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2007 Best of the Rest in Urological Survey
2007 Best of the Rest in Urological Survey The goal of the 18 editors of the Urological Survey Section is to provide readers with brief reviews of articles on their areas of expertise which have been published in journals other than The Journal of Urology®. This effort benefits editors and readers alike as it pushes the former to always be up-to-date in his/her field of expertise and assures that by reading The Journal the latter are kept abreast of the latest information in all areas of urology across the breadth of urology journals. To be sure, while publications are many, the actual advance of our specialty through new knowledge is slow and many times real progress is recognized only after a temporal perspective has been gained. To this end, the editors of the Survey Section, with the approval and encouragement of Dr. Martin I. Resnick, agreed to provide a year-end summary as warranted of what they perceive as the most important advances in their field based on their literature searches throughout the year. Ralph V. Clayman, M.D. Section Editor
UROLOGICAL ONCOLOGY: RENAL, URETERAL AND RETROPERITONEAL TUMORS Sorafenib in Advanced Clear-Cell Renal-Cell Carcinoma B. Escudier, T. Eisen, W. M. Stadler, C. Szczylik, S. Oudard, M. Siebels, S. Negrier, C. Chevreau, E. Solska, A. A. Desai, F. Rolland, T. Demkow, T. E. Hutson, M. Gore, S. Freeman, B. Schwartz, M. Shan, R. Simantov and R. M. Bukowski; TARGET Study Group, Department of Medicine, Institut Gustave Roussy, Villejuif, France N Engl J Med 2007; 356: 125–134. Abstract printed in J Urol 2007; 178: 456 Editorial Comment: Renal cell carcinoma has been well categorized on a molecular basis. As more understanding is gained on the molecular mechanisms of renal cell carcinoma it is possible to try and block progression of cancer. Sorafenib is a new agent that inhibits proangiogenic kinases and, therefore, may help disrupt tumor vasculature. Other new agents such as an antagonist of vascular endothelial growth factor or its receptor inhibitors are also being used as new forms of treatment for metastatic renal cell carcinoma. Although the positive responses are real they have typically been measured in months. These advances are important in the development of new strategies for the treatment of renal cell carcinoma.
Thrombocytosis as a Prognostic Factor for Survival in Patients With Metastatic Renal Cell Carcinoma R. Suppiah, P. E. Shaheen, P. Elson, S. A. Misbah, L. Wood, R. J. Motzer, S. Negrier, S. W. Andresen and R. M. Bukowski, Department of Hematology and Oncology, Cleveland Clinic Foundation, Taussig Cancer Center, Cleveland, Ohio Cancer 2006; 107: 1793–1800. Abstract printed in J Urol 2007; 178: 819
Genetic Variation in Platelet Integrin ␣IIb3 (GPIIb/IIIa) and the Metastatic Potential of Renal Cell Carcinoma J. P. Kallio, J. Mikkelsson, T. L. Tammela, P. J. Karhunen and P. Kellokumpu-Lehtinen, Department of Urology, Tampere University Hosital, Tampere, Finland BJU Int 2006; 98: 201–204. Abstract printed in J Urol 2007; 177: 489 0022-5347/07/1786-2239/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
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Vol. 178, 2239-2245, December 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.09.009
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BEST IN UROLOGICAL SURVEY Editorial Comment: Thrombocytosis in patients with renal cell carcinoma has been associated with a significantly shorter survival in multiple studies. Cancer specific death rate has been markedly higher in patients with thrombocytosis. Platelets have the capability of enhancing sequestration, adherence and penetration of malignant cells through endothelial walls. In the second study by Kallio et al possessing 1 or 2 specific alleles appeared to be associated with greater platelet aggregation. Patients had a higher incidence of metastatic disease, and so the platelet fibrinogen receptor appears to be associated with a higher risk of metastatic disease. A precisely targeted monoclonal antibody may provide possible treatment in the future.
Cancers as Wounds That Do Not Heal: Differences and Similarities Between Renal Regeneration/Repair and Renal Cell Carcinoma J. Riss, C. Khanna, S. Koo, G. V. Chandramouli, H. H. Yang, Y. Hu, D. E. Kleiner, A. Rosenwald, C. F. Schaefer, S. A. Ben-Sasson, L. Yang, J. Powell, D. W. Kane, R. A. Star, O. Aprelikova, K. Bauer, J. R. Vasselli, J. K. Maranchie, K. W. Kohn, K. H. Buetow, W. M. Linehan, J. N. Weinstein, M. P. Lee, R. D. Klausner and J. C. Barrett, Laboratory of Biosystems and Cancer, Comparative Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Cancer Res 2006; 66: 7216 –7224. Abstract printed in J Urol 2007; 177: 1733 Editorial Comment: A novel way to study genetic changes in cancer is reported. Differences and similarities between renal generation/repair genes and renal cell carcinoma were studied. Only 23% of genes were discordant. The discordant gene pool included von Hippel-Lindau, hypoxia, insulin growth factor and p53 genes. Morphogenesis genes appeared to be more commonly seen in a discordant process. This study reveals 2 distinctive qualitative gene expression signatures, a concordant signature and discordant signature, which can help elucidate basic mechanisms of the evolution of renal cell carcinoma. Fray F. Marshall, M.D.
