What’s new in urology

What’s New in Urology Gerald H Jordan, MD, FACS, FAAP drome and interstitial cystitis. Interstitial cystitis, per se, is poorly understood and is thought to predominate in women. It was noticed that a large percentage of men, when cystoscoped for their symptoms of nonbacterial prostatitis and prostatodynia, often have the cystoscopic appearance of interstitial cystitis by NIH-NIDDK criteria. This obviously raises the possibility that, in men, interstitial cystitis masquerades as nonbacterial prostatitis/prostatodynia or chronic pelvic pain syndrome. In this study, 300 men were identified who were diagnosed with chronic pelvic pain syndrome and were examined with cystoscopy and hydrodistension; 80% were found to have glomerulations that were believed to confirm the diagnosis of interstitial cystitis. Additionally, levels of nerve growth factors, tryptase, heparinbinding epidermal growth factor, and epidermal growth factor were evaluated in postprostatic massage urine and compared with these levels in controls. In these symptomatic young men, levels of nerve growth factor and tryptase were significantly elevated in those patients versus controls; heparin-binding epidermal growth factor levels were lower. All of these findings were statistically highly significant, raising the possibility that nerve growth factor, heparin-binding epidermal growth factor, and tryptase could serve as new markers for the evaluation of such patients.2 At the University of Pittsburgh, interesting research seeks to determine if gene therapy could be potentially useful for the treatment of interstitial cystitis patients. The investigators proposed that targeted and localized expression of endogenous opioid peptide in the bladder could be useful in treating bladder pain associated with interstitial cystitis. In one report from that institution, they described a gene gun method for the transfer of precursor molecules of endogenous opioid peptide in vivo and sought to investigate its therapeutic effect in rats using an acetic acid-induced bladder hyperactivity model. They found that, indeed, the proopiomelanocortin gene can be transferred to the bladder of these rats using the gene gun and the increased secretion of endorphin seemed to suppress bladder pain in the model.3 In a second study, they investigated the effects of enkephalin gene therapy using a replication deficient herpes sim-

As with much of medicine, the quest to do more for patients, with less morbidity, dominates much of the urologic literature and discussion. This pervades not only surgical therapy, but also medical and chemotherapy. Minimally invasive techniques are being refined, and they clearly influence our thinking mechanisms. INFECTIOUS DISEASE AND CHRONIC PELVIC PAIN SYNDROME Interstitial cystitis, urethral syndrome, chronic pelvic pain syndrome, nonbacterial prostatitis, prostatodynia, and postejaculatory pain might all be different presentations of a single disease. The prevalence of these disease entities has an impact on the physician not only in the direct treatment of the diseases, but also in their relationship to other issues. A major issue for the urologist is the patient with the rising or elevated PSA, negative biopsies, and findings or symptoms compatible with prostatitis or chronic pelvic pain syndrome. A multicenter study was convened to determine if PSA or percent free PSA could be used as a marker for chronic pelvic pain syndrome or prostatitis. Another issue is whether PSA and percent free PSA values will be in the range associated with prostate cancer. In a study examining 424 patients with chronic prostatitis, etc, PSA values were compared with those from 114 age-matched asymptomatic controls. Findings showed total PSA in general was slightly higher in patients with chronic pelvic pain syndrome or prostatitis than in controls. But this slight elevation in level was not clinically significant, and although percent free PSA levels correlated with inflammation, the negative association was weak and not clinically significant. So the recommendation of the study was that male patients with chronic pelvic pain syndrome, etc, and abnormal PSA values should be evaluated for prostate cancer in accordance with current standard protocols.1 A study from France sought to determine the overlap between chronic pelvic pain synReceived June 11, 2003, Accepted June 12, 2003. From the Department of Urology, Eastern Virginia Medical School, Norfolk, VA. Correspondence address: Gerald H Jordan, MD, FACS, FAAP, Suite 100, 400 W Brambleton Ave, Norfolk, VA 23510.

© 2003 by the American College of Surgeons Published by Elsevier Inc.

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ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(03)00674-4

Vol. 197, No. 3, September 2003

Abbreviations and Acronyms

AUA BPH MTOPS Qmax

⫽ ⫽ ⫽ ⫽

American Urological Association benign prostatic hypertrophy medical therapy of prostatic symptom study maximum flow

plex virus. In that study group, the rats with induced bladder hyperactivity displayed suppressed bladder pain responses in both behavioral and functional studies. Both studies proposed the potential of interesting new treatment modalities for refractory interstitital cystitis, or visceral bladder pain syndromes such as prostatitis, prostatodynia, postejaculatory pain, orchialgia, vulvodynia, etc.4 Benign prostatic hyperplasia

The medical therapy of prostatic symptom study (MTOPS) continues to be analyzed. The goal of these analyses is to develop and refine treatment guidelines for the patient with lower urinary tract symptomatology and benign prostatic hypertrophy (BPH). In the MTOPS study, it was demonstrated that doxazosin, an alpha-blocker, and finasteride, both alone and in combination, reduced the risk of BPH clinical progression. The placebo group in the MTOPS study was analyzed to determine if the risk of BPH progression, acute urinary retention, or the need for BPH-related surgery could be predicted from commonly used baseline measures. It was found that serum PSA can predict a patient’s future risk of BPH clinical progression to urinary retention, and BPH-related invasive therapy.5 Further evaluation of the MTOPS data studied baseline prostate volume measurement and serum PSA as predictors of volume changes. Transrectal ultrasonography (TRUS) can determine total prostate volume and the transitional zone volume. These volumes were measured at baseline in the study and at the end of the study (4 to 5 years). Baseline prostate volume measurements (total prostate volume and transitional zone volume) were found to predict future growth and prostate size in men treated with placebo or doxazosin. Interestingly, men with larger glands at baseline experienced less growth over time. Serum PSA at baseline was also found to predict volume increase in both total prostate volume and transitional zone volume over time. Higher PSA values predicted greater increase in volume. If one examines the cumula-

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tive incidence of the risk of acute urinary retention, out to 4 to 5 years, patients with placebo are shown to be at the highest risk. The risk of acute urinary retention is lessened with doxazosin therapy. It is further lessened with finasteride therapy; interestingly, the combination of both compared with placebo drastically reduces the risk of acute urinary retention. But if one examines the cumulative incidence of a patient requiring BPH-related invasive therapy, the patients treated with the doxazosin have the highest risk during the time frame from baseline to 4- to 5-year analysis. Those treated with placebo have a lesser risk. Those curves cross between 4 and 5 years of therapy. The placebo group has a higher risk from baseline to 4 years of requiring BPH-related invasive therapy as compared with the doxazosin group. In the patients treated with finasteride or with the combination of doxazosin and finasteride, throughout the 4to 5-year study, the curves are virtually superimposed and are markedly less than those from patients treated with doxazosin alone or with placebo.6 A 9-year examination of Olmsted County study data showed that in men with a maximum flow during urodynamics (Qmax) of less than 12 mL per second, a postvoid residual ⬎230 mL, or a PSA ⬎1.4 have a threefold increase in the risk of acute urinary retention. In patients with an incident episode of acute urinary retention during the duration of study, 10% to 20% suffered recurrence and required transurethral resection of the prostate with that second recurrence. An interesting observation was made concerning the American Urological Association (AUA) symptom score7 and its use in predicting the risk of lower urinary tract symptomatology progression. In men with an AUA symptom score of ⬍ 7 (no symptoms or mild symptoms at baseline) but with a Qmax of less than 12 mL per second, a postvoid residual ⬎ 30 mL, or a PSA ⬎ 1.4 showed a 50% increase in the risk of lower urinary tract symptomatology progression. Interestingly, in contrast, there was no evidence of such an association among men with an AUA symptom index ⬎ 7 (moderate to severe symptoms). These observed differences in the association of depressed peak urinary flow rates and enlarged prostate and elevated serum PSA level with symptom progression in nonsymptomatic and symptomatic men will obviously deserve further consideration.8 In the Baltimore longitudinal aging study, data from the cohort were examined to determine if the absence of

