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lipoprotein (LDL) and HDL cholesterol, triglycerides], and sexual evaluation [International Index of Erectile Function (IIEF)] before and after 1 month of therapy with transdermal testosterone (5 mg/day, n ⫽ 10) or placebo along with sildenafil treatment on demand. Measurement of flow parameters by D-CDU on cavernous arteries was the primary endpoint of the study. Improvement of erectile function was assessed using the IIEF questionnaire and the Global Assessment Question (GAQ). RESULTS: One month treatment with transdermal testosterone led to a significant increase in T and FT levels (23.7 ⫹/⫺ 3.3 SD vs. 12.8 ⫹/⫺ 2.1 nmol/l and 473 ⫹/⫺ 40.2 vs. 260 ⫹/⫺ 18.1 pmol/l, P ⬍0.01, respectively). In addition testosterone administration induced a significant increase in arterial inflow to cavernous arteries measured by D-CDU (32 ⫹/⫺ 3.6 vs. 25.2 ⫹/⫺ 4 cm/s, P ⬍0.05), with no adverse effects. Also, a significant improvement in erectile function domain score at IIEF was found in the androgen but not in the placebo-treated patients (21.8 ⫹/⫺ 2.1 vs. 14.4 ⫹/⫺ 1.4, P ⬍0.05) which was associated with significant changes in the GAQ score (80% vs. 10%, P ⬍0.01). CONCLUSIONS: In patients with arteriogenic ED and low-normal androgen levels, short-term testosterone administration increases T and FT levels and improves the erectile response to sildenafil likely by increasing arterial inflow to the penis during sexual stimulation. Editorial Comment: The field of male sexual function, most notably testosterone replacement therapy, is about to undergo an explosion. There is a wealth of information available on sexual function, mood, body composition and various other parameters that appear to improve with testosterone supplementation. The article by Steidle et al is an important one in that it shows that a novel topical testosterone gel appeared to improve body composition, mood and sexual functioning in a placebo controlled trial of 406 men with hypogonadism. Interestingly, there were improvements in spontaneous erectile function, sexual desire and sexual motivation with the highest dose of 100 mg daily. This drug also improved lean body mass and decreased body fat. The study by McNicholas et al is the European counterpart of the Steidle study, and reiterates the fact that testosterone gel does indeed improve androgen levels, body composition and sexual function in men with hypogonadism. The study by Fukui et al correlates testosterone levels with carotid atherosclerosis. Men with lower free testosterone concentrations had higher intima media thickness and plaque score of the carotid arteries, suggesting that lower testosterone may be associated with atherosclerosis. It may be that individuals have a lower sense of self-esteem and lower mood with a higher degree of obesity, are predisposed toward atherosclerosis. Finally, the study by Aversa et al is extremely provocative and quite interesting. This article suggests that in men with erectile dysfunction free testosterone levels correlate directly with penile arterial inflow. Twenty patients with arteriogenic erectile dysfunction evaluated by dynamic color duplex ultrasound who did not respond to sildenafil were given transdermal testosterone vs placebo along with sildenafil on demand. The study end points were the flow parameters in the cavernous artery as assessed by repeat duplex ultrasound, as well as the IIEF questionnaire and global assessment question. Interestingly, testosterone administration induces a significant increase in arterial inflow to the cavernous arteries, as well as a significant improvement in erectile function as evidenced by an improvement in the erectile function domain score of the IIEF and an improvement in the GAQ score. This concept is a significant one in that it may be that men who have not responded well to sildenafil should have serum testosterone evaluated. If their testosterone is in the low range or in the low-normal range, then perhaps improving the testosterone levels may allow for a greater success rate with sildenafil. Allen Seftel, M.D.

UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Major Vascular Injuries in Laparoscopic Surgery G. C. ROVIARO, F. VAROLI, L. SAGUATTI, C. VERGANI, M. MACIOCCO AND A. SCARDUELLI, Department of Surgery, S. Giuseppe Hospital Fbf, A.Fa.R, University of Milan, Milan, Italy Surg Endosc, 16: 1192–1196, 2002 Permission to Publish Abstract Not Granted Editorial Comment: The authors stress the importance for all laparoscopic surgeons, regardless of experience, of being constantly vigilant with regard to major vascular injury. The relatively low incidence of 0.05% may well be a result of underreporting. The mortality rate of 8% to 17% is sobering. While the use of open Hasson placement of cannulas or the use of