INFECTION AND INFLAMMATION OF THE GENITOURINARY TRACT
Catastrophizing and Pain-Contingent Rest Predict Patient Adjustment in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome D. A. Tripp, J. C. Nickel, Y. Wang, M. S. Litwin, M. McNaughton-Collins, J. R. Landis, R. B. Alexander, A. J. Schaeffer, M. P. O’Leary, M. A. Pontari, J. E. Fowler, Jr., L. M. Nyberg and J. W. Kusek; National Institutes of Health-Chronic Prostatitis Collaborative Research Network (NIH-CPCRN) Study Group, Department of Psychology, Anesthesiology and Urology, Queen’s University, Kingston, Ontario, Canada J Pain 2006; 7: 697–708. Abstract printed in J Urol 2007; 178: 157 Editorial Comment: Catastrophizing is the process by which people either magnify the negative or minimize the positive. They usually do both. It has been associated with decreased quality of life and pain disability associated with numerous pain syndromes. The trait has even been associated with a shortened of life span. It represents a serious road block to recovery since the slightest setback is seen as catastrophic and a reason to stop therapy and get off the sometimes long road to recovery. It is more often practiced by women than men and is even seen in children. Cognitive therapy has been shown to decrease catastrophizing by making the patient
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more aware of this destructive pattern and learning ways to control unproductive thoughts and behaviors. In this article catastrophizing was a strong predictor of overall pain scores in men with chronic prostatitis/chronic pelvic pain syndrome. Men and women who exhibit catastrophic thinking about urological pain should be strongly recommended to see a psychologist familiar with treating pain patients. Many are reluctant, but I try to point out that it may take a long time to help the pain and in the meantime they can get help with coping with the pain and improving their life. Richard E. Berger, M.D.
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY
Urolithiasis: 2007 Dietary Therapy in Idiopathic Nephrolithiasis L. Borghi, T. Meschi, U. Maggiore and B. Prati, Dipartimento di Scienze Cliniche, Universita di Parma, Parma, Italy Nutr Rev 2006; 64: 301–312. Abstract printed in J Urol 2007; 177: 1366
Relationship and Interaction Between Sodium and Potassium R. C. Morris, Jr., O. Schmidlin, L. A. Frassetto and A. Sebastian, Department of Medicine, University of California at San Francisco, San Francisco, California J Am Coll Nutr, suppl., 2006; 25: 262S–270S. Abstract printed in J Urol 2007; 177: 2193
Causes of Hypocitraturia in Recurrent Calcium Stone Formers: Focusing on Urinary Potassium Excretion S. Domrongkitchaiporn, W. Stitchantrakul and W. Kochakarn, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Am J Kidney Dis 2006; 48: 546 –554. Abstract printed in J Urol 2007; 177: 1792 Editorial Comment: In urolithiasis the urologist continues to be the primary purveyor of care, as he/she is able to diagnose, medically treat and surgically handle all problems in the stone former. In this regard, during the last year several helpful articles on the prevention of stone disease were published. While the recommendations for a urine volume of 2 liters or greater, preservation of a normal calcium diet (1,200 mg per day) and a low animal protein diet remain a constant theme, the adherence to a low sodium diet (2 gm or less) and maintenance of a normal serum potassium are also stressed. In the stone former a diet high in sodium chloride doubles the obligatory loss of calcium in the urine. The rationale for the negative effects of sodium chloride and the positive impact of potassium bicarbonate are clearly discussed in the article by Morris et al. While sodium chloride is poorly handled by the human body, bringing with it hypertension and hypercalciuria, potassium bicarbonate provides protection from stone disease by normalizing levels of citrate and calcium in the urine, hence the recommendation, to correct any hypokalemic state in the stone former.
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Endourology: 2007 Laparoscopic Pyeloplasty: Evolution of a New Gold Standard D. A. Moon, M. A. El-Shazly, C. M. Chang, T. R. Gianduzzo and C. G. Eden, Department of Urology, North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom Urology 2006; 67: 932–936.
