The Journal of Urology
Volume 179, Issue 1 , Pages 1-3, January 2008

This Month in Clinical Urology

published online 14 November 2007.

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Analysis of a Computer Based Simulator as an Educational Tool for Cystoscopy 

Gettman et al (page 267) from Rochester, Minnesota evaluated a computer based simulator as an educational tool for cystoscopy. They compared 27 experts with 30 individuals considered novice even though most were health care professionals. The expert group performed better initially and through 5 successive trials in the time required to complete certain tasks. The expert subjects had a lower subjective opinion of the simulator, indicating that additional refinement of the computer based simulator is required to optimize the learning of cystoscopic skills.

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Prediction of Survival in Metastatic Prostate Cancer 

Robinson et al (page 117) from Jönköping, Sweden analyzed 697 men participating in a prospective randomized trial to determine predictors of survival in those receiving hormonal therapy for metastatic prostate cancer. Alkaline phosphatase at 6 months gave a better prediction of survival than baseline levels. This finding is explained by the fact that 6-month levels reflect the extent of the response to hormonal therapy. These parameters may help identify men who should be considered for additional therapy early in the course of treatment.

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Deferred Androgen Deprivation Therapy for Men With Metastatic Prostate Cancer After Radical Prostatectomy 

Makarov et al (page 156) from Baltimore, Maryland evaluated data from 91 men in whom disease metastasized after radical prostatectomy. Of these men 41 died of prostate cancer. Median time from surgery to prostate specific antigen (PSA) failure was 24 months, from PSA failure to metastasis was 36 months and from radical prostatectomy to death was 168 months. Pain and a short PSA doubling time predicted an unfavorable outcome. Whether the surgery itself altered the outcome for these patients is uncertain. Furthermore, these data cannot be used to determine the optimal timing of androgen deprivation. However, they do show that patients in whom disease recurs after surgery can generally anticipate many years of survival.

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The Effect of Shock Wave Rate on the Outcome of Shock Wave Lithotripsy 

Semins et al (page 194) from Baltimore, Maryland performed a meta-analysis of the effects of shock wave rate on outcome. They selected 4 randomized prospective trials, each of which originated in a different country, and used a different lithotriptor. Patients treated at a rate of 60 shocks per minute had a significantly greater likelihood of a successful outcome. The exact mechanism by which a slower shock wave may enhance the breakup of stones is not well understood but is likely related to the dynamic behavior of cavitation bubbles.

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Outcomes of Vasovasostomy Performed in the Convoluted vs Straight Vas Deferens 

Patel and Sigman (page 256) from Providence, Rhode Island retrospectively compared the results of 42 patients who underwent vasovasostomy in the straight portion of the vas deferens and 64 in the convoluted vas. The groups were well matched for patient age and mean time from the original vasectomy. The patency rate was 98.1% and 97.3% for the convoluted and straight vas reversal groups, respectively. Although vasovasostomy in the convoluted vas deferens is technically more challenging than in the straight vas deferens, the patency rate and postoperative semen analysis parameters were not statistically different between the groups.

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The Impact of Phytotherapy on Utility Scores for 5 Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms Health States 

A symptom based perspective affords the clinician or researcher a better understanding of the symptoms which most severely affect patient quality of life. Dedhia et al (page 220) from Chicago, Illinois evaluated utility scores for 5 benign prostatic hyperplasia/lower urinary tract symptoms health states. In their health states they included a history of urinary tract infection, erectile dysfunction or ejaculatory dysfunction, domains not included in the American Urological Association symptom index. Patients who had used phytotherapy had markedly lower and statistically significantly decreased utility scores than those who had not used phytotherapy despite comparable clinical parameters. The authors speculated that an increased education level and higher expectations for health status among the herbal users accounted for these differences.

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Myoblast and Fibroblast Therapy for Post-Prostatectomy Urinary Incontinence 

Mitterberger et al (page 226) from Innsbruck, Austria evaluated 1-year followup data on patients undergoing autologous biceps muscle derived myoblast and fibroblast therapy for post-prostatectomy incontinence. Of 63 patients 41 were continent 12 months after implantation of cells. Thickness and contractility of the rhabdosphincter were significantly improved after surgery. They anticipate multicenter studies with larger patient numbers will confirm their findings.