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nonbladed trocars can decrease the incidence of this devastating complication, it is not entirely eliminated. The authors caution against attributing sudden collapse to a carbon dioxide embolism as this is 100-fold less common than a vascular cause. It is noteworthy that with a transumbilical approach the aortic bifurcation is below the umbilicus in more than 70% of obese patients, whereas in normal-size patients this occurs in less than 50%. The authors stress in nonobese patients use of a 45-degree caudal direction of the Veress needle and stabilization of the abdominal wall with a forceps to help avoid the aorta, which can lie as close as 2 to 3 cm beneath the umbilicus. Also, they cite using a pneumoperitoneum pressure of 25 to 30 mm Hg for placement of the first trocar. In addition, use of an endoscopic optical cannula is helpful as the layers of the abdominal wall can be directly seen as the cannula is advanced. Ralph V. Clayman, M.D. Nephrostomy Tract Tumor Seeding Following Percutaneous Manipulation of a Renal Pelvic Carcinoma Y. YAMADA, Y. KOBAYASHI, A. YAO, K. YAMANAKA, Y. TAKECHI AND K. UMEZU, Departments of Urology, Hyogo Prefectural Awaji Hospital, Hyogo and Ono Municipal Hospital, Ono, Japan Acta Urol Jpn, 48: 415– 418, 2002 We report a case of nephrostomy tract tumor seeding following percutaneous pyeloscopic manipulation of a renal pelvic carcinoma. To our knowledge, this is the second reported case of such a lesion surrounding the nephrostomy tract. Percutaneous pyeloscopic treatment carries a potential risk of local tumor spillage and implantation in the nephrostomy tract. Editorial Comment: This is only the second reported case of nephrostomy tract seeding following a percutaneous approach to upper tract transitional cell cancer. Unfortunately the authors do not supply details with regard to how large the tract was dilated or whether an Amplatz sheath was used. However, the nephrostomy tract passed directly into the calyx containing the tumor. Likewise, neither the duration nor difficulty of the procedure is presented. In general, when doing these procedures, I prefer to place the nephrostomy tube into a calyx uninvolved with the tumor and to work with an Amplatz sheath to try to minimize extravasation. I also like to end the case by instilling either thiotepa or, more recently, mitomycin C into the nephrostomy tract and collecting system. This procedure can be repeated on postoperative days 1 and 2. A second look procedure and repeat biopsies are scheduled for 2 to 3 weeks later, at which time another dose of mitomycin C can be given, and if all looks clear, the nephrostomy tube can be removed. In the literature there are more than 200 cases of percutaneous resection of upper tract transitional cell carcinoma. None report any nephrostomy tract seeding. I have to believe, even given underreporting of nephrostomy tract seeding, that the chances of this occurring are likely less than 1% and largely limited to grade III or invasive (pT2) tumors. It is certainly worth considering excision of the nephrostomy tract as much as possible whenever a patient with high grade disease who was previously treated with percutaneous therapy comes to nephroureterectomy. Ralph V. Clayman, M.D. Lateral Decubitus Position for Percutaneous Nephrolithotripsy in the Morbidly Obese or Kyphotic Patient O. N. GOFRIT, A. SHAPIRO, Y. DONCHIN, A. I. BLOOM, O. Z. SHENFELD, E. H. LANDAU AND D. PODE, Departments of Urology, Anesthesiology and Radiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel J Endourol, 16: 383–386, 2002 Background and Purpose: Morbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty. Patients and Methods: Two morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position. Results: An attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously. Conclusion: We highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.

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Editorial Comment: This is a clever solution to a difficult problem. With the patient initially in a straight lateral decubitus position the authors rotated the table toward the abdominal side and then positioned the C-arm in a complementary oblique position such that an anteroposterior view of the collecting system could be obtained. (For example if the table is rotated forward 40 degrees one way, the C-arm is placed in a 50-degree opposite oblique position.) As such, the passage of the nephrostomy needle becomes identical to what one would normally perceive with the patient completely prone. Ralph V. Clayman, M.D. Management of Failed Primary Intervention for Ureteropelvic Junction Obstruction: 12-Year, Single-Center Experience C. S. NG, A. J. YOST

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S. B. STREEM, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio

Urology, 61: 291–296, 2003 Objectives. To compare contemporary endourologic and open surgical management of failed primary intervention for ureteropelvic junction obstruction, specifically in regard to immediate and long-term results and complications. Methods. Since 1989, 48 patients have undergone management of failed primary intervention for ureteropelvic junction obstruction. Of these, 42 patients (21 females and 21 males; age range 16 to 68 years, mean age 34.9) underwent follow-up evaluations. These 42 patients constitute the present study group. The mode of secondary intervention was determined by individual upper tract anatomy, concurrent medical conditions, and informed patient preference. Secondary intervention included open operative repair (n ⫽ 20) or percutaneous (n ⫽ 11), ureteroscopic (n ⫽ 5), or retrograde cautery wire balloon (n ⫽ 6) endopyelotomy. Success was defined as symptomatic relief and improved calicectasis on radiographic evaluation at latest follow-up. Results. Follow-up ranged from 6 to 148 months (mean 47.7). Endourologic intervention was associated with a mean hospital stay of 2.3 nights and a complication rate of 13.6%. The long-term success rate of these endoscopic approaches was 59.1% overall, including a 71.4% success rate after a failed open operative procedure and a 37.5% success rate after a failed endourologic procedure. In contrast, open operative salvage was associated with a mean stay of 4.3 nights and a 15% complication rate. The success of open operative salvage was 95% overall, including 94.1% after failed endourologic intervention and 100% after failed open operative intervention. Conclusions. Endourologic intervention for failed primary management of ureteropelvic junction obstruction is associated with a short hospital stay and low rate of complications. Such intervention provides acceptable success rates in the setting of prior failed open operative intervention. However, when endourologic salvage was used for prior failed endourologic intervention, the success rates were limited. This suggests that intrinsic factors such as crossing vessels or periureteral fibrosis may play a role in limiting the utility of such procedures in this setting. In contrast, open operative salvage after any prior failed intervention for ureteropelvic junction obstruction provides excellent functional results without any increase in morbidity, with, in this contemporary series, an acceptably short hospital stay. These data should help urologists and patients make well-informed treatment decisions. Editorial Comment: “If at first you don’t succeed, try again. Then quit. There’s no use being a damn fool about it” (W.C. Fields). Early in the history of endopyelotomy this aphorism seemed applicable as several investigators reported success rates of 70% to 75% among a small series of patients undergoing repeat endopyelotomy after an initial failed endopyelotomy. However, this extensive long-term report from the Cleveland Clinic serves to refute that initial impression. In their experience if an open operation failed, either a repeat open operation or endopyelotomy appeared to work equally well. However, when endopyelotomy failed, a repeat endopyelotomy provided only a dismal 37.5% long-term success (eg symptomatic relief and improved calicectasis). Indeed, one wonders if with analogue pain scales and renal scan criteria this “success” rate would have been even lower. The bottom line appears to be that when faced with endopyelotomy failure, if not previously obtained, a spiral computerized tomographic angiogram to assess for crossing vessels is indicated. If there are no crossing vessels, function is greater than 25% and only grade 1 to 2 hydronephrosis is present, then repeat endopyelotomy might be worth a try. However, in all other circumstances open or laparoscopic pyeloplasty is recommended. In truth, at our center among all patients with ureteropelvic junction obstruction, either primary or secondary, we are now routinely obtaining a furosemide washout renal scan and a spiral computerized tomographic angiogram to assess for crossing vessels, percent function and grade of hydronephrosis. Based on these findings, an accurate assessment regarding the chance of success with each form of therapy can be provided to the patient. Ralph V. Clayman, M.D.