Antegrade Versus Retrograde Endopyelotomy for Pelvi-Ureteric Junction (PUJ) Obstruction A. Minervini, K. Davenport, F. X. Keeley, Jr. and A. G. Timoney, Department of Urology, University of Florence, Careggi Hospital, Florence, Italy Eur Urol 2006; 49: 536 –543. Abstracts printed in J Urol 2007; 177: 988 Editorial Comment: Is the end of endopyelotomy nigh? The 4 “E’s” of procedural evaluation come into play here as the efficiency, economy and equanimity factors favor endopyelotomy, in particular a retrograde holmium laser approach, whereas effectiveness clearly favors laparoscopic pyeloplasty. Several articles have addressed these procedures recently.1 The views of Stein et al appear to provide an algorithm for maximizing cost-effectiveness. To wit, the keystone of their evaluation is the renal scan. Laparoscopic pyeloplasty is indicated if function is less than 20%, nephrectomy is recommended, or if function is 20% to 30% in any renal unit with high grade hydronephrosis. Only among patients with function greater than 30% and low grade hydronephrosis is a spiral computerized tomography angiogram with 3D reconstruction suggested to assess for a crossing vessel. If there is a crossing vessel, then a laparoscopic pyeloplasty is done, whereas in the absence of a crossing vessel a retrograde endopyelotomy (or in their hands, an antegrade endopyeloplasty) is performed. As Gettman et al previously noted, despite the 10% to 15% inferior success of retrograde endopyelotomy, a failed endopyelotomy followed by a pyeloplasty is still more cost-effective than performing pyeloplasty in everyone.2 Again, the importance of the renal scan for determining the method of treatment and for followup cannot be overemphasized. Likewise, the importance of analog pain scales needs to be stressed. It is only through the use of objective validated tests for the functional and subjective outcomes of the treatment of ureteropelvic junction that we, as a specialty, can properly assess old and new procedures. The days of the “it looks good to me” excretory urogram and the anecdotal office visit assessment of “no pain” need to be abandoned. Today, we can do better and we must do better for our patients and our specialty. Is the end of endopyelotomy nigh? No. 1. Stein RJ, Gill IS and Desai MM: Comparison of surgical approaches to ureteropelvic junction obstruction: endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty. Curr Urol Rep 2007; 8: 140. 2. Gettman MT, Lotan Y, Roerhborn CG, Cadeddu JA and Pearle MS: Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis. J Urol 2003; 169: 228.
Laparoscopy: 2007 Efficacy and Safety of En Bloc Ligation of Renal Hilum During Laparoscopic Nephrectomy E. Kouba, A. M. Smith, J. E. Derksen, K. Gunn, E. Wallen and R. S. Pruthi, Division of Urologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Urology 2007; 69: 226 –229. Abstract printed in J Urol 2007; 178: 000
BEST IN UROLOGICAL SURVEY Editorial Comment: My vote for the most important practical point for laparoscopic surgery in 2007 goes to Kouba et al, who corroborated the safety of en bloc hilar stapling for laparoscopic nephrectomy. In their series this simple maneuver decreased blood loss and operative time. To date, among their patients as well as patients from an earlier series reported by Rapp et al1 postoperative arteriovenous malformations have yet to be noted. 1. Rapp DE, Orvieto MA, Gerber GS, Johnston WK, Wolf JS and Shalhav AL: En bloc stapling of renal hilum during laparoscopic nephrectomy and nephroureterectomy. Urology 2004; 64: 655.
New Technology: 2007 Minimally Invasive Nephron-Sparing Surgery (MINSS) for Renal Tumours. Part I: Laparoscopic Partial Nephrectomy M. Aron and I. S. Gill, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Eur Urol 2007; 51: 337–347.
Current Status of Minimally Invasive Ablative Techniques in the Treatment of Small Renal Tumours V. Mouraviev, S. Joniau, H. Van Poppel and T. J. Polascik, Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina Eur Urol 2007; 51: 328 –336. Abstracts printed in J Urol 2007; 178: 822– 823
Minimally Invasive Nephron-Sparing Surgery (MINSS) for Renal Tumours. Part II: Probe Ablative Therapy M. Aron and I. S. Gill, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Eur Urol 2007; 51: 348 –357. Abstract printed in J Urol 2007; 178: 823 Editorial Comment: While laparoscopic robotic prostatectomy continues to gain momentum, the area, in my mind, of greatest change has been in the treatment of the small renal mass. The challenge of laparoscopic partial nephrectomy lies in the realization that the procedure can be performed safely only in the hands of the few and, in this regard, the article by Aron and Gill is quite sobering. Despite their vast and varied laparoscopic experience, among their initial 200 laparoscopic partial nephrectomies/wedge excisions the hemorrhage rate was 9.5% and the urine extravasation rate was 4.5%, with an overall complication rate of 33%. While the authors are quick to point out that these problems have markedly decreased in their subsequent 200 cases, what is clear to me is that few surgeons in the world will have a sufficient volume of small renal masses to proceed through such a voluminous laparoscopic “learning curve.” I believe that for the most part laparoscopic partial nephrectomy is going to give way to needle ablative therapy. Whether it be by ice or by fire (ie cryoablation or radio frequency ablation), the needle will and already is replacing the knife. Indeed, at 5-year followup local recurrence rates were 0% and 5% for cryoablation and radio frequency respectively, and Aron and Gill noted a 0% local recurrence rate in their cryoablation series out to 9 years. At our institution for nonanterior, nonhilar lesions 3 cm or smaller, percutaneous computerized tomography guided cryoablation (performed by an interventional radiologist and urologist together) has replaced the laparoscopic approach. Even some anterior lesions are being approached using methods to “float” neighboring organs or bowel away from the lesion. I would predict that in the near future we will see a situation whereby large renal masses are treated with radical nephrectomy, small renal masses are treated with image guided, percutaneous ablation and only those relatively few lesions that are too large for needle ablation but too small
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BEST IN UROLOGICAL SURVEY for nephrectomy (ie 4 to 7 cm) with a favorable position in the kidney (ie nonhilar) will be treated with laparoscopic or open partial nephrectomy. Laparoscopic partial nephrectomy, like endopyelotomy, is likely to fade. Ralph V. Clayman, M.D.