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BPH might reflect that a man might be encountering a slower rate of aging. PSA has been shown to be a marker for BPH, so PSA was examined to see if an association with overall survival among men could be made. It was found that the proportion of men surviving for 20 years after age 75 was 21.6% when the rate of change PSA was 0 ng/mL/year and 9.6% when the rate of change in PSA was at the 99th percentile. So, an inverse relationship was found between rate of change from baseline of PSA and the probability of survival. PSA correlates with BPH, so BPH might progress more rapidly in men who are aging at a more rapid rate than those without a rising PSA.9 A number of studies examined the relationship of BPH, lower urinary tract symptomatology, and erectile dysfunction. Recent studies show that lower urinary tract symptoms correlate with the incidence of erectile dysfunction.10 Ejaculatory disorders are more frequent in aging men with lower urinary tract symptomatology, and, in fact, are as bothersome as the symptoms of erectile dysfunction.11 New minimally invasive therapies for BPH are developed and examined. The microwave thermotherapy devices continue to adjust computer programs. To date, the mechanism of efficacy of microwave thermotherapy continues to be elusive. At the recent AUA meeting, a system termed “fast liquid ablation system for hyperplasia” (FLASH) was reported.12 A number of abstracts reported on transurethral ethanol ablation of the prostate,13-15 and two abstracts reported on photo selective vaporization of the prostate. The FLASH liquid ablation system represents a novel high-temperature, liquid-filled flexible balloon thermotherapy system. Photoselective vaporization of the prostate uses the potassium-titanyl-phosphate photoselective laser.16,17 A number of other laser modalities continue to be used and refined. These include the interstitial laser system (Indigo Laser System, Ethicon Endo-Surgery)18 and holmium19 laser enucleation of the prostate. There also is interest in stents for relief of lower urinary tract symptomatology. In the past, stents placed for BPH were difficult to remove. The Memokath (Engineers & Doctors A/S, Ltd) prostatic stent20 and “The Spanner” (AbbeyMoor Medical, Inc) intraprostatic stent represent technologic innovation that provide easily removable stents for relief of lower urinary tract obstructive symptoms. All of these reports continue to influence the management of BPH, and will adjust the AUA BPH guidelines.21,22

J Am Coll Surg

Stone disease

Extracorporeal shockwave lithotripsy has become the “go to” management modality for the majority of renal lithiasis and ureteral lithiasis cases. A study has been convened to examine the efficacy of shockwave lithotripsy as compared with ureterorenoscopic surgery for smaller lower pole stones (arbitrarily defined as less than 1 cm in diameter). Patients with larger lower pole stones (measuring 11 mm to 25 mm) were randomized to ureterorenoscopic surgery or percutaneous nephrostolithotomy. Initial findings in this study concluded that, in patients with smaller lower pole stones, shockwave lithotripsy and ureterorenoscopic surgery gave equivalent results. Shockwave lithotripsy took less operative time to perform. Ureterorenoscopic surgery patients tended toward a better stone-free status with fewer treatments, but unfortunately suffered more complications. In the patients with larger lower pole stones, complication rates and operating room times for ureterorenoscopic surgery and percutaneous nephrostolithotomy were equivalent. Hospital stays and recovery times were shorter for patients treated with ureterorenoscopic surgery. In patients treated with percutaneous nephrostolithotomy, the stone-free rate was lower than that in the ureterorenoscopic surgery group, but the differences are not, to date, statistically significant.23 New technology in lithotripsy was reported. Dualpulse lithotripsy uses two shock sources that are confocal and opposed and that generate simultaneous converging shock pulses. At the focus where the pulses meet, pressures and cavitation intensity are doubled. This form of lithotripsy is shown to enhance stone comminution, to reduce tissue injury, and to accelerate treatment, with lower treatment times noted. Further studies in vitro are planned.24 Twenty obese stone formers were examined in another study. Obesity has been found in past studies to predispose patients to stone formation. These patients received detailed metabolic evaluation. The most common presenting metabolic abnormalities in descending order of frequency were hypercitrauria, low urine volumes, hyperuricosuria, gouty diathesis, and hyperoxaluria. Uric acid stones were identified in approximately two-thirds of patients who had stone analysis. With initiation of selective and appropriate medical therapy, stone formation in compliant patients decreased drastically.25

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Male sexual medicine

A recent study assessed the association between erectile dysfunction and cardiovascular disease. It has been proposed in recent years that erectile dysfunction can be a very sensitive hallmark of occult cardiovascular disease. In this study, diagnosed cardiovascular disease is strongly associated with erectile dysfunction particularly in younger men. Additionally, even in men who were free of overt cardiovascular disease during the course of the study, the future risk of developing cardiovascular disease was also strongly associated with erectile dysfunction.26 An additional study, in a cohort of men with diagnosed coronary artery disease, shows a direct relationship between cardiac ejection fraction and erectile function.27 Two studies examine groups of patients that were declared sildenafil failures. In these patients, morning testosterone levels were drawn and if abnormal or low normal, the patients were offered testosterone replacement using either T-Gel28 or Androgel (Unimed Pharmaceuticals, Inc),29 along with sildenafil on demand. Both studies showed improved efficacy of sildenafil in the androgen-replaced patients. Longterm safety experience from a multicenter study examining tadalafil is reported. The study consisted of patients who had previously participated in placebo controlled safety and efficacy studies. Patients were begun on a 10-mg dose. Dose escalation to 20mg could be undertaken, and in the presence of an adverse event, the dose could be reduced to 5mg. Dosing was on demand, but no more frequently than once a day. In this study, tadalafil showed good safety and tolerability. Most frequently reported treatment-emergent adverse events in decreasing order of frequency were headache, dyspepsia, infection, back pain, rhinitis, flu-like syndrome, pain, and surgical procedures. Not all obviously were believed to be directly related to the treatment medication.30 A study was undertaken in 76 men who had bilateral nerve-sparing radical prostatectomy. All of the men were determined to have normal preoperative erectile function based on the International Index of Erectile Function questionnaires and normal nocturnal penile tumescence testing. Patients were put on nightly administration of sildenafil for 7 months, immediately postoperatively. Compared with the placebo group, treated patients had a sevenfold greater return of spontaneous erections within 48 weeks after surgery.31 Another interesting study examines patient response to sildenafil after pelvic fracture injuries. The study sug-

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gests that patients who respond to sildenafil seem to have spontaneous resumption of normal erectile function more frequently than the sildenafil nonresponder population.32 In interesting study to determine the prevalence of premature ejaculation among men aged 40 years or older, 1,520 men were interviewed by phone using a random digit dialing design. Investigators sought to sample non-Hispanic white patients, non-Hispanic black patients, and Hispanic men. Findings showed that premature ejaculation is a relatively frequent problem, but men in different racial or ethnic groups define it differently. In the group surveyed, few men considered premature ejaculation a major problem and few had received treatment for it, although if effective treatment was available, approximately 45% of those interviewed would consider treatment.33 A second study looked at the treatment of premature ejaculation with the use of sildenafil plus sertraline, sertraline alone, or sildenafil alone. Ejaculatory delay has been reported with a number of antidepressant medications for reasons that are undetermined. Additionally, sildenafil has been found in older men to perhaps also be associated with a delay in ejaculation. The study group was subdivided into three groups as mentioned. In the sildenafil group and the sertraline plus sildenafil group, mean ejaculatory latency increased from a range of 0.5 to 1 minute to 5 to 6 minutes, respectively.34 A study examined the effect of internal spermatic vein ligation in a population of subfertile men. It was found that early treatment of varicocele resulted in a threefold increase in the chance of natural conception.35 Smoking has been implicated as a male reproductive toxicant. Recent studies have focused on the effects of smoking and semen parameters, reactive oxygen species, and birth defects. One study examines the effect of smoking on sperm DNA. DNA damage in sperm has been shown to correlate with fertility potential. But this study failed to show any association between smoking status and DNA damage.36 Definition of the etiology of Peyronie’s disease continues to be undertaken. An interesting study suggests that viral pathogens may be involved in the pathobiology of Peyronie’s disease. This investigation was prompted by recent evidence supporting a role for viral pathogens in the development of atherosclerosis. The pathogens specifically implicated are cytomegalovirus and Chlamydia pneumoniae.37 Another study looked at