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Role of Dopamine in Renal Dysfunction During Laparoscopic Surgery J. PEREZ, P. TAURA, J. RUEDA, J. BALUST, T. ANGLADA, J. BELTRAN, A. M. LACY AND J. C. GARCIA-VALDECASAS, Anesthesiology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain Surg Endosc, 16: 1297–1301, 2002 Permission to Publish Abstract Not Granted Editorial Comment: In this prospective randomized study the authors attempted to overcome laparoscopic related oliguria with renal dose dopamine (2 ␮g/kg per minute) among patients undergoing laparoscopic colorectal surgery. Their results show a 6-fold greater decrease in creatinine clearance intraoperatively in the control group and failure to return to baseline values at 2 hours postoperatively. Meanwhile, the treated group had a modest intraoperative decrease in creatinine clearance and completely returned to baseline levels within 2 hours of the procedure. These are fascinating observations that might well bear repeating in urology, especially in the atmosphere of nephrectomy, either donor or radical. Ralph V. Clayman, M.D. Music Decreases Anxiety and Provides Sedation in Extracorporeal Shock Wave Lithotripsy E. YILMAZ, S. OZCAN, M. BASAR, H. BASAR, E. BATISLAM AND M. FERHAT, Departments of Urology and Anesthesiology, Kirikkale University Medical Faculty, Kirikkale, Turkey Urology, 61: 282–286, 2003 Objectives. To evaluate the efficacy of music on sedation in extracorporeal shock wave lithotripsy (ESWL) treatment to compare its anxiolytic effects with those of midazolam. Methods. Ninety-eight urolithiasis patients were randomly divided into two groups. Hemodynamic parameters, including mean arterial pressure, heart rate, respiration rate, and oxygen saturation, were recorded in all patients. In 50 patients (group 1), 2 mg of midazolam was administered intravenously 5 minutes before ESWL. In group 2 (n ⫽ 48), music chosen by the patients was listened to with a headset and continued during the treatment. The visual analog scale (0 to 100 mm), Observer’s Assessment of Alertness/Sedation Scale, State and Trait Anxiety Inventory-Trait Anxiety test, and State and Trait Anxiety Inventory-State Anxiety test were administered for the evaluation of pain, sedation level, and patient anxiety. Results. For the hemodynamic parameters, a statistically significant decrease in mean arterial pressure was noted at the end of the ESWL procedure in group 2 and in oxygen saturation from the 10th minute to the end of the treatment in group 1. Although the visual analog scale, Observer’s Assessment of Alertness/ Sedation Scale, and State and Trait Anxiety Inventory-State Anxiety test did not show statistically significant differences, the State and Trait Anxiety Inventory-Trait Anxiety score was found to be lower in the music group (group 2) than in the midazolam group (group 1). Conclusions. With the anxiolytic effects of music, ESWL can be performed more effectively with the patient in a comfortable state. Listening to music by patients during the ESWL session is a feasible and convenient alternative to sedatives and anxiolytics. Editorial Comment: In this randomized trial patients who listened to music of their own choosing during their ESWL (Dornier Medical Systems, Inc., Marietta, Georgia) treatment had a statistically significant 43% decrease in the amount of fentanyl used during therapy, despite the fact that, unlike the nonmusic group, they received no preoperative midazolam. It is interesting that the authors report a 1-minute, statistically significant decrease in operative time. Overall, this approach seems to be an inexpensive and safe substitute for the usual analgesics used during ESWL. While the authors did not address it, one wonders if the music group also had a shorter stay in the outpatient area, thereby incurring even lower expenses. Ralph V. Clayman, M.D. Radiation Protection During Percutaneous Nephrolithotomy: A New Urologic Surgery Radiation Shield R. M. YANG, T. MORGAN AND G. C. BELLMAN, Department of Urology and Office of Radiation Safety, Kaiser Permanente Medical Center, Los Angeles, California J Endourol, 16: 727–731, 2002 Background and Purpose: As endourology becomes an important part of the practice of urology, the use of fluoroscopic guidance has increased the exposure of urologists to the possibly deleterious effects of radiation. There is a need for a method of radiation protection for percutaneous nephrolithotomy (PCNL), as the exposure from radiation scatter may be significant, depending on the difficulty of establishing access. Patients and Methods: We ascertained the effectiveness of a newly modified radiation shield during PCNL. Exposure readings were taken using a thermoluminescent dose monitor placed different distances

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from the radiation source during six PCNLs. We compared the exposure readings with and without the shield. Results: The shield was able to reduce the radiation by an average of 96.1% at a distance of 25 cm and 71.2% at a distance of 50 cm from the source. Conclusion: The shield can be used as one step toward the goal of reducing surgeon radiation exposure. Other methods, such as dose-minimizing imaging protocols and adaptation of equipment optimized to reduce exposure, are also important measures in creating a safe environment for both the urologist and the patient. Editorial Comment: “Physician, heal [“protect”] thyself” (Luke 4:23). Radiation exposure is not a singular event, but rather a cumulative risk to the urological surgeon. Precautions should be taken—lead apron, thyroid shield, maximizing distance from the x-ray source, keeping the x-ray source under the table, using an x-ray machine equipped with “electronic reduction” and last image hold, and considering the use of a “shield.” The shield that the authors developed appears to be easily deployed with minimal interference with the actions of the surgeon. It was highly effective, decreasing the radiation dose by more than 70%. It is noteworthy that the average fluoroscopy time during a percutaneous procedure in their experience was 12.8 minutes. The maximum permissible radiation dose for the combined whole body is 5 rem per year. Given the stated exposure and assuming a 2-hour case time per percutaneous procedure, a urologist would only be able to do 14 cases per year before exceeding the maximum dose. In contrast, using a shield, the same urologist would be able to do more than 400 cases before exceeding the limit. Bottom line— excessive radiation exposure can be avoided. You owe it to yourself and your family to be careful. Ralph V. Clayman, M.D. Renal Cell Carcinoma: Clinical Experience and Technical Success With Radio-Frequency Ablation of 42 Tumors D. A. GERVAIS, F. J. MCGOVERN, R. S. ARELLANO, W. S. MCDOUGAL Radiology, Massachusetts General Hospital, Boston, Massachusetts

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P. R. MUELLER, Department of