MALE INFERTILITY Paternal Age and Birth Defects: How Strong is the Association? Q. Yang, S. W. Wen, A. Leader, X. K. Chen, J. Lipson and M. Walker, OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Canada Hum Reprod 2007; 22: 696 –701. Abstract printed in J Urol 2007; 178: 620 Editorial Comment: An active topic for male reproductive medicine in the literature in 2007 was the effect of male age on sperm DNA. In the past the only tool available to evaluate male reproductive potential was the semen analysis, and by bulk parameters it seemed that male fertility declined slightly if at all with advancing age. Using modern molecular biological laboratory techniques, investigators in 2007 reported targeted genetic defects in sperm DNA that were correlated with increasing male age, including structural chromosomal abnormalities and DNA fragmentation. While reports of molecular DNA damage in sperm increasing with male age drew great attention in 2007, it is reasonable to ask about the real significance of these observations. Late into life men certainly father healthy children. Thus, this study by Yang et al sheds perspective on the molecular observations presented this year on sperm DNA and paternal age. They correlated birth defects to paternal age in more than 5 million subjects in a logistic regression analysis that adjusted for a number of well-known confounding factors, and found a small but significant increase in certain types of birth defects with paternal age. Importantly, the authors also observed that certain types of birth defects were more frequent with younger fathers. While it is tempting to yield to the bias of “older is worse,” the global observations of Yang et al indicate that a man’s age and sperm DNA integrity are a subtle and complicated issue.
Immune-Related Disease Before and After Vasectomy: An Epidemiological Database Study M. J. Goldacre, C. J. Wotton, V. Seagroatt and D. Yeates, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford, United Kingdom Hum Reprod 2007; 22: 1273–1278. Abstract printed in J Urol 2007; 178: 000 Editorial Comment: Vasectomy is a highly effective, relatively simple sterilization technique. For decades investigators have sporadically reported associations between vasectomy and health issues in studies that have been generally flawed, including atherosclerosis, immune disease, prostate cancer and neurological disease. However, what investigator really wants to embark on a large scale study that is most likely to show a negative association when it is much more gratifying to demonstrate a positive one? As a result, alarm bells are frequently raised in epidemiological studies that go unanswered, ringing in the ears of an increasingly nervous public. So when a well conducted negative study graces the literature that answers a previous alarm, the investigators are to be heartily commended. Goldacre et al analyzed more than 2 decades of data from several large databases from the Oxford National Health Service region, the largest of which included 2.5 million entries. These investigators compared rates of immune related diseases in men after vasectomy to those in a similar untreated reference group, and observed no long-term increased risk following vasectomy for a wide variety of immune diseases. Thanks to the efforts of Goldacre et al reported in
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2007, urologists may comfortably tell patients that vasectomy does not cause immune disease. However globally, isn’t it time we insist that if an epidemiological study raises alarm bells, it at least be well designed and conducted? Craig Niederberger, M.D.
PEDIATRIC UROLOGY Reflux Nephropathy in Kidney Transplants, Demonstrated by Dimercaptosuccinic Acid Scanning M. G. Coulthard and M. J. Keir, Department of Paediatric Nephrology, Royal Victoria Infirmary, Newcastle, United Kingdom Transplantation 2006; 82: 205–210. Abstract printed in J Urol 2007; 177: 1887 Editorial Comment: In this large group of children with a history of end stage renal disease and transplant scarring developed in the transplant more often when urinary tract infection was present and if there was vesicoureteral reflux into the graft. This report is important for 2 reasons: 1) it shows that at least in the child vesicoureteral reflux even into an adult kidney is not a benign condition, and 2) the presence of urinary tract infection plus vesicoureteral reflux appears to result in more frequent scarring and in some cases decreased glomerular filtration rate. My impression is that most transplant surgeons use a nontunneled or minimally tunneled ureteral anastomosis. It may be that reflux into the graft is better tolerated in adults who void more effectively than children. At any rate, this study carefully demonstrates the progression of scarring in these children and suggests that vesicoureteral reflux is harmful to the transplanted kidney. I now believe that a careful, posteriorly placed tunneled anastomosis from transplant ureter to bladder at the time of renal transplant may be worth the additional operative time and may result in improved graft survival in children.
The ‘Learning Curve’ in Hypospadias Surgery M. Horowitz and E. Salzhauer, Department of Urology, New York Weill Cornell Medical Center, New York, New York BJU Int 2006; 97: 593–596. Abstract printed in J Urol 2007; 177: 1520 Editorial Comment: In this article a well respected surgeon shares his success rate at intervals as he gains surgical experience with hypospadias repair. After separating the boys into 5 groups based on year of surgery, success rate improved with each interval. Patient age was similar each year except for year 1 when the boys were slightly older (and possibly more prone to fistula). Severity of the hypospadias was similar in each group. These data suggest that the main variable appeared to be the experience of the surgeon as his career progressed. The series documents the time required for a full-time pediatric urologist to become skillful in hypospadias repair. It may underscore the importance of ensuring that this operation remains in the hands of specialists who devote considerable time to genital reconstruction in children. The data are also important for surgeons at the beginning of their career. We get better with each operation. Douglas A. Canning, M.D.
