Although performed infrequently, the ileal ureter represents a vital operation in the urologist's armamentarium. The open technique for the ileal ureter involves extensive dissection and a large incision, and is associated with significant morbidity. Stein et al (page 1032) from Cleveland, Ohio compared the technique and outcomes of the laparoscopic assisted ileal ureter to the open technique. There was a trend toward shorter hospital stay and less analgesic use in the patients treated with laparoscopic surgery. The authors stress that the laparoscopic procedure requires more time than the open procedure and is challenging to perform. The use of robotics may allow a smoother transition for the average urologist since the anastomoses of ileum to the bladder and renal pelvis should be theoretically much easier.
Second Cancers as Competing Causes of Death After Radical Prostatectomy
There is a continuing debate whether treatment of prostate cancer improves overall patient survival as one of the competing causes of death is secondary malignancies. Froehner et al (page 967) from Dresden, Germany reviewed the records of 1,910 consecutive patients who underwent prostatectomy for prostate cancer between 1992 and 2004. Median patient age was 65 years and the risk of dying of a second malignancy within 10 years of prostatectomy was approximately 4%. This death rate was somewhat lower than that from prostate cancer (5.4%) and other causes (5.8%). Among secondary cancers colorectal cancer, lung cancer and hematopoietic malignancies were the most common. The authors conclude that the relative contribution of secondary cancers to mortality within 10 years of treatment reflects the overall good health of patients selected for radical prostatectomy.
Effect of Carbohydrate-Electrolyte Sports Beverages on Urinary Stone Risk
Debate continues on whether certain sports drinks are associated with an increased or reduced incidence of renal calculi. Consuming any fluids to avoid dehydration likely reduces the risk of stone formation regardless of composition but whether sports drink formulation alters urine composition to specially reduce the risk of calcium containing calculi is unknown. The use of additives such as vitamin C, citrate and other constituents is postulated to decrease stone formation. Sweeney et al (page 992) from Pittsburgh, Pennsylvania evaluated 12 normal and 12 hypercalciuric stone formers during a 4-week period, and performed a crossover study in which patients were first normalized for fluid intake and then underwent 24-hour urine and blood analysis for stone risk factors. Gatorade® failed to change urinary volume, calcium and citrate compared to water at baseline. The authors conclude that Gatorade does not increase or decrease the risk of stone disease.
Robot Versus Laparoscopic Partial Nephrectomy for Renal Tumors
Laparoscopic partial nephrectomy has emerged as one of the principal options for surgical removal of small renal masses. However, the challenges of tumor dissection and intracorporeal suturing hinder the widespread adoption of this approach. Robotic laparoscopic surgery, with its technical advances such as magnified stereoscopic visualization and fully articulating instruments, may reduce the technical challenges of minimally invasive partial nephrectomy. The use of robotic technology has facilitated suturing so reconstruction of the renal capsule and small vessels may be improved. Benway et al (page 866) compared 118 consecutive pure laparoscopic partial nephrectomies to 129 consecutive robotic partial nephrectomies in a 4-year period at 3 academic centers. Although this was not a prospective randomized trial the 2 groups were comparable in tumor size and pathology. Intraoperative blood loss and warm ischemia times (15.3 vs 25.2 minutes for simple tumors and 25.2 vs 36.7 minutes for complex tumors) were substantially less for robotic surgery, and wounds healed faster with shorter hospital stays in the robotic series. The authors conclude that robotic assisted laparoscopic partial nephrectomy offers advantages over pure laparoscopic partial nephrectomy for renal tumors.
The R.E.N.A.L. Nephrometry Score
The increase in new focal ablative approaches for small renal tumors, such as thermal ablation, laparoscopy and robotics, has expanded treatment choices for nephron sparing approaches as well. However, it is difficult to compare series or stratify patients using only tumor size. Surgeons recognize that in addition to size, location and depth of penetration are critical. A staging system incorporating these variables would be useful. Kutikov and Uzzo (page 844) from Philadelphia, Pennsylvania propose a novel methodology to standardize reporting for small renal masses and partial nephrectomy. Their technique uses the acronym R.E.N.A.L. (Radius, Exophytic versus Endophytic, Nearness of the tumor to the collecting system, Anterior or posterior and Location relative to the polar line). The authors used this system to classify 50 consecutive renal masses treated with radical or partial nephrectomy using a laparoscopic or robotic approach. The staging characteristics were based primarily on computerized tomography to classify these cases. The authors conclude that such a classification system is feasible. It will be interesting to correlate this scoring system with such surgical parameters as intraoperative blood loss, duration of surgery, ease of surgical removal and recurrence rates.
