate specific antigen less than 10 ng/ml, pathological stage pT2c or less, Gleason score 6 or less, negative lymph nodes and negative surgical margins. Patients who underwent neoadjuvant or adjuvant therapy were excluded from analysis. Biochemical failure was defined as a prostate specific antigen greater than 0.4 ng/ml and prostate specific antigen values less than 0.15 ng/ml were considered undetectable. Biochemical failure rates were calculated according to the duration of the prostate specific antigen-free period after radical prostatectomy.Results: A total of 142 (6.4%) patients experienced biochemical failure during the course of the study. The risk of biochemical failure decreased with increasing duration of the prostate specific antigen-free interval. For example 1, 3 and 5-year biochemical failure rates calculated at surgery were 1.8%, 4.2% and 6.3%, respectively. For patients with undetectable prostate specific antigen measurements 5 years after surgery the 1, 3 and 5-year biochemical failure rates were 0.0%, 0.7% and 1.3%, respectively. In addition, 1-year biochemical failure rates were 0.2%, 0.4%, 0.0% and 0.0% after a prostate specific antigen-free period of 1, 3, 5 and 10 years, respectively.Conclusions: The risk of biochemical failure is inversely proportional to the duration of the prostate specific antigen-free interval after radical prostatectomy in low risk patients. Biochemical failure 1 year after an undetectable prostate specific antigen is uncommon, especially after a prostate specific antigen-free period of 3 years. These data suggest that annual prostate specific antigen measurements are unnecessary, especially after a prostate specific antigen-free interval of 3 years. Prostate specific antigen measurements every 2 years should capture the majority of low risk patients who experience progression.

Smaller Prostate Size Predicts High Grade Prostate Cancer at Final Pathology

2010-07-20

Purpose: Prostate size may influence the likelihood of detecting high grade prostate cancer at final pathology. We evaluated the association between prostate size and high grade (Gleason score 7 or greater) cancer.Materials and Methods: We analyzed data from 2,880 patients who underwent surgical treatment of prostate cancer between January 2000 and June 2008. Prostate size measured at prostatectomy was compared across a strata of clinical variables (age, body mass index, prostate specific antigen, biopsy Gleason score, clinical stage and year of surgery) and pathological outcomes (final Gleason score, extraprostatic extension, positive surgical margin, seminal vesicle invasion and lymph node involvement). Multivariate logistic regression was used to assess prostate size as a predictor of high grade cancer.Results: Older age, higher prostate specific antigen and later year of surgery were associated with larger gland size. Small prostate size was associated with high grade prostate cancer as well as extraprostatic extension and positive surgical margins on univariate and adjusted analysis. The probability of high grade disease decreased approximately 15% across the lowest vs highest prostate sizes. On multivariate analysis adjusted for age, race, prostate specific antigen, clinical stage, biopsy Gleason score and date of surgery prostate size was an important predictor of high grade disease (OR 0.94; 95% CI 0.92, 0.97 per 2 gm increments, p <0.001). The area under the ROC curve was 0.82 (95% CI 0.81, 0.84).Conclusions: Prostate size was inversely associated with the risk of high grade cancer at final pathology. The ability to predict high grade disease could have implications for the management of prostate cancer.

[11C]Choline Positron Emission Tomography/Computerized Tomography to Restage Prostate Cancer Cases With Biochemical Failure After Radical Prostatectomy and No Disease Evidence on Conventional Imaging

2010-07-20

Purpose: We assessed the value of [11C]choline positron emission tomography/computerized tomography in patients with prostate cancer in whom biochemical failure developed after radical prostatectomy but who showed no disease evidence on conventional imaging.Materials and Methods: Considered for this study were 2,124 patients treated with radical prostatectomy who underwent [11C]choline positron emission tomography/computerized tomography to restage disease between December 2004 and January 2007. Study inclusion criteria were 1) previous radical prostatectomy and pelvic lymph node dissection, 2) increasing prostate specific antigen beyond 0.2 ng/ml after radical prostatectomy, 3) no lymph node disease at radical prostatectomy, 4) no evidence of metastatic disease on conventional imaging, 5) no androgen deprivation therapy and 6) no adjuvant or salvage radiotherapy. These criteria were satisfied in 109 of the 2,124 patients (5%).Results: Median prostate specific antigen at imaging was 0.81 ng/ml (range 0.22 to 16.76 ml). Imaging suggested local recurrence in 4 patients (4%) and pelvic lymph node disease in 8 (7%). Scans were positive in 5%, 15% and 28% of patients with prostate specific antigen less than 1, between 1 and 2, and greater than 2 ng/ml, respectively (p <0.05). Prostate specific antigen was the only significant predictor of tomography results (p <0.05).Conclusions: Positron emission tomography/computerized tomography detected increased [11C]choline uptake, suggesting recurrent disease in 11% of patients with prostate cancer, increasing prostate specific antigen after radical prostatectomy and no evidence of disease on conventional imaging. This modality may be useful to restage disease but it cannot be used to guide therapy.

Reporting Complications After Open Radical Retropubic Prostatectomy Using the Martin Criteria

Björn Löppenberg, Joachim Noldus, Alexander Holz, Rein Jüri Palisaar — 2010-07-20

Purpose: In 2002, 10 Martin criteria were proposed that should be met when reporting complications following surgery. To date, few studies have evaluated complication rates after radical prostatectomy using these criteria. Therefore, we assessed complications in a contemporary series of open retropubic radical prostatectomy using a standardized reporting methodology.Materials and Methods: Complications in 2,893 consecutive patients who underwent radical prostatectomy at a single center between 2003 and 2009 were recorded prospectively. All 10 Martin criteria for a high quality report of complications were fulfilled. Complications within a 30-day postoperative period were graded retrospectively according to the Clavien-Dindo classification.Results: The overall complication rate was 27.7% (801 of 2,893), and 943 medical and surgical complications were recorded in 801 patients. Of these complications 596 were grade I (63.2%), 183 grade II (19.5%), 142 grade III (15.1%) and 15 grade IV (1.8%). The mortality rate (grade V) was 0.1% (4 of 2,893). Independent predictors of high grade complications (grade III or greater) on multivariate analysis were patient age (HR 1.051, p = 0.002), prostate volume (HR 1.013, p = 0.004) and lymphadenectomy (HR 2.023, p = 0.005).Conclusions: Complications after radical prostatectomy should be reported using a standardized methodology. Using the Clavien-Dindo classification we observed an acceptable overall complication rate. In the majority of cases lower grade complications occurred. Patients of older age, those with greater prostate volume and those who had undergone simultaneous lymphadenectomy were at risk for higher grade complications.

Is Retroperitoneal Histology Predictive of Liver Histology at Concurrent Post-Chemotherapy Retroperitoneal Lymph Node Dissection and Hepatic Resection?

2010-07-20

Purpose: We identified factors predicting liver histology in patients with nonseminomatous germ cell tumor undergoing concurrent post-chemotherapy retroperitoneal lymph node dissection and liver resection.Materials and Methods: We reviewed the Indiana University testis cancer database to identify all patients with nonseminomatous germ cell tumor and liver metastasis who underwent post-chemotherapy retroperitoneal lymph node dissection and liver resection between 1976 and 2006.Results: A total of 59 patients met study inclusion criteria. Necrosis, teratoma and cancer were identified in 31%, 46% and 24% of retroperitoneal specimens, and in 73%, 17% and 10% of liver specimens, respectively. Concordance between retroperitoneal and liver histology was 49% overall, including 94% for necrosis, 26% for teratoma and 36% for cancer. Liver necrosis alone was found in 94%, 70% and 50% of patients with retroperitoneal necrosis, teratoma and cancer, respectively.Conclusions: The overall rate of histological discordance between retroperitoneal and liver histology was 51% with 73% of all liver specimens containing necrosis only. Retroperitoneal necrosis is highly predictive of hepatic necrosis (94%). Management for liver lesions at post-chemotherapy retroperitoneal lymph node dissection must be individualized. Observation may be warranted for liver lesions requiring complicated hepatic surgery regardless of retroperitoneal pathology.

Urological Oncology: Prostate Cancer

Patrick C. Walsh — 2010-07-20

K. Devisetty, K. C. Zorn, M. H. Katz, A. B. Jani and S. L. Liauw Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois

Urological Oncology: Testis Cancer

Jerome P. Richie — 2010-07-22

J. Hansen and A. G. Jurik Department of Medical Physics, Aarhus University Hospital, Aarhus Sygehus, Aarhus, Denmark

Gating of Sensory Information Differs in Patients With Interstitial Cystitis/Painful Bladder Syndrome

2010-07-20

Purpose: Altered sensory processing in interstitial cystitis/painful bladder syndrome cases may result from a deficiency of the central nervous system to adequately filter incoming visceral afferent information. We used prepulse inhibition as an operational measure of sensorimotor gating to examine early pre-attentive stages of information processing in females with interstitial cystitis/painful bladder syndrome and healthy controls.Materials and Methods: We assessed prepulse inhibition in 14 female patients with interstitial cystitis/painful bladder syndrome and 17 healthy controls at 60 and 120-millisecond prepulse-to-startle stimulus intervals. We evaluated group differences in prepulse inhibition, and relationships between prepulse inhibition, neuroticism and acute stress ratings.Results: Patients showed significantly decreased prepulse inhibition at 60 and 120-millisecond prepulse intervals. The prepulse inhibition deficit was related to acute stress ratings in the patients. However, increased neuroticism appeared to mitigate the prepulse inhibition deficit in those with interstitial cystitis/painful bladder syndrome, possibly reflecting greater vigilance.Conclusions: Compared to healthy controls, female patients with interstitial cystitis/painful bladder syndrome had decreased ability to adequately filter incoming information and perform appropriate sensorimotor gating. These results suggest that a possible mechanism for altered interoceptive information processing in interstitial cystitis/painful bladder syndrome cases may be a general deficit in filtering mechanisms due to altered pre-attentive processing.

Infection and Inflammation of the Genitourinary Tract

Richard E. Berger — 2010-07-20

O. F. Karatas, C. Turkay, O. Bayrak, E. Cimentepe and D. Unal Department of Urology, Fatih University Medical School, Ankara, Turkey

Socioeconomic Factors, Urological Epidemiology and Practice Patterns

David F. Penson — 2010-07-22

D. Turner, P. Little, J. Raftery, S. Turner, H. Smith, K. Rumsby and M. Mullee; UTIS Group Wessex Institute, University of Southampton, Chilworth, Southampton, United Kingdom

Opening Ambulatory Surgery Centers and Stone Surgery Rates in Health Care Markets

2010-07-20

Purpose: Ambulatory surgery centers deliver surgical care more efficiently than hospitals but may increase overall procedure use and adversely affect competing hospitals. Motivated by these concerns we evaluated how opening of an ambulatory surgery center impacts stone surgery use in a health care market and assessed the effect of its opening on the patient mix at nearby hospitals.Materials and Methods: In a 100% sample of outpatient surgery from Florida we measured annual stone surgery use between 1998 and 2006. We used multiple regression to determine if the rate of change in use differed between markets, defined by the hospital service area, without and with a recently opened ambulatory surgery center.Results: Stone surgery use increased an average of 11 procedures per 100,000 individuals per year (95% CI 1–20, p <0.001) after an ambulatory surgery center opened in a hospital service area. Four years after opening the relative increase in the stone surgery rate was approximately 64% higher (95% CI 27 to 102) in hospital service areas where a center opened vs hospital service areas without a center. These market level increases in surgery were not associated with decreased surgical volume at competing hospitals and the absolute change in patient disease severity treated at nearby hospitals was small.Conclusions: While opening of an ambulatory surgery center did not appear to have an overly detrimental effect on competing hospitals, it led to a significant increase in the population based rate of stone surgery in the hospital service area. Possible explanations are the role of physician financial incentives and unmet surgical demand.