UROLOGICAL ONCOLOGY: RENAL, URETERAL AND RETROPERITONEAL TUMORS Sorafenib in Advanced Clear-Cell Renal-Cell Carcinoma B. Escudier, T. Eisen, W. M. Stadler, C. Szczylik, S. Oudard, M. Siebels, S. Negrier, C. Chevreau, E. Solska, A. A. Desai, F. Rolland, T. Demkow, T. E. Hutson, M. Gore, S. Freeman, B. Schwartz, M. Shan, R. Simantov and R. M. Bukowski; TARGET Study Group, Department of Medicine, Institut Gustave Roussy, Villejuif, France N Engl J Med 2007; 356: 125–134. Abstract printed in J Urol 2007; 178: 456 Editorial Comment: Renal cell carcinoma has been well categorized on a molecular basis. As more understanding is gained on the molecular mechanisms of renal cell carcinoma it is possible to try and block progression of cancer. Sorafenib is a new agent that inhibits proangiogenic kinases and, therefore, may help disrupt tumor vasculature. Other new agents such as an antagonist of vascular endothelial growth factor or its receptor inhibitors are also being used as new forms of treatment for metastatic renal cell carcinoma. Although the positive responses are real they have typically been measured in months. These advances are important in the development of new strategies for the treatment of renal cell carcinoma.
Thrombocytosis as a Prognostic Factor for Survival in Patients With Metastatic Renal Cell Carcinoma R. Suppiah, P. E. Shaheen, P. Elson, S. A. Misbah, L. Wood, R. J. Motzer, S. Negrier, S. W. Andresen and R. M. Bukowski, Department of Hematology and Oncology, Cleveland Clinic Foundation, Taussig Cancer Center, Cleveland, Ohio Cancer 2006; 107: 1793–1800. Abstract printed in J Urol 2007; 178: 819
Genetic Variation in Platelet Integrin ␣IIb3 (GPIIb/IIIa) and the Metastatic Potential of Renal Cell Carcinoma J. P. Kallio, J. Mikkelsson, T. L. Tammela, P. J. Karhunen and P. Kellokumpu-Lehtinen, Department of Urology, Tampere University Hosital, Tampere, Finland BJU Int 2006; 98: 201–204. Abstract printed in J Urol 2007; 177: 489 0022-5347/07/1786-2239/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
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Vol. 178, 2239-2245, December 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.09.009
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BEST IN UROLOGICAL SURVEY Editorial Comment: Thrombocytosis in patients with renal cell carcinoma has been associated with a significantly shorter survival in multiple studies. Cancer specific death rate has been markedly higher in patients with thrombocytosis. Platelets have the capability of enhancing sequestration, adherence and penetration of malignant cells through endothelial walls. In the second study by Kallio et al possessing 1 or 2 specific alleles appeared to be associated with greater platelet aggregation. Patients had a higher incidence of metastatic disease, and so the platelet fibrinogen receptor appears to be associated with a higher risk of metastatic disease. A precisely targeted monoclonal antibody may provide possible treatment in the future.
Cancers as Wounds That Do Not Heal: Differences and Similarities Between Renal Regeneration/Repair and Renal Cell Carcinoma J. Riss, C. Khanna, S. Koo, G. V. Chandramouli, H. H. Yang, Y. Hu, D. E. Kleiner, A. Rosenwald, C. F. Schaefer, S. A. Ben-Sasson, L. Yang, J. Powell, D. W. Kane, R. A. Star, O. Aprelikova, K. Bauer, J. R. Vasselli, J. K. Maranchie, K. W. Kohn, K. H. Buetow, W. M. Linehan, J. N. Weinstein, M. P. Lee, R. D. Klausner and J. C. Barrett, Laboratory of Biosystems and Cancer, Comparative Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Cancer Res 2006; 66: 7216 –7224. Abstract printed in J Urol 2007; 177: 1733 Editorial Comment: A novel way to study genetic changes in cancer is reported. Differences and similarities between renal generation/repair genes and renal cell carcinoma were studied. Only 23% of genes were discordant. The discordant gene pool included von Hippel-Lindau, hypoxia, insulin growth factor and p53 genes. Morphogenesis genes appeared to be more commonly seen in a discordant process. This study reveals 2 distinctive qualitative gene expression signatures, a concordant signature and discordant signature, which can help elucidate basic mechanisms of the evolution of renal cell carcinoma. Fray F. Marshall, M.D.