Open Versus Laparoscopic Radical Prostatectomy
Debate continues whether laparoscopic radical prostatectomy offers any advantages over the open retropubic technique. Dahl et al (page 956) from Boston, Massachusetts compared pure laparoscopic to open radical prostatectomy for similar stage and grade tumors. There were no differences between the groups in regard to baseline or 1-year postoperative erectile and voiding functions. Cancer control status was excellent in both groups. The unadjusted life table estimate for the likelihood of returning to full physical function at 6 months was 82.4% after laparoscopic surgery and 89.1% after open surgery. At 1 year postoperatively prostate specific antigen (PSA) was less than 0.2 ng/ml in 98% of men who underwent the open procedure and 93% of those treated with the laparoscopic approach. Thus, the authors question the overall value of the pure laparoscopic technique.
Percutaneous Tibial Nerve Stimulation Versus Extended-Release Tolterodine
The treatment of urinary frequency and overactive bladder is frustrating for patients in whom antimuscarinics fail. In this multi-institutional, randomized, controlled study reported by Peters et al (page 1055) percutaneous tibial nerve stimulation (PTNS) was compared to extended-release tolterodine for a 12-week period. Patients were randomized to receive either extended-release tolterodine or PTNS and an overactive bladder questionnaire was used to compare results with baseline. In the PTNS arm 79% of the patients reported improvement or cure vs 54% of the tolterodine subjects. However, differences in overall assessment scores did not reach statistical significance. Objective measurements showed improvements in both groups including reduction in frequency and severity of incontinence episodes. In this small trial PTNS resulted in greater patient satisfaction and self-reported improvement or cure than extended-release tolterodine, although relief from symptoms was similar in both groups. The authors note that a noninvasive, low morbidity method of neuromodulation that is effective for overactive bladder would be of value.
Urinary Collecting System Invasion and Organ Confined Renal Cell Carcinoma
Accurate staging of renal cell carcinoma is crucial for defining prognostic tools to identify patients at greater risk of recurrence, selecting adjuvant or neoadjuvant chemotherapy and providing effective post-therapy surveillance protocols. Verhoest et al (page 854) evaluated the records of 1,224 patients treated with nephrectomy for renal tumor at 5 European centers. On univariate analysis TNM stage, Fuhrman grade, tumor size, Eastern Cooperative Oncology Group performance status and urinary collecting system invasion were identified as independent prognostic factors for predicting cancer specific survival. Urinary collecting system invasion was an independent predictor comparable only in the setting of pT1-T2 tumors. When the urinary collecting system was invaded, 5 and 10-year probabilities of survival were 43% and 41%, respectively. Thus, the authors suggest that urinary collecting system invasion should be included among prognostic variables in cases of renal cell carcinoma.
Is Sperm Banking of Interest to Patients With Nongerm Cell Urological Cancer?
The American Society of Clinical Oncology released guidelines several years ago stating that oncologists seeing reproductive aged patients should address treatment related fertility. However, physicians are unsure how many men are actually interested in sperm banking. Salonia et al (page 1101) from Milan, Italy asked a rather diverse group of 753 patients their opinions on sperm banking before procedures potentially damaging to male fertility, of whom 69% had nongerm cell urological cancer. Only 242 men (32%) favored pretreatment sperm banking. Age, a stable relationship and fatherhood were inversely associated with sperm banking, and urological cancer and education were positively associated with sperm banking. This relatively low rate of urological patients willing to bank sperm before a potentially fertility damaging procedure suggests that better patient information is needed regarding risks, cost and usefulness of sperm banking.
Primary Cryoablation Nadir PSA and Biochemical Failure
There are differences of opinion regarding what represents a standard nadir PSA and the criteria for progression to biochemical failure for a variety of ablation techniques for prostate cancer. Levy et al (page 931) contribute to this debate by examining the records of 2,427 cryoablation cases from the Cryo On-Line Data Registry. Cases were stratified by a PSA nadir of less than 0.1, 0.1 to 0.5, 0.6 to 1 and 1.1 to 2.5 ng/ml, and as low, intermediate or high risk. The data reflected that when initial post-cryoablation PSA was 0.6 ng/ml or greater the 24-month biochemical failure rate was significant (29.5% in the low risk group, 46% in the intermediate risk group and 54% in the high risk group). The authors recommend using 0.6 ng/ml as the cut point for close surveillance.
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