Radiology, 226: 417– 424, 2003 PURPOSE: To evaluate clinical experience with percutaneous image-guided radio-frequency (RF) ablation of renal cell carcinoma (RCC) and to assess factors that may influence technical success. MATERIALS AND METHODS: Thirty-four patients who underwent RF ablation of 42 RCC tumors during a 3.5-year period were evaluated. Overlapping ablations were performed on the basis of tumor size and geometry. Technical success was defined as elimination of areas that enhanced at imaging within the entire tumor. With the exception of those patients with renal insufficiency, who were followed up with unenhanced and gadolinium-enhanced magnetic resonance imaging, patients were followed up with unenhanced and contrast material-enhanced computed tomography. Univariate analysis of the results was performed with the Fisher exact test to assess the effect of tumor size and location on technical success. P ⬍ or ⫽ .05 was considered to represent a significant difference. Complications and the management and outcomes of the complications were recorded. RESULTS: All 29 exophytic tumors (mean size, 3.2 cm; size range, 1.1–5.0 cm) were completely ablated, as were two parenchymal tumors. The remaining 11 tumors had a component in the renal sinus. For large (⬎3.0 cm) tumors, presence of a tumor component in the renal sinus was a significant negative predictor of technical success (P ⫽ .004); only five of these 11 tumors were completely treated, compared with 11 of 11 tumors without a renal sinus component. A similar analysis was not possible for small tumors because no small tumors involved the renal sinus. Four complications occurred in a total of 54 ablation sessions: one minor hemorrhage, two major hemorrhages, and one ureteral stricture. CONCLUSION: RF ablation of RCC can be successful in exophytic RCC tumors up to 5.0 cm in size. Tumors larger than 3.0 cm with a component in the renal sinus are more difficult to treat but can be ablated successfully. Editorial Comment: What are the limits of percutaneous ablative therapy? In this study 42 tumors were treated using a percutaneously placed cool tip radio frequency probe, under usually computerized tomography and rarely ultrasound guidance. Tumors in the center of the kidney had a poor result, with only 45% being successfully treated. In contrast, all exophytic tumors regardless of size (ie up to 5.3 cm) were treated with “technical” success. Among the 34 patients there were 3 major complications— hemorrhage (2) and ureteral stricture (1). Followup, as the authors note, is brief, only 6 to 12 months. The other worrisome aspect is the recent studies from the Lahey Clinic and University of Toronto, both showing incomplete tumor treatment in more than 70% of patients treated with RF ablation, albeit with a standard probe tip.1, 2 Presently, this form of therapy needs to be limited to internal review board approved investigational studies, where meticulous followup can be done. Only in this manner will the

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urological community be able to assess whether this therapy, while it can be done, should be done. Ralph V. Clayman, M.D. 1. Rendon, R. A., Kachura, J. R., Sweet, J. M., Gertner, M. R., Sherar, M. D., Robinette, M. et al: The uncertainty of radio frequency treatment of renal cell carcinoma: findings at immediate and delayed nephrectomy. J Urol, 167: 1587, 2002 2. Michaels, M. J., Rhee, H. K., Mourtzinos, A. P., Summerhayes, I. C., Silverman, M. L. and Libertino, J. A.: Incomplete renal tumor destruction using radio frequency interstitial ablation. J Urol, 168: 2406, 2002

Does Adrenal Mass Size Really Affect Safety and Effectiveness of Laparoscopic Adrenalectomy? F. PORPIGLIA, P. DESTEFANIS, C. FIORI, G. GIRAUDO, C. GARRONE, R. M. SCARPA, D. FONTANA AND M. MORINO, Divisione Universitaria di Urologia, Dipartimento di Scienze Cliniche e Biologiche, Universita` degli Studi di Torino, Ospedale San Luigi, Orbassano, and Divisione Universitaria di Urologia II and Clinica Chirurgica, Dipartimento di Discipline Medico-chirurgiche, Universita` degli Studi di Torino, Ospedale San Giovanni Battista, Turin, Italy Urology, 60: 801– 805, 2002 Objectives. To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. Methods. A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson’s correlation coefficient. Fisher’s exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results. Results. A slight correlation was observed between the size and operative time (P ⫽ 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn’s adenoma, Cushing’s adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P ⫽ 0.011), but not with the other parameters. Conclusions. Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles. Editorial Comment: The answer to the question is “No.” Indeed, among 22 adrenal masses 6 to 11 cm the only difference was a slightly longer operative time by half an hour. There were no differences in complications, hospital stay or estimated blood loss. There were 8 tumors (4 primary adrenal and 4 metastatic), all but one of which were larger than 5 cm. In one case the procedure was converted to open due to involvement of surrounding tissues. At a median followup of 19 months in the patients with malignancy there were no deaths from recurrent or metastatic adrenal cancer. It would appear that in experienced hands endoscopic oncology is also beginning to encompass the realm of adrenal malignancy. Ralph V. Clayman, M.D. Comparison of Intrarenal Pressure and Irrigant Flow During Percutaneous Nephroscopy With an Indwelling Ureteral Catheter, Ureteral Occlusion Balloon and Ureteral Access Sheath J. LANDMAN, R. VENKATESH, M. RAGAB, J. REHMAN, D. I. LEE, K. G. MORRISSEY, M. MONGA AND C. P. SUNDARAM, Division of Urology, Washington University School of Medicine, St. Louis, Missouri, and Department of Urology, University of Minnesota, Minneapolis, Minnesota Urology, 60: 584 –587, 2002 Objectives. To determine the differential effects on renal pressures and irrigation flow associated with the application of different ureteral catheters during percutaneous nephrolithotomy. Methods. Using ex vivo fresh cadaveric tissue, we established a percutaneous nephrolithotomy model. After obtaining lower pole percutaneous access, we recorded the pressure and irrigant flow measurements. Measurements were made with an empty ureter, 6F ureteral catheter, occlusion balloon catheter, and ureteral access sheaths (10/12F and 12/14F). Three 1-minute trials for each condition were recorded in each of four kidneys. Results. Ureteral catheterization with both the 10/12F and the 12/14F ureteral access sheaths resulted in significantly decreased intrarenal pressures in the pressure range tested compared with an empty ureter, a ureteral catheter, or an occlusion balloon application. Total irrigant flow for the 12/14F ureteral access sheath was significantly higher than for the empty ureter, ureteral catheter, or occlusion balloon in the entire pressure range evaluated.

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Conclusions. In this in vitro cadaveric model, application of the ureteral access sheath during percutaneous nephrolithotomy resulted in decreased intrarenal pressures and increased irrigant flow. Editorial Comment: Use of a retrograde ureteral access sheath, whether it was 12Fr or 14Fr, resulted in pressures in the renal pelvis of less than 20 cm H2O when the irrigant flowing through a 26Fr rigid nephroscope positioned in the lower pole calyx via a lower pole nephrostomy tube (30Fr Amplatz sheath) was pressurized to 300 mm Hg. In contrast, under the same irrigation conditions renal pelvis pressures exceeded 30 cm H2O when the ureter was empty, or contained a 6Fr ureteral catheter or a 7Fr occlusion balloon catheter. Once pressures exceed 20 cm H2O, pyelovenous, pyelosinus or pyelolymphatic backflow of irrigant is likely to occur. Recently Venkatesh et al have presented the clinical usefulness of an access sheath during percutaneous stone removal with regard to facilitating expulsion of small stone fragments, maintaining low intrapelvic pressure and providing retrograde access for passage of the flexible ureteroscope to enter additional stone containing calices.1 Ralph V. Clayman, M.D. 1. Venkatesh, R., Lee, D. I., Vanlangendonk, R., Sundaram, C. P. and Landman, J.: Application of the ureteral access sheath to facilitate percutaneous nephrolithotomy. J Urol, suppl., 169: 408, abstract V1865, 2003

Effect of Laparoscopy on Immune Function A. GUPTA AND D. I. WATSON, University of Adelaide Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia Br J Surg, 88: 1296 –1306, 2001 Background: Laparoscopic surgery is believed to lessen surgical trauma and so cause less disturbance of immune function. This may contribute to the rapid recovery noted after many laparoscopic operations. Preservation of both systemic and intraperitoneal immunity is particularly important in surgery for sepsis or cancer and so an understanding of the impact of laparoscopy on immune function is relevant. Methods: Literature on immunological changes following laparoscopy and open surgery was identified from Medline, along with cross-referencing from the reference lists of major articles on the subject. Results and discussion: Despite a few contradictory reports, systemic immunity appears to be better preserved after laparoscopic surgery than after open surgery. However, the local intraperitoneal immune system behaves in a particular way when exposed to carbon dioxide pneumoperitoneum; suppression of intraperitoneal cell-mediated immunity has been demonstrated in a number of studies. This feature may be clinically important and should be acknowledged when considering laparoscopic surgery in patients with malignancy or sepsis. The Theories and Realities of Port-Site Metastases: A Critical Appraisal P. ZIPRIN, P. F. RIDGWAY, D. H. PECK AND A. W. DARZI, Department of Surgical Oncology and Technology, Faculty of Medicine, Imperial College of Science Technology and Medicine, St. Mary’s Hospital, London, United Kingdom J Am Coll Surg, 195: 395– 408, 2002 No Abstract Editorial Comment: Together, these articles provide a comprehensive overview of the impact of laparoscopy on immune function and the problem of port site seeding. What becomes clear is that one must consider the development of metastatic disease on two levels—systemic and intraperitoneal. With regard to the former, laparoscopy has a beneficial impact on the immune system, causing less perturbation than open surgery with regard to smaller increase in C-reactive protein, smaller increase in interleukins (1, 6, 8 and 10), less leukocytosis, smaller decrease in leukocyte function, less impact on delayed hypersensitivity and less impairment of monocyte mediated cytotoxicity. However, the decrease in natural killer cell activity appears to be similar to that incurred after open surgery. On an intraperitoneal level the introduction of carbon dioxide in and of itself may be detrimental as there are several studies showing that exposure to high levels of carbon dioxide may indeed stimulate tumor cell growth while impairing the function of peritoneal macrophages. In contrast, helium was better tolerated. Nonetheless, while hypothetically one would reason that less impairment of immune function should lead to less systemic development of metastatic disease, this outcome has not been documented clinically. With regard to intraperitoneal metastases and trocar site implantation, it would appear that the surgeon factor is far more important than any impact on the immune system. Specifically the key factors with regard to tumor cell implantation, at either the port site or other intraperitoneal sites, appear to be direct tumor cell implantation due to the method of tumor removal

UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY

(ie not using an impermeable sack), tumor cell implantation due to instrument contamination of the port site and violation of the tumor itself during the procedure. Tumor cell aerosolization appears to have a minor role, if any. When the procedure is performed by an experienced laparoscopic surgeon, the incidence of intraperitoneal metastases during laparoscopy or open surgery decreases to equal and almost nil levels. As Whiteside wrote more than 90 years ago, it is the surgeon behind the “gun” that ultimately determines the outcome. Ralph V. Clayman, M.D. Osteopontin—A Molecule for All Seasons M. MAZZALI, T. KIPARI, V. OPHASCHAROENSUK, J. A. WESSON, R. JOHNSON AND J. HUGHES, Baylor College of Medicine, Houston, Texas, Phagocyte Laboratory, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom, Renal Division, Department of Medicine, Chiang Mai University, Chiang Mai, Thailand, and Department of Veterans Affairs, Medical Centre and Medical College of Wisconsin, Milwaukee, Wisconsin Q J Med, 95: 3–13, 2002 No Abstract Editorial Comment: Osteopontin is a 300 amino acid residue protein that is produced by myriad cells—macrophages, endothelial cells, epithelial cells and smooth muscle cells. Osteopontin impacts directly on inflammation, leukocyte recruitment, cell survival, wound repair and urinary stone formation. Regarding stone formation, its impact is marked as it favorably affects initial calcium oxalate crystal formation, crystal growth, crystal aggregation and crystal adhesion to tubular epithelial cells. It is interesting that when calcium oxalate stones form in the absence of osteopontin, the monohydrate form predominates. In the kidney osteopontin is released into the urine along the loop of Henle, in the distal convoluted tubule and at the level of the papillary epithelium. How osteopontin works to limit stone formation remains under investigation. Likewise, there are currently no pharmaceuticals available that will increase osteopontin concentrations in the urine. Ralph V. Clayman, M.D. Effect of Potassium Citrate Therapy on Stone Recurrence and Residual Fragments After Shockwave Lithotripsy in Lower Caliceal Calcium Oxalate Urolithiasis: A Randomized Controlled Trial ¨ , A. AKBAY AND S. KUPELI ¨ , Departments of Urology and Biochemistry, Faculty of Medicine, T. SOYGUR University of Ankara, Ankara, Turkey J Endourol, 16: 149 –152, 2002 Background and Purpose: To evaluate the efficacy of potassium citrate treatment in preventing stone recurrences and residual fragments after shockwave lithotripsy (SWL) for lower pole calcium oxalate urolithiasis. Patients and Methods: One hundred ten patients who underwent SWL because of lower caliceal stones and who were stone free or who had residual stone 4 weeks later were enrolled in the study. The average patient age was 41.7 years. All patients had documented simple calcium oxalate lithiasis without urinary tract infection and with normal renal morphology and function. Four weeks after SWL, patients who were stone free (N ⫽ 56) and patients who had residual stones (N ⫽ 34) were independently randomized into two subgroups that were matched for sex, age, and urinary values of citrate, calcium, and uric acid. One group was given oral potassium citrate 60 mEq per day, and the other group served as controls. Results: In patients who were stone free after SWL and receiving medical treatment, the stone recurrence rate at 12 months was 0 whereas untreated patients showed a 28.5% stone recurrence rate (P ⬍0.05). Similarly, in the residual fragment group, the medically treated patients had a significantly greater remission rate than the untreated patients (44.5 v 12.5%; P ⬍0.05). Conclusion: Potassium citrate therapy significantly alleviated calcium oxalate stone activity after SWL for lower pole stones in patients who were stone free. An important observation was the beneficial effect of medical treatment on stone activity after SWL among patients with residual calculi. Editorial Comment: Using potassium citrate (20 mEq 3 times daily) after SWL of lower pole calcium oxalate caliceal stones, the 1-year stone recurrence rate among patients stone-free at 4 weeks after SWL was 0% compared to 28.5% in the controls, and the 1-year stone-free rate among patients with residual fragments at 4 weeks after SWL was 44.5% compared to 12.5% in the controls. Indeed, among the treated patients with residual stones after therapy none had evidence of stone growth at 1 year, whereas 62.5% of the untreated residual fragment group had an increase in size of the fragments. Given that this medication is well tolerated and inexpensive

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(less than $400 per year), it would seem that this is a cost-effective therapy. Indeed, the earlier findings of Parks and Coe supporting medical therapy (ie cost savings of $2,100 per year) would seem to apply equally well to the post-SWL patient.1 Ralph V. Clayman, M.D. 1. Parks, J. H. and Coe, F. L.: The financial effects of kidney stone prevention. Kidney Int, 50: 1706, 1996

Contribution of Dietary Oxalate to Urinary Oxalate Excretion R. P. HOLMES, H. O. GOODMAN AND D. G. ASSIMOS, Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Kidney Int, 59: 270 –276, 2001 Background. The amount of oxalate excreted in urine has a significant impact on calcium oxalate supersaturation and stone formation. Dietary oxalate is believed to make only a minor (10 to 20%) contribution to the amount of oxalate excreted in urine, but the validity of the experimental observations that support this conclusion can be questioned. An understanding of the actual contribution of dietary oxalate to urinary oxalate excretion is important, as it is potentially modifiable. Methods. We varied the amount of dietary oxalate consumed by a group of adult individuals using formula diets and controlled, solid-food diets with a known oxalate content, determined by a recently developed analytical procedure. Controlled solid-food diets were consumed containing 10, 50, and 250 mg of oxalate/ 2500 kcal, as well as formula diets containing 0 and 180 mg oxalate/2500 kcal. Changes in the content of oxalate and other ions were assessed in 24-hour urine collections. Results. Urinary oxalate excretion increased as dietary oxalate intake increased. With oxalate-containing diets, the mean contribution of dietary oxalate to urinary oxalate excretion ranged from 24.4 ⫾ 15.5% on the 10 mg/2500 kcal/day diet to 41.5 ⫾ 9.1% on the 250 mg/2500 kcal/day diet, much higher than previously estimated. When the calcium content of a diet containing 250 mg of oxalate was reduced from 1002 mg to 391 mg, urinary oxalate excretion increased by a mean of 28.2 ⫾ 4.8%, and the mean dietary contribution increased to 52.6 ⫾ 8.6%. Conclusions. These results suggest that dietary oxalate makes a much greater contribution to urinary oxalate excretion than previously recognized, that dietary calcium influences the bioavailability of ingested oxalate, and that the absorption of dietary oxalate may be an important factor in calcium oxalate stone formation. Editorial Comment: This is a landmark study that could potentially impact our approach to the treatment of hyperoxaluria. The authors have shown that, contrary to prior belief, upwards of 25% to 50% of urinary oxalate is derived from the diet. By decreasing oxalate in the diet from 250 mg to 50 mg a day, oxalate excretion was decreased by 20%. Also documented in this report is the increase in oxalate excretion on a low calcium diet (increase of 34% when oral calcium load was decreased from 1,002 mg to 391 mg) and an association between hyperoxaluria and hypocitraturia. Based on these findings, albeit in nonstone forming volunteers, perhaps more effort should be expended with regard to dietary counseling in the patient with idiopathic hyperoxaluria to decrease the oral oxalate load while maintaining a normal intake of calcium products. Ralph V. Clayman, M.D. Recommended Reading: Prager, G., Heinz-Peer, G., Passler, C., Kaczirek, K., Schindl, M., Scheuba, C. et al: Surgical strategy in adrenal masses. Eur J Radiol, 41: 70, 2002. This is a thorough review of more than 30 series on adrenalectomy. The surgical strategy portion of the article is a basic overview of the various laparoscopic approaches. Rowbotham, C. and Anson, K. M.: Benign lateralizing haematuria: the impact of upper tract endoscopy. BJU Int, 88: 841, 2001. This is a thorough and well reasoned treatment of this topic—the best I have seen in ages. The authors have done an excellent job of reviewing the literature and providing the reader with extensive informative tables. A worthwhile algorithm is also part of this article. Ogan, K. and Cadeddu, J. A.: Minimally invasive management of the small renal tumor: review of laparoscopic partial nephrectomy and ablative techniques. J Endourol, 16: 635, 2002. This is a comprehensive overview of laparoscopic, needle ablative and noninvasive therapies for the small renal mass. The authors provide the reader with an extensive overview of each approach, including myriad instruments available for laparoscopic nephron sparing surgery. Smith, L. H.: The many roles of oxalate in nature. Trans Am Clin Climatol Assoc, 113: 1, 2002. This is a thoroughgoing review of the 2 carbon carboxylic acid that has been the bane of so many of our patients’ existence. The author provides valuable insights into the cause of oxalate stones and their treatment.