The Journal of Urology
Volume 177, Issue 2 , Pages 417-419, February 2007

This Month in Clinical Urology

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Open versus laparoscopic radical prostatectomy and postoperative urinary incontinence rates 

Questions have been raised about continence rates in patients undergoing laparoscopic radical prostatectomy. Jacobsen et al (page 615) from Edmonton, Alberta, Canada compared 12-month postoperative urinary incontinence rates of patients undergoing open radical prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP). This prospective study of men with clinically localized prostate cancer was performed from October 1999 to July 2002, and preoperative evaluation included 24-hour pad test, fluid volume diary and International Prostate Symptom Score questionnaire. A total of 239 patients (RRP 172, LRP 67) met the eligibility criteria and consented to participate in the study. Of the patients 87% treated with RRP and 88% treated with LRP completed 12-month followup, and 13% and 17%, respectively, remained incontinent at 1 year. No differences were noted in 24-hour pad weight, urinary symptoms score and urinary quality of life between the groups. (CME credit article)

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Hyperoxaluria in kidney stone formers treated with modern bariatric surgery 

It has long been recognized that patients undergoing jejunoileal bypass for morbid obesity become hyperoxaluric and that nephrolithiasis subsequently develops in many of them. These observations led to discontinuation of this procedure but other bariatric procedures being used have not been evaluated for assessment of nephrolithiasis. Asplin and Coe (page 565) from Chicago, Illinois compared 24-hour urine chemistry studies of 132 patients with nephrolithiasis who had undergone bariatric surgery with results of those treated with jejunoileal bypass, those with routine kidney stones and normal subjects. Patients undergoing bariatric surgery had an adjusted mean urinary oxalate excretion of 83 mg a day compared to 39 mg a day for routine kidney stone formers, 34 mg a day for normal subjects and 102 mg a day for those undergoing jejunoileal bypass. Urinary supersaturation of calcium oxalate was higher in patients who underwent bariatric surgery than in routine kidney stone formers and normal subjects. Hyperoxaluria is the most significant urinary abnormality in patients with kidney stones treated with bariatric surgery. Further studies are required to determine the prevalence of this problem in patients who have undergone this procedure. (CME credit article)

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Complications of urological laparoscopic procedures 

In a cooperative multi-institutional study Permpongkosol et al (page 580) assessed the complications associated with 2,775 urological laparoscopic surgeries at high volume centers performed between 1993 and 2005. Complication rates were 20% for radical nephrectomy (549 cases), 28% for partial nephrectomy (345), 28% for donor nephrectomy (553), 15% for simple nephrectomy (186), 13.3% for pyeloplasty (301), 40.9% for nephroureterectomy (105), 26.7% for retroperitoneal lymph node dissection (86), 18.6% for renal ablation (81), 25.5% for adrenalectomy (106) and 15% for radical prostatectomy (463). Overall complication rate was 22.1% (614 cases), and overall intraoperative and postoperative complication rates were 4.7% and 17.5%, respectively. Vascular injuries were the most common intraoperative complication. (CME credit article)

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Predictive value of cell cycle biomarkers for bladder carcinoma 

Tumor grade and stage are typically used as prognostic indicators when evaluating patients with transitional cell carcinoma (TCC) of the bladder. To identify better prognostic factors Shariat et al (page 481) from Dallas, Texas determined whether the combined expression of p53, p21, pRB and p27 is predictive of outcomes in patients with nonmuscle invasive bladder TCC. Immunohistochemical staining for these agents was performed in 9 normal controls and 74 patients undergoing transurethral bladder tumor resection. Normal urothelium had a wild-type status of p53, pRB, p21 and p27. Of patients with TCC p53 expression was altered in 34%, pRB in 39%, p21 in 35% and p27 in 47%. When analyzed separately, p53, pRB and p21 were each independently associated with tumor progression. When tumor stage and grade were modeled with all 4 biomarkers, p53 and p27 were the sole independent predictors of disease recurrence and progression. The risk ratio for disease recurrence and progression increased incrementally with the number of biomarkers altered. Higher total numbers of altered biomarkers were independently associated with an increased risk of disease progression and death. (CME credit article)

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Computerized tomographic urography in the initial evaluation of hematuria 

Controversy continues regarding the appropriate imaging studies required for evaluation of hematuria. The usefulness of computerized tomographic urography (CTU) for the initial evaluation of hematuria was compared to that of excretory urography (IVP) by Albani et al (page 644) from Cleveland, Ohio. CTU was performed in 259 patients 20 to 100 years old and IVP was done in 253 patients 21 to 92 years old. A source of hematuria was identified in 107 patients in the CTU cohort and 103 in the IVP cohort. CTU alone identified a source of hematuria in 25.5% of patients with the most commonly diagnosed lesions being renal calculi (18.9%), ureteral calculi (2.7%), renal pelvic masses in the upper tract (2.3%), bladder masses (8.1%), prostatic abnormalities (5.4%) and inflammatory disorders of the lower urinary tract (3.5%). The overall detection rate (19.5%), the most commonly diagnosed lesions, and lower urinary tract sensitivity and specificity were similar in the IVP cohort. However, IVP exhibited a markedly lower sensitivity in detecting upper tract lesions. CTU exhibited a significantly higher sensitivity than conventional IVP in detecting upper tract abnormalities, although sensitivity for detecting lower tract lesions was low. CTU offers a comprehensive alternative to IVP but does not obviate the need for adjunctive cystourethroscopy for accurate evaluation of the lower urinary tract. (CME credit article)

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Serum marker identification of benign prostatic hyperplasia 