Laparoscopy/New Technology

Jeffrey A. Cadeddu — 2010-07-20

P. N. Montero, T. N. Robinson, J. S. Weaver and G. V. Stiegmann Department of Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado

Assessing the Usefulness of Delayed Imaging in Routine Followup for Renal Trauma

2010-07-20

Purpose: Renal trauma is often managed conservatively. Repeat imaging within 48 hours of injury is recommended but to our knowledge the value of further delayed imaging is unknown. We determined the usefulness of routine followup imaging beyond 48 hours in cases of conservatively managed renal trauma.Materials and Methods: Of 377 patients who presented to our institution with renal injury in the last 8 years we identified 138 who underwent a trial of conservative treatment and repeat imaging more than 48 hours after injury. Followup imaging was categorized as routine in 108 patients (group 1) and indicated in 30 (group 2), and assessed for complications and the need for subsequent intervention.Results: Of the patients 121 (76%) were male. Mean age was 36 years. All except 4 injuries were the result of blunt trauma, predominantly due to road traffic accidents. Injury was grade 1 to 5 in 26, 24, 44, 33 and 11 cases, respectively. We identified 108 patients with routine followup imaging (group 1) while 30 were re-imaged due to a clinical indication. The rate of progression was 0.93% in group 1 with only 1 complication requiring a management change. In contrast, 20% of group 2 patients had progression requiring a treatment change (p = 0.0004).Conclusions: Routine re-imaging in patients with renal trauma outside the initial 48-hour window in the absence of a clear clinical indication had little benefit and changed treatment in less than 1%.

No-Needle Local Anesthesia for Adult Male Circumcision

2010-07-20

Purpose: We used a local anesthetic jet injection technique for adult male circumcision. This method eliminates needle use and may decrease the fear of local anesthetic injection used for male circumcision.Materials and Methods: We recruited 60 men seeking voluntary adult male circumcision into the study from June to September 2009. We used a MadaJet® Medical Injector to deliver a high pressure spray of 0.1 ml 2% plain lidocaine solution directly through the penile skin circumferentially around the proximal third of the penis. All men underwent circumcision using the Shang Ring™ and were evaluated for anesthetic safety, efficacy and acceptability. Pain was measured on a visual analog scale.Results: The average volume of 2% lidocaine anesthetic solution delivered by jet injection was 0.1 ml with a mean total of 0.9 ml per circumcision procedure. More than 85% of men did not require supplemental anesthesia. Anesthetic onset required approximately 45 seconds from the time that injections were completed. Mean pain scores for immediate postoperative, 24-hour postoperative, ring removal and post-ring removal events were 0.1, 6.8, 2.2 and 0.9, respectively. In 4 patients (6.67%) mild urethral bleeding resolved with pressure, resulting in technique modification.Conclusions: No-needle jet injection is safe and effective for adult MC. The technique efficiently delivers local anesthesia with rapid onset in men undergoing circumcision. This needle-free approach may enhance the popularity of adult male circumcision.

Post-Radical Prostatectomy Inguinal Hernia: A Simple Surgical Intervention can Substantially Reduce the Incidence—Results From a Prospective Randomized Trial

2010-07-20

Purpose: After radical retropubic prostatectomy a postoperative inguinal hernia develops in 15% to 20% of patients. We investigated whether a simple prophylactic procedure during radical retropubic prostatectomy would reduce this incidence.Materials and Methods: A total of 294 consecutive patients scheduled for radical retropubic prostatectomy at our clinic were prospectively included in the study. Patients with a present inguinal hernia or a previous inguinal hernia surgery were not included in the analysis. The subjects were randomized for side of prophylactic intervention (left or right). At radical retropubic prostatectomy a nonresorbable figure-of-8 suture was placed lateral to the internal ring of the inguinal canal and the spermatic cord on either side according to outcome of the randomization. Patients were followed at regular followup visits at the clinic. At the end of the study all patients were invited for a final interview and examination by an independent examiner who was unaware of the side of intervention.Results: Of the patients 86% (254) showed up for the final examination. The cumulative inguinal hernia incidence was 3.5% on the intervention side and 9.1% on the control side (log rank Mantel-Cox p = 0.011). There were no serious adverse events, and no increase in postoperative discomfort in the groin and testicular region on the intervention side. The procedure added 5 to 10 minutes to the duration of surgery.Conclusions: The prophylactic procedure was simple and safe to perform, and it decreased the risk of postoperative inguinal hernia formation by 62%. We believe it should be considered for patients undergoing radical retropubic prostatectomy.

Lessons Learned From 1,000 Neobladders: The 90-Day Complication Rate

Richard E. Hautmann, Robert C. de Petriconi, Bjoern G. Volkmer — 2010-07-20

Purpose: We report the 90-day morbidity of the ileal neobladder in a large, contemporary, homogenous series of patients who underwent radical cystectomy at a tertiary academic referral center using a standard approach.Materials and Methods: Between January 1986 and September 2008 we performed 1,540 radical cystectomies. A total of 281 patients had an absolute contraindication for orthotopic reconstruction. The remaining 1,259 patients were candidates for a neobladder. Of these patients 1,013 (66%) finally received a neobladder and form the basis of this report. All patients had a thorough followup until December 2008 or until death. All complications within 90 days of surgery were defined, categorized and classified by an established 5 grade and 11 domain modification of the original Clavien system.Results: Of 1,013 patients 587 (58%) experienced at least 1 complication within 90 days of surgery. Infectious complications were most common (24%) followed by genitourinary (17%), gastrointestinal (15%) and wound related complications (9%). The 90-day mortality rate was 2.3%. Of the patients 36% had minor (grade 1 to 2) and 22% had major (grade 3 to 5) complications. On univariate analysis the incidence and severity of the 90-day complications rate correlate highly significantly with age, tumor stage, American Society of Anesthesiologists score and preoperative comorbidity.Conclusions: Radical cystectomy and ileal neobladder formation represent a major surgery with potential relevant early complications even in the most experienced hands. The rate of severe and lethal complications is acceptably low.

Trauma, and Genital and Urethral Reconstruction

Allen F. Morey — 2010-07-20

E. Palminteri, M. Gacci, E. Berdondini, M. Poluzzi, G. Franco and V. Gentile Centre for Reconstructive Urethral and Genitalia Surgery, Arezzo, Italy

Voiding Function and Dysfunction, Bladder Physiology and Pharmacology, and Female Urology

Alan J. Wein — 2010-07-22

T. Sugimura, E. Arnold, S. English and J. Moore Department of Urology, Christchurch Hospital, Christchurch, New Zealand

Efficacy of Nondrug Lifestyle Measures for the Treatment of Nocturia

2010-07-20

Purpose: Nocturia has a major impact on quality of life and affects numerous aspects of health. Lifestyle modifications are expected to be helpful in improving nocturia. However, the efficacy of this strategy has not been established. We tested the efficacy of nondrug lifestyle measures as a first step in treating nocturia and found factors predictive of the efficacy of the intervention.Materials and Methods: We conducted a prospective evaluation of 56 patients treated at 3 hospitals between 2005 and 2009 for symptomatic nocturia. The patients were advised to modify their lifestyle to improve nocturia. Lifestyle modifications consisted of 4 directives of 1) restriction of fluid intake, 2) refraining from excess hours in bed, 3) moderate daily exercise and 4) keeping warm in bed. The frequency volume chart, International Prostate Symptom Score, and Pittsburgh Sleep Quality Index before and 4 weeks after the intervention were used to evaluate the efficacy of the therapy.Results: Mean nocturnal voids and nocturnal urine volume decreased significantly from 3.6 to 2.7 (p <0.0001) and from 923 to 768 ml (p = 0.0005), respectively. Of the 56 patients 26 (53.1%) showed an improvement of more than 1 episode. This treatment was significantly more effective in patients with a larger 24-hour urine production.Conclusions: Nondrug lifestyle measures were effective in decreasing the number of nocturia episodes and improving patient quality of life. Patients with polyuria showed a better response to the treatment.

Editorial Comment

Tomas L. Griebling — 2010-07-20

Nocturia is a highly prevalent and bothersome condition that often affects elderly patients. Associated sleep deprivation can negatively impact quality of life. The etiology is usually multifactorial. Treatments can be directed toward the bladder, or causative comorbid conditions such as sleep apnea, congestive heart failure and pulmonary or peripheral edema.

Reply by Authors

2010-07-20

The lack of a control group is a weakness of our study but the objective improvements derived from the FVC analyses strongly suggest something more than a placebo effect. Even if a placebo effect contributed to the improvement of nocturia to a certain degree, it can also be considered part of the efficacy of our nondrug therapy. In any case lifestyle modification is the most basic therapy for nocturia. The distinct lack of evidence about lifestyle modification makes this single arm study an important first step. We agree that additional testing is warranted to determine actual cause and effect of the lifestyle modifications in this study.

Effect of Weight Loss on Urinary Incontinence in Overweight and Obese Women: Results at 12 and 18 Months

2010-07-20

Purpose: Initial weight loss improves urinary incontinence in overweight and obese women. In this study we examined the longer term effects of a weight loss intervention on urinary incontinence.Materials and Methods: Overweight and obese women (mean ± SD age 53 ± 10 years) with 10 or more urinary incontinence episodes weekly were randomized to an 18-month behavioral weight loss intervention (226) or control group (112). Outcome measures were collected at 12 and 18 months.Results: At baseline women had a mean body mass index of 36 ± 6 kg/m2 and reported a mean of 24 ± 18 incontinence episodes weekly. Of the patients 86% completed 18-month measurements. The percent weight loss in the intervention group averaged 8.0%, 7.5% and 5.5% at 6, 12 and 18 months, respectively, vs approximately 1.5% in the control group (all values p <0.001). Compared with controls at 12 months the intervention group reported a greater percent reduction in weekly stress urinary incontinence episodes (65% vs 47%, p <0.001), and a greater proportion achieved at least a 70% decrease in weekly total and stress urinary incontinence episodes. At 18 months a greater proportion of women in the weight loss intervention group had more than 70% improvement in urge incontinence episodes but there were no significant differences between the groups for stress or total urinary incontinence. The intervention group also reported greater satisfaction with changes in urinary incontinence than the control group at 6, 12 and 18 months.Conclusions: Weight loss intervention reduced the frequency of stress incontinence episodes through 12 months and improved patient satisfaction with changes in incontinence through 18 months. Improving weight loss maintenance may provide longer term benefits for urinary incontinence.

The Effect of Botulinum Toxin Type A on Overactive Bladder Symptoms in Patients With Multiple Sclerosis: A Pilot Study

Ulrich Mehnert, Jan Birzele, Katja Reuter, Brigitte Schurch — 2010-07-20

Purpose: Patients with multiple sclerosis often experience overactive bladder symptoms. High dose intradetrusor botulinum toxin A treatment is effective but often results in urinary retention and urinary diversion via a catheter. In this pilot study we evaluated whether only 100 U botulinum toxin A would significantly decrease overactive bladder symptoms in patients with multiple sclerosis without impairing pretreatment voluntary voiding.Materials and Methods: Included in our study were 12 patients with multiple sclerosis who had overactive bladder symptoms such as urgency, frequency and/or urgency incontinence. The treatment effect was evaluated using data on 3 consecutive visits, that is before, and a mean ± SD of 46.2 ± 11.9 and 101 ± 21 days after intradetrusor injection of 100 U Botox®, including the results of cystometry and uroflowmetry at visits 1 and 2, and uroflowmetry alone at visit 3. Patients completed a 3-day voiding diary for all 3 visits.Results: Maximum bladder capacity significantly increased and maximum detrusor pressure decreased. Daytime and nighttime frequency, urgency and pad use significantly decreased. Post-void residual volume significantly increased initially but decreased until 12 weeks. Median time to re-injection due to recurrent overactive bladder symptoms was 8 months.Conclusions: Overactive bladder treatment in patients with multiple sclerosis using 100 U Botox intradetrusor injections seems to be effective and safe. Despite slightly impaired detrusor contractility most patients still voided voluntarily without symptoms. Thus, 100 U Botox may be a reasonable treatment option for overactive bladder symptoms in patients with multiple sclerosis who still void voluntarily.