INFECTION AND INFLAMMATION OF THE GENITOURINARY TRACT
Catastrophizing and Pain-Contingent Rest Predict Patient Adjustment in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome D. A. Tripp, J. C. Nickel, Y. Wang, M. S. Litwin, M. McNaughton-Collins, J. R. Landis, R. B. Alexander, A. J. Schaeffer, M. P. O’Leary, M. A. Pontari, J. E. Fowler, Jr., L. M. Nyberg and J. W. Kusek; National Institutes of Health-Chronic Prostatitis Collaborative Research Network (NIH-CPCRN) Study Group, Department of Psychology, Anesthesiology and Urology, Queen’s University, Kingston, Ontario, Canada J Pain 2006; 7: 697–708. Abstract printed in J Urol 2007; 178: 157 Editorial Comment: Catastrophizing is the process by which people either magnify the negative or minimize the positive. They usually do both. It has been associated with decreased quality of life and pain disability associated with numerous pain syndromes. The trait has even been associated with a shortened of life span. It represents a serious road block to recovery since the slightest setback is seen as catastrophic and a reason to stop therapy and get off the sometimes long road to recovery. It is more often practiced by women than men and is even seen in children. Cognitive therapy has been shown to decrease catastrophizing by making the patient
BEST IN UROLOGICAL SURVEY
2241
more aware of this destructive pattern and learning ways to control unproductive thoughts and behaviors. In this article catastrophizing was a strong predictor of overall pain scores in men with chronic prostatitis/chronic pelvic pain syndrome. Men and women who exhibit catastrophic thinking about urological pain should be strongly recommended to see a psychologist familiar with treating pain patients. Many are reluctant, but I try to point out that it may take a long time to help the pain and in the meantime they can get help with coping with the pain and improving their life. Richard E. Berger, M.D.
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY
Urolithiasis: 2007 Dietary Therapy in Idiopathic Nephrolithiasis L. Borghi, T. Meschi, U. Maggiore and B. Prati, Dipartimento di Scienze Cliniche, Universita di Parma, Parma, Italy Nutr Rev 2006; 64: 301–312. Abstract printed in J Urol 2007; 177: 1366
Relationship and Interaction Between Sodium and Potassium R. C. Morris, Jr., O. Schmidlin, L. A. Frassetto and A. Sebastian, Department of Medicine, University of California at San Francisco, San Francisco, California J Am Coll Nutr, suppl., 2006; 25: 262S–270S. Abstract printed in J Urol 2007; 177: 2193
Causes of Hypocitraturia in Recurrent Calcium Stone Formers: Focusing on Urinary Potassium Excretion S. Domrongkitchaiporn, W. Stitchantrakul and W. Kochakarn, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Am J Kidney Dis 2006; 48: 546 –554. Abstract printed in J Urol 2007; 177: 1792 Editorial Comment: In urolithiasis the urologist continues to be the primary purveyor of care, as he/she is able to diagnose, medically treat and surgically handle all problems in the stone former. In this regard, during the last year several helpful articles on the prevention of stone disease were published. While the recommendations for a urine volume of 2 liters or greater, preservation of a normal calcium diet (1,200 mg per day) and a low animal protein diet remain a constant theme, the adherence to a low sodium diet (2 gm or less) and maintenance of a normal serum potassium are also stressed. In the stone former a diet high in sodium chloride doubles the obligatory loss of calcium in the urine. The rationale for the negative effects of sodium chloride and the positive impact of potassium bicarbonate are clearly discussed in the article by Morris et al. While sodium chloride is poorly handled by the human body, bringing with it hypertension and hypercalciuria, potassium bicarbonate provides protection from stone disease by normalizing levels of citrate and calcium in the urine, hence the recommendation, to correct any hypokalemic state in the stone former.
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Endourology: 2007 Laparoscopic Pyeloplasty: Evolution of a New Gold Standard D. A. Moon, M. A. El-Shazly, C. M. Chang, T. R. Gianduzzo and C. G. Eden, Department of Urology, North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom Urology 2006; 67: 932–936.
Antegrade Versus Retrograde Endopyelotomy for Pelvi-Ureteric Junction (PUJ) Obstruction A. Minervini, K. Davenport, F. X. Keeley, Jr. and A. G. Timoney, Department of Urology, University of Florence, Careggi Hospital, Florence, Italy Eur Urol 2006; 49: 536 –543. Abstracts printed in J Urol 2007; 177: 988 Editorial Comment: Is the end of endopyelotomy nigh? The 4 “E’s” of procedural evaluation come into play here as the efficiency, economy and equanimity factors favor endopyelotomy, in particular a retrograde holmium laser approach, whereas effectiveness clearly favors laparoscopic pyeloplasty. Several articles have addressed these procedures recently.1 The views of Stein et al appear to provide an algorithm for maximizing cost-effectiveness. To wit, the keystone of their evaluation is the renal scan. Laparoscopic pyeloplasty is indicated if function is less than 20%, nephrectomy is recommended, or if function is 20% to 30% in any renal unit with high grade hydronephrosis. Only among patients with function greater than 30% and low grade hydronephrosis is a spiral computerized tomography angiogram with 3D reconstruction suggested to assess for a crossing vessel. If there is a crossing vessel, then a laparoscopic pyeloplasty is done, whereas in the absence of a crossing vessel a retrograde endopyelotomy (or in their hands, an antegrade endopyeloplasty) is performed. As Gettman et al previously noted, despite the 10% to 15% inferior success of retrograde endopyelotomy, a failed endopyelotomy followed by a pyeloplasty is still more cost-effective than performing pyeloplasty in everyone.2 Again, the importance of the renal scan for determining the method of treatment and for followup cannot be overemphasized. Likewise, the importance of analog pain scales needs to be stressed. It is only through the use of objective validated tests for the functional and subjective outcomes of the treatment of ureteropelvic junction that we, as a specialty, can properly assess old and new procedures. The days of the “it looks good to me” excretory urogram and the anecdotal office visit assessment of “no pain” need to be abandoned. Today, we can do better and we must do better for our patients and our specialty. Is the end of endopyelotomy nigh? No. 1. Stein RJ, Gill IS and Desai MM: Comparison of surgical approaches to ureteropelvic junction obstruction: endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty. Curr Urol Rep 2007; 8: 140. 2. Gettman MT, Lotan Y, Roerhborn CG, Cadeddu JA and Pearle MS: Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis. J Urol 2003; 169: 228.