Benign prostatic hyperplasia (BPH) is a common disease in men that until recently was considered to be a single disease with varying symptoms. Molecular marker JM-27, an androgen regulated gene, is strongly expressed in the prostate, testes and uterus, and has been identified as one of a number of genetic components that appear to be central to the development of BPH. JM-27 is expressed at a greater than 17-fold rate in individuals with BPH symptoms in comparison to the same region of the prostate in those without the disease, and it is much higher than that in men without symptoms. In a cooperative study Cannon et al (page 610) performed quantitative measurements of serum JM-27 in 68 patients (asymptomatic BPH 29, symptomatic BPH 39 and prostate cancer 17). Using determined cutoff serum levels of JM-27, the authors were able to distinguish between symptomatic and asymptomatic BPH, and determine that the sensitivity and specificity of the assay were 90% and 77%, respectively. The presence of prostate cancer in these men did not appear to alter the level of the marker.

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The impact of ischemia time during nephron sparing surgery on solitary kidneys 

The impact of renal ischemia on subsequent renal function is of concern, particularly with the use of vascular clamping for laparoscopic partial nephrectomy. To gain information regarding the safe duration of ischemia during nephron sparing open surgery, Thompson et al (page 471) evaluated renal effects of vascular clamping in a cooperative study in 537 cases of solitary kidneys. Renal complications were compared among patients who did not require vascular clamping (85), and those who had warm ischemia (174) and cold ischemia (278). Median tumor size was smaller in patients with no ischemia compared to warm and cold ischemia. Warm and cold ischemia was associated with a significantly increased risk of urine leak, acute and chronic renal failure, and temporary dialysis compared to no ischemia. Warm ischemia longer than 20 minutes and cold ischemia longer than 35 minutes were associated with a higher incidence of acute renal failure. Additionally, warm ischemia longer than 20 minutes was associated with an increased risk of chronic renal insufficiency. Vascular clamping during open nephron sparing surgery was associated with a higher incidence of renal complications. Attempts to limit warm ischemia to 20 minutes and cold ischemia to 35 minutes should be used when vascular clamping is necessary.

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Predicting urethral injury from pelvic fracture patterns 

Basta et al (page 571) from Seattle, Washington hypothesized that injuries to the urethra in males with pelvic fractures caused by diastasis of the symphysis pubis or by direct penetration of inferomedial pubic bone fragments can be predicted by identification of the pelvic fracture patterns. In this retrospective, nested, case control study of 119 patients evaluated at a single, large, level 1 trauma center between January 1, 1997 and July 15, 2003 detailed measurements were performed of the location, displacement and direction of force of each anterior pelvic fracture using computerized tomography and pelvic radiography. Urethral injury was present in 25 patients, all of whom had anterior pelvic fracture (including symphysis pubis diastasis). There were no urethral injuries in patients with fractures isolated to the acetabulum. Pelvic fractures that were independently associated with urethral injury included displaced fractures of the inferior medial pubic bone and symphysis pubic diastasis. Each millimeter of symphysis pubic diastasis or inferior medial pubic bone fracture displacement was associated with an approximately 10% increase in risk of urethral injury.

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Is the metabolic syndrome an independent risk factor for erectile dysfunction? 

Erectile dysfunction (ED) is recognized as having a multifactorial pathogenesis including lifestyle, neurological, hormonal, vascular and psychological factors. To determine the role of the metabolic syndrome (MS) as an independent risk factor for erectile dysfunction, Heidler et al (page 651) from Vienna, Austria assessed 2,371 men participating in a health screening project who completed the International Index of Erectile Function-5. MS was defined according to the 2005 International Diabetes Federation consensus definition. Of the men studied 33.4% had no ED, 59.7% mild ED and 6.9% moderate to severe ED. MS was present in 33.8% of men. On multiple linear regression analysis an increased waist-to-hip ratio and MS were independently associated with decreasing International Index of Erectile Function-5 score. MS was correlated with ED only in men 50 years old or older with an increase in severe ED of 48%.

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Watchful waiting for solid renal masses 

As more solid renal masses are identified with increasing use of computerized tomography and magnetic resonance imaging, the question arises whether all patients need treatment and whether some could be followed. Kouba et al (page 466) from Chapel Hill, North Carolina examined the characteristics of enhancing renal masses in patients undergoing serial imaging and expectant management because of comorbidity or patient choice. They also examined the outcome of patients who underwent definitive intervention after a period of surveillance using serial imaging. A total of 43 patients with 46 renal masses underwent planned expectant management of enhancing solid or cystic (Bosniak IV) renal masses. At a mean followup of 36 months 74% of patients had tumor growth (mean growth rate 0.7 cm, median 0.35 cm per year). None of the patients had significant symptoms, disease progression or cancer specific death. Four patients died of other causes. The 13 patients (14 tumors) undergoing eventual intervention were younger than those who did not undergo intervention (age 56 vs 72 years), and the patients undergoing intervention tended to have higher tumor growth rates than those on continued observation (0.9 vs 0.61 cm per year). Renal cell carcinoma was present in 12 of the 14 tumors (87%) in the 13 patients undergoing intervention. All tumors were stage pT1 and 12 of the 13 patients were alive after a mean followup of 41 months (1 patient died of other causes 30 months after surgery). The authors conclude that watchful waiting for renal masses is a reasonable option for appropriately selected patients, especially those with competing comorbidities.

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Book review 

On page 800 Wolf reviews Prevention and Management of Laparoendoscopic Surgical Complications.

PII: S0022-5347(06)02798-4

doi:10.1016/j.juro.2006.10.090

The Journal of Urology
Volume 177, Issue 2 , Pages 417-419, February 2007

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