- Email: [email protected]
Re: Factors Associated with the Adoption of Minimally Invasive Radical Prostatectomy in the United States
LETTERS TO THE EDITOR/ERRATA
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main driver of steroidogenesis in the adrenal gland, although LH receptors are present in the adrenal androgen producing zona reticularis,10 and LH hypersecretion could potentiate adrenal androgen production (including testosterone). Long-term LH hypersecretion is not a factor in chemical castration as gonadotropins are suppressed, and this finding may explain differences in castrate testosterone concentrations between men undergoing orchiectomy and chemical castration with GnRH agonists/antagonists. Regardless of the type of androgen deprivation therapy, it is important to consider the use of agents such as lyase selective P450C17 (CYP17) inhibitors to minimize the production of adrenal androgens, which can have a role in castration resistant disease. In conclusion, while the results of this study are interesting, they will require confirmation in a larger and more homogeneous population. It is also important to consider that control of prostate cancer progression is not simply a reflection of median testosterone levels, but likely reflects dynamic changes in this hormone as well as other hormones, such as FSH. Respectfully, E. David Crawford Departments of Surgery, Urology Radiation Oncology University of Colorado Cancer Center Aurora, Colorado
Joel Eisner Product Development Viamet Pharmaceuticals, Inc.® Morrisville, North Carolina
Bo-Eric Persson Ferring Pharmaceuticals Saint-Prex, Switzerland 1. van Poppel H and Nilsson S: Testosterone surge: rationale for gonadotropin-releasing hormone blockers? Urology 2008; 71: 1001.
6. Ben-Josef E, Yang SY, Ji TH et al: Hormone-refractory prostate cancer cells express functional follicle-stimulating hormone receptor (FSHR). J Urol 1999; 161: 970.
2. Morote J, Orsola A, Planas J et al: Redefining clinically significant castration levels in patients with prostate cancer receiving continuous androgen deprivation therapy. J Urol 2007; 178: 1290.
7. Radu A, Pichon C, Camparo P et al: Expression of follicle-stimulating hormone receptor in tumor blood vessels. N Engl J Med 2010; 363: 1621.
3. Gartrell BA, Tsao CK and Galsky MD: The follicle-stimulating hormone receptor: a novel target in genitourinary malignancies. Urol Oncol, Epub ahead of print April 16, 2012.
8. Klotz L, Boccon-Gibod L, Shore ND et al: The efficacy and safety of degarelix: a 12-month, comparative, randomized, open-label, parallelgroup phase III study in patients with prostate cancer. BJU Int 2008; 102: 1531.
4. Dirnhofer S, Berger C, Hermann M et al: Coexpression of gonadotropic hormones and their corresponding FSH- and LH/CG-receptors in the human prostate. Prostate 1998; 35: 212. 5. Mariani S, Salvatori L, Basciani S et al: Expression and cellular localization of follicle-stimulating hormone receptor in normal human prostate, benign prostatic hyperplasia and prostate cancer. J Urol 2006; 175: 2072.
9. Tombal B, Miller K, Boccon-Gibod L et al: Additional analysis of the secondary end point of biochemical recurrence rate in a phase 3 trial (CS21) comparing degarelix 80 mg versus leuprolide in prostate cancer patients segmented by baseline characteristics. Eur Urol 2010; 57: 836. 10. Pabon JE, Li X, Lei ZM et al: Novel presence of luteinizing hormone/ chorionic gonadotropin receptors in human adrenal glands. J Clin Endocrinol Metab 1996; 81: 2397.
Re: Factors Associated with the Adoption of Minimally Invasive Radical Prostatectomy in the United States W. D. Ulmer, S. M. Prasad, K. J. Kowalczyk, X. Gu, C. Dodgion, S. Lipsitz, G. S. Palapattu, T. K. Choueiri and J. C. Hu J Urol 2012; 188: 775–780.