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Effects of Hospital Procedure Volume and Resident Training on Clinical Outcomes of Radical Retropubic Prostatectomy 

Ku et al (page 272) from San Francisco, California used data from the National Surgical Quality Improvement Program of the Veterans Health Administration to examine the effects of case volume and resident participation on radical retropubic prostatectomy outcomes. Clinical outcomes data were evaluated from 5,736 patients. Longer operative times but shorter hospital lengths of stay were found in Veterans Affairs hospitals associated with academic training institutions. Among the academic institutions low vs high hospital volume was associated with a longer length of stay and higher transfusion rates. There was a significant clustering of outcomes at the hospital level, suggesting that unmeasured institutional factors may be key predictors of clinical and resource related outcomes after radical retropubic prostatectomy.

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Risk of Upper Tract Recurrence Following Radical Cystectomy for Urothelial Cancer 

Tran et al (page 96) from New York, New York evaluated the longitudinal risk of upper tract recurrence after cystectomy in 1,329 patients. The 3 and 5-year cumulative incidence of upper tract recurrence was 4% and 7%, respectively. Landmark time analysis showed the 3-year cumulative incidence remained at 4% to 6% even 4 years after surgery. Any ureteral involvement (including carcinoma in situ) was associated with a significantly higher risk of upper tract recurrence. As the incidence of recurrence did not change over time, the authors emphasized the critical importance of long-term surveillance of the upper tracts following radical cystectomy. (CME credit article)

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Long-Term Urinary Sequelae Following 125Iodine Prostate Brachytherapy 

Crook et al (page 141) from Toronto, Canada evaluated long-term urinary function in 484 patients with favorable risk prostate cancer treated with 125iodine brachytherapy. A year after treatment 73.3% of men had no significant urinary sequelae. An increase of more than 5 points above baseline International Prostate Symptom Score was seen in 112 patients (23%) but the majority responded to medical therapy. Of the patients 8% required long-term α-blocker therapy and 13 men (2%) required a catheter at some point more than 1 year after brachytherapy. Only 2 (0.4%) of the original 484 patients required transurethral prostatectomy. (CME credit article)

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Incidence of Detrusor Overactivity in Women With Stress Urinary Incontinence 

Choe et al (page 214) from Seoul, Korea assessed the impact of the tension-free vaginal tape procedure on overactive bladder symptoms. Of 549 women with stress urinary incontinence undergoing the procedure 180 had overactive bladder syndrome. Of these patients 132 had more than 3 months of followup and 31 of the 132 (23%) had complete resolution of all overactive bladder symptoms. Patients with detrusor overactivity had a significantly greater amount of urinary leakage than those without detrusor overactivity but there was no significant difference in the 2 groups in terms of the cure rate for stress incontinence. (CME credit article)

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Conservative Management of Low Risk Superficial Bladder Tumors 

Traditionally patients with low grade and low stage bladder tumors have been treated with transurethral resection or fulguration. However, because of the high rate of recurrence, many patients require frequent surgical intervention. Less aggressive treatment is increasingly being considered for low risk patients. Pruthi et al (page 87) from Chapel Hill, North Carolina evaluated outcomes in 22 patients under expectant management for low risk bladder tumors. With a mean followup of 25 months 8 patients showed no growth in tumor volume, 9 had minimal growth and 5 had moderate growth. There were 15 patients who remained without any active intervention. Two had evidence of progression in tumor grade on followup transurethral bladder tumor resection and 1 (4.5%) had progression in stage to T1 disease. The authors concluded that expectant management may be appropriate for some patients, especially those who are older or with significant comorbidity. However, they pointed out that careful periodic cystoscopic and cytological surveillance is necessary as long as there remains at least some progression in grade or stage. (CME credit article)

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Safety and Efficacy of Intravesical and Oral Pentosan Polysulfate Sodium for Interstitial Cystitis 

The safety and efficacy of a combination of intravesical and oral pentosan polysulfate sodium (PPS) vs only oral PPS for the treatment of interstitial cystitis were evaluated in a randomized prospective trial by Davis et al (page 177) from Glendora, California. Patients with interstitial cystitis were randomized to receive combination therapy or intravesical placebo plus oral PPS for 6 weeks. All subjects continued to receive oral PPS for another 12 weeks. A statistically greater change in symptom score occurred in the combination treatment group compared to the placebo group. There was no significant difference in adverse events between treated and placebo groups. (CME credit article)

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Book Review 

On page 387 Monga reviews Clinical Research Methods for Surgeons.

PII: S0022-5347(07)02648-1

doi:10.1016/j.juro.2007.10.002

The Journal of Urology
Volume 179, Issue 1 , Pages 1-3, January 2008

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