European Urology

Editorial Board

2012-03-01

Award pages

2012-03-01

Academic Ranking Score: A Publication-Based Reproducible Metric of Thought Leadership in Urology

2011-10-26

Abstract: Background: Hospital rankings have become integral to the marketing strategies of many health care systems. Methodology used in compiling these lists appears highly flawed.Objective: To improve on current hospital ranking systems and to develop a more meaningful measure of a urology department's contribution to the field, we developed an academic ranking score (ARS) based on publicly available data.Design, setting, and participants: An active faculty list was assembled for each department. A list of all publications from each department from 2005 to 2010 was then compiled. Only publications with faculty members as first or last author were considered. The ARS was then derived by identifying the number of publications within an institution, normalized by the impact factor of the peer-reviewed journal in which the publication appeared.Measurements: The 2010 U.S. News & World Report (USNWR) urology list was reranked based on ARS and compared with the USNWR rank list. ARS was also calculated for several leading European urologic centers.Results and limitations: A total of 6437 urologic publications were indexed to calculate the ARS. Two of the top three programs in the USNWR rankings dropped out of the top 10. The top 10 academically ranked programs increased or decreased an average of >5 positions (range: 0–17). No correlation was seen between programs ranked in the top 10 by USNWR and our objective ARS method (Spearman ρ: −0.1; p=0.75). Because ARS only includes first- or last-author publications for faculty with clinical duties, ARS likely excludes basic science contributions and contributions from nonclinical faculty.Conclusions: Ranking of urology departments through quantification of each program's recent academic contribution, as captured by the ARS, differs substantially from rankings developed by USNWR. Integration of such objective measures into an overall urology program ranking system would replace current subjective opinions marred by historical biases with up-to-date merit-based assessments.Take Home Message: As we move toward increasingly accountable, evidence-based care, the urology community must test and publish objective performance assessments. The academic ranking system presented in this paper affords quantification of a department's thought leadership and academic contributions.

Impact Factor for Ranking Academic Urologic Institutions

Manfred P. Wirth, Michael Froehner — 2011-11-21

Although serious criticism surrounds the measurement of scientific activity of individuals or institutions by counting impact factors, it continues to enjoy great popularity in the scientific community and is difficult to resist . In this issue, Kutikov and coworkers present an academic ranking system to afford quantification and comparability of the scientific output of leading institutions in the field of urology . Rankings of the reputation of academic institutions or individuals are always interesting to read, particularly when oneself or one's own institution plays a prominent role. Providing objective and reproducible measures for such rankings could be an improvement. But do Kutikov et al. provide such a measure?

Reply from Authors re: Manfred P. Wirth, Michael Froehner. Impact Factor for Ranking Academic Urologic Institutions. Eur Urol 2012;61:440–1

Alexander Kutikov, Robert G. Uzzo — 2011-12-08

We appreciate the comments regarding our work describing the academic ranking score (ARS), an objective measure of thought leadership in urology . The effort was motivated by reviewing the annual rankings of urology departments by US News & World Report (USNWR) magazine . Although these highly publicized rankings are legitimized by heavy hospital advertising, the methodology used for generating the lists is questionable at best. In fact, of the three “quality domains” the magazine uses to generate hospital rankings—structure, process, and outcomes—the process domain has had a tremendous dominating effect on the final rankings. This process domain overwhelmingly measures the hospital's reputation score . As such, the rankings in USNWR essentially reflect a hospital's supposed national reputation, a characteristic that is only further reinforced by the magazine's rankings.

Postoperative Radiation Therapy for Pathologically Advanced Prostate Cancer After Radical Prostatectomy

2011-10-24

Abstract: Context: Approximately 15–25% of men who undergo radical prostatectomy for localized prostate cancer (PCa) will experience recurrence of their cancer; men with poorly differentiated cancer, non–organ-confined disease, and positive surgical margins are at the highest risk.Objective: Review accumulating evidence indicating that postoperative radiotherapy (RT) to the prostate bed favorably influences the course of disease in men with adverse pathologic features.Evidence acquisition: Three phase 3 randomized trials of adjuvant RT versus observation have reported improved freedom from biochemical recurrence (BCR) and local control: Southwest Oncology Group (SWOG) 8794, European Organization for Research and Treatment of Cancer (EORTC) 22911, and the German Cancer Society (ARO 96-02).Evidence synthesis: Conflicting evidence from these trials suggests that adjuvant RT can have a favorable impact on systemic progression, PCa-specific mortality, or overall survival. Observational studies have reported durable responses to salvage RT in a substantial proportion of high-risk patients (provided that it is administered at the earliest evidence of BCR) and reduced PCa-specific mortality. There is consensus that the outcome of patients receiving postoperative RT is best when the prostate-specific antigen (PSA) level is the lowest. However, it is unclear if better outcomes will be achieved administering adjuvant RT to all patients at increased risk for recurrent PCa who have an undetectable postoperative PSA level compared to close observation and timely salvage RT at the earliest indications of BCR.Conclusions: Given the absence of data from randomized trials demonstrating superiority of one approach over the other in terms of quantity and quality of life, we advocate multidisciplinary input and shared and informed decision making among patients, urologists, and radiation oncologists based on the relative advantages and disadvantages of each approach.Take Home Message: For patients with adverse pathologic features of prostate cancer, the issue of whether they should receive adjuvant radiotherapy or should be monitored closely and receive salvage radiotherapy at the earliest signs of biochemical recurrence is controversial. The authors advocate multidisciplinary input and shared and informed decision making among patients, urologists, and radiation oncologists based on the relative advantages and disadvantages of each approach.

Treat Now or Later: The Dilemma of Postoperative Radiotherapy

Adam S. Kibel — 2011-12-05

The management of adverse pathology following radical prostatectomy (RP) is a difficult treatment dilemma. The debate centers on three treatment paradigms: additional systemic therapy, additional local therapy, or close observation. For the individual patient, the decision focuses on risk of systemic disease and risk of local recurrence. The excellent review article by Stephenson et al. concisely and completely outlines the literature surrounding adjuvant versus salvage radiation therapy (RT) for patients with adverse pathology. It is unfortunate that although we are blessed with three randomized trials addressing the utilization of adjuvant RT, a lack of consensus remains as to the optimal management of these patients.