To the Editor: We read this article with great interest. The study represents a critical, in-depth contribution to the issue of factors associated with the adoption of minimally invasive radical prostatectomy (MIRP) in the United States and its application in everyday clinical practice. The authors identified 11,732 men who underwent radical prostatectomy between 2003 and 2007, and
1170
LETTERS TO THE EDITOR/ERRATA
assessed the contribution of patient, surgeon and hospital characteristics to the likelihood of MIRP vs radical retropubic prostatectomy (RRP) being performed. They concluded that patient factors contributed most to the use of MIRP vs RRP, followed by surgeon and hospital factors. Among patient specific factors (excluding race) men undergoing MIRP were more likely to be married, and to have higher education and income levels. Furthermore, they were more likely to have clinically organ confined tumors and to have obtained a second opinion from a urologist. Among surgeon and hospital specific factors greater surgeon volume, surgeon age younger than 50 years and greater number of hospital beds were associated with increased use of MIRP. The authors concluded that the majority of the identifiable variability in the use of MIRP vs RRP appears to be attributable to patient and surgeon level characteristics rather than hospital characteristics. During the last several years robot-assisted radical prostatectomy (RARP) has become profoundly popular among urologists treating localized prostate cancer. Several studies suggest the robotic approach may offer significant benefits in clinical outcomes, as well as a decrease in the number of major and minor complications.1,2 A total of 4,000 patients underwent RARP at our institution between February 2006 and April 2012, making it probably the largest center in Europe performing RARP. All perioperative and postoperative patient data were recorded prospectively in our database and retrospectively reviewed. We have also assessed the relative contribution of various patient, surgeon and hospital factors associated with the use of RARP at our institution. Like our colleagues from the United States, we noted that patients undergoing RARP at our institution are more likely to have a high education level (49% of our international patients and 41% of our patients overall vs 19% to 28% of the 50 to 75-year age group in Germany). Race has no influence, but migration status does (about 3.5% of the population in Germany has a Turkish migration background, compared to only 1.1% of our patients). In conclusion, similar patient factors to those in the United States seem to be associated with adoption of MIRP and especially RARP in Europe. Respectfully, Jorn H. Witt, Vahudin Zugor and Apostolos P. Labanaris Department of Urology Pediatric Urology Prostate Center Northwest St. Antonius Hospital Gronau, Germany e-mail: [email protected] 1. Smith JA Jr, Chan RC, Chang SS et al: A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol 2007; 178: 2385. 2. Berryhill R Jr, Jhaveri J, Yadav R et al: Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology 2008; 72: 15.
Re: “Snodgraft” Technique for the Treatment of Primary Distal Hypospadias: Pushing the Envelope M. S. Silay, H. Sirin, A. Tepeler, T. Karatag, A. Armagan, K. Horasanli and C. Miroglu J Urol 2012; 188: 938 –942.
To the Editor: This article is a valuable addition to the literature. The authors are to be congratulated for obtaining uroflow studies in 40% of the patients. With a relatively short followup of 30 months the results are promising. We hope the authors will maintain their database and reexamine the patients after puberty, and report the results. It also would have been interesting to compare patients who underwent an inlay graft to those who did not because they had previously been circumcised. We were disturbed by the accompanying editorial comment by Snodgrass, objecting that his report describing more than 400 cases of the tubularized incised plate (TIP) technique was not cited.1 The authors may have had good reason not to cite the study. Although Snodgrass reported rather extraordinarily good results, it is noteworthy that 1) 23% of the cases had no followup, 2) although the series spanned a 10-year period, the mean followup was only 8.2 months and
1169
main driver of steroidogenesis in the adrenal gland, although LH receptors are present in the adrenal androgen producing zona reticularis,10 and LH hypersecretion could potentiate adrenal androgen production (including testosterone). Long-term LH hypersecretion is not a factor in chemical castration as gonadotropins are suppressed, and this finding may explain differences in castrate testosterone concentrations between men undergoing orchiectomy and chemical castration with GnRH agonists/antagonists. Regardless of the type of androgen deprivation therapy, it is important to consider the use of agents such as lyase selective P450C17 (CYP17) inhibitors to minimize the production of adrenal androgens, which can have a role in castration resistant disease. In conclusion, while the results of this study are interesting, they will require confirmation in a larger and more homogeneous population. It is also important to consider that control of prostate cancer progression is not simply a reflection of median testosterone levels, but likely reflects dynamic changes in this hormone as well as other hormones, such as FSH. Respectfully, E. David Crawford Departments of Surgery, Urology Radiation Oncology University of Colorado Cancer Center Aurora, Colorado
Joel Eisner Product Development Viamet Pharmaceuticals, Inc.® Morrisville, North Carolina
Bo-Eric Persson Ferring Pharmaceuticals Saint-Prex, Switzerland 1. van Poppel H and Nilsson S: Testosterone surge: rationale for gonadotropin-releasing hormone blockers? Urology 2008; 71: 1001.
6. Ben-Josef E, Yang SY, Ji TH et al: Hormone-refractory prostate cancer cells express functional follicle-stimulating hormone receptor (FSHR). J Urol 1999; 161: 970.
2. Morote J, Orsola A, Planas J et al: Redefining clinically significant castration levels in patients with prostate cancer receiving continuous androgen deprivation therapy. J Urol 2007; 178: 1290.
7. Radu A, Pichon C, Camparo P et al: Expression of follicle-stimulating hormone receptor in tumor blood vessels. N Engl J Med 2010; 363: 1621.
3. Gartrell BA, Tsao CK and Galsky MD: The follicle-stimulating hormone receptor: a novel target in genitourinary malignancies. Urol Oncol, Epub ahead of print April 16, 2012.
8. Klotz L, Boccon-Gibod L, Shore ND et al: The efficacy and safety of degarelix: a 12-month, comparative, randomized, open-label, parallelgroup phase III study in patients with prostate cancer. BJU Int 2008; 102: 1531.