Adjustable Continence Therapy for Severe Intrinsic Sphincter Deficiency and Recurrent Female Stress Urinary Incontinence: Long-Term Experience

2010-07-20

Purpose: ACT® was developed to treat female stress urinary incontinence resulting from intrinsic sphincter deficiency by increasing urethral resistance. We evaluated the implantation procedure and assessed patient outcomes at our center.Materials and Methods: The adjustable continence device consists of 2 silicone balloons on either side of the proximal urethra under the bladder neck, each attached to a titanium port buried in the labia to allow postoperative titration. Urodynamic assessment was done in 57 female patients in whom previous pelvic surgery had failed. Pad use and an incontinence quality of life questionnaire were evaluated before ACT implantation, postoperatively at 1, 3, 6 and 12 months, and annually thereafter. Patients recorded the overall impression and percent of improvement postoperatively based on the Patient Global Impression Index and a visual analog scale.Results: Mean followup was 72 months (range 12 to 84). At 6-year followup in 29 patients mean pad use improved from 5.6 daily at baseline to 0.41 and intrinsic sphincter deficiency improved from 27.2 to 78.6 (p <0.001). As measured on the visual analog scale, 68% of patients considered themselves dry. On the Patient Global Impression Index questionnaire 64% were very much improved, 23% were much improved and 13% were only minimally improved or unchanged. No patients considered themselves worse after the procedure. Complications necessitating device removal developed in 21.1% of patients.Conclusions: Relative ease of insertion and the ability to tailor this therapy to individual needs makes this an attractive option for the challenging treatment for recurrent stress urinary incontinence due to intrinsic sphincter deficiency.

Prevalence of Urinary Incontinence in Men: Results From the National Health and Nutrition Examination Survey

2010-07-20

Purpose: We estimated the prevalence of urinary incontinence in the United States adult male population and identified associated factors.Materials and Methods: Data were analyzed for 5,297 men 20 years old or older who participated in the 2005 to 2006 and 2007 to 2008 cycles of the National Health and Nutrition Examination Survey, a cross-sectional, nationally representative survey of the United States noninstitutionalized population. Urinary incontinence (score of 3 or greater on a validated incontinence severity index, indicating moderate to severe leakage) was assessed. Potential associated factors included age, race/ethnicity, education, self-reported health status, prior diagnosis of prostate cancer and/or enlarged prostate (men 40 years old or older), chronic diseases and depression status. Prevalence ORs were estimated from a multivariable logistic regression analysis using appropriate sampling weights.Results: The prevalence of moderate/severe urinary incontinence was 4.5% (95% CI 3.8, 5.4). Prevalence increased with age from 0.7% (95% CI 0.4, 1.6) in men 20 to 34 years old, to 16.0% (95% CI 13.0, 19.4) in men 75 years old or older (p <0.001). We found no difference in prevalence by racial/ethnic group (p = 0.38). Factors significantly associated (p <0.05) with urinary incontinence were age (per 10-year increase, OR 1.8; 95% CI 1.6, 2.0), major depression (OR 2.7; 95% CI 1.6, 4.0) and hypertension (OR 1.3; 95% CI 1.1, 1.5).Conclusions: Age and race adjusted prevalence estimates for urinary incontinence in men are consistent with other estimates using a similar definition. To our knowledge this is the first study that identifies factors associated with moderate to severe urinary incontinence in men.

Evaluating Urinary Continence and Preoperative Predictors of Urinary Continence After Robot Assisted Laparoscopic Radical Prostatectomy

G. Novara, V. Ficarra, C. D'elia, S. Secco, A. Cioffi, S. Cavalleri, W. Artibani — 2010-07-20

Purpose: We evaluated urinary continence using a validated questionnaire in a series of consecutive patients who underwent robot assisted laparoscopic radical prostatectomy, and identified the preoperative predictors of the return to urinary continence.Materials and Methods: The clinical records of 308 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer at a tertiary academic center were prospectively collected. All patients were continent before surgery. Urinary continence was evaluated using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form instrument. All of the patients reporting no leak in response to the question, “How often do you leak urine?” were defined as continent.Results: A total of 273 patients (90%) were continent 12 months after robot assisted laparoscopic radical prostatectomy. Continent patients were significantly younger (61.4 ± 6.4 vs 64.1 ± 6.1 years, p = 0.02) than those who were incontinent. On univariable regression analysis patient age at surgery (OR 1.075, p = 0.024) and Charlson comorbidity index (OR 1.671, p = 0.007) were significantly associated with 12-month continence status. On multivariable analysis age (OR 1.076, p = 0.027) and Charlson comorbidity index (OR 1.635, p = 0.009) were independent predictors of continence rates.Conclusions: Using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form 90% of patients undergoing robot assisted laparoscopic radical prostatectomy reported no urine leak 12 months after surgery. Patient age at surgery and Charlson comorbidity index were independent predictors of the return to urinary continence, whereas notably no variable related to prostate cancer was significantly correlated with urinary continence.

Long-Term Effect of Early Postoperative Pelvic Floor Biofeedback on Continence in Men Undergoing Radical Prostatectomy: A Prospective, Randomized, Controlled Trial

2010-07-20

Purpose: The impact of pelvic floor muscle training on the recovery of urinary continence after radical prostatectomy is still controversial. We tested the effectiveness of biofeedback-pelvic floor muscle training in improving urinary incontinence in the 12 months following radical prostatectomy.Materials and Methods: A total of 73 patients who underwent radical prostatectomy were randomized to a treatment group (36) receiving biofeedback-pelvic floor muscle training once a week for 3 months as well as home exercises or a control group (37). Patients were evaluated 1, 3, 6 and 12 months postoperatively. Continence was defined as the use of 1 pad or less daily and incontinence severity was measured by the 24-hour pad test. Incontinence symptoms and quality of life were assessed with the International Continence Society male Short Form questionnaire and the Incontinence Impact Questionnaire. Pelvic floor muscle strength was evaluated with the Oxford score.Results: A total of 54 patients (26 pelvic floor muscle training and 28 controls) completed the trial. Duration of incontinence was shorter in the treatment group. At postoperative month 12, 25 (96.15%) patients in the treatment group and 21 (75.0%) in the control group were continent (p = 0.028). The absolute risk reduction was 21.2% (95% CI 3.45–38.81) and the relative risk of recovering continence was 1.28 (95% CI 1.02–1.69). The number needed to treat was 5 (95% CI 2.6–28.6). Overall there were significant changes in both groups in terms of incontinence symptoms, lower urinary tract symptoms, quality of life and pelvic floor muscle strength (p <0.0001).Conclusions: Early biofeedback-pelvic floor muscle training not only hastens the recovery of urinary continence after radical prostatectomy but allows for significant improvements in the severity of incontinence, voiding symptoms and pelvic floor muscle strength 12 months postoperatively.

Prospective Study of Serum Dihydrotestosterone and Subsequent Risk of Benign Prostatic Hyperplasia in Community Dwelling Men: The Rancho Bernardo Study

2010-07-20

Purpose: Little is known about midlife serum levels of dihydrotestosterone and other androgens before the onset of clinical benign prostatic hyperplasia in community dwelling older men.Materials and Methods: We measured sex steroid hormones between 1984 and 1987 in the Rancho Bernardo Study. Between 1992 and 1996 surviving participants were evaluated for benign prostatic hyperplasia at followup clinic visits. Benign prostatic hyperplasia was defined as a history of noncancer prostate surgery or a medical diagnosis of benign prostatic hyperplasia. Regression modeling was used to examine associations of serum hormone measures with benign prostatic hyperplasia.Results: In 340 surviving participants with complete data available and no history of prostate cancer or benign prostatic hyperplasia at baseline mean ± SD age was 64 ± 9 years and mean followup was 8.4 ± 0.8 years. Men who reported benign prostatic hyperplasia during followup were older at baseline than those who did not (p <0.001). Higher baseline serum dihydrotestosterone was associated with an increased risk of benign prostatic hyperplasia. The OR for the second, third and fourth quartiles of dihydrotestosterone was 1.83 (95% CI 0.96–3.47), 1.50 (0.79–2.85) and 2.75 (1.46–5.19), respectively (p trend = 0.02). A higher testosterone-to-dihydrotestosterone ratio was associated with a 42% decreased risk of benign prostatic hyperplasia when comparing the top 3 quartiles to the first quartile (OR 0.58, 95% CI 0.35–0.97, p = 0.04). Higher dehydroepiandrosterone was associated with an increased benign prostatic hyperplasia risk (p = 0.05).Conclusions: Community dwelling men show a stepwise increase in benign prostatic hyperplasia risk with higher midlife serum dihydrotestosterone. These data justify investigations of 5α-reductase inhibitors for primary prevention of benign prostatic hyperplasia.

Voiding Function and Dysfunction, Bladder Physiology and Pharmacology, and Female Urology

Alan J. Wein — 2010-07-20

D. E. Rapp, N. J. Neil and K. C. Kobashi Continence Center at Virginia Mason Medical Center, Seattle, Washington

Benign Prostatic Hyperplasia

Steven A. Kaplan — 2010-07-22

R. Leonardi Department of Urology, Clinica Basile, Catania, Italy

Imaging

Cary Siegel — 2010-07-22

G. L. Bennett, E. M. Hecht, T. P. Tanpitukpongse, J. S. Babb, B. Taouli, S. Wong, N. Rosenblum, J. A. Kanofsky and V. S. Lee Department of Radiology, New York University Medical Center, New York, New York

Geriatrics

Tomas L. Griebling — 2010-07-22

S. Tibaek, G. Gard, P. Klarskov, H. K. Iversen, C. Dehlendorff and R. Jensen Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden

Predictors of Kidney Volume Change and Delayed Kidney Function Recovery After Donor Nephrectomy

2010-07-20

Purpose: To our knowledge the effects of preoperative kidney volume in living donors on the post-donation change in size and function of the remaining kidney have not been investigated. We studied the association between preoperative kidney volume, and volume change and delayed kidney function recovery in donors.Materials and Methods: From 2007 to 2008 we investigated 222 living donors. Kidney volume before and 6 months after surgery was estimated using the voxel count method. We analyzed correlations of kidney volume with patient characteristics, kidney function and actual kidney weight. To identify predictors of the volume increase of the remaining kidney and predictors of delayed kidney function recovery we performed regression analysis.Results: Mean ± SD total kidney volume was 311.9 ± 50.6 cc and it correlated with weight, body surface area and kidney function (p <0.001). The mean volume increase in the remaining kidney was 27.6% ± 9.7% (range 4.5% to 66.1%). Younger age (p <0.001) and lower preoperative volume of the remaining kidney (p = 0.019) were significant predictors of a greater increase in kidney volume on multiple linear regression analysis. Older age (OR 1.07, p <0.001), higher body mass index (OR 1.20, p = 0.008), lower preoperative kidney volume of the remaining kidney (OR 0.98, p = 0.003) and a lower preoperative diethylenetetramine pentaacetic acid glomerular filtration rate in the remaining kidney (OR 0.95, p = 0.017) were significant predictors of delayed kidney function recovery on multiple regression analysis.Conclusions: Kidney volume measured by the voxel count method was accurate and correlated with kidney function. Preoperative kidney volume is an independent predictor of the volume increase and delayed kidney function recovery in donors that could be used clinically.