Laparoscopy: 2007 Efficacy and Safety of En Bloc Ligation of Renal Hilum During Laparoscopic Nephrectomy E. Kouba, A. M. Smith, J. E. Derksen, K. Gunn, E. Wallen and R. S. Pruthi, Division of Urologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Urology 2007; 69: 226 –229. Abstract printed in J Urol 2007; 178: 000
BEST IN UROLOGICAL SURVEY Editorial Comment: My vote for the most important practical point for laparoscopic surgery in 2007 goes to Kouba et al, who corroborated the safety of en bloc hilar stapling for laparoscopic nephrectomy. In their series this simple maneuver decreased blood loss and operative time. To date, among their patients as well as patients from an earlier series reported by Rapp et al1 postoperative arteriovenous malformations have yet to be noted. 1. Rapp DE, Orvieto MA, Gerber GS, Johnston WK, Wolf JS and Shalhav AL: En bloc stapling of renal hilum during laparoscopic nephrectomy and nephroureterectomy. Urology 2004; 64: 655.
New Technology: 2007 Minimally Invasive Nephron-Sparing Surgery (MINSS) for Renal Tumours. Part I: Laparoscopic Partial Nephrectomy M. Aron and I. S. Gill, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Eur Urol 2007; 51: 337–347.
Current Status of Minimally Invasive Ablative Techniques in the Treatment of Small Renal Tumours V. Mouraviev, S. Joniau, H. Van Poppel and T. J. Polascik, Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina Eur Urol 2007; 51: 328 –336. Abstracts printed in J Urol 2007; 178: 822– 823
Minimally Invasive Nephron-Sparing Surgery (MINSS) for Renal Tumours. Part II: Probe Ablative Therapy M. Aron and I. S. Gill, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Eur Urol 2007; 51: 348 –357. Abstract printed in J Urol 2007; 178: 823 Editorial Comment: While laparoscopic robotic prostatectomy continues to gain momentum, the area, in my mind, of greatest change has been in the treatment of the small renal mass. The challenge of laparoscopic partial nephrectomy lies in the realization that the procedure can be performed safely only in the hands of the few and, in this regard, the article by Aron and Gill is quite sobering. Despite their vast and varied laparoscopic experience, among their initial 200 laparoscopic partial nephrectomies/wedge excisions the hemorrhage rate was 9.5% and the urine extravasation rate was 4.5%, with an overall complication rate of 33%. While the authors are quick to point out that these problems have markedly decreased in their subsequent 200 cases, what is clear to me is that few surgeons in the world will have a sufficient volume of small renal masses to proceed through such a voluminous laparoscopic “learning curve.” I believe that for the most part laparoscopic partial nephrectomy is going to give way to needle ablative therapy. Whether it be by ice or by fire (ie cryoablation or radio frequency ablation), the needle will and already is replacing the knife. Indeed, at 5-year followup local recurrence rates were 0% and 5% for cryoablation and radio frequency respectively, and Aron and Gill noted a 0% local recurrence rate in their cryoablation series out to 9 years. At our institution for nonanterior, nonhilar lesions 3 cm or smaller, percutaneous computerized tomography guided cryoablation (performed by an interventional radiologist and urologist together) has replaced the laparoscopic approach. Even some anterior lesions are being approached using methods to “float” neighboring organs or bowel away from the lesion. I would predict that in the near future we will see a situation whereby large renal masses are treated with radical nephrectomy, small renal masses are treated with image guided, percutaneous ablation and only those relatively few lesions that are too large for needle ablation but too small
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BEST IN UROLOGICAL SURVEY for nephrectomy (ie 4 to 7 cm) with a favorable position in the kidney (ie nonhilar) will be treated with laparoscopic or open partial nephrectomy. Laparoscopic partial nephrectomy, like endopyelotomy, is likely to fade. Ralph V. Clayman, M.D.