4. Dirnhofer S, Berger C, Hermann M et al: Coexpression of gonadotropic hormones and their corresponding FSH- and LH/CG-receptors in the human prostate. Prostate 1998; 35: 212. 5. Mariani S, Salvatori L, Basciani S et al: Expression and cellular localization of follicle-stimulating hormone receptor in normal human prostate, benign prostatic hyperplasia and prostate cancer. J Urol 2006; 175: 2072.
9. Tombal B, Miller K, Boccon-Gibod L et al: Additional analysis of the secondary end point of biochemical recurrence rate in a phase 3 trial (CS21) comparing degarelix 80 mg versus leuprolide in prostate cancer patients segmented by baseline characteristics. Eur Urol 2010; 57: 836. 10. Pabon JE, Li X, Lei ZM et al: Novel presence of luteinizing hormone/ chorionic gonadotropin receptors in human adrenal glands. J Clin Endocrinol Metab 1996; 81: 2397.
Re: Factors Associated with the Adoption of Minimally Invasive Radical Prostatectomy in the United States W. D. Ulmer, S. M. Prasad, K. J. Kowalczyk, X. Gu, C. Dodgion, S. Lipsitz, G. S. Palapattu, T. K. Choueiri and J. C. Hu J Urol 2012; 188: 775–780.
To the Editor: We read this article with great interest. The study represents a critical, in-depth contribution to the issue of factors associated with the adoption of minimally invasive radical prostatectomy (MIRP) in the United States and its application in everyday clinical practice. The authors identified 11,732 men who underwent radical prostatectomy between 2003 and 2007, and
1170
LETTERS TO THE EDITOR/ERRATA
assessed the contribution of patient, surgeon and hospital characteristics to the likelihood of MIRP vs radical retropubic prostatectomy (RRP) being performed. They concluded that patient factors contributed most to the use of MIRP vs RRP, followed by surgeon and hospital factors. Among patient specific factors (excluding race) men undergoing MIRP were more likely to be married, and to have higher education and income levels. Furthermore, they were more likely to have clinically organ confined tumors and to have obtained a second opinion from a urologist. Among surgeon and hospital specific factors greater surgeon volume, surgeon age younger than 50 years and greater number of hospital beds were associated with increased use of MIRP. The authors concluded that the majority of the identifiable variability in the use of MIRP vs RRP appears to be attributable to patient and surgeon level characteristics rather than hospital characteristics. During the last several years robot-assisted radical prostatectomy (RARP) has become profoundly popular among urologists treating localized prostate cancer. Several studies suggest the robotic approach may offer significant benefits in clinical outcomes, as well as a decrease in the number of major and minor complications.1,2 A total of 4,000 patients underwent RARP at our institution between February 2006 and April 2012, making it probably the largest center in Europe performing RARP. All perioperative and postoperative patient data were recorded prospectively in our database and retrospectively reviewed. We have also assessed the relative contribution of various patient, surgeon and hospital factors associated with the use of RARP at our institution. Like our colleagues from the United States, we noted that patients undergoing RARP at our institution are more likely to have a high education level (49% of our international patients and 41% of our patients overall vs 19% to 28% of the 50 to 75-year age group in Germany). Race has no influence, but migration status does (about 3.5% of the population in Germany has a Turkish migration background, compared to only 1.1% of our patients). In conclusion, similar patient factors to those in the United States seem to be associated with adoption of MIRP and especially RARP in Europe. Respectfully, Jorn H. Witt, Vahudin Zugor and Apostolos P. Labanaris Department of Urology Pediatric Urology Prostate Center Northwest St. Antonius Hospital Gronau, Germany e-mail: [email protected] 1. Smith JA Jr, Chan RC, Chang SS et al: A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol 2007; 178: 2385. 2. Berryhill R Jr, Jhaveri J, Yadav R et al: Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology 2008; 72: 15.
Re: “Snodgraft” Technique for the Treatment of Primary Distal Hypospadias: Pushing the Envelope M. S. Silay, H. Sirin, A. Tepeler, T. Karatag, A. Armagan, K. Horasanli and C. Miroglu J Urol 2012; 188: 938 –942.
To the Editor: This article is a valuable addition to the literature. The authors are to be congratulated for obtaining uroflow studies in 40% of the patients. With a relatively short followup of 30 months the results are promising. We hope the authors will maintain their database and reexamine the patients after puberty, and report the results. It also would have been interesting to compare patients who underwent an inlay graft to those who did not because they had previously been circumcised. We were disturbed by the accompanying editorial comment by Snodgrass, objecting that his report describing more than 400 cases of the tubularized incised plate (TIP) technique was not cited.1 The authors may have had good reason not to cite the study. Although Snodgrass reported rather extraordinarily good results, it is noteworthy that 1) 23% of the cases had no followup, 2) although the series spanned a 10-year period, the mean followup was only 8.2 months and