Pelvic Organ Prolapse Management in Female Kidney Transplant Recipients

M. Raschid Hoda, Sigrid Wagner, Francesco Greco, Hans Heynemann, Paolo Fornara — 2010-07-20

Purpose: Pelvic organ prolapse in female postmenopausal kidney transplant recipients may be complicated by adverse events affecting graft function. We describe our experience with pelvic reconstructive surgery in renal transplant recipients.Materials and Methods: Pelvic reconstructive surgery was done in 16 female renal transplant recipients with pelvic organ prolapse with or without stress urinary incontinence. Intraoperative and postoperative data were recorded prospectively, including medical and surgical history, pelvic organ prolapse quantification measurement, 24-hour pad count, quality of life measurements and graft outcome. Patients were followed up to 12 months.Results: Mean ± SD age at surgery was 58.3 ± 7.7 years (range 50 to 66). Mean time to renal transplantation was 54.2 ± 15.1 months (range 38 to 123). A total of 12 anterior and 4 combined anterior/posterior colporrhaphies were done. A concomitant suburethral single incision transobturator sling procedure was performed in 8 women. We noted no bladder or rectal injury, bleeding necessitating transfusion or infection. Pelvic floor testing at 12-month followup showed stage I vaginal wall prolapse in only 4 patients (25%). No patient had evidence of de novo incontinence, synthetic sling infection, erosion or rejection. All women reported improved quality of life on the SF-36™ questionnaire. Renal graft function remained stable in all patients.Conclusions: Pelvic reconstructive surgery is feasible for pelvic organ prolapse in patients with a kidney allograft on immunosuppression. However, concern about impaired graft function, infection and wound healing remains important.

Renal Transplantation and Renovascular Hypertension

David A. Goldfarb — 2010-07-20

M. A. Rees, J. E. Kopke, R. P. Pelletier, D. L. Segev, M. E. Rutter, A. J. Fabrega, J. Rogers, O. G. Pankewycz, J. Hiller, A. E. Roth, T. Sandholm, M. U. Unver and R. A. Montgomery

Laparoscopy/New Technology

Jeffrey A. Cadeddu — 2010-07-22

D. Canes, A. Berger, M. Aron, R. Brandina, D. A. Goldfarb, D. Shoskes, M. M. Desai and I. S. Gill Department of Urology, Lahey Clinic, Burlington, Massachusetts

Adrenal and Renal Physiology, and Medical Renal Disease

W. Scott McDougal — 2010-07-22

M. Blanco, J. Medina, M. Pamplona, N. Miranda, E. Gonzalez, J. F. Aguirre, A. Andres, O. Leiva and J. M. Morales Department of Urology, Doce de Octubre University Hospital, Madrid, Spain

Male and Female Sexual Function and Dysfunction; Andrology

Allen Seftel — 2010-07-22

M. R. Safarinejad, M. A. Asgari, S. Y. Hosseini and F. Dadkhah Urology and Nephrology Research Centre, and Department of Urology, Shaheed Modarress Hospital, Shahid Beheshti University (MC), Tehran, Iran

Male and Female Sexual Function and Dysfunction; Andrology

Allen Seftel — 2010-07-22

R. Haring, H. Völzke, A. Steveling, A. Krebs, S. B. Felix, C. Schöfl, M. Dörr, M. Nauck and H. Wallaschofski Institute of Clinical Chemistry and Laboratory Medicine, Ernst Moritz Arndt University Greifswald, Greifswald, Germany

Male Infertility

Craig Niederberger — 2010-07-22

M. A. Elbendary and A. M. Elbadry Urology Department, Tanta University, Tanta, Egypt

Male Infertility

Craig Niederberger — 2010-07-22

J. D. Meeker, M. G. Rossano, B. Protas, V. Padmanahban, M. P. Diamond, E. Puscheck, D. Daly, N. Paneth and J. J. Wirth Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan

Urological Malpractice: Analysis of Indemnity and Claim Data From 1985 to 2007

Jonas S. Benson, Christopher L. Coogan — 2010-07-21

Purpose: The possibility of a medical malpractice lawsuit is present in the practice of modern day medicine. A basic knowledge of trends, monetary values and types of claims involved in urological litigation is beneficial to the practicing surgeon.Materials and Methods: Cumulative analysis of claims data from 1985 to 2007 from more than 20 member companies of the Physician Insurers Association of America was performed. A total of 28 medical specialties are represented in 230,000 claims. An analysis of urological claims with regard to other specialties, trends, and most prevalent and types of procedures was performed.Results: Urology ranks 12th of 28 in the number of claims reported (5,577) and monies paid, totaling $285 million during 22 years. The average urology paid claim from 1985 to 2007 was $174,245, which is less than the average of all groups ($204,268). In 2007 the average indemnity paid was $227,838, which is an increase from $176,213 in 1997. The 2 most prevalent medical misadventures were improper performance and diagnostic errors, which accounted for 51% of all of the claims.Conclusions: Urology tends to be at or below average compared to other medical specialties in regard to total claims, total monies paid and average monies paid during the last 23 years. From 1997 to 2007 the average indemnity paid increased by 23%. Improper performance, diagnostic errors and failure to monitor cases resulted in the most lawsuits. In those groups malignancy of the prostate, testis and kidney appeared consistently. Continued analysis and education on medical litigation in urology can aid in increased awareness and possibly improved care for patients in the future.

Outcome of Antibiotic Prophylaxis Discontinuation in Patients With Persistent Vesicoureteral Reflux Initially Presenting With Febrile Urinary Tract Infection: Time to Event Analysis

2010-07-21

Purpose: The use of antibiotic prophylaxis for preventing urinary tract infections has recently been called into question. Some studies support discontinuation of antibiotic prophylaxis in selected groups of children with vesicoureteral reflux. We report on the outcome of this practice in a cohort of patients assembled based on initial presentation with a febrile urinary tract infection.Materials and Methods: We retrospectively reviewed records of patients with persistent vesicoureteral reflux without symptoms suggestive of dysfunctional elimination who discontinued antibiotic prophylaxis after being toilet trained. Exclusion criteria consisted of secondary reflux and previous surgery for vesicoureteral reflux. End points included development of febrile urinary tract infections, renal abnormalities on followup ultrasound and need for further interventions. Infection-free survival was analyzed using the Kaplan-Meier method and compared using the log rank and Cox's tests.Results: We evaluated 84 girls and 26 boys with a mean age of 5.4 years. Febrile urinary tract infections developed in 10 girls and 1 boy at an average of 17.2 months after discontinuation of antibiotic prophylaxis. In a time to event analysis group comparison showed no significant differences when patients were stratified by gender (p = 0.22), age at antibiotic prophylaxis discontinuation (p = 0.14) or disease laterality (p = 0.23). However, a significant difference was found in number of patients with high grade vesicoureteral reflux (III to V, p = 0.05) and development of symptoms suggestive of bladder/bowel dysfunction (p <0.01).Conclusions: Our data support antibiotic prophylaxis discontinuation in the majority of patients with persistent vesicoureteral reflux who initially present with a febrile urinary tract infection, once their elimination habits have been optimized. Those with high grade reflux appear to be at increased risk for recurrent urinary tract infections. Development of dysfunctional elimination symptoms appears to be a risk factor amenable to treatment.

Editorial Comment

Christopher S. Cooper — 2010-07-21

The authors further define risk factors for UTI recurrence in children with a history of UTI and VUR. They correctly conclude what most pediatric urologists now believe, which is that many children with reflux do not benefit from antibiotic prophylaxis. This conclusion raises the question of which children actually benefit from the diagnosis of VUR. The limitations of this study are well described. However, the mean followup is relatively short (2 years), which raises the important question of what will happen to these children during a longer period. Both of these questions serve as a challenge for pediatric urologists to define further the risk factors that will help determine which children are likely to benefit from the diagnosis of VUR and which are likely to benefit from various interventions. Further detailed retrospective reviews with longer followup as well as prospective studies should help to answer these questions.

Editorial Comment

Saul P. Greenfield — 2010-07-21

This retrospective study adds little clarity to the controversy surrounding the need for treatment of older children with VUR. Renal scarring is a major, if not the major, concern in these children and should be documented with a radionuclide DMSA scan. Renal ultrasound cannot accurately determine renal scarring and has little place in the ongoing evaluation of patients with reflux. DMSA scanning was not uniformly performed in this series. Furthermore, since an initial DMSA scan is not reported, a major risk factor for additional infections remains unknown, ie renal scar at the time of clinical presentation. The assessment of dysfunctional voiding was surprisingly informal, given the fact that a reproducible symptom scoring system was developed in Toronto. We do not really know who had voiding dysfunction in this cohort. Nonfebrile UTIs were not reported and they can be a significant cause of morbidity in children with VUR. The observation period was extraordinarily wide, ranging from 6 months to 8.5 years, and no patient underwent VCUG at the end of this period, so we do not know how many were still refluxing—an important denominator.

Reply by Authors

2010-07-21

We agree that in many patients reflux can be managed expectantly. Nevertheless, one of the main issues and sources of anxiety is the uncertainty behind selecting those who will benefit from treatment and, equally important, which treatment. Far from a broad recommendation to stop antibiotic prophylaxis in all patients, our data provide further evidence that many patients with reflux will do well without intervention, bring to light questions about who may be eligible to have antibiotics safely discontinued and provoke more controversy, hopefully leading to future studies.

Epidemiological Trends in Pediatric Urolithiasis at United States Freestanding Pediatric Hospitals

Jonathan C. Routh, Dionne A. Graham, Caleb P. Nelson — 2010-07-21

Purpose: Anecdotal and lay press reports suggest that the incidence of pediatric urolithiasis is increasing but reliable data are lacking. The objective of this study was to examine trends in the epidemiology of urolithiasis at pediatric hospitals nationwide.Materials and Methods: The Pediatric Health Information System database is a national database covering 42 freestanding United States pediatric hospitals that captures inpatient admissions, and emergency department and outpatient surgery visits. We searched the Pediatric Health Information System database to identify children (18 years old or younger) treated for urolithiasis between 1999 and 2008. Patients with urolithiasis were measured as a proportion of the total number of patients seen per hospital annually. Trends were verified by comparing results to 2 other common pediatric diagnoses—appendicitis and viral bronchiolitis.Results: We identified 7,921 children diagnosed with urolithiasis during the study period. The total number of children with urolithiasis seen in Pediatric Health Information System hospitals increased from 125 in 1999 to 1,389 in 2008. Mean number of stone cases per hospital per year increased from 13.9 to 32.6. Compared to total hospital patients, the proportion of patients with pediatric urolithiasis increased from 18.4 per 100,000 in 1999 to 57.0 per 100,000 in 2008, an adjusted annual increase of 10.6% (p <0.0001). Urolithiasis also increased compared to appendicitis (p <0.0001) and bronchiolitis (p <0.0001).Conclusions: Even after correcting for increases in total patient volume at Pediatric Health Information System hospitals, there has been a significant increase in the number of children diagnosed with and treated for urolithiasis at these hospitals in the last decade.

Editorial Comment

Nicol Corbin Bush — 2010-07-21

The authors have nicely shown that increasing numbers of pediatric stone cases, such as those reported in the lay press and from single institutions, are indeed being seen in this collection of freestanding pediatric hospitals. The change in total number of stone cases (from 125 to 1,369) is misleading due to increasing hospital participation in PHIS and, thus, large increases in total patients during this 10-year period. However, there was still an impressive increase in urolithiasis diagnoses of 10.6% annually when corrected for hospital volume. As table 3 illustrates, the average increase in stone cases per hospital in the past 5 years has been modest, with the bulk of the increase occurring from 1999 to 2003 for unclear reasons. Continued longitudinal followup within PHIS using a stable number of participating hospitals or, preferably, population based analyses will continue to illuminate this topic of growing concern among pediatric urologists and the families affected by pediatric urolithiasis.