Preoperative Prostate-Specific Antigen Isoform p2PSA and Its Derivatives, %p2PSA and Prostate Health Index, Predict Pathologic Outcomes in Patients Undergoing Radical Prostatectomy for Prostate Cancer

2011-11-07

Abstract: Background: Currently available predictive models fail to assist clinical decision making in prostate cancer (PCa) patients who are possible candidates for radical prostatectomy (RP). New biomarkers would be welcome.Objective: Test the hypothesis that prostate-specific antigen (PSA) isoform p2PSA and its derivates, percentage of p2PSA to free PSA (%p2PSA) and the Prostate Health Index (PHI), predict PCa characteristics at final pathology after RP.Design, setting, and participants: An observational prospective study was performed in 350 consecutive men diagnosed with clinically localised PCa who underwent RP.Measurements: We determined the predictive accuracy of serum total PSA (tPSA), free PSA (fPSA), fPSA-to-tPSA ratio (%fPSA), p2PSA, %p2PSA, and PHI. The primary end point was to determine the accuracy of these biomarkers in predicting the presence of pT3 disease, pathologic Gleason sum ≥7, Gleason sum upgrading, and tumour volume <0.5ml.Intervention: Open retropubic and robot-assisted laparoscopic RP was performed. Pelvic lymphadenectomy was performed according to baseline oncologic parameters and the surgeon's judgement.Results and limitations: The %p2PSA and PHI levels were significantly higher in patients with pT3 disease, pathologic Gleason sum ≥7, and Gleason sum upgrading (all p values <0.001). Conversely, %p2PSA and PHI levels were significantly lower in patients with tumour volume <0.5ml (p < 0.001). By univariate analysis, both %p2PSA and PHI were accurate predictors of pT3 disease, pathologic Gleason sum ≥7, Gleason sum upgrading, and tumour volume <0.5ml. By multivariate analyses, the inclusion of both %p2PSA and PHI significantly increased the predictive accuracy of a base multivariate model (excluding the tumour volume prediction for both variables, and Gleason sum upgrading for the model including %p2PSA) that included patient age, tPSA, fPSA, f/tPSA, clinical stage, and biopsy Gleason sum.Conclusions: We found that p2PSA and its derivatives are predictors of PCa characteristics at final pathology after RP and are more accurate than currently available markers.Take Home Message: Two new biomarkers, percentage of p2PSA to free prostate-specific antigen and Prostate Health Index, are predictors of several prostate cancer (PCa) characteristics at final pathology. They might be adopted in preoperative counseling for patients with localised PCa.

PSA is Dead, Long Live PSA

Andrew J. Vickers, Hans Lilja — 2011-12-05

Prostate-specific antigen (PSA) has been called many things in recent years, few of them nice. Some of the words used to describe PSA include over, discredited, and lost. The chair of the US Preventive Services Task Force stated that PSA “cannot tell the difference between cancers that will and will not affect a man during his natural lifetime.” Some have gone further, calling PSA “an unconscionable crime against humanity” (references available on request).

Reply from Authors re: Andrew J. Vickers, Hans Lilja. PSA Is Dead, Long Live PSA. Eur Urol 2012;61:467–8

2011-12-21

We really appreciated the comments reported in the full-length editorial by Vickers and Lilja about our study on the predictive role of preoperative prostate-specific antigen (PSA) isoform p2PSA and its derivatives, %p2PSA and the Prostate Health Index (PHI), for pathologic outcomes in patients undergoing radical prostatectomy for prostate cancer (PCa) . In recent years, there has been increased interest in cancer biomarkers for the diagnosis, prognosis, and monitoring of PCa, and PSA is also being studied intensely to find out how it can be of more use in PCa screening .

Evaluation of Multiple Risk–Associated Single Nucleotide Polymorphisms Versus Prostate-Specific Antigen at Baseline to Predict Prostate Cancer in Unscreened Men

2011-11-09

Abstract: Background: Although case-control studies have identified numerous single nucleotide polymorphisms (SNPs) associated with prostate cancer, the clinical role of these SNPs remains unclear.Objective: Evaluate previously identified SNPs for association with prostate cancer and accuracy in predicting prostate cancer in a large prospective population-based cohort of unscreened men.Design, setting, and participants: This study used a nested case-control design based on the Malmö Diet and Cancer cohort with 943 men diagnosed with prostate cancer and 2829 matched controls. Blood samples were collected between 1991 and 1996, and follow-up lasted through 2005.Measurements: We genotyped 50 SNPs, analyzed prostate-specific antigen (PSA) in blood from baseline, and tested for association with prostate cancer using the Cochran-Mantel-Haenszel test. We further developed a predictive model using SNPs nominally significant in univariate analysis and determined its accuracy to predict prostate cancer.Results and limitations: Eighteen SNPs at 10 independent loci were associated with prostate cancer. Four independent SNPs at four independent loci remained significant after multiple test correction (p<0.001). Seven SNPs at five independent loci were associated with advanced prostate cancer defined as clinical stage ≥T3 or evidence of metastasis at diagnosis. Four independent SNPs were associated with advanced or aggressive cancer defined as stage ≥T3, metastasis, Gleason score ≥8, or World Health Organization grade 3 at diagnosis. Prostate cancer risk prediction with SNPs alone was less accurate than with PSA at baseline (area under the curve of 0.57 vs 0.79), with no benefit from combining SNPs with PSA. This study is limited by our reliance on clinical diagnosis of prostate cancer; there are likely undiagnosed cases among our control group.Conclusions: Only a few previously reported SNPs were associated with prostate cancer risk in the large prospective Diet and Cancer cohort in Malmö, Sweden. SNPs were less useful in predicting prostate cancer risk than PSA at baseline.Take Home Message: Although numerous single nucleotide polymorphisms (SNPs) associated with prostate cancer risk have been identified and can be consistently replicated, these SNPs neither can predict who will develop prostate cancer alone nor do they enhance the predictive power of prostate-specific antigen testing.