MALE INFERTILITY Paternal Age and Birth Defects: How Strong is the Association? Q. Yang, S. W. Wen, A. Leader, X. K. Chen, J. Lipson and M. Walker, OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Canada Hum Reprod 2007; 22: 696 –701. Abstract printed in J Urol 2007; 178: 620 Editorial Comment: An active topic for male reproductive medicine in the literature in 2007 was the effect of male age on sperm DNA. In the past the only tool available to evaluate male reproductive potential was the semen analysis, and by bulk parameters it seemed that male fertility declined slightly if at all with advancing age. Using modern molecular biological laboratory techniques, investigators in 2007 reported targeted genetic defects in sperm DNA that were correlated with increasing male age, including structural chromosomal abnormalities and DNA fragmentation. While reports of molecular DNA damage in sperm increasing with male age drew great attention in 2007, it is reasonable to ask about the real significance of these observations. Late into life men certainly father healthy children. Thus, this study by Yang et al sheds perspective on the molecular observations presented this year on sperm DNA and paternal age. They correlated birth defects to paternal age in more than 5 million subjects in a logistic regression analysis that adjusted for a number of well-known confounding factors, and found a small but significant increase in certain types of birth defects with paternal age. Importantly, the authors also observed that certain types of birth defects were more frequent with younger fathers. While it is tempting to yield to the bias of “older is worse,” the global observations of Yang et al indicate that a man’s age and sperm DNA integrity are a subtle and complicated issue.
Immune-Related Disease Before and After Vasectomy: An Epidemiological Database Study M. J. Goldacre, C. J. Wotton, V. Seagroatt and D. Yeates, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford, United Kingdom Hum Reprod 2007; 22: 1273–1278. Abstract printed in J Urol 2007; 178: 000 Editorial Comment: Vasectomy is a highly effective, relatively simple sterilization technique. For decades investigators have sporadically reported associations between vasectomy and health issues in studies that have been generally flawed, including atherosclerosis, immune disease, prostate cancer and neurological disease. However, what investigator really wants to embark on a large scale study that is most likely to show a negative association when it is much more gratifying to demonstrate a positive one? As a result, alarm bells are frequently raised in epidemiological studies that go unanswered, ringing in the ears of an increasingly nervous public. So when a well conducted negative study graces the literature that answers a previous alarm, the investigators are to be heartily commended. Goldacre et al analyzed more than 2 decades of data from several large databases from the Oxford National Health Service region, the largest of which included 2.5 million entries. These investigators compared rates of immune related diseases in men after vasectomy to those in a similar untreated reference group, and observed no long-term increased risk following vasectomy for a wide variety of immune diseases. Thanks to the efforts of Goldacre et al reported in
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2007, urologists may comfortably tell patients that vasectomy does not cause immune disease. However globally, isn’t it time we insist that if an epidemiological study raises alarm bells, it at least be well designed and conducted? Craig Niederberger, M.D.
PEDIATRIC UROLOGY Reflux Nephropathy in Kidney Transplants, Demonstrated by Dimercaptosuccinic Acid Scanning M. G. Coulthard and M. J. Keir, Department of Paediatric Nephrology, Royal Victoria Infirmary, Newcastle, United Kingdom Transplantation 2006; 82: 205–210. Abstract printed in J Urol 2007; 177: 1887 Editorial Comment: In this large group of children with a history of end stage renal disease and transplant scarring developed in the transplant more often when urinary tract infection was present and if there was vesicoureteral reflux into the graft. This report is important for 2 reasons: 1) it shows that at least in the child vesicoureteral reflux even into an adult kidney is not a benign condition, and 2) the presence of urinary tract infection plus vesicoureteral reflux appears to result in more frequent scarring and in some cases decreased glomerular filtration rate. My impression is that most transplant surgeons use a nontunneled or minimally tunneled ureteral anastomosis. It may be that reflux into the graft is better tolerated in adults who void more effectively than children. At any rate, this study carefully demonstrates the progression of scarring in these children and suggests that vesicoureteral reflux is harmful to the transplanted kidney. I now believe that a careful, posteriorly placed tunneled anastomosis from transplant ureter to bladder at the time of renal transplant may be worth the additional operative time and may result in improved graft survival in children.
The ‘Learning Curve’ in Hypospadias Surgery M. Horowitz and E. Salzhauer, Department of Urology, New York Weill Cornell Medical Center, New York, New York BJU Int 2006; 97: 593–596. Abstract printed in J Urol 2007; 177: 1520 Editorial Comment: In this article a well respected surgeon shares his success rate at intervals as he gains surgical experience with hypospadias repair. After separating the boys into 5 groups based on year of surgery, success rate improved with each interval. Patient age was similar each year except for year 1 when the boys were slightly older (and possibly more prone to fistula). Severity of the hypospadias was similar in each group. These data suggest that the main variable appeared to be the experience of the surgeon as his career progressed. The series documents the time required for a full-time pediatric urologist to become skillful in hypospadias repair. It may underscore the importance of ensuring that this operation remains in the hands of specialists who devote considerable time to genital reconstruction in children. The data are also important for surgeons at the beginning of their career. We get better with each operation. Douglas A. Canning, M.D.