Editorial Comment

Thomas Novak, Brian Matlaga — 2010-07-21

In the present environment of health care reform the diagnosis, management and prevention of costly diseases such as urolithiasis will be under immense scrutiny. The authors identified a significant increase in the incidence of pediatric stone diagnoses at hospitals contributing to the PHIS data set during the last decade while accounting for increased hospital referral volume during that time. While this study suffers from the inherent limitations of the PHIS data set, the authors clearly acknowledge these limitations, and account for them in their analysis and scope of their conclusions. Given the morbidity of stone disease and the high likelihood of recurrence, a significant increase in pediatric urolithiasis would represent a major public health issue. Confirmation of this trend and subsequent investigations into the underlying causes should be the focus of future studies.

A Multicenter, Randomized, Controlled Trial of Transureteral and Shock Wave Lithotripsy—Which is the Best Minimally Invasive Modality to Treat Distal Ureteral Calculi in Children?

2010-07-21

Purpose: Since there is insufficient evidence to determine the best treatment modality in children with distal ureteral calculi, we designed a multicenter, randomized, controlled trial to evaluate the efficacy and complications of transureteral and shock wave lithotripsy in these patients.Materials and Methods: A total of 100 children with distal ureteral calculi were included in the study. Of the patients 50 were randomized consecutively to undergo shock wave lithotripsy using a Compact Delta II lithotriptor (Dornier MedTech, Kennesaw, Georgia), and 50 were randomized to undergo transureteral lithotripsy with holmium laser and pneumatic lithotriptor between February 2007 and October 2009. Stone-free, complication and efficiency quotient rates were assessed in each group.Results: Mean ± SD patient age was 6.5 ± 3.7 years (range 1 to 13). Mean stone surface was 35 mm2 in the transureteral group and 37 mm2 in the shock wave lithotripsy group. Stone-free rates at 2 weeks after transureteral lithotripsy and single session shock wave lithotripsy differed significantly, at 78% and 56%, respectively (p = 0.004). With 2 sessions of shock wave lithotripsy the stone-free rate increased to 72%. Efficiency quotient was significantly higher for transureteral vs shock wave lithotripsy (81% vs 62%, p = 0.001). Minor complications were comparable and negligible between the groups. Two patients (4%) who underwent transureteral lithotripsy sustained a ureteral perforation.Conclusions: In the short term it seems that transureteral and shock wave lithotripsy are acceptable modalities for the treatment of distal ureteral calculi in children. However, transureteral lithotripsy has a higher efficacy rate when performed meticulously by experienced hands using appropriate instruments.

Editorial Comment

Ezekiel H. Landau — 2010-07-21

This is a prospective, randomized, multicenter study comparing extracorporeal SWL with TUL for distal ureteral calculi in children. The authors claim superiority of TUL over SWL in this series. Recently there has been an increasing tendency to use TUL in pediatric ureteral stone disease, to the point of suggesting TUL as first line treatment in these cases (reference 20 in article). The advanced technology in ureteroscopy design is responsible for the increasing popularity of TUL over SWL. TUL using laser energy had a better stone-free rate (5 patients, 100%) than pneumatic TUL (45 patients, 91%). Smaldone et al used holmium laser exclusively in their patients (reference 20 in article). Will these authors recommend using laser energy in future pediatric TUL? Prevention of perforation and stricture is still a challenge for every pediatric endourologist. Perforation can lead to stricture that, by itself, can potentially cause severe ipsilateral renal damage. These severe complications do not happen in modern SWL. We should all remember that TUL demands expertise and experience to achieve superior results, whereas SWL is much simpler to execute.

Reply by Authors

2010-07-21

Use of the laser in our 5 cases of susceptibility for stone retropulsion was safe and effective. Regardless of the small number of patients, it seems that laser lithotripsy is an advisable modality for pediatric URS. Although it seems that SWL is easier and safer to perform, recently miniature ureteroscopes and accessory instruments have made ureteroscopy safer and more feasible than in the past. It needs to be emphasized that both procedures require general anesthesia in children.

Evaluation of Renal Function in Children Undergoing Extracorporeal Shock Wave Lithotripsy

A. Fayad, M.G. El-Sheikh, M. AbdelMohsen, H. AbdelRaouf — 2010-07-21

Purpose: The effect of extracorporeal shock wave lithotripsy on the growing kidneys of young children has always been a concern. We determined whether shock wave lithotripsy causes renal parenchymal scarring or affects glomerular filtration rate in children.Materials and Methods: This prospective study included 100 children with renal stones who presented to the shock wave lithotripsy unit at our institution between March 2005 and March 2008. A total of 28 children had multiple stones in the same kidney. All children with bilateral renal stones had 1 kidney cleared of stones by percutaneous nephrolithotomy before undergoing shock wave lithotripsy. A total of 138 stones were subjected to shock wave lithotripsy. All children underwent radionuclide scan of the renal parenchyma using dimercapto-succinic acid, and glomerular filtration rate was estimated using diethylenetriamine pentaacetic acid before extracorporeal shock wave lithotripsy and 6 months afterward. Children with renal scarring due to previous surgery or vesicoureteral reflux were excluded from the study. The number of shock wave lithotripsy sessions to achieve stone-free status and the dose of shock waves used were recorded for each patient.Results: No patient demonstrated renal parenchymal scarring on dimercapto-succinic acid scan or any statistically significant change in glomerular filtration rate on diethylenetriamine pentaacetic acid scan up to 6 months after shock wave lithotripsy.Conclusions: Shock wave lithotripsy is a safe modality for treating renal calculous disease in children up to 16 years old, with no impact on long-term kidney function.

Editorial Comment

Gerald Mingin — 2010-07-21

These authors address the clinically important question of whether SWL causes renal parenchymal scarring or affects glomerular filtration rate. Based on their findings, it appears that SWL is safe in childhood regardless of stone burden and number of sessions. These findings are consistent with the literature (reference 27 in article). Strengths of the study include its prospective design and the number of stones treated. Although encouraging, enthusiasm should be tempered with caution. Unfortunately all of these patients were treated on the same machine and a good comparison with similar parameters on different SWL machines is lacking. Similar to other reported series, the relatively short followup of this study, although probably adequate for detecting scar formation and assessing GFR, might not allow for detection of subtle microvascular injury. Potential small or cumulative insults could contribute to pathological changes later in life. Despite these shortcomings, this information is important in deciding on a treatment plan, considering the recent advent of endoscopic devices that increase the success and safety of the retrograde approach to treating renal calculi in children.

Editorial Comment

Scott Cuda, Edwin Smith — 2010-07-21

Despite the widespread acceptance of SWL for stone treatment in children, the potential long-term deleterious effects on the renal parenchyma remain incompletely defined. To address this issue, the authors present a well designed prospective study of 100 children who underwent treatment of renal stones with a modern lithotriptor. The importance of their investigation is amplified by animal studies revealing that the cavitation forces of SWL can cause direct tubular cell injury and microvascular damage, and possibly produce additional tissue injury by generation of free radicals. Furthermore, earlier studies have demonstrated acute perfusion defects by DMSA scan following SWL.

Use of Cutaneous Flap for Continent Cystostomy (Daoud Technique)

2010-07-21

Purpose: We present the results of a new technique using a pedicled cutaneous flap for continent cystostomy.Materials and Methods: A total of 15 boys and 8 girls (mean ± SD age 13.4 ± 6.4 years) underwent continent cystostomy for neurogenic bladder (20), bladder exstrophy (2) and sequelae of hypospadias (1) between 1999 and 2008. In this procedure a rectangular pedicled flap is surgically elevated from a hairless area on the abdomen. The flap is tubularized and passed through the anterior abdominal wall directly into the bladder. A submucosal detrusor incision is made to expose the bladder mucosa, and the distal part of the flap is anastomosed to the bladder mucosa in a circular manner. The tube is positioned along the incised detrusor, which is closed over. Viability of the flap, self-catheterization management and continence status are then evaluated.Results: Mean ± SD followup was 4.5 ± 3.1 years. There was 1 case of distal necrosis of the flap, which required a secondary surgery using the Mitrofanoff technique. The 22 remaining flaps were initially viable, although 2 patients were eventually lost to followup and 3 subsequently presented with false-passage incidents requiring a few days of calibration using a balloon catheter. Dryness was achieved immediately in 73% of the cases. After adding a complementary bulking agent the dryness rate reached 77%.Conclusions: We present a novel approach to continent cystostomy that is safe and easy to perform. This technique is a less invasive and more efficient alternative to other commonly used approaches.

Editorial Comment

R. Maximilian Cervellione — 2010-07-21

The authors present an attractive technique to create a continent urinary diversion using a cutaneous flap. Four of 23 patients (17%) experienced complications, including immediate necrosis of the conduit (1), lost channel (1) and false passage (2). Of the 21 functioning channels 1 (5%) required an endoscopic injection of bulking agent to achieve continence and 2 (10%) are still incontinent.

Long-Term Surgical Outcome of Masculinizing Genitoplasty in Large Cohort of Patients With Disorders of Sex Development

2010-07-21

Purpose: We evaluated the results of masculinizing genitoplasty in a large cohort of patients with disorders of sex development treated at a single public tertiary center.Materials and Methods: We evaluated 52 patients with 46,XY and 7 with 46,XX disorders of sex development with proximal hypospadias and genital ambiguity reared as males who had undergone surgery between 1965 and 2008. Mean ± SD followup was 14.1 ± 9.2 years and median age at last examination was 22 years, with 38 patients having reached adulthood. Morphological result and urinary stream were evaluated by a physician. Urinary and sexual symptoms, and satisfaction with surgical results were assessed by questionnaire.Results: Mean penile length at diagnosis was compared between 46,XY patients and showed that those with 5α-reductase 2 deficiency had the shortest penile length (−5.4 ± 1.2 SD). At the last clinical evaluation following surgical and hormonal treatment mean ± SD penile length in 38 adults was 7.5 ± 2.1 cm (range 4 to 12), corresponding to −4.3 ± 1.3 SD (−6.5 to −1.5). All but 2 patients had penile length less than −2 SD. At that time mean penile length remained shorter in patients with 5α-reductase 2 deficiency (−5.4 ± 1 SD) compared to those with testosterone production deficiency or indeterminate disorders of sex development (p <0.05). There was no statistical difference between mean penile length before and after treatment in all etiological groups (p >0.05). Morphological results were good in 43% of patients, fair in 54% and poor in 3%. The most common complications were urethral fistula (51%) and urethral stenosis (22%). Dribbling after voiding was the most frequent urinary symptom. Satisfaction with surgical results was reported by 89% of patients. Among adults 87% were sexually active, with 64% reporting normal sexual activity.Conclusions: Most patients with 46,XY disorders of sex development were satisfied with long-term results of masculinizing genitoplasty, although specific complaints about small penile length, sexual activity and urinary symptoms were frequent. New surgical approaches should be developed to ensure full satisfaction in adulthood among patients with disorders of sex development.

Is Routine Renography Required After Pyeloplasty?

2010-07-21

Purpose: We assessed whether renography should be performed routinely following pyeloplasty.Materials and Methods: We identified the records of all patients undergoing pyeloplasty at our hospital between 1989 and 2005. Patients were eligible for the study if they had undergone preoperative ultrasound and renal scan, and postoperative ultrasound and renal scan within 3 months and 1 year postoperatively, respectively. Patients were excluded if they had associated anomalies or high grade reflux. Postoperative downgrading or decompression of the pelvicaliceal dilatation within the same grade was recorded as “improved,” while unchanged or worsening hydronephrosis was recorded as “no improvement.” All information was obtained from the official radiologist reports rather than from the postoperative surgeon notes. Data obtained from the postoperative renal scan included the presence or absence of obstruction as well as split renal function. We compared postoperative ultrasound and renal scan, as well as changes between preoperative and postoperative split renal function in patients with a normal contralateral kidney. Fisher's exact test was used for comparison.Results: A total of 97 patients who underwent 101 pyeloplasties at a median age of 18 months were eligible for review. Mean ± SD followup was 4.5 ± 2 years. Of the 91 kidneys with improvement on postoperative ultrasound 2 (2%) had an obstructive postoperative renal scan, which spontaneously resolved during followup. In contrast, of the 10 kidneys with postoperative ultrasound showing no improvement 4 (40%) had an obstructive renal scan, of which 2 (50%) required a second procedure (p <0.001). Of the 46 kidneys with downgraded hydronephrosis none had an obstructive postoperative renal scan, compared to 6 of 55 (11%) without downgrading (p <0.03). Of the 49 patients with preoperative split renal function greater than 45% none demonstrated changes of more than 5% postoperatively, compared to 15 of 35 (43%) with split renal function less than 45% (p <0.001).Conclusions: Patients in whom postoperative ultrasound reveals downgrading may not require postoperative renal scan to rule out obstruction. However, those with preoperative function less than 45% may exhibit functional changes greater than 5% that can be determined by postoperative renal scan.

Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children

2010-07-21

Purpose: The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to children with diagnosed reflux including those young or older than 1 year without evidence of bladder and bowel dysfunction and those older than 1 year with evidence of bladder and bowel dysfunction. From this evidence clinical practice guidelines were developed to manage the clinical scenarios insofar as the data permit.Materials and Methods: The Panel searched the MEDLINE® database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children with vesicoureteral reflux and a defined care program that permitted identification of cohort specific clinical outcomes. The reporting of meta-analysis of observational studies elaborated by the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) group was followed. The extracted data were analyzed and formulated into evidence-based recommendations.Results: A total of 2,028 articles were reviewed and data were extracted from 131 articles. Data from 17,972 patients were included in this analysis. This systematic meta-analysis identified increasing frequency of urinary tract infection, increasing grade of vesicoureteral reflux and presence of bladder and bowel dysfunction as unique risk factors for renal cortical scarring. The efficacy of continuous antibiotic prophylaxis could not be established with current data. However, its purported lack of efficacy, as reported in selected prospective clinical trials, also is unproven owing to significant limitations in these studies. Reflux resolution and endoscopic surgical success rates are dependent upon bladder and bowel dysfunction. The Panel then structured guidelines for clinical vesicoureteral reflux management based on the goals of minimizing the risk of acute infection and renal injury, while minimizing the morbidity of testing and management. These guidelines are specific to children based on age as well as the presence of bladder and bowel dysfunction. Recommendations for long-term followup based on risk level are also included.Conclusions: Using a structured, formal meta-analytic technique with rigorous data selection, conditioning and quality assessment, we attempted to structure clinically relevant guidelines for managing vesicoureteral reflux in children. The lack of robust prospective randomized controlled trials limits the strength of these guidelines but they can serve to provide a framework for practice and set boundaries for safe and effective practice. As new data emerge, these guidelines will necessarily evolve.

Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report: Clinical Practice Guidelines for Screening Siblings of Children With Vesicoureteral Reflux and Neonates/Infants With Prenatal Hydronephrosis

2010-07-21

Purpose: The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to screening of siblings and offspring of index patients with vesicoureteral reflux and infants with prenatal hydronephrosis. From this evidence clinical practice guidelines are developed to manage the clinical scenarios insofar as the data permit.Materials and Methods: The Panel searched the MEDLINE® database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children, clearly stating the number of children undergoing screening for vesicoureteral reflux. Vesicoureteral reflux should have been diagnosed with a cystogram and renal outcomes assessed by nuclear scintigraphy. The screening articles were extracted into data tables developed to evaluate epidemiological factors, patient and renal outcomes, and results of treatment. The reporting of meta-analysis of observational studies elaborated by the MOOSE group was followed. The extracted data were analyzed and formulated into evidence-based recommendations regarding the screening of siblings and offspring in index cases with vesicoureteral reflux and infants with prenatal hydronephrosis.Results: In screened populations the prevalence of vesicoureteral reflux is 27.4% in siblings and 35.7% in offspring. Prevalence decreases at a rate of 1 screened person every 3 months of age. The prevalence is the same in males and females. Bilateral reflux prevalence is similar to unilateral reflux. Grade I–II reflux is estimated to be present in 16.7% and grade III–V reflux in 9.8% of screened patients. The estimate for renal cortical abnormalities overall is 19.3%, with 27.8% having renal damage in cohorts of symptomatic and asymptomatic children combined. In asymptomatic siblings only the rate of renal damage is 14.4%. There are presently no randomized, controlled trials of treated vs untreated screened siblings with vesicoureteral reflux to evaluate health outcomes as spontaneous resolution, decreased rates of urinary infection, pyelonephritis or renal scarring.In screened populations with prenatal hydronephrosis the prevalence of vesicoureteral reflux is 16.2%. Reflux in the contralateral nondilated kidney accounted for a mean of 25.2% of detected cases for a mean prevalence of 4.1%. In patients with a normal postnatal renal ultrasound the prevalence of reflux is 17%. The prenatal anteroposterior renal pelvic diameter was not predictive of reflux prevalence. A diameter of 4 mm is associated with a 10% to 20% prevalence of vesicoureteral reflux. The prevalence of reflux is statistically significantly greater in females (23%) than males (16%) (p=0.022). Reflux grade distribution is approximately a third each for grades I–II, III and IV–V. The estimate of renal damage in screened infants without infection is 21.8%. When stratified by reflux grade renal damage was estimated to be present in 6.2% grade I–III and 47.9% grade IV–V (p <0.0001). The risk of urinary tract infection in patients with and without prenatal hydronephrosis and vesicoureteral reflux could not be determined. The incidence of reported urinary tract infection in patients with reflux was 4.2%.Conclusions: The meta-analysis provided meaningful information regarding screening for vesicoureteral reflux. However, the lack of randomized clinical trials for screened patients to assess clinical health outcomes has made evidence-based guideline recommendations difficult. Consequently, screening guidelines are based on present practice, risk assessment, meta-analysis results and Panel consensus.

Preliminary Experience With Epsilon Aminocaproic Acid for Treatment of Intractable Upper Tract Hematuria in Children With Hematological Disorders

2010-07-21

Purpose: Gross, intractable hematuria is rare in children. Although the role of epsilon aminocaproic acid in the management of refractory hematuria is well established in the adult population, few data exist about its use in children for this indication. We present our initial experience with epsilon aminocaproic acid for the treatment of intractable hematuria after more conservative measures failed, and propose an algorithm for administration of epsilon aminocaproic acid in children.Materials and Methods: We reviewed the charts of all patients treated with epsilon aminocaproic acid for intractable gross hematuria at our institution during a period of 36 months. All patients underwent hematological evaluation and any underlying bleeding dyscrasias were addressed. All patients also underwent renal and bladder ultrasound, retrograde pyelogram and ureteroscopy. Demographic information, medical and surgical histories, and epsilon aminocaproic acid dosing and outcomes were recorded.Results: Three boys and 1 girl 11 to 17 years old were treated with epsilon aminocaproic acid. Three patients had sickle trait (1 with nutcracker phenomenon) and 1 had hemophilia A. Three patients required packed red blood cell transfusions to maintain hematocrit. Three renal angiograms were performed, all of which were nondiagnostic. Duration of hematuria ranged from 1 to 52 weeks before administration of epsilon aminocaproic acid. Endoscopic evaluation demonstrated hematuria localized to 1 ureteral orifice in all 4 patients. All patients received 100 mg/kg epsilon aminocaproic acid orally every 6 hours, which uniformly led to cessation of hematuria.Conclusions: Epsilon aminocaproic acid is useful for the management of gross refractory hematuria when more conservative measures fail. Because of its potential side effects, it should be used cautiously.

Editorial Comment

Richard Schlussel — 2010-07-21

One of the more difficult clinical problems that pediatric urologists deal with is refractory hematuria, often in the setting of hemorrhagic cystitis. This article deals with a subset of pediatric patients whose bleeding was mainly from the upper tracts. Faced with a choice of continued bleeding or nephrectomy, the authors chose an alternative approach, the administration of aminocaproic acid. There has been a fair amount of experience in pediatric scoliosis and cardiac surgery with this agent in reduction of postoperative bleeding. In those settings aminocaproic acid has been effective and safe. The experience of the authors (albeit in a small group) showed similar efficacy and safety. This medication may help as a last-ditch effort in children who might otherwise undergo nephrectomy to stop their poorly localized and poorly controlled upper tract bleeding.

Pediatric Urology

Douglas A. Canning — 2010-07-21

S. Arena, C. Romeo, F. A. Borruto, S. Racchiusa, V. Di Benedetto and F. Arena Unit of Pediatric Surgery, Department of Pediatric Surgery, University of Catania, Catania, Italy

Testicular Plasmacytoma

Youssef Tanagho, Mark Stovsky, Gregory T. MacLennan — 2010-07-21

Patients with plasma cell neoplasia typically present with diffuse marrow involvement, multiple osseous plasmacytomas or both and 1 or more extramedullary plasmacytomas, a condition called multiple myeloma. Infrequently a patient presents with a single osseous or extramedullary (solitary) plasmacytoma. About 80% to 90% of extramedullary plasmacytomas develop in the head and neck area, especially in the aerodigestive tract. Less commonly they arise in diverse sites anywhere in the body, including the bladder, testis and epididymis.

Unusual Presentation of Urothelial Carcinoma of the Bladder With Noncontiguous Rectal and Diffuse Muscular Skeletal Metastases

Jhang Ying-Yue, Shu-Huei Shen, Jia-Hwia Wang — 2010-07-21

An 83-year-old man presented with frequent bowel movements and weight loss in the last 6 months. History was remarkable for hypertension and diabetes mellitus. Digital rectal examination revealed a tumor 3 cm from the anal verge, which was subsequently confirmed by rectoscopy. Biopsy revealed poorly differentiated carcinoma. The tumor cells stained strongly positive for CK7, weakly positive for CK20, and negative for CDX-2 and S-100. Therefore, primary adenocarcinoma of the colon was less likely and tumor growth of urothelial origin was suspected.

TRAIL and Interferon-α Act Synergistically to Induce Renal Cell Carcinoma Apoptosis

2010-07-21

Purpose: Despite modern targeted therapy metastatic renal cell carcinoma remains a deadly disease. Interferon-α (Calbiochem®) is currently used to treat this condition, mainly combined with the targeted anti-vascular endothelial growth factor antibody bevacizumab. TRAIL (Apo2 ligand/tumor necrosis factor related apoptosis inducing ligand) (Calbiochem) is a novel antineoplastic agent now in early phase clinical trials. Interferon-α and TRAIL can act synergistically to kill cancer cells but to our knowledge this has never been tested in the context of renal cell carcinoma. We hypothesized that TRAIL and interferon-α could synergistically induce apoptosis in renal cell carcinoma cells.Materials and Methods: We treated renal cell carcinoma cell lines with recombinant TRAIL and/or interferon-α. Viability and apoptosis were assessed by MTS assay, flow cytometry and Western blot. Synergy was confirmed by isobologram. Interferon-α induced changes in renal cell carcinoma cell signaling were assessed by Western blot, flow cytometry and enzyme-linked immunosorbent assay.Results: TRAIL and interferon-α acted synergistically to increase apoptotic cell death in renal cell carcinoma cells. Interferon-α treatment altered the ability of cells to activate extracellular signal-regulated kinase while inhibiting extracellular signal-regulated kinase with UO126 abrogated TRAIL and interferon-α apoptotic synergy. Interferon-α did not induce changes in TRAIL or death receptor expression, or change other known mediators of the intrinsic and extrinsic apoptotic cascade in the cells.Conclusions: TRAIL plus interferon-α synergistically induces apoptosis in renal cell carcinoma cells, which is due at least in part to interferon-α mediated changes in extracellular signal-regulated kinase activation. TRAIL and interferon-α combination therapy may be a novel approach to advanced renal cell carcinoma that warrants further testing in vivo.

A Potent Chemotherapeutic Strategy for Bladder Cancer: (S)-Methoxy-Trityl-L-Cystein, a Novel Eg5 Inhibitor

2010-07-21

Purpose: Eg5, which has an essential role in the formation and maintenance of a bipolar mitotic spindle, was recently identified as an attractive target in cancer chemotherapy. We examined the anticancer activity of a novel Eg5 inhibitor for bladder cancer with particular reference to metastatic disease.Materials and Methods: We examined bladder cancer cell lines and clinical tissue samples for Eg5 expression and analyzed the antiproliferative activity of 5 Eg5 inhibitors in cell lines by cell viability assay. The anticancer efficacy of the most potent Eg5 inhibitor was investigated in vitro by apoptosis assay with Hoechst nuclear staining and flow cytometry. Immunofluorescence and immunostaining were used to elucidate the inhibitory mechanism. We evaluated the inhibitory effect in vivo in subcutaneous xenograft and metastatic cancer models.Results: Eg5 expression was increased in bladder cancer samples vs that in normal bladder epithelium samples. (S)-methoxy-trityl-L-cystein showed the strongest antiproliferative activity of the 5 Eg5 inhibitors and induced cell death after mitotic arrest via the caspase dependent apoptotic pathway. In vivo (S)-methoxy-trityl-L-cystein effectively suppressed tumor growth in subcutaneous and metastatic xenograft models. Survival time in (S)-methoxy-trityl-L-cystein treated nude mice was significantly longer than in untreated mice (p <0.001).Conclusions: (S)-methoxy-trityl-L-cystein is a promising, novel anticancer agent for bladder cancer. Our data indicates its potential as effective therapy for metastatic bladder cancer.

Clinical Significance of Polymorphism and Expression of Chromogranin A and Endothelin-1 in Prostate Cancer

2010-07-21

Purpose: We investigated the clinical significance of chromogranin A and endothelin-1 polymorphism and expression in prostate cancer.Materials and Methods: We analyzed 2 CHGA polymorphisms by polymerase chain reaction-restriction fragment length polymorphism in DNA samples of 435 patients with prostate cancer and 316 age matched male controls. Chromogranin A and endothelin-1 expression was evaluated by immunohistochemistry in prostate specimens of 114 men with prostate cancer who underwent radical retropubic prostatectomy and in 27 with bladder cancer who underwent radical cystectomy and served as controls.Results: For the CHGA Glu264Asp polymorphism men with the GG genotype were at 2.05 times higher risk for prostate cancer than men with the CC genotype (p = 0.014). In men with prostate cancer higher chromogranin A immunohistochemistry grade was associated with higher stage and higher Gleason score (p = 0.011 and 0.044, respectively). Multivariate analysis showed that chromogranin A immunohistochemistry grade was an independent variable for predicting biochemical failure after radical prostatectomy (p = 0.023). Higher endothelin-1 expression was observed in prostate cancers (p = 0.011), especially those with a higher Gleason score (p = 0.042). There was no significant relationship between chromogranin A polymorphisms, and chromogranin A and endothelin-1 expression.Conclusions: Polymorphism and expression of chromogranin A and endothelin-1 have clinical significance in prostate cancer. Chromogranin A expression was an independent predictor of biochemical failure after prostatectomy in patients with localized prostate cancer.

Experimental Induction of Calcium Oxalate Nephrolithiasis in Mice

Saeed R. Khan, Patricia A. Glenton — 2010-07-21

Purpose: The availability of various transgenic and knockout mice provides an excellent opportunity to better understand the pathophysiology of calcium oxalate stone disease. However, attempts to produce calcium oxalate nephrolithiasis in mice have not been successful. We hypothesized that calcium oxalate nephrolithiasis in mice requires increasing urine calcium and oxalate excretion, and experimentally induced hyperoxaluria alone is not sufficient. To provide evidence we induced hyperoxaluria by administering hyperoxaluria inducing agents in normocalciuric and hypercalciuric mice, and investigating various aspects of nephrolithiasis.Materials and Methods: We administered ethylene glycol, glyoxylate or hydroxyl proline via diet in male and female normocalciuric B6 mice, and in hypercalciuric sodium phosphate co-transporter type 2 a −/− mice for 4 weeks. We collected 24-hour urine samples on days 0, 3, 7, 14, 21 and 28, and analyzed them for pH, creatinine, lactate dehydrogenase calcium and oxalate. Kidneys were examined using light microscopy. Urine was examined for crystals using light and scanning electron microscopy.Results: Hypercalciuric mice on hydroxyl proline did not tolerate treatment and were sacrificed before 28 days. All mice on ethylene glycol, glyoxylate or hydroxyl proline became hyperoxaluric and showed calcium oxalate crystalluria. No female, normocalciuric or hypercalciuric mice showed renal calcium oxalate crystal deposits. Calcium oxalate nephrolithiasis developed in all mice on glyoxylate and in some on ethylene glycol. In all mice the kidneys showed epithelial injury. Male mice particularly on glyoxylate had more renal injury and inflammatory cell migration into the interstitium around the crystal deposits.Conclusions: Results confirm that hyperoxaluria induction alone is not sufficient to create calcium oxalate nephrolithiasis in mice. Hypercalciuria is also required. Kidneys in male mice are more prone to injury than those in female mice and are susceptible to calcium oxalate crystal deposition. Perhaps epithelial injury promotes crystal retention. Thus, calcium oxalate nephrolithiasis in mice is gender dependent, and requires hypercalciuria and hyperoxaluria.

A New Technique for Ureteral Defect Lesion Reconstruction Using an Autologous Vein Graft and a Biodegradable Endoluminal Stent

2010-07-21

Purpose: Ureteral defect lesions are severe complications caused by iatrogenic lesions or trauma. For ureteral defect lesions elaborate surgical intervention is needed, such as autotransplantation or ureteral replacement with small bowel. Thus, we developed a new technique for ureteral defect reconstruction in a pig model using an autologous vein graft splinted by an endoluminal biodegradable poly-L-lactic acid stent (Institute of Textile Technology and Process Engineering, Denkendorf, Germany).Materials and Methods: In 42 pigs we removed the external jugular vein and used it as an autologous vein graft. After median laparotomy a 3 cm segment was resected from the proximal ureter and replaced by the vein with or without an endoluminal biodegradable poly-L-lactic acid stent. As controls, we used 14 pigs. We observed survival, kidney function, and neoureteral and kidney morphological changes for 7 days and for 6 months.Results: After 6 months the stent material was completely broken down and the vein graft was relined with urothelium. It resembled native ureter with cytokeratin-7 positive columnar epithelium and newly formed capillaries in the ureteral wall. All animals had normal kidney function without renal pelvis congestion.Conclusions: This new technique for ureteral defect reconstruction using an autologous vein graft and a biodegradable endoluminal stent is feasible. It is an interesting alternative in the clinic due to the preservation of physiological urine passage and the antireflux mechanism.

Suppression of Detrusor-Sphincter Dyssynergia by Herpes Simplex Virus Vector Mediated Gene Delivery of Glutamic Acid Decarboxylase in Spinal Cord Injured Rats

2010-07-21

Purpose: We investigated whether replication defective herpes simplex virus vectors encoding genes of glutamic acid decarboxylase, the γ-aminobutyric acid synthesis enzyme, could suppress detrusor-sphincter dyssynergia in rats with spinal cord injury.Materials and Methods: One week after spinalization herpes simplex virus vectors expressing glutamic acid decarboxylase and green fluorescent protein were injected into the bladder wall. Spinal cord injured rats without herpes simplex virus injection (sham treated) and those injected with LacZ encoding herpes simplex virus vectors served as controls. Three weeks after viral injection we simultaneously recorded urethral and intravesical pressure in awake rats.Results: In the glutamic acid decarboxylase group the urethral pressure increase during bladder contraction was significantly decreased by 77% to 79% compared with that in the sham treated and LacZ groups. Bladder activity and urethral baseline pressure did not differ among the 3 groups. Intrathecal application of the γ-aminobutyric acid-A receptor antagonist bicuculline almost completely reversed the decrease in the urethral pressure increase during bladder contractions while intrathecal saclofen (Tocris Cookson, Ellisville, Missouri), a γ-aminobutyric acid-B receptor antagonist, partially reversed it. In the glutamic acid decarboxylase group the mRNA of glutamic acid decarboxylase 67 was significantly increased in L6-S1 dorsal root ganglia, which is where bladder afferents originate, compared with that in the LacZ group.Conclusions: Herpes simplex virus based glutamic acid decarboxylase gene transfer to bladder afferent pathway may represent a novel approach to detrusor-sphincter dyssynergia in cases of spinal cord injury.

Quantitative Evaluation of High Power Effect on 532 nm Laser Vaporization of Bovine Prostate In Vitro

Hyun Wook Kang, Yihlih Steven Peng, Douglas Stinson — 2010-07-21

Purpose: We investigated the effect of 120 to 200 W high power levels on in vitro vaporization of bovine prostate using a custom-made 532 nm lithium triborate laser system.Materials and Methods: Light (532 nm) delivered through a newly designed 750 μm core diameter side firing prototype fiber vaporized 114 bovine prostate tissue specimens in saline at 20C using a 2-dimensional scanning system. Various conditions were tested, including 120 to 200 W power, 1 to 5 mm working distance and 2 to 8 mm per second treatment speed.Results: Regardless of treatment speed 180 W was the optimal power to maximize tissue vaporization efficiency by removing 80% more tissue than at 120 W. At 120 and 180 W laser light vaporized tissue more efficiently at a 4 mm per second treatment speed and vaporized equally efficiently at up to 3 mm working distance. At the slowest treatment speed the mean thickness of the coagulation zone at 180 W was 20% thicker than at 120 W (1.31 vs 1.09 mm) but still thin, comparable to previous findings of 1 to 2 mm.Conclusions: In vitro the 532 nm lithium triborate laser showed that 180 W is the optimal power to maximize tissue vaporization efficiency with enhanced coagulation characteristics. These desirable outcomes must be validated in vivo.

Uro-Science

Anthony Atala — 2010-07-21

E. L. Richman, M. J. Stampfer, A. Paciorek, J. M. Broering, P. R. Carroll and J. M. Chan Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts

Urolithiasis/Endourology

Dean Assimos — 2010-07-22

E. Gaffney-Stomberg, B. H. Sun, C. E. Cucchi, C. A. Simpson, C. Gundberg, J. E. Kerstetter and K. L. Insogna Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut

Benign Prostatic Hyperplasia

Steven A. Kaplan — 2010-07-22

A. Vikram, G. B. Jena and P. Ramarao Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Mohali, Punjab, India

Re: Effect of Reclassification on the Incidence of Benign and Malignant Renal Tumors: T. A. Skolarus, M. F. Serrano, R. L. Grubb, III, M. D. Katz, T. L. Bullock, F. Gao, P. A. Humphrey and A. S. Kibel J Urol 2010; 183: 455–458

Bayram Dogan, Ziya Akbulut, Abdullah Erdem Canda, Mevlana Derya Balbay — 2010-07-21

According to the authors, lesions originally diagnosed as malignant tumors are increasingly being reported as oncocytomas based on the TNM classification published in 2004. Our knowledge of renal tumors suggests that most renal oncocytomas cannot be differentiated from malignant renal cell carcinoma (RCC) by clinical or radiographic means. It has been reported that fine needle aspiration of renal lesions cannot accurately distinguish oncocytoma from granular forms of conventional RCC or eosinophilic variants of chromophobe or chromophilic RCC. Additionally RCC and oncocytoma reportedly exist in the same lesion or at different locations in the same kidney in 7% to 32% of cases, reflecting another limitation of fine needle aspiration of kidney lesions. Thus, most urologists seem keen to treat these lesions with partial or radical nephrectomy. Partial nephrectomy can be performed in oncocytomas, which are suitable for nephron sparing surgery as they can be bilateral and multifocal in up to 13% of cases. Based on these data, we suggest that if oncocytoma is discovered on the pathological examination, followup and imaging of these lesions should be similar to renal cell carcinoma.