It Is Time to Move On

George N. Thalmann — 2011-12-02

Prostate-specific antigen (PSA) screening is currently under scrutiny by many governmental agencies worldwide. Current practice for prostate cancer diagnosis relies on PSA-triggered biopsies that do not identify only clinically relevant cancers. This has important clinical implications for a growing population at risk. Finding new and more reliable and predictive markers is a dire need of utmost importance.

Updated Nomogram Predicting Lymph Node Invasion in Patients with Prostate Cancer Undergoing Extended Pelvic Lymph Node Dissection: The Essential Importance of Percentage of Positive Cores

2011-11-07

Abstract: Background: Few predictive models aimed at predicting the presence of lymph node invasion (LNI) in patients with prostate cancer (PCa) treated with extended pelvic lymph node dissection (ePLND) are available to date.Objective: Update a nomogram predicting the presence of LNI in patients treated with ePLND at the time of radical prostatectomy (RP).Design, setting, and participants: The study included 588 patients with clinically localised PCa treated between September 2006 and October 2010 at a single tertiary referral centre.Intervention: All patients underwent RP and ePLND invariably including removal of obturator, external iliac, and hypogastric nodes.Measurements: Prostate-specific antigen, clinical stage, and primary and secondary biopsy Gleason grade as well as percentage of positive cores were included in univariable (UVA) and multivariable (MVA) logistic regression models predicting LNI and formed the basis for the regression coefficient-based nomogram. The area under the curve (AUC) method was used to quantify the predictive accuracy (PA) of the model.Results and limitations: The mean number of lymph nodes removed and examined was 20.8 (median: 19; range: 10–52). LNI was found in 49 of 588 patients (8.3%). All preoperative PCa characteristics differed significantly between LNI-positive and LNI-negative patients (all p<0.001). In UVA predictive accuracy analyses, percentage of positive cores was the most accurate predictor of LNI (AUC: 79.5%). At MVA, clinical stage, primary biopsy Gleason grade, and percentage of positive cores were independent predictors of LNI (all p ≤ 0.006). The updated nomogram demonstrated a bootstrap-corrected PA of 87.6%. Using a 5% nomogram cut-off, 385 of 588 patients (65.5%) would be spared ePLND. and LNI would be missed in only 6 patients (1.5%). The sensitivity, specificity, and negative predictive value associated with the 5% cut-off were 87.8%, 70.3%, and 98.4%, respectively. The relatively low number of patients included as well as the lack of an external validation represent the main limitations of our study.Conclusions: We report the first update of a nomogram predicting the presence of LNI in patients treated with ePLND. The nomogram maintained high accuracy, even in more contemporary patients (87.6%). Because percentage of positive cores represents the foremost predictor of LNI, its inclusion should be mandatory in any LNI prediction model. Based on our model, those patients with a LNI risk<5% might be safely spared ePLND.Take Home Message: The updated nomogram based on preoperative prostate-specific antigen, clinical stage, primary and secondary biopsy Gleason score, and percentage of positive cores showed high accuracy (87.6%) in contemporary patients treated with extended pelvic lymph node dissection (ePLND). Based on our model, those patients with a risk of nodal metastases <5% might be safely spared ePLND.

Updated Nomogram Predicting Lymph Node Invasion in Patients with Prostate Cancer Undergoing Extended Pelvic Lymphadenectomy: Optimizing a Risk-Adapted Surgical Approach

Axel Heidenreich — 2011-11-28

The current manuscript by Briganti et al. updates a nomogram to predict the presence of lymph node metastases (LNM) in 588 patients who underwent retropubic radical prostatectomy (RPE) and an extended pelvic lymphadenectomy (ePLND) for clinically organ-confined prostate cancer (PCa). EPLND was performed according to the currently recommended standards, including the obturator fossa, and the external and the internal iliac arteries . The lymph nodes (LNs) were sent for pathohistologic analysis in separate packages, thus increasing the quality of specimen assessment, number of analysed LNs, and, subsequently, the percentage of patients with positive LNs . The anatomic extent of pelvic lymphadenectomy (PLND) and communication and cooperation with pathologists already represent two major contributors to a high-quality RPE.

Long-term Renal Function After Urinary Diversion by Ileal Conduit or Orthotopic Ileal Bladder Substitution

2011-09-19

Abstract: Background: Data on long-term renal function are scarce for ileal conduit diversion (ICD) and even rarer for orthotopic ileal bladder substitution (BS).Objective: Explore the changes in renal function of patients who lived ≥10 yr with an ICD or BS and determine the risk factors contributing to renal function deterioration.Design, setting, and participants: Fifty consecutive ICD patients and 111 consecutive BS patients who lived ≥10 yr after undergoing surgery between January 1985 and December 2000 were retrospectively analyzed.Measurements: The glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease (MDRD) equation before and 10 yr after surgery. Decreased renal function was defined as a decrease in GFR >10ml/min per 1.73 m2 in 10 yr.Results and limitations: Median GFR values in patients with ICD or BS decreased from 65.5 (range: 23–90) to 57 (range: 7–100) ml/min per 1.73 m2 and from 68 (range: 33–106) to 66 (range: 16–100) ml/min per 1.73 m2, respectively. Eighteen ICD patients (36%) and 23 BS patients (21%) had deteriorating renal function. Seven of 12 ICD patients with obstruction (ureteroileal stricture, stomal stenosis/parastomal hernia) (58%) had renal function deterioration, as did 17 of 46 BS patients with obstruction (ureteroileal/nipple stricture and/or bladder outlet obstruction) (37%). Logistic regression analysis confirmed that obstruction was the leading, and an independent, risk factor for renal function deterioration for both ICD patients (p=0.045) and BS patients (p=0.002). Patients with diabetes or hypertension were significantly more likely to have deterioration of renal function if they had ICD (p=0.002 and p=0.05, respectively). The limitation of the study is its retrospective nature and its composition that included many patients who did not survive 10 yr.Conclusions: Urinary tract obstruction was the leading cause of long-term renal function impairment, regardless of whether the patient had ICD or BS. ICD patients with predisposing risk factors, such as diabetes or hypertension, were at increased risk for impaired renal function.Take Home Message: Urinary tract obstruction was the leading cause of renal function deterioration in both ileal conduit diversion (ICD) and bladder substitution (BS) patients during a ≥10-yr follow-up. It may be safer for patients with diabetes and/or hypertension to undergo BS than to receive an ICD.