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messenger RNA levels for genes involved in fibroblast replication, myofibroblast differentiation and collagen metabolism, tissue repair, and ossification. Previous studies suggested that these entities were affected. The current study shows that a similar pattern of alterations in the expression of certain gene families in Peyronie’s disease and Dupuytren’s contracture nodules might suggest a common pathophysiology and fibrotic tissue turnover.38 This, of course, is in line with the long noted observation of Nyberg and colleagues39 of a clinical association between Dupuytren’s contracture and Peyronie’s disease. Questions have arisen concerning the degree of curvature and the vascular status of the penis. Are patients with more severe curvature more affected from a penovascular status? In a study from New Orleans, no relationship between degree of curvature and vascular status was shown.40 The association of erectile dysfunction with Peyronie’s disease is relatively clear, but the actual nature of the association of erectile dysfunction with Peyronie’s disease remains elusive. One study looked at risk factors for systemic vascular disease such as diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, and ischemic heart disease. The impact of these factors continues to be obscure.41 In the past, the relationship of the immune phenomena to Peyronie’s disease has been investigated, with some studies supporting an immune component and others showing no relationship.42-44 A study from Brazil showed some relationship of immune factors, but its data remain insufficient to formulate a definite hypothesis.45 The use of intralesional injection for Peyronie’s disease continues to be investigated. A single blinded placebo-controlled study demonstrated clinical benefit of intralesional interferon-alpha 2B injection therapy.46 The use of electromotive drug administration with verapamil was investigated and preliminary data seem to suggest efficacy; a placebo-controlled trial is underway.47 In patients operated on with either plaque excision and grafting or plaque incision and grafting, the quest for the ideal replacement graft continues. Two studies examined different nonautologous graft materials; one study looked at human acellular dermal matrix,48 and the other examined the use of porcine small intestinal submucosal graft.49 Both studies suggested that these grafts provide good results.

J Am Coll Surg

Trauma and reconstructive surgery

The damage control philosophy of trauma management is gaining acceptance. A study from St. Louis examined a group of patients so treated. Damage control was performed for patients who were becoming acidotic, hypothermic, requiring massive transfusions, or displaying evidence of coagulopathy. Fifty-eight patients were identified from the standpoint of their urinary tract injuries. Damage control, for the urologist, entailed exteriorizing ureters, draining or packing renal fossas, and undertaking nephrectomy even in the face of a potentially salvageable kidney under other circumstances. The damage control strategy improved overall survival in this cohort.50 Several studies examined renal trauma. A study from San Francisco General Hospital looked at main renal arterial injuries or renal segmental arterial injuries. This study found that the repair of main renal artery injuries was seldom successful and could not be recommended, except in the face of bilateral injury or a single renal unit. Segmental renal artery injuries, when associated with fracture, could be managed expectantly. Segmental renal artery injuries, when associated with stab wounds, seemed to benefit from exploration and repair.51 Another interesting study examined the effect of an institutionalized policy of nonoperative management of renal injuries. In that group, the ultimate nephrectomy rate was 5%. So the authors questioned other series that advocate more aggressive therapy. Many series, at least historically, are associated with significantly higher rates of nephrectomy.52 Another series analyzed the effect of laparotomy for intraabdominal injury with regard to its effect on therapeutic decisions about associated renal trauma. It was found that the decision to explore was more important in patients with Grade IV blunt trauma and for stab wounds more severe than Grade III.53 An interesting analysis examined the patient with a short-length bulbous stricture from a cost minimization approach. Primary urethral reconstruction was compared with internal urethrotomy. The probability estimates were derived from published series with at least midterm followup. The model predicted that the treatment of the short-length bulbous stricture with primary open reconstruction is, in the long run, less costly than treatment with an initial direct vision internal urethrotomy, with a cost savings of approximately $1,300 per patient.54

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A series from the Boston Children’s Hospital reported experience with acellular collagen matrix for onlay urethral reconstruction. Their collagen matrix was obtained from cadaveric bladders. The matrix was used for urethral repair in 28 adults and 5 children with strictures and in hypospadias in seven children. The series had 4- to 7-year followup; six patients with urethral stricture had a recurrence and one patient in the hypospadias group developed a fistula. Patients were followed with cystoscopy and urine flow rates. The series suggested that further examination of this nonautologous “graft” material warrants consideration.55 Laparoscopic surgery

The use of laparoscopic exposure continues to grow. Already validated is the use of laparoscopic adrenalectomy for benign and some malignant disease, and laparoscopic nephrectomy for both benign and malignant disease.56-59 Larger and larger renal tumors are being addressed laparoscopically. Laparoscopic partial nephrectomy has proved itself to be very demanding. Development of better coagulation techniques and a variety of tissue glues and sealants have drastically improved the results of these operations. An interesting series from the Cleveland Clinic examined the use of laparoscopic partial nephrectomy in unusual situations: the horseshoe kidney, the kidney with ipsilateral renovascular disease, the kidney with two renal tumors, and the kidney with an ipsilateral renal and adrenal mass. All were performed with good efficacy and good results.60 A number of centers have examined methods to produce cold ischemia during laparoscopic surgery. Cold ischemia would allow more complex procedures and longer renal vessel clamping times. The group from Innsbruck, Austria, reported a 10year experience in laparoscopic retroperitoneal lymph node dissection. Lymph node dissections were done for both stage I and stage II nonseminomatous germ cell tumors. With experience, laparoscopic retroperitoneal lymph node dissection could be done in the postchemotherapy patient. The group reported no compromise in tumor control, no compromise in diagnostic accuracy, and significantly lower surgical morbidity.61 The Johns Hopkins Hospital reported a large longitudinal 5-year analysis of complications of abdominal urologic laparoscopic surgery. Interestingly, they found no difference in overall incidence of complica-

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tions during the 5-year period, and they attributed that to a constant flow of less experienced laparoscopic trainee surgeons along with an expansion in complexity of the laparoscopic procedures during that period. They reported a 13.2% incidence of complications. The most common intraoperative complications were vascular complications followed by bowel complications. The most common postoperative complications were neuromuscular pain, wound infection, and hematoma.62 A group from France examined the return of sexual function after laparoscopic radical prostatectomy with either unilateral or bilateral nerve sparing. They reported a 53% return of potency.63 Interestingly, other series have shown an approximate 10% potency rate after non-nerve-sparing radical prostatectomy, making us reexamine all rates of potency after nerve-sparing procedures and sural nerve graft procedures.64 The Cleveland Clinic examined the outcomes of laparoscopic donor nephrectomy versus open donor nephrectomy. The series showed markedly diminished morbidity associated with laparoscopic donor nephrectomy and no measurable increase in renal morbidity. Only patients with data available on renal scintography (TC-MAG3) were reviewed. Renal scintography was done on postoperative days 1 and 5. At day 5, TMAX was the same and there was no negative impact on longterm renal function.65 Urodynamics and female pelvic reconstruction

It has been recognized that in women, asymptomatic voiding occurs by integration of bladder contractility and abdominal straining with simultaneous relaxation of the urethral musculature. In most women, the voiding detrusor pressures are lower than in men. The question has arisen as to whether, after sling procedures, women who void predominantly by valsalva, have equivalent results to women who void predominantly by detrusor contractility. A validated questionnaire-based study showed that women who void predominantly by valsalva have a higher risk of postoperative voiding dysfunction after pubovaginal sling surgery. They likewise have a much higher likelihood of continuing to wear pads postoperatively (87% of women in this category wear pads). A higher use of pads would suggest that these patients are at an increased risk for recurrent incontinence. In contrast, women who void predominantly by detrusor contractility only have a 45% rate of continued pad usage after surgery.66

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In the postradical prostatectomy male population, urodynamic evaluation is often performed and valsalva leak point pressure is frequently used as a guide concerning the treatment of incontinence. Patients with high valsalva leak point pressures are often offered injection with bulking agents versus some other form of management. It is believed by some that patients in this category do better with the injection of bulking agents. A recent study examined the effect of small urodynamics catheters in the male urethra on valsalva leak point pressure. The study found that the valsalva leak point pressure can be significantly elevated by the presence of the catheter. This of course could be of significant clinical importance if one uses valsalva leak point pressure as a factor in recommending therapy.67 Since the development of nonautologous graft materials, questions have arisen concerning the results obtained with autologous fascia versus cadaveric fascia. A study examined 200 patients; 100 had a pubovaginal sling using autologous fascia and the second group used cadaveric fascia lata. The patients were randomized depending on their choice. The durability of allograft fascia appears to be similar to autologous fascial slings at 2 years. Patient satisfaction, cure rate, and improved rates were identical.68 A study from Europe sought to determine if there was a difference between sling techniques. The so-called “sling on a string” was compared with the full-length sling technique. One hundred seventy-seven women were recruited for a randomized, controlled trial. The authors found that the “sling on a string” technique is quicker to perform and that patients complain of less abdominal angle pain. There appear to be no other significant differences between the efficacy and the morbidity of the two procedures at 12 months minimum or at a median of 42 months.69 Tissue engineering continues to be a hot topic. The use of adult adipose-derived stem cells for reconstruction of the atrophic female urethra was examined in an animal study. The cells were injected into the bladder walls of immunodeficient mice. The cells survived and differentiated into multiple tissue types, including smooth muscle. The results warrant further study.70 From the Boston group, the engineering of vaginal tissue for total vaginal reconstruction likewise showed promise, and engineering of innervated sphincteric muscle using neuronal stem cells showed the stem cells were capable of differentiation into motor neurons.71 The results likewise would support further studies.72

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Pediatric urology

As with adults, a great deal of effort is aimed at the treatment of children with minimally invasive techniques. Vesicoureteral reflux is one of the most common problems faced by pediatric urologists. Subtrigonal injection procedures have been used for years, but the optimal injectable substance has remained illusive. A study in Dallas of 70 girls and 5 boys (117 renal units) was done using Deflux (Q-Med AB). Deflux is an FDAapproved dextranomer/hyaluronic copolymer. In this study, a single Deflux injection resolved reflux in 70% of the treated ureters. Researchers found, as with open surgery, that contralateral reflux can be precipitated, and in one patient, ureteral obstruction was seen.73 A second study examined the use of Urocol (triple calcium phosphate) (ColBar R&D Ltd) and demonstrated excellent outcomes, cure rates as expected were higher in lower grades of reflux, but in children with Grade V reflux, a 63% cure rate was seen and in the cohort in general a 71% cure rate noted.74 An interesting procedure was reported from Japan using a transvesical/transurethral technique for what is termed “trigonoplasty.” These authors did their procedure in 22 refluxing ureters and resolved the reflux in 19 ureters (86% of the study cohort). Their preliminary experience stated that patients “were satisfied with both cosmetics and amount of postoperative pain.”75 A second study examined laparoscopic bilateral extravesical ureteroreimplantation. Over the past 5 years, 98 ureters were addressed. They had a 2% obstruction rate but a 100% resolution of reflux rate. A number of years ago, Koyle and colleagues76 reported a study suggesting the superiority of laparoscopy for the localization of the impalpable testis. A multiinstitutional study again looked at this issue. Laparoscopy was found to have a 100% diagnostic accuracy in patients who had undergone previous nondiagnostic open exploration.77 In this group, a missed intraabdominal testicle was found in 63% of the cohort. Laparoscopic donor nephrectomy in the adult population is believed have potentially increased the donor pool of kidneys. It is thought that donors might be willing to undergo laparoscopic renal donation because of the diminished morbidity associated with the laparoscopic approach. But the issue had not been examined when donation was to a child. A recent study looked at laparoscopic renal donation in the adult for the pediatric recipient. Interestingly, the data suggest that the parent-

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to-child bond supercedes any potential concern about the procurement mode, so it does not influence the decision to donate. The study further pointed out that shorter hospital stay and shorter convalescence make the laparoscopic donor nephrectomy particularly advantageous for typical parental donors, who will quickly have to assume responsibility for their children in addition to other family and work obligations.78 Urethrorrhagia in the male child is a frequently encountered problem. Two recent studies looked at patients with this problem; one study postulated that urethrorrhagia in the male is a manifestation of voiding dysfunction. The authors recommended close attention to the treatment of voiding dysfunction and constipation in these children.79 A second study retrospectively looked at the same type of patient population from the standpoint of yield from evaluation. This study concluded that upper tract imaging is not useful in evaluating these patients. Voiding cystourethrogram was believed to be useful in the diagnosis of these patients, detecting abnormalities in 44% of the patients. Meatal stenosis noted in 23% of the patients they studied.80 Genital sensitivity after surgery for intersex was looked at in two studies. One study examined clitoral sensitivity and proposed a modification to classic reduction clitoroplasty procedures. In general, the proposed modification does not reduce the bulk of the glans clitoris at all. The clitoris is otherwise reduced by debulking and excision of the erectile bodies without damage to the dorsal neurovascular structures.81 A second study looked at sexual sensation using questionnaires, with mapping of areas associated with erogenous sensibility. Further studies such as these will clearly assist in redefining methods of surgery for intersex.82 Cancer

Laparoscopic exposure for radical nephrectomy and partial nephrectomy dominated a good bit of the literature concerning renal cell carcinoma. Laparoscopic nephrectomy and laparoscopic partial nephrectomy were advocated for even larger lesions.83 These procedures were found to be feasible, safe, and reproducible. In a large series from the Cleveland Clinic comparing laparoscopic partial nephrectomy to open partial nephrectomy, the complication rate was higher in the laparoscopic partial nephrectomy group, possibly representing a learning curve. But laparoscopic nephron sparing surgery is emerging as equally efficacious to open nephron-sparing

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surgery.84 Tissue sealants such as FloSeal (Baxter Healthcare Corp) continue to be reported as efficacious.85 The TissueLink (TissueLink Medical, Inc) dissecting sealer 3.0 device was also reported effective for performing laparoscopic partial nephrectomy.86 Laparoscopic partial nephrectomy with hand assistance was also reported highly effective and safe.87 Other more minimally invasive options being explored for renal cell cancer include renal cryoblation, radiofrequency ablation, and noninvasive high-intensity focused ultrasonographic ablation.88-91 Two centers report an interesting subset of T3A renal cell carcinoma patients. Renal cell carcinoma that invades the adjacent adrenal gland is currently staged T3A. In both studies, ipsilateral adrenal involvement was found to adversely affect survival, and both studies recommended a recategorization of these tumors to T4 or T4M1.92,93 An interesting study from Sweden examined a population-based study of newly detected bladder tumors. Over a period of 2 years, 538 patients were registered with newly diagnosed primary bladder neoplasms with followup of at least 5 years. During the period of followup, all patients were treated in accordance with a protocol that was adopted by all hospitals and urology units in the area. TA Grade I tumors behaved benignly, and no patient showed progression or died of bladder cancer during the period of the study. Forty-two percent of patients presenting with T1 tumors at diagnosis progressed to muscle invasive disease. Patients with TA Grade III and T1 Grade II tumors had disease-specific death rates of 20% and 27%, respectively. Eighty-nine percent of patients with T2⫹tumors died of their disease during the study interval.94 A second interesting study examined the Surveillance, Epidemiology, and End Results (SEER) database for the years 1973 to 1990. The question asked by the study was whether the incidence of bladder cancer among patients who had initial primary tumors of the lung, head, neck, prostate, and colorectal region was higher. Relative risk and true incidence of bladder cancer were assessed. The incidence of developing bladder cancer among the general population in the area studied is 0.018%. The risk among patients with an earlier neoplasm for developing a second primary was 9%; the risk for developing bladder cancer as the second cancer was 0.13%. The risk was highest in the prostate cancer population (0.27%). The higher risk among prostate cancer patients might reflect

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the low threshold for screening among urologists; but also, the possible effect of therapeutic radiation for the prostate must be considered. This study found a tenfold increased risk for developing bladder cancer among patients with other primary tumors. This group represents an ideal population in which to intensify routine bladder cancer screening.95 Three centers sought to increase the sensitivity of cystoscopy using fluorescent endoscopy. Two centers used 5-amino levulinic acid-based fluoroscopic endoscopy;6,96 one center used fluorescent light only.97 In all three studies, an increased detection rate was noted. When fluorescent cystoscopy was compared with white light fluoroscopy, diminished recurrences were shown at 12, 24, and 48 months followup. Interim results from the national multicenter phase 2 trial of combination intravesical bacillus of Calmette and Guerin (BCG) plus interferon-alpha-2B for superficial bladder cancer were reported. The trial substantiated previous early encouraging reports of the efficacy of combination BCG plus interferon as upfront and salvage therapy for patients with moderate to high-risk superficial bladder cancer. Investigators found a high level of patient tolerance with minimal serious toxicity. They reported that data are still immature, but tumor recurrences in the first year after the protocol completion appeared rare.98 A study examined a group of patients treated with radical cystectomy after having undergone therapy for carcinoma of the prostate. They found that these patients, previously treated for carcinoma of the prostate with external beam radiotherapy or radical prostatectomy, have an increased risk of perioperative complications compared with the patients undergoing cystectomy without having had prior therapy for carcinoma of the prostate. But, the risk is not prohibitive and radical cystectomy remains the treatment of choice for high-risk bladder cancer. They have also found that orthotopic urinary diversion is a reasonable option and should be considered for select patients.99 The group from Monsoura, Egypt, examined radical cystectomy and orthotopic bladder substitution in women prospectively. The study looked at early postoperative and late complications. They found that most complications after radical cystectomy and orthotopic bladder substitution in women were minor and could be conservatively treated. Endoscopic measures were successful for the majority of complications secondary to calculi and also for early ureteroileal strictures. From the cohort of 145

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patients, 4 had pouch vaginal fistulas that were repaired vaginally.100 A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer patients was reported from the Scandinavian Prostate Cancer Group study. The protocol enrolled 695 men with newly diagnosed prostate cancer between October 1989 and February 1999. Patients with clinical stages T1B, T1C, or T2 were randomly assigned to watchful waiting or radical prostatectomy. Death from prostate cancer occurred in 8.9% of those assigned to watchful waiting. To those assigned radical prostatectomy, the death rate was 4.6%. An interesting observation was made at 8 years after radical prostatectomy. The absolute reduction in both overall and disease-specific mortality rates was approximately 6%. For distant metastasis, the absolute reduction at 8 years was 14%. The absolute difference of 6% at 8 years implies that 17 patients would need to be treated to prevent one death from prostate cancer over an 8-year period. In terms of overall survival, there was no significant difference between the surgery group and watchful waiting group. But, for the first time, there is clear evidence that surgical treatment of localized prostate cancer reduces the risk of death from prostate cancer.101-103 The Prostate Cancer Intervention Versus Observation Trial (PIVOT) is the largest randomized trial in the world to study treatment with surgery versus watchful waiting. Recruitment for that trial began in November 1994 and was finished in January 2002. Men were recruited from 44 VA Medical Centers and 8 National Cancer Institute sites. In those sites, a total of 12,980 men were identified with newly diagnosed prostate cancer at the 52 recruitment sites; of those, 4,279 men were eligible for enrollment and 731 men ultimately consented to participate. Men declined to enroll because of the following: not willing to participate in research, 13%; not willing to leave the decision for treatment to chance, 68%; and family opposition to their participation, 14%. So the greatest obstacle to recruiting participants for such a study was that men do not want to be randomized into two very different treatment modes.104 A report compared radical prostatectomy to radiotherapy, hormonal therapy, and watchful waiting for screen detected prostate cancer. Followup after defined therapy was accomplished every 6 months with PSA testing. Cancer progression was defined as a PSA ⬎0.2ng/mL for surgery patients and three consecutive PSA rises for

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all other treatments included in the analysis. In this analysis, radical prostatectomy provided a better 7-year progression-free survival than radiotherapy, hormonal therapy, or watchful waiting.105 Other reports (one from Memorial Sloan-Kettering Cancer Institute and one from the Cleveland Clinic) found different results. In the report from the Memorial Sloan-Kettering Cancer Institute, in patients treated with radical prostatectomy, external beam irradiation, and brachytherapy, for localized prostate cancer, biochemical relapse-free survival was 81% at 5 years and 76% at 7 years in the entire cohort. Kaplan Meier outcomes plots in that study were essentially superimposed.106 In the Cleveland Clinic study, 8-year biochemical failure rates were identical between external beam radiotherapy and radical prostatectomy patients.64 The natural history of progression after PSA elevation after radical prostatectomy was reported and represents an update to the previously reported study by Pound and coworkers.107 This study added 38 new recurrences since the last report. Immediate actuarial time from biochemical to metastatic progression was approximately 721 years and median actuarial time from development of metastasis to death was approximately 621 years.108 Because of the increased interest in various forms of radiotherapy, its use in the treatment of men with initially localized carcinoma of the prostate increases. But when patients are biopsied, they demonstrate a sizeable proportion of foci of local and persistent cancer. A study from the Mayo Clinic examined 211 patients who underwent salvage radical prostatectomy. They found that, in these patients, salvage surgery can result in a longterm diseasefree state. With experience, continence rates have improved and in the experience with salvage surgery patients, hormonal therapy for resistant prostate cancer conferred no longterm survival benefit.109 The use of bisphosphonates in advanced prostate cancer continues to be explored. A multicenter, randomized, placebo-controlled trial was conducted in patients with hormone refractory prostate cancer and at least one bone metastasis. Patients were randomized to zoledronic acid or placebo every 3 weeks for up to 24 months. Zoledronic acid was found to be safe and well tolerated for up to 24 months and significantly reduced skeletal related events. Skeletal-related events were defined as pathologic fracture, spinal cord compression, the requirement for radiotherapy or surgery to the bone, or a change in chemotherapy to treat bone pain.110 A second

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study from Brazil examined the use of clodronate; it was found to be highly effective and efficient for the treatment of metastatic bone pain. Bisphosphonates are believed to diminish osteoclastic activity, improving the osseous rarification and possibly increasing bone strength and metastatic lesions.111 It has been suggested that there is an interference with calcium homeostasis in patients with hormone refractory prostate cancer. A study from the Netherlands examined this phenomenon. Investigators observed a vitamin E-independent decrease in the intestinal absorption of calcium that did not appear associated with hypocalcemia. This suggests that the phenomena might be paraneoplastic, because the impairment of intestinal absorption of calcium and the severity of tumor load show a clear relationship. They proposed that patients in the late stages of prostate cancer be routinely treated with vitamin D and calcium supplements.112 Another study examined outcomes among hospitals and surgeons as they relate to hospital volume and surgeon volume. They found that, in men undergoing radical prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high volume hospital and by a surgeon who performs a high number of such procedures.113 I have elected to use the proceedings of the 2003 AUA annual meeting as the major source of content for this article. Interestingly, at the AUA 2003, Fleshner and colleagues114 examined the publication rate of abstracts from the 1998 to 2000 meetings to be 37%. But, takehome presentations help to scrutinize the presentations and further screen what is new versus what is new and potentially durable. REFERENCES 1. Nadler RB, Schaeffer AJ, Knauss JS, et al. Total prostatespecific antigen is elevated and statistically, but not clinically significant in patients with chronic pelvic pain syndrome/ prostatitis (abstract 107). J Urol 2003;169:27–28. 2. Dimitrakov JD, et al. Male interstitial cystitis—time for a change (abstract 272). J Urol 2003;169:70–71. 3. Chuang Y, Chou A, Yang L, et al. Gene therapy of bladder pain with gene gun particle encoding pro-opiomelanocortis (POMC) CDNA (abstract 256). J Urol 2003;160:66. 4. Nishiguchiu MB, Sasaki K, Kim JH, et al. Gene therapy of urinary bladder pain using replication defective herpes simplex virus (HSV) vectors expressing preproenkephalin (PPE) (abstract 257). J Urol 2003;169:66–67.

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5. McConnell JD, Roehrborn CG, et al. Baseline measures predict the risk of benign prostatic hyperplasia clinical progression in placebo-treated patients (abstract 1287). J Urol 2003;169: 332. 6. Roehrborn CG, McConnell J, et al. Baseline prostate volume and serum PSA predict rate of prostate growth: analysis of the MTOPS data (abstract 1361). J Urol 2003;169:364. 7. Jacobsen SJ, Jacobson DJ, et al. Acute urinary retention in community-dwelling men: 9-year followup of the Olmsted County study of urinary symptoms and health status among men (abstract 1364). J Urol 2003;169:365. 8. Lieber MM, Jacobson DJ, et al. Incidence of lower urinary tract symptom progression in community-dwelling men: 9-year followup of the Olmstead County study of urinary symptoms and health status among men (abstract 1369). J Urol 2003;169:366–367. 9. Carter B, Metter J, et al. PSA and all cause mortality: results from the Baltimore longitudinal study of aging (abstract 1373). J Urol 2003;169:367–368. 10. Elliott SP, Gulati M, et al. Lower urinary tract symptoms correlate with erectile dysfunction (abstract 1366). J Urol 2003; 169:366–367. 11. Rosen R, et al. Ejaculatory disorders are frequent and bothersome in aging males with LUTS: a world-wide survey (MSAM-7) (abstract 1365). J Urol 2003;169:365–366. 12. Corica AP, Corica FA, et al. Fast liquid ablation system for hyperplasia (FLASH), a new minimal invasive thermal treatment for BPH: a time-sequential study (abstract 1468). J Urol 2003;169:393. 13. Plante MK, Gross AL, Folsom J, Zvara P. Diffusion properties of transurethral intraprostatic injection using real time fluoroscopic evaluation (abstract 1462). J Urol 2003;169:391. 14. Badlani G, Desai M, Kumar A. A randomized trial comparing transurethral ethanol ablation of the prostate (TEAP) treatment and TURP for bladder outlet obstruction (BOO) (abstract 1460). J Urol 2003;169:391. 15. Plante MK, Palmer J, Martinez-Sagarra J, et al. Complications associated with transurethral ethanol ablation of theprostate for treatment of benign prostatic hyperplasia: a worldwide experience (abstract 1466). J Urol 2003;169:392. 16. Huidobro C, Cabezas J, Cote E, et al. Results of a new advancement in high temperature cooled thermotherapy (TUMT) for benign prostatic hyperplasia (BPH) (abstract 1459). J Urol 2003;169:390. 17. Sandhu J, Vanderbrink B, Egan C, et al. High-power KTP photoselective laser vaporization prostatectomy for the treatment of benign prostatic hyperplasia in men with large prostates (abstract 1470). J Urol 2003;169:393. 18. Chandrasekar P, Virdi J, Kapasi F. Interstitial laser ablation (Indigo) of the prostate; a prospective, randomized study, five year follow-up (abstract 1465). J Urol 2003;169:392. 19. Gilling PJ, Kennett KA, McCammon MD, et al. Holmium laser enucleation of the prostate (HOLEP) is superior to TURP for the relief of bladder outflow obstruction (BOO): a randomized trial with two year follow up (abstract 1467). J Urol 2003;169:392–393. 20. Perry MJA, Roodhouse AJ, Gidlow AB, et al. Thermoexpandable intraprostatic stents in bladder outlet obstruction: an 8-year study. BJU Int 2002;90:216–223. 21. Barry MJ, Fowler FJ Jr, O’Leary MP, et al. The American Urological Association symptom index for benign prostatic hypertrophy. J Urol 1992;148:1549–1557.

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22. Poulsen AL, Schou J, Ovesen H, Nordling J. Memokath®: a second generation of intraprostatic spirals. Br J Urol 1993; 72:331–334. 23. Kuo R, Lingeman J, Leveillee R, et al. Lower pole II: initial results from a comparison of shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrostolithotomy (PNL) for lower pole nephrolithiasis (abstract 1821). J Urol 2003;169:486. 24. Bailey MR, Sokolov D, Clevel and R, Crum LA. Dual-pulse lithotripsy accelerates stone comminution and reduces cell injury in vitro (abstract 1771). J Urol 2003;169:472. 25. Ekeruo WO, Mathias BJ, Delvecchio FC, Preminger GM. Impact of medical therapy on the management of nephrolithiasis in obese patients (abstract 1269). J Urol 2003;169:327. 26. Grover S, Kaouache M, De Carolis E, et al. Assessing the association between erectile dysfunction and cardiovascular disease: preliminary results of the CANSED study (abstract 1247). J Urol 2003;169:321. 27. Rivera AC, Pareek G, Armenakas NA. Correlation of erectile dysfunction with reduced cardiac ejection fraction in men with coronary artery disease (abstract 1248). J Urol 2003;169:321. 28. Shabsigh R, Kaufman JM, Steidle C, Padma-Nathan H. Testosterone replacement therapy with testosterone-gel 1% converts sildenafil nonresponders to responders in men with hypogonadism and erectile dysfunction who failed prior sildenafil therapy (abstract 954). J Urol 2003;169: 247. 29. Rosenthal B, Ginsberg PC, Metro M, Harkaway RC. The addition of testosterone replacement therapy to treat erectile dysfunction after failure of sildenafil alone in men with acquired androgen deficiency syndrome (abstract 1408). J Urol 2003; 169:377. 30. Montorsi F, Berheyden B, Junemann KP, et al. Long-term safety experience with tadalafil (abstract 947). J Urol 2003; 169:245. 31. Padama-Nathan H, McCullough AR, Giuliano F, et al. Postoperative nightly administration of sildenafil citrate significantly improves the return of normal spontaneous erectile function after bilateral nerve-sparing radical prostatectomy (abstract 1402). J Urol 2003;169:375. 32. Shenfeld O, Gofrit O, Landau E, Pode D. Does response to sildenafil predict spontaneousn improvement of erectile function in patients with erection dysfunction due to pelvic fractures associated with urethral injuries (abstract 70)? J Urol 2003;169:18–19. 33. Carson C, Glasser D, Laumann E, et al. Prevalence and correlates of premature ejaculation among men aged 40 years and older: a United States nationwide population-based study (abstract 1249). J Urol 2003;169:321–322. 34. Lozano AF, Castane ER. Premature ejaculation: sildenafil plus setraline versus sertraline along and sildenafil alone (abstract 956). J Urol 2003;169:247. 35. Dohle G, Pierik F, Weber R. Varicocele repair results in more spontaneous pregnancies? A randomized prospective trial (abstract 1525). J Urol 2003;169:408. 36. Matschke HM, Lo KA, Brugh VM, et al. Sperm DNA damage and smoking: evaluation of association using comet assay (abstract 1566). J Urol 2003;169:419. 37. Mulhall JP, Barnas JL, Martin DJ. Peyronie’s disease plaquederived fibroblasts harbor cytomegalovirus (CMV) DNA (abstract 1059). J Urol 2003;169:273.

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38. Qian A, Meals RA, Raifer J, Gonzalez-Cadavid, NF. Profiles of multiple gene expression in the Peyronie’s plaque and Dupuytren’s nodules suggest a common pathophysiology (abstract 1061). J Urol 2003;169:273. 39. Nyberg LM Jr, Bias WB, Hochberg MC, Walsh PC. Identification of an inherited form of Peyronie’s disease with autosomal dominant inheritance and association with Dupuytren’s contracture and histocompatibility B7 cross-reacting antigen. J Urol 1982;128:48–51. 40. Usta M, Hellstrom W, Jabren GW, et al. Is there a relationship between the severity of penile curvature and risk factors in patients with Peyronie’s disease (abstract 1062)? J Urol 2003; 169:273. 41. Oktar T, Kendirci M, Sanli O, Kadioglu A. The impact of risk factors on the severity of penile deformity in 484 Peyronie patients (abstract 1063). J Urol 2003;169:274. 42. Schiavino D, Sasso F, Nucera E, et al. Immunologic findings in Peyronie’s disease: a controlled study. Urology 1997;50:764– 768. 43. Stewart S, Malton M, Sandberg L, Colburn KK. Increased serum levels of anti-elastin antibodies in patients with Peyronie’s disease. J Urol 1994;152:105–106. 44. Leffell MS. Is there an immunogenetic basis for Peyronie’s disease? J Urol 1997;157:295–297. 45. Da Ros CT, Teloken C, Graziottin TM, et al. Can we find any immunological marker correlated to Peyronie’s disease (abstract 1064)? J Urol 2003;169:274. 46. Hellstrom W, Eichelberg C, Pryor JL, et al. A single-blind multi-center placebo-controlled study to assess the safety and efficacy of intralesional interferon alpha-2B in the nonsurgical treatment of Peyronie’s disease (abstract 1065). J Urol 2003; 169:274. 47. Levine LA, Sevier VL. A double-blind, placebo-controlled trial of electromotive drug administration (EMDA) using Verapamil vs. saline for Peyronie’s disease: preliminary results. (abstract 1066). J Urol 2003;169:274. 48. Yerkes E, Herndon A, Shaw M, et al. Human acellular dermis as a corporal patch (abstract 1067). J Urol 2003;169:275. 49. Knoll LD. Use of porcine small intestinal submucosal graft in the surgical management of Peyronie’s disease: a review of 97 patients (abstract 1068). J Urol 2003;169:275. 50. Brandes SB. Damage control for urologic trauma: an approach for improved survival (abstract 69). J Urol 2003;169:18. 51. Minor TX, Rosenstein D, McAninch JW. Management of renal arterial injuries (abstract 380). J Urol 2003;169:98. 52. Hammer CC, Santucci RA. Effect of an institutionalized policy of nonoperative treatment of renal injuries (abstract 62). J Urol 2003;169:17. 53. Cavalcanti AG, Rosenstein D, McAninch JW. How a laparotomy to treat an intra-abdominal associated lesion could change our therapeutic decision in major renal trauma (abstract 61). J Urol 2003;169:16. 54. Rourke KF, Jordan GH. Primary urethral reconstruction: the cost minimized approach to urethral stricture disease (abstract 64). J Urol 2003;169:17. 55. Atala A, El Kassaby A, Guzman L, et al. Acellular collagen matrix for urethral repair: long-term results (abstract 395). J Urol 2003;169:102. 56. Meraney A, Rami AP, Kaouk J, et al. Adrenalectomy for pheochromocytoma in 115 cases: laparoscopy vs. open surgery (abstract 90). J Urol 2003;169:23.

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57. Cestari A, Bellinzoni P, Centemero A, et al. Laparoscopic transperitoneal adrenalectomy: 10 year experience (abstract 92) J Urol 2003;169:23. 58. Ishidoya S, Ito A, Satoh M, et al. Incidence of multiple aldosterone-producing adenomas-laparoscopic total versus partial adrenalectomy (abstract 91). J Urol 2003;169:23. 59. Gholami S, Bermudez H, Widmer H, et al. The treatment of solid renal masses: 5 year review of our treatment pattern (abstract 93). J Urol 2003;169:24. 60. Steinberg A, Abreau SC, Ramani A, et al. Laparoscopic partial nephrectomy: unique applications (abstract 87). J Urol 2003; 169:22. 61. Steiner H, Peschel R, Holtl L, et al. 10 years of laparoscopic retroperitoneal lymph node dissection (abstract 931). J Urol 2003;169:240–241. 62. Parsons JK, Varkarakis I, Rha KH, et al. Complications of abdominal urology laparoscopy: a longitudinal 5-year analysis (abstract 297). J Urol 2003;169:77. 63. Katz R, Salomon L, Hoznek A, et al. Patient reported sexual function following laparoscopic radical prostatectomy (abstract 1657). J Urol 2003;169:443. 64. Kupelian PA, Elshaikh M, Reddy CA, et al. Comparison of the efficacy of local therapies for localized prostate cancer in the prostate-specific antigen era: a large single-institution experience with radical prostatectomy and external beam radiotherapy. J Clin Oncol 2002;20:3376–3385. 65. Derweesh IH, Abreu SC, Goldfarb DA, et al. Laparoscopic live donor nephrectomy has equivalent early and late renal function outcomes compared to open door nephrectomy (abstract 1759). J Urol 2003;169:469. 66. Kershen RT, Boon JR, Ganeshappa A, et al. Preoperative voiding mechanism may affect patient satisfaction with pubovaginal sling surgery (abstract 1497). J Urol 2003;169:401. 67. Ferlise VJ, Wein AJ, Ramchandani P, et al. Effect of a 7F transurethral catheter on valsalva leak point pressure measurement in men with post-prostatectomy incontinence (abstract 1500). J Urol 2003;169:401. 68. Cespedes RD, Kraus SR. A comparison of the pubovaginal sling using either allograft or cadaveric fascia for stress urinary incontinence in 200 consecutive patients (abstract 368). J Urol 2003;169:95. 69. Lucas MG, Giannitsas KL, Wareham K, et al. A randomized controlled trial comparing two techniques of tension free autologous fascial sling for surgical treatment of genuine stress incontinence in women (abstract 477). J Urol 2003;169:123. 70. De Almeida F, Alfonso Z, Strem B, Rodriguez LV. Adult adipose derived stem cells for reconstruction of the atrophic femal urethra: tissue engineering techniques for treatment of SUI (abstract 482). J Urol 2003;169:125. 71. Defilippo RE, Yoo JJ, Atala A. Engineering of vaginal tissue for total reconstruction (abstract 1057). J Urol 2003;169:272. 72. Yiou R, Lachyankar M, Yoo JJ, et al. Engineering of innervated sphincteric muscle using neuronal stem cells (abstract 1055). J Urol 2003;169:272. 73. Elmore JM, Ewalt DH, Snodgrass WT. Initial results of Deflux injection for vesicoureteral reflux: the Dallas experience (abstract 487). J Urol 2003;169:126. 74. Kajbafzadeh A, Habibi Z. Endoscopic subureteric Urocol injection in treatment of vesicoureteral reflux in children (abstract 659). J Urol 2003;169:170. 75. Tsuji Y, Okamura K, Hirano A, et al. A novel endoscopic ureteral reimplantation for primary vesico-ureteral reflux (en-

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doscopic trigonoplasty II) (abstract 413). J Urol 2003;169: 106–107. Koyle MA, Pfister RR, Jordan GH, et al. The role of laparoscopy in the patient with previous negative inguinal exploration for impalpable testis (abstract 35). J Urol 1994;151:236A. Cooper CS, Kryger JV, Docimo SG, Hedican SP. Outcome of laparoscopy following non-diagnostic open exploration for cryptorchidism (abstract 488). J Urol 2003;169:126. Johnston III WK, Pierce JL, McVicar JP, et al. Clinical outcomes and quality of life (QOL) assessment of live donors after laparoscopic (LD) vs. open (OD) donor nephrectomy for pediatric renal transplantation (PED-KTX) (abstract 491). J Urol 2003;169:127. Herz DB, Weiser A, Franco I, et al. Voiding dysfunction as an etiology for bulbar urethritis (urethrorrhagia) in children (abstract 410). J Urol 2003;169:106. Palagiri A, Steinhardt GF, Decter RM. A retrospective analysis on the diagnosis and management of idiopathic urethrorrhagia (abstract 412). J Urol 2003;169:106. Poppas D, El Chaar MM, Kelly C, New M. Clitoral sensitivity and viability following a modified reduction clitoroplasty with follow-up testing in 21 patients (abstract 494). J Urol 2003; 169:128. Schober T. Sexual sensation and its impact on genitoplasty, presented at the Society of Genitourinary Reconstructive Surgeons, April 28, 2003, Chicago, IL. Steinberg AP, Lin C, Matin S, et al. Impact of tumor size on laparoscopic partial nephrectomy: analysis of 163 patients (abstract 671). J Urol 2003;169:174. Gill IS, Matin SF, Desai MM, et al. Laparoscopic and open partial nephrectomy in 200 cases (abstract 84). J Urol 2003; 169:21. Richter F, Tullman M, Turk I, et al. Gelatine-matrix-thrombin tissue sealant (Floseal) as a tool for effective hemostasis in open and laparoscopic partial nephrectomies (abstract 88). J Urol 2003;169:22. Ahmed M, Andrade C, Sawczuk I. Decrease in blood loss in patients who underwent Tissuelink Dissecting Sealer 3.0TM device assisted partial nephrectomy for suspected renal cell carcinoma: a new surgical technique (abstract 89). J Urol 2003; 169:23. Munver R, Sosa RE, Del Pizzo JJ. Laparoscopic partial nephrectomy is feasible: will hand-assistance make it the standard of care? (abstract 86) J Urol 2003;169:22. Harmon JD, Parulkar BG, Haleblian G, et al. Long-term outcomes of renal cryoablation (abstract 888). J Urol 2003;169: 229. Shingleton WB. Long-term follow up of percutaneous renal cryoablation (abstract 8). J Urol 2003;169:2. Johnson DB, Duchene DA, Ogan K, Cadeddu JA. Radiofrequency ablation of small renal tumors using a laparoscopic or percutaneous approach early experience (abstract 672). J Urol 2003;169:174. Axel H, Stephan MM, Thomas K, et al. Non-invasive tissue ablation of kidney tumors by high intensity focused ultrasound (abstract 673). J Urol 2003;169:174. Patel MI, Beck S, Simmons R, Russo P. Adrenal and nodal status are indicators of metastatic disease. Time to change the TNM classification for kidney cancer (abstract 2). J Urol 2003; 169:1.

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93. Han K, Bui MH, Pantuck AJ, et al. T3A renal cell carcinoma: adrenal gland involvement is not the same as renal fat invasion (abstract 666). J Urol 2003;169:172–173. 94. Thorstenson AG, Larsson P, Wijkstrom H, et al. Bladder cancer characteristics in a population based study of newly detected tumors (abstract 864). J Urol 2003;169:223. 95. Anderson K, Slaton JW. Should patients with other primary neoplasms be evaluated for bladder cancer? A risk-related analysis of the SEE database (abstract 865). J Urol 2003;169:223. 96. Filbeck TN, Pichlmeier U, Knuechel R, et al. 5-Aminolevulinic acid-induced fluorescence diagnosis reduces recurrence of superficial bladder cancer: final results with a medican follow-up of 3.5 years (abstract 994). J Urol 2003; 169:256. 97. Filbeck TN, Pichlmeier U, Knuechel R, et al. 5-Aminolevulinic acid-induced fluorescence diagnosis in detection and resection of bladder carcinoma: any profit for patients (abstract 862). J Urol 2003;169:223. 98. Odonnell MA, Lilli K, Leopold C. Interim results from a national multicenter phase II trial of combination BCG plus interferon-alfa-2B for superficial bladder cancer (abstract 993). J Urol 2003;169:256. 99. Schuster TG, Marcovich R, Sheffield J, et al. Radical cystectomy for bladder cancer after definitive prostate cancer treatment (abstract 403). J Urol 2003;169:104. 100. Ali-Elodein B, Ashamallah A, El-Azab ME, Ghoneim MA. Early and late complications after radical cystectomy and orthotopic bladder substitution in women: a prospective study (abstract 402). J Urol 2003;169:104. 101. Holmberg L, Bill-Axelson A, Adami H, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer (abstract 689). J Urol 2003;169:179. 102. Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 2002;347:781–789. 103. Walsh PC. Surgery and the reduction of mortality from prostate cancer (editorial). N Engl J Med 2003;347:839–840. 104. Wilt TJ, McKeehen D, Brawer MK, et al. Recruitment strategies in a large randomized clinical trial for prostate cancerPIVOT (abstract 1676). J Urol 2003;169:447. 105. Krygiel JM, Roehl KA, Weinberg V, Catalona WJ. Comparison of radical prostatectomy, radiotherapy, hormonal therapy, and watchful waiting for screen-detected prostate cancer (abstract 1715). J Urol 2003;169:457. 106. Bankhead C. RP, XRT, and seeds show similar relapse-free survival. Urology Times 2003;May:8. 107. Pound CR, Partin AW, Eisenberger MA, et al. Natural history of progression after PSA elevation following radical prostatectomy. JAMA 1999;281:159–207. 108. Partin AW, Pound CR, Van Rootselaar C, et al. Natural history of progression after PSA elevation following radical prostatectomy: update (abstract 935). J Urol 2003;169:241. 109. Ward JF, Zincke H, Debo TJ, Blute ML. Salvage surgery for radiorecurrent prostate cancer: outcomes and complications from a 30-year experience (abstract 1484). J Urol 2003;169: 397. 110. Saad F, Gleason D, Murray R, et al. Zoledronig acid is well tolerated for up to 24 months and significantly reduces skeletal complications in patients with advanced prostate cancer metastatic to bone (abstract 1472). J Urol 2003;169:394. 111. Rodrigues PT, Meller A, Campagnari JC, Hering F. Use of bisphosphonates can dramatically improve pain in patients

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with advanced prostate cancer (abstract 1474). J Urol 2003; 169:394. 112. Pelger R, Nijeholt G, Zwinderman A, Papapoulos S. Significantly decreased intestinal absorption of calcium hormone refractory prostate cancer metastatic to the skeleton: a paraneoplastic phenomenon (abstract 939)? J Urol 2003;169: 243.

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113. Begg CB, Ridel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med 2002;346:1138– 1144. 114. Fleshner NE, Longena NG, Hersey K. Publication rate of abstracts presented at the annual meeting of the American Urological Association (abstract 135). J Urol 2003;169: 35.