Re: Significance of Distal Ureteral Margin at Radical Cystectomy for Urothelial Carcinoma: M. K. Tollefson, M. L. Blute, S. A. Farmer and I. Frank J Urol 2010; 183: 81–86

Yi-Hsiu Huang — 2010-07-26

The authors analyzed the records of 1,397 patients who underwent radical cystectomy for nonmetastatic urothelial carcinoma. They further analyzed the connection between initial and sequential section of distal ureteral margins and followup clinicopathological features, including survival and upper tract recurrence. They concluded that patients with positive ureteral margins at cystectomy are at increased risk for upper tract recurrence. Furthermore, patients with an initial positive ureteral margin with conversion to a negative final margin after serial sectioning are at decreased risk for upper tract disease. The importance of intraoperative frozen section analysis of the distal ureteral margin is also highlighted.

Reply by Authors

2010-07-26

We appreciate the thoughtful comments by Huang. Regarding the concern that our analysis should have focused on renal units rather than patients, the study contains data addressing concordance of the laterality of a positive margin and recurrence. We found that 18 of 28 recurrences (64%) were observed on the same side as the positive margin. However, much more importantly, while analysis based on renal units has scientific merit, risk stratification based on patients has more clinical value. The statement regarding lack of followup for the 178 patients with positive margins is inaccurate, as these patients represent the study cohort and the focus of the entire article. As reported, of the 178 patients with a positive initial ureteral margin 28 (16%) experienced upper tract recurrence. Finally regarding the type of diversion, the majority of patients (84.5%) underwent either ileal or colon conduit, as this cohort represents our experience from 1980 to 1998. The type of diversion did not impact the development of upper tract carcinoma.

Re: A Multi-Institutional Evaluation of Active Surveillance for Low Risk Prostate Cancer: S. E. Eggener, A. Mueller, R. K. Berglund, R. Ayyathurai, C. Soloway, M. S. Soloway, R. Abouassaly, E. A. Klein, S. J. Jones, C. Zappavigna, L. Goldenberg, P. T. Scardino, J. A. Eastham and B. Guillonneau J Urol 2009; 181: 1635–1641

B.E. Ayres, S.R.J. Bott, N.J. Barber, S.E.M. Langley, B.S.I. Montgomery — 2010-07-22

These authors report their multicenter experience of active surveillance for low risk prostate cancer. We were particularly interested in their opinions on the role of repeat prostate biopsies. They report that 19 of 157 cases were upgraded to Gleason 7 or greater at the followup biopsy, and an additional 7 failed active surveillance due to a higher volume of cancer in these biopsies. Prostate specific antigen (PSA) kinetics was not predictive of upgrading or higher volume disease. The authors believe their low rate of upgrading was due to performing restaging biopsies before enrollment in the active surveillance program, which reportedly excludes 27% of patients by allowing a more accurate diagnosis at the outset. However, the diagnostic accuracy of the biopsies is questionable because only 3 of 9 patients with Gleason 7 prostate cancer at radical prostatectomy had Gleason 7 disease on preoperative biopsies. Therefore, their low rate may actually represent persistent under sampling of the disease. It has also been reported that the detection rate for prostate cancer with repeat transrectal prostate biopsies decreases with each subsequent set, from 22% (first set) to 10% (second) to 5% (third) to 4% (fourth).

Re: Dipstick Pseudohematuria: Unnecessary Consultation and Evaluation: P. K. Rao, T. Gao, M. Pohl and J. S. Jones J Urol 2010; 183: 560–565

Edward M. Messing, Dragan Golijanin, Joy Knopf, Ralph Madeb — 2010-07-30

We applaud the authors for their study and totally agree with their attempt to reduce the number of unnecessary, costly and unpleasant/harmful evaluations that urologists perform. However, we have several concerns about the information presented.

Reply by Authors

2010-07-30

We thank Messing et al for their thoughtful comments. We offer the following responses to their questions. We designed our study based on AUA guidelines—a de facto standard of care among urologists—for the definition and management of asymptomatic microhematuria. We focused on patients presumed to have asymptomatic nonmacroscopic hematuria without any other reason for referral, to assess whether referral and/or evaluation was warranted. We used the diagnosis code 599.7 (hematuria) as our only means of identifying these patients. As expected, the majority of the 320 patients with this diagnosis code had at least 1 other reasonable cause for urological referral and, thus, did not represent the population we wanted to study. As explained in the methods section, the exclusions were applied to identify a pure population referred solely for pseudohematuria or microhematuria.

Re: Is Suppression of Hypothalamic-Pituitary-Adrenal Axis Significant During Clinical Treatment of Phimosis? F. O. Pileggi, C. E. Martinelli, Jr., M. F. G. S. Tazima, J. C. Daneluzzi and Y. A. M. V. A. Vicente J Urol 2010; 183: 2327–2331

Armando J. Lorenzo — 2010-07-30

This Letter to the Editor was submitted at the request of the Editors due to the fact that the article was released for press before the Editorial Comment was appended. The use and abuse of steroids are commonplace in medicine, and pediatric urologists are slowly becoming shareholders in the phenomenon. Pileggi et al present data on the impact of medical treatment of phimosis on the hypothalamic-pituitary axis. Although published clinical experience with this condition has not presented a worrisome picture in terms of significant adverse effects, the possible clinical implications should not be overlooked.

Reply by Authors

2010-07-30

The use and abuse of corticoids in our country are facts, and our intention was to cause a little discomfort in abusers. We agree that our study brought more questions than answers. The cutoff was based on values equivalent to the 5th percentile of saliva cortisol levels noted in normal samples from children before corticoid treatment. Our recommendation to measure the saliva before and after repeat cortisol treatment was based on the fact that cortisol levels decreased after clobetazol in 2 children without any clinical signs. We hope to continue our study and get more answers.

Re: A Prospective, Randomized Trial of Management for Asymptomatic Lower Pole Calculi: E. Yuruk, M. Binbay, E. Sari, T. Akman, E. Altinyay, M. Baykal, A. Y. Muslumanoglu and A. Tefekli J Urol 2010; 183: 1424–1428

H.I. Cimen, M.D. Balbay — 2010-07-22

In this prospective, randomized trial the authors compared extracorporeal shock wave lithotripsy (ESWL®), percutaneous nephrolithotomy (PNL) and observation for management of asymptomatic lower pole calculi in terms of stone-free rates and renal parenchymal scars. They determined that PNL had a significantly higher stone-free rate with less renal scarring than ESWL.

Re: Melamine Related Bilateral Renal Calculi in 50 Children: Single Center Experience in Clinical Diagnosis and Treatment: J. G. Wen, Z. Z. Li, H. Zhang, Y. Wang, R. F. Zhang, L. Yang, Y. Chen, J. X. Wang and S. J. Zhang J Urol 2010; 183: 1533–1538

Viroj Wiwanitkit — 2010-07-22

I read this report with great interest. The authors conclude that “melamine related urinary calculi were most often seen in patients 6 to 18 months old” and “conservative management has been sufficient in most cases.” Indeed, melamine related nephropathy following the consumption of tainted milk is an interesting emerging issue. This work generates some observations. First, a problem with breastfeeding might be suspected, since patients at 6 months should receive only breast milk, not powdered milk. Also, the calculi described in this scenario are not a chronic urological obstructive problem as seen in general cases of renal calculi. It is noteworthy that the nephropathy in children with melamine ingestion is not totally due to the calculi. Other additional processes such as fluctuation of energy and acute injury of the urological tract due to excreted melamine crystal are also reported. Focusing on the basic biochemical reaction of formation of a molecule of melamine crystal, a considerable amount of energy is expelled into the surrounding cells, which can cause thermal injury to the cells. Additionally the formed crystals are geometrically considered to be a larger, nonflexible, sharp molecule compared to the tubular shape in the pediatric population, and hence mechanical injury of the tubular system can be expected. Certainly it is not surprising that conservative management is successful, since the described underlying pathogenesis is not a pure obstructive uropathy that requires surgical removal.

Re: Can AdVance™ Transobturator Sling Suspension Cure Male Urinary Postoperative Stress Incontinence? E. B. Cornel, H. W. Elzevier and H. Putter J Urol 2010; 183: 1459–1463

Jean-Nicolas Cornu, Francois Haab — 2010-07-22

The authors present their results in 36 patients who underwent AdVance male sling for stress urinary incontinence after prostatic surgery. The reported efficacy in this study is low, with cure in 9% of patients, improvement in 45%, no effect in 36.5% and worsening symptoms in 9%. The authors have little explanation for this outcome. These data have to be compared to larger series currently available and new advances in this field.

Re: Is Type 2 Diabetes Mellitus a Predictive Factor for Incontinence After Laparoscopic Radical Prostatectomy? A Matched Pair and Multivariate Analysis: D. Teber, M. Sofikerim, M. Ates, A. S. Gözen, O. Güven, O. Sanli and J. Rassweiler J Urol 2010; 183: 1087–1091

Abdullah Erdem Canda — 2010-07-26

I read with great interest this important article demonstrating the impact of diabetes on the recovery of urinary function following laparoscopic radical prostatectomy (LRP). The authors showed that after LRP patients with type 2 diabetes mellitus (DM) needed a longer time to recover continence compared to those without diabetes, although type 2 DM did not affect overall return to continence. Duration of DM also seems to have a significant impact on post-prostatectomy incontinence.

Reply by Authors

2010-07-26

We appreciate the interest of Canda in our analysis regarding the impact of diabetes mellitus. With all of the technical and technological improvements in radical prostatectomy, such as high-definition television laparoscopy and robot assistance, the focus is on achievement of early continence. Despite refined, anatomically oriented modification of the apical dissection, including preservation of the puboprostatic collar, reconstruction of the posterior urethral plate and suspension of the dorsal vein complex, such techniques have no impact on LUT dysfunction. As mentioned by Canda, type 2 diabetes mellitus should be considered a main factor interfering with the goal of early continence. In this scenario his study attempting to stimulate interstitial cell function of the bladder may be of major importance in the future.

Joel B. Nelson — 2010-07-21

In the preface to this text the late James Glenn writes that “urology is—first and foremost—a surgical specialty.” Historically this was true. For example there was limited medical therapy for benign prostatic hyperplasia and no endoscopic or expulsive therapies for stone disease, and female incontinence was managed in an open, retropubic approach. There is now growing evidence that urologists are performing fewer open operative procedures. A recent study found that 25% of United States surgeons performed only 1 radical prostatectomy annually and approximately 80% performed fewer than 10 procedures per year. Likewise, with specialization many urologists focus their clinical and surgical practices on a well-defined area. Yet to provide care across the breadth of the field, the need for an accessible resource for surgical approach and technique is now more important than ever. The 7th edition of Glenn's Urologic Surgery provides such a resource.

The Journal of Urology® Home Study Course 2010 Volume 183/184

2010-07-21

News and Announcements

2010-07-21

Dr. Datta G. Wagle, Main Urology Associates, 6645 Main St., Williamsville, New York 14221-5934

Editorial Board

2010-09-01