Variables Affecting Long-term Maintenance of Renal Function Following Ileal Based Urinary Diversion

Ja Hyeon Ku, Seth P. Lerner — 2011-12-15

Urinary diversion is performed most frequently at the time of radical cystectomy for bladder cancer but may also be required in a variety of benign urologic conditions. Some of the key principles of urinary diversion are to create a low-pressure system, protect the upper urinary tract by minimizing the risk of mechanical or functional obstruction, and use the minimum amount of intestine for the reconstruction. Age, comorbidities, and nutritional depletion contribute to both perioperative and long-term morbidity.

Reply from Authors re: Ja Hyeon Ku, Seth P. Lerner. Variables Affecting Long-term Maintenance of Renal Function Following Ileal Based Urinary Diversion. Eur Urol 2012;61:498–500

Urs E. Studer — 2011-12-30

We read with great interest the editorial written by Ku and Lerner on our paper, “Long-term renal function after urinary diversion by ileal conduit or orthotopic ileal bladder substitution” . The following points are noteworthy.

Should Follow-up Cystoscopy in Bacillus Calmette-Guérin–Treated Patients Continue After Five Tumour-Free Years?

Sten Holmäng, Viveka Ströck — 2011-11-17

Abstract: Background: It is not known how long follow-up cystoscopy in tumour-free bacillus Calmette-Guérin (BCG)–treated patients should continue.Objective: Determine the incidence of late recurrences and progression after a tumour-free period of >5 yr after BCG treatment.Design, setting, and participants: Data on 542 patients with non–muscle-invasive bladder cancer treated with BCG between 1986 and 2003 were analysed. Of 542 patients, 204 patients (37.6%) were tumour-free for ≥5 yr. The median tumour-free period was 105.5 mo (range: 60–252 mo).Measurements: To compare the tumour-free group with patients who were not tumour-free for 5 yr, traditional variables (tumour grade, tumour stage, age, gender, tumour number and size, primary or recurrent tumour, BCG strain, previous chemotherapy, previous upper tract tumour, number of earlier resections, and European Organisation for Research and Treatment of Cancer recurrence and progression risk groups) were analysed using the Fisher exact test for dichotomous variables, the Mantel-Haenszel chi-square test for ordered categorical variables, and the Mann-Whitney U-test for continuous variables. Kaplan-Meier curves for time to recurrence were constructed using Statistica software (StatSoft, Tulsa, Oklahoma, USA). Differences between groups were tested with the log-rank test. For continuous variables, Cox proportional hazard regression was performed to find significant effect on the time to recurrence.Results and limitations: Twenty-two of 204 patients (10.8%) had a recurrence after being tumour-free for ≥5 yr. The Kaplan-Meier estimated risk for recurrence was 12.5% at 10 yr and 20.5% at 15 yr. Among patients with TaG1–TaG2 before BCG, 11 of 79 patients (13.9%) had recurrences, including three patients with invasive extravesical tumours. Among the bladder recurrences were seven TaG1s and one carcinoma in situ (CIS). Among the 125 patients with TaG3/CIS/T1 before BCG, 11 patients (8.8%) had recurrences, including 2 patients with invasive ureter tumours. The bladder recurrences were one T2, four CIS, and four TaG1. Late recurrences were 8.5 times more common among patients with recurrent tumours before BCG compared with patients treated after their first tumour episode. The study was retrospective and nonrandomised but unselected and population-based.Conclusions: A tumour-free period of 5 yr after BCG treatment is a good prognostic sign, but recurrences after >10 yr are not unusual. Literature data and the present report support cystoscopy follow-up for ≥10–15 tumour-free years, at least among patients with recurrent tumours and/or high-grade lesions before BCG treatment.Take Home Message: A tumour-free period of 5 yr after bacillus Calmette-Guérin (BCG) treatment is a good prognostic sign, but recurrences after >10 yr are not unusual. Cystoscopy follow-up should be considered for 10–15 yr after the last recurrence in patients treated with BCG.

A Plea for Long-Term Surveillance in Bacillus Calmette-Guérin–Treated Non–Muscle-Invasive Bladder Cancer

Richard P. Meijer, Bas W.G. van Rhijn — 2011-12-08

Guidelines provide detailed information on diagnosis and treatment but are less specific on how and how often patients need to be seen for follow-up after treatment for non–muscle-invasive bladder cancer (NMIBC) . Follow-up is essential in NMIBC, as 30–80% will recur and 1–45% will progress to muscle invasion within 5 yr . NMIBC is a chronic disease with varying oncologic outcomes requiring frequent follow-up and repeated treatments, rendering the cost per patient from diagnosis to death the highest of all cancers . It is concerning that despite the obvious importance of regular follow-up, adherence to surveillance among patients with NMIBC in a 3-yr surveillance period after initial treatment is <50%. Schrag et al. reported that only 40% of patients under surveillance had undergone all cystoscopic examinations, as recommended by the clinical guidelines.

Laparoendoscopic Single-Site Upper Urinary Tract Surgery: Assessment of Postoperative Complications and Analysis of Risk Factors

2011-08-22

Abstract: Background: Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to minimise the morbidity and scarring associated with surgical intervention.Objective: To evaluate the incidence of and the risk factors for complications in patients undergoing LESS upper urinary tract surgery.Design, setting, and participants: Between September 2007 and February 2011, 192 consecutive patients underwent LESS for upper urinary tract diseases at four institutions.Measurements: All complications occurring at any time after surgery were captured, including the inpatient stay as well as in the outpatient setting. They were classified as early (onset <30 d), intermediate (onset 31–90 d), or late (onset >90 d) complications, depending on the date of onset. All complications were graded according to the modified Clavien classification.Results and limitations: The patient population was generally young (mean: 55±18 yr of age), nonobese (mean body mass index [BMI]: 26.5±4.8kg/m2), and healthy (mean preoperative American Society of Anaesthesiologists [ASA] score: 2±1). Forty-six patients had had prior abdominal surgery. Mean operative time was 164±63min, with a mean estimated blood loss (EBL) of 147±221ml. In 77 cases (40%), the surgeons required additional ports, with a standard laparoscopy conversion rate of 6%. Mean hospital stay was 3.3±2.3 d, and the mean visual analogue scale (VAS) score at discharge was 1.7±1.43. Thirty-three complications were recorded—30 early, 2 intermediate, and 1 late—for an overall complication rate of 17%. Statistically significant associations were noted between the occurrence of a complication and age, ASA score, EBL, length of stay (LOS), and malignant disease at pathology. Univariable and the multivariable analyses showed that a higher ASA score (incidence rate ratio [IRR]: 1.4; 95% confidence interval [CI], 1.0–2.1; p=0.034) and malignant disease at pathology (IRR: 2.5; 95% CI, 1.3–4.7; p=0.039) represented risk factors for complications. Poisson regression analysis over time showed a 23% non-statistically significant reduction in risk of complications every year (IRR: 0.77; 95% CI, 0.5–1.19; p=0.242).Conclusions: Malignant disease at pathology and high ASA score represent a predictive factor for complication after LESS for upper urinary tract surgery. Thus, surgeons approaching LESS should start with benign diseases in low-surgical-risk patients to minimise the likelihood of postoperative complications.Take Home Message: Malignant disease at pathology and high American Society of Anaesthesiologists score represent predictive factors for complications after laparoendoscopic single-site surgery (LESS) for upper urinary tract disease. Surgeons approaching LESS should start with benign diseases in low-surgical-risk patients to minimise the likelihood of postoperative complications.

Laparoendoscopic Single-Site Surgery for the Upper Urinary Tract: Awaiting Evidence

Jonathan A. Coleman — 2011-11-21

Changes in surgical techniques, purported advances in particular, have traditionally been poorly studied and nearly always reported as a retrospective experience, looking back over a series of cases in which a single surgeon or group of surgeons attempted something different that they believed provided an advantage. In this issue, Greco and colleagues provide a similar report about laparoendoscopic single-site (LESS) surgical approaches used to address a variety of benign and malignant conditions involving the upper urinary tract and adrenal glands .

Reply from Authors re: Jonathan A. Coleman. Laparoendoscopic Single-Site Surgery for the Upper Urinary Tract: Awaiting Evidence. Eur Urol 2012;61:517–8

Francesco Greco, Luca Cindolo, Riccardo Autorino — 2011-12-08

Minimally invasive surgery aims to provide effective treatment of diseases while decreasing access-related morbidity with reduced postoperative pain, shorter hospital stay, faster recovery, improved cosmesis, and early return to normal daily activity. Laparoscopy has undoubtedly represented a major step in this direction, as it has revolutionized the way surgery has been done, taught, and implemented. If we look at our field, laparoscopic surgery has moved from the skepticism and criticism of the early 1990s to widespread acceptance, so that, for example, laparoscopic nephrectomy is now defined as standard of care for patients with T2 renal tumors.

Efficacy and Safety of Low Doses of OnabotulinumtoxinA for the Treatment of Refractory Idiopathic Overactive Bladder: A Multicentre, Double-Blind, Randomised, Placebo-Controlled Dose-Ranging Study

2011-10-26

Abstract: Background: In the treatment of patients with idiopathic overactive bladder (iOAB), high doses of botulinum toxin type A (BoNTA) were often associated with complications resulting from high postvoid residuals (PVR), leading to clean intermittent catheterisation (CIC) and urinary tract infections (UTI).Objective: Evaluate the efficacy and tolerability of low doses of onabotulinumtoxinA compared to placebo in patients with iOAB.Design, setting, and participants: Between 2005 and 2009, adults with persistent iOAB were included in a prospective, randomised, double-blind, placebo-controlled comparative trial.Intervention: Patients were randomised to undergo a single intradetrusor injection procedure of either placebo or onabotulinumtoxinA (50U, 100U or 150U).Measurements: The initial evaluations (ie, clinical and urodynamic variables as well as quality of life [QoL]) were repeated at day 8 and months 1, 3, 5, and 6.Results and limitations: Ninety-nine patients were included in the efficacy analysis. Three months after the procedure, we observed >50% improvement versus baseline in urgency and urge urinary incontinence (UUI) in 65% and 56% of patients who respectively received 100U (p=0.086) and 150U (p=0.261) BoNTA injections and >75% improvement in 40% of patients of both groups (100U [p=0.058] and 150U [p=0.022]). Complete continence was observed in 55% and 50% patients after 100U and 150U BoNTA treatment, respectively, at month 3. Frequency symptoms and QoL improved up to the 6-mo visit. We observed only three patients with a PVR >200ml in the 150U group and a few UTIs.Conclusions: 100U and 150U BoNTA injections were well tolerated and have both shown to improve symptoms and QoL in patients with iOAB. Nevertheless, 100U injections showed a reasonable efficacy, with a lower risk of high PVR.Trial registration: ClinicalTrials.gov NCT00231491.Take Home Message: Injection of low doses of botulinum toxin type A (100 or 150U) results in a significant improvement in objective and subjective symptoms, with a good safety profile in patients with idiopathic overactive bladder associated with detrusor overactivity refractory to anticholinergics.

Finding the Correct Starting Dose for OnabotulinumtoxinA

Christopher R. Chapple — 2011-12-15

The article by Denys and colleagues in this edition of the journal reports the results of a multicentre double-blind randomised placebo-controlled dose-ranging study using onabotulinumtoxinA (ObTA) (Botox; Allergan Inc., Irvine, CA, USA) at doses of 50, 100, and 150 international units (IU) in patients with refractory idiopathic detrusor overactivity (IDO) and overactive bladder (OAB) . This paper tackles the important issue of which dose at the lower end of the dose range is most appropriate for the management of patients with IDO/OAB. ObTA is commonly used at present in a number of centres on an off-label basis for the treatment of IDO/OAB. The evidence base for the use of this therapy is currently being accrued and was recently the subject of a consensus report . More recently, an update on this therapy has been published in a comprehensive meta-analysis . It is very clear from the existing literature that although four previous randomised controlled trials have been conducted, three of them have been based on small patient numbers.

Reply from Authors re: Christopher R. Chapple. Finding the Correct Starting Dose for OnabotulinumtoxinA. Eur Urol 2012;61:530–2

Pierre Denys, Emmanuel Chartier-Kastler — 2011-12-22

The editorial comment submitted by Chapple is of great value, and we thank him for this. OnabotulinumtoxinA (ObTA) seems destined to become one of the new treatments for non-neurogenic (idiopathic) refractory overactive bladder (OAB). The risks and benefits are clearly demonstrated through the results of our work and through the recent studies described by Chapple that focus on finding the optimal dosage, with a clear trend to reducing the dose in comparison with patients with neurogenic detrusor overactivity (NDO) . The issue of defining clinically significant residual urine and urinary tract infection (UTI) has not been solved at this time.

The Future of Urology

2011-11-14

Take Home Message: The focus in urology for the next decade will be on improved education and training to ensure that every patient receives high-quality urologic care that is delivered in an efficient and effective way throughout Europe.Abstract: The Future of Urology has been written in times of economic downturn, with the inevitable effects on health sector spending. Nevertheless, this document aims to define a path whereby the EAU can play a pivotal role in ensuring the highest standard of care throughout Europe, and by setting standards, throughout the rest of the world. The future of urology will be dependent on improved education and training leading to high quality urological care, and to developing a service that is patient focused. The patient focus is becoming increasingly important in urology. This means providing full information about disease processes and urological procedures to patients and allowing them to judge the quality of the urological service that they may choose. Education must start in medical school and as 5% of community medical practice is urology then every medical student must receive urological training. This also applies to nurses and the other professions allied to medicine (PAMS). The EAU should provide a urological curriculum for training of medical students, nurses and PAMS, as well as the more conventional curriculum for postgraduate training and continued medical education for urological specialists. An integrated EAU Knowledge and Learning Centre would provide an invaluable resource to patients and to those who deliver urologic care alike. With high quality training must come a vigorous assessment of knowledge and competence. In the future, the competence of all those delivering urological care will need to be assessed. For urologists in training and specialist urologists this will include not only an assessment of knowledge but an assessment of surgical competence. Improving quality will be supported by the continued subspecialisation of urology, ensuring that all urologists have a surgical portfolio which ensures their competency in the procedures they deliver. This will inevitably result in a concentration of urological services and indeed to the development of larger urological centres. The concept of Centres of Excellence could be developed to include all aspects and subspecialties of urological care. The SPO envisages that all urology will be carried out in Centres of Excellence which will vary in terms of their size and the range of urology offered, but nevertheless all urological care will be of the highest quality.Finally, the future of urology will depend on the medico-political interface and the EAU has a great deal to offer in this respect. The patterns of urological care differ throughout Europe but this should be seen as a challenge for the EAU to define quality, irrespective of the different methods of healthcare provision. The EAU has made extraordinary advances in the last two decades and the SPO hope this document will support the EAU's efforts to maintain its aim of improving urological care for the benefit of patients.

Systematic Review of Methods for Reporting Combined Outcomes After Radical Prostatectomy and Proposal of a Novel System: The Survival, Continence, and Potency (SCP) Classification

2011-12-05

Abstract: Context: Although oncologic results remain the main outcome assessment for radical prostatectomy (RP), there is a need to include both urinary continence and potency recovery in the assessment of success for this procedure. Unfortunately, the widely used trifecta system does not weigh these outcomes differently. Moreover, the trifecta system—and even more so, the recently described pentafecta system—is only applicable in preoperatively continent and potent patients who receive bilateral nerve-sparing RP, and thus it is not an appropriate reporting tool for the majority of patients undergoing RP.Objective: Perform a systematic review to evaluate critically the trifecta and pentafecta models and describe a novel system that can be used to report the most relevant intermediate- and long-term outcomes after RP. This system has increased generalizability by being applicable to all patients undergoing RP.Evidence acquisition: A literature search was performed in March 2011 using the Medline, Embase, and Web of Science databases. The Medline search included only a free-text protocol using the terms radical prostatectomy, trifecta, and pentafecta across the Title and Abstract fields of the records. Subsequently, the following limits were used: humans, gender (male), and language (English). The searches of the Embase and Web of Science databases used the same free-text protocol and the same keywords, applying no limits.Evidence synthesis: Eleven original articles reported trifecta outcomes, and only one original article used the pentafecta model. These systems were correctly applied in only 28–62% of treated patients. A mean of 57% (range: 20–83%) of patients achieved continence and potency without prostate-specific antigen failure after RP. All the original articles were surgical series (level 4 evidence). The new proposed system categorizes the three outcomes using the letter S for biochemical disease-free survival, the letter C for urinary continence, and the letter P for potency recovery. This SCP system can be applied to all patients who undergo RP and is thus analogous to the use of the TNM system for classifying disease stage. Moreover, the SCP system allows us to distinguish four different clinical scenarios: (1) oncologic and functional success, (2) oncologic success and functional failure, (3) oncologic failure and functional success, and (4) oncologic and functional failure.Conclusions: The proposed novel SCP system offers the opportunity to appropriately classify all patients who undergo RP according to the oncologic and functional outcomes of relevance to them on an individual basis. We contend that this system's greater generalizability may make it more useful than the currently used trifecta and pentafecta systems, though its validation remains to be performed.Take Home Message: Trifecta and pentafecta systems are only applicable in preoperatively continent and potent patients who receive bilateral nerve-sparing radical prostatectomy (RP) and thus are not appropriate reporting tools for the majority of patients undergoing RP. The proposed novel survival, continence, and potency system offers the opportunity to appropriately classify all patients who undergo RP according to the oncologic and functional outcomes of relevance to them on an individual basis.

Biomarkers in the Management and Treatment of Men with Metastatic Castration-Resistant Prostate Cancer

2011-11-14

Abstract: Context: We have recently witnessed a rapid increase in the number of effective systemic agents for men with metastatic castration-resistant prostate cancer (CRPC), including novel hormonal therapies (abiraterone acetate and MDV3100), immunotherapies (sipuleucel-T), chemotherapies (cabazitaxel), and bone microenvironment targeting agents (denosumab, radium 223). Given the increasing complexity of treatment decisions for this disease, major research and clinical priorities are (1) finding biomarkers that enable an understanding of the natural history and complex biology of this heterogeneous malignancy, (2) defining predictive biomarkers that identify men most likely to benefit from a given therapy, and (3) identifying biomarkers of early response or progression to optimize outcomes.Objective: In this review, we discuss existing and potential biomarkers in CRPC and how they may currently inform prognosis, aid in treatment selection (predictive value), and relate to survival outcomes (surrogacy).Evidence acquisition: PubMed-based literature searches and abstracts through September 2011 provided the basis for this literature review as well as expert opinion.Evidence synthesis: We address blood and urine-based biomarkers such as prostate-specific antigen, lactate dehydrogenase, total and bone alkaline phosphatase and other bone turnover markers, hemoglobin, and circulating tumor cells in the context of prognosis, prediction, and patient selection for therapy. Given the inherent problems associated with defining progression-free survival in CRPC, the importance of biomarker development and the needed steps are highlighted. We place the discussion of biomarkers within the context of the design/intent of a trial and mechanism of action of a given systemic therapy. We discuss novel biomarker development and the pathway for surrogate or predictive biomarkers to become credentialed as useful tests that inform therapeutic decisions.Conclusions: A greater understanding of biomarkers in CRPC permits a more personalized approach to care that maximizes benefit and minimizes harm and can inform clinical trials tailored to men most likely to derive benefit.Take Home Message: We have discussed a range of biomarkers in research and clinical use in men with castration-resistant prostate cancer. If successfully identified, predictive and surrogate biomarkers should accelerate drug development and speed delivery of clinical benefit to the patient while minimizing harm.

The Correlation Between Metabolic Syndrome and Prostatic Diseases

2011-11-17

Abstract: Context: Metabolic syndrome (MetS), a cluster of several metabolic abnormalities with a high socioeconomic cost, is considered a worldwide epidemic. Recent epidemiologic and clinical data suggest that MetS is involved in the pathogenesis and progression of prostatic diseases such as benign prostatic hyperplasia (BPH) and prostate cancer (PCa).Objective: This review evaluates the available evidence of the role of MetS in BPH and PCa development and progression and discusses possible clinical implications for the management, prevention, and treatment of these diseases.Evidence acquisition: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published between 1995 and September 2011 was performed by combining the following Patient population, Intervention, Comparison, Outcome (PICO) terms: male, metabolic syndrome, prostate, benign prostatic hyperplasia, prostate cancer, prevention, diagnosis, treatment, and prognosis. Additional references were obtained from the reference list of full-text manuscripts.Evidence synthesis: MetS is a complex, highly prevalent disorder and a worldwide epidemic. Central obesity, insulin resistance, dyslipidemia, and hypertension are the main components of MetS. Notwithstanding all the attempts made to correctly define MetS, a major problem related to most definitions remains the applicability to different populations and ethnic groups. Although there is growing evidence of the association of MetS with the initiation and clinical progression of BPH and PCa, molecular mechanisms and effects on treatment efficacy remain unclear. Further research is required to better understand the role of MetS in BPH and PCa.Conclusions: Data from the peer-reviewed literature suggest an association of MetS with BPH and PCa, although the evidence for a causal relationship remains missing. MetS should be considered a new domain in basic and clinical research in patients with prostatic disorders.Take Home Message: Recent data support the hypothesis that metabolic syndrome (MetS) may be involved in the development and progression of benign prostatic hyperplasia (BPH) and prostate cancer (PCa), although proof of causal relationship is still missing. Research evaluating the effect of treating MetS on PCa and BPH is under way.

The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy

2012-01-03

Abstract: Background: Macroscopic landmarks are lacking to identify the cavernosal nerves (CNs) during radical prostatectomy. The prostatic and capsular arteries run along the lateral border of the prostate and could help identify the location of the CNs during robot-assisted radical prostatectomy (RARP).Objective: Describe the visual cues that have helped us achieve consistent nerve sparing (NS) during RARP, placing special emphasis on the usefulness of the prostatic vasculature (PV).Design, setting, and participants: Retrospective video analysis of 133 consecutive patients who underwent RARP in a single institution between January and February 2011.Surgical procedure: NS was performed using a retrograde, antegrade, or combined approach.Measurements: A landmark artery (LA) was identified running on the lateral border of the prostate corresponding to either a prostatic or capsular artery. NS was classified as either medial or lateral to the LA. The area of residual nerve tissue on surgical specimens was measured to compare the amount of NS between the groups.Results and limitations: We could identify an LA in 73.3% (195 of 266) of the operated sides. The area of residual nerve tissue was significantly different whether the NS was performed medial (between the LA and the prostate) or lateral to the LA (between the LA and pelvic side wall): median (interquartile range) of 0 (0–3) mm2 versus14 (9–25) mm2; p<0.001, respectively.Conclusions: The PV is an identifiable landmark during NS. Fine tailoring on the medial border of an LA can consistently result in a complete or almost complete NS, whereas performing the NS on its lateral border results in several degrees of incomplete NS.Take Home Message: The prostatic vasculature is a reliable cue for identifying the neurovascular bundles during robot-assisted radical prostatectomy. Nerve sparing medial to the prostatic vasculature consistently results in complete or almost complete nerve preservation.

Prediction of Prostate Cancer Risk: The Role of Prostate Volume and Digital Rectal Examination in the ERSPC Risk Calculators

2011-11-17

Abstract: Background: The European Randomized Study of Screening for Prostate Cancer (ERSPC) risk calculators (RCs) are validated tools for prostate cancer (PCa) risk assessment and include prostate volume (PV) data from transrectal ultrasound (TRUS).Objective: Develop and validate an RC based on digital rectal examination (DRE) that circumvents the need for TRUS but still includes information on PV.Design, setting, and participants: For development of the DRE-based RC, we studied the original ERSPC Rotterdam RC population including 3624 men (885 PCa cases) and 2896 men (547 PCa cases) detected at first and repeat screening 4 yr later, respectively. A validation cohort consisted of 322 men, screened in 2010–2011 as participants in ERSPC Rotterdam.Measurements: Data on TRUS-assessed PV in the development cohorts were re-coded into three categories (25, 40, and 60cm3) to assess the loss of information by categorization of volume information. New RCs including PSA, DRE, and PV categories (DRE-based RC) were developed for men with and without a previous negative biopsy to predict overall and clinically significant PCa (high-grade [HG] PCa) defined as T stage >T2b and/or Gleason score ≥7. Predictive accuracy was quantified by the area under the receiver operating curve. We compared performance with the Prostate Cancer Prevention Trial (PCPT) RC in the validation study.Results and limitations: Areas under the curve (AUC) of prostate-specific antigen (PSA) alone, PSA and DRE, the DRE-based RC, and the original ERSPC RC to predict PCa at initial biopsy were 0.69, 0.73, 0.77, and 0.79, respectively. The corresponding AUCs for predicting HG PCa were higher (0.74, 0.82, 0.85, and 0.86). Similar results were seen in men previously biopsied and in the validation cohort. The DRE-based RC outperformed the PCPT RC (AUC 0.69 vs 0.59; p=0.0001) and a model based on PSA and DRE only (AUC 0.69 vs 0.63; p=0.0075) in the relatively small validation cohort. Further validation is required.Conclusions: An RC should contain volume estimates based either on TRUS or DRE. Replacing TRUS measurements by DRE estimates may enhance implementation in the daily practice of urologists and general practitioners.Take Home Message: A prostate cancer risk calculator should contain volume estimates. Replacing transrectal ultrasound volume measurements with digital rectal examination estimates results in improvement in predictive accuracy compared with prediction models without volume and may enhance implementation in the daily practice of urologists and general practitioners.

Identifying the Best Candidate for Radical Prostatectomy Among Patients with High-Risk Prostate Cancer

2011-12-05

Abstract: Background: The current role of radical prostatectomy (RP) in patients with high-risk disease remains controversial.Objective: To identify which high-risk prostate cancer (PCa) patients might have favorable pathologic outcomes when surgically treated.Design, setting, and participants: We evaluated 1366 patients with high-risk PCa (ie, at least one of the following risk factors: prostate-specific antigen [PSA] >20 ng/ml, cT3, biopsy Gleason 8–10) treated with RP and pelvic lymph node dissection (PLND) at eight European centers between 1987 and 2009. A favorable pathologic outcome was defined as specimen-confined (SC) disease—namely, pT2–pT3a, node negative PCa with negative surgical margins.Intervention: All patients underwent radical retropubic prostatectomy and PLND.Measurements: Univariable and multivariable logistic regression models tested the association between predictors and SC disease. A logistic regression coefficient-based nomogram was developed and internally validated using 200 bootstrap resamples. The Kaplan-Meier method was used to depict biochemical recurrence (BCR) and cancer-specific survival (CSS) rates.Results and limitations: Overall, 505 of 1366 patients (37%) had SC disease at RP. All preoperative variables (ie, age and PSA at surgery, clinical stage, and biopsy Gleason sum) were independent predictors of SC PCa at RP (all p ≤ 0.04). Patients with SC disease had significantly higher 10-yr BCR-free survival and CSS rates than patients without SC disease at RP (66% vs 47% and 98 vs 88%, respectively; all p<0.001). A nomogram including PSA, age, clinical stage, and biopsy Gleason sum demonstrated 72% accuracy in predicting SC PCa. This study is limited by its retrospective design and by the lack of an external validation of the nomogram.Conclusions: Roughly 40% of patients with high-risk PCa have SC disease at final pathology. These patients showed excellent long-term outcomes when surgically treated, thus representing the ideal candidates for RP as the primary treatment for PCa. Prediction of such patients is possible using a nomogram based on routinely available clinical parameters.Take Home Message: Roughly 40% of patients with high-risk prostate cancer (PCa) have specimen-confined disease (pT2–pT3a, SM-, pN0) at final pathology. These patients showed excellent long-term outcomes when surgically treated, thus representing the ideal candidates for radical prostatectomy as the primary treatment for PCa. A nomogram based on routinely available clinical parameters was developed and internally validated to preoperatively identify these patients.

Comparison of Open and Minimally Invasive Partial Nephrectomy for Renal Tumors 4–7 Centimeters

2011-12-05

Abstract: Background: Indications for partial nephrectomy (PN) in the treatment of renal cell carcinoma are evolving, particularly for larger, more complex tumors.Objective: Compare single-institution outcomes for minimally invasive partial nephrectomy (MIPN) and open partial nephrectomy (OPN) for tumors >4–7cm.Design, setting, and participants: A total of 2290 patients underwent PN from 2002 to 2010 at Memorial Sloan-Kettering Cancer Center; 280 had >4–7cm renal cortical tumors. Of these 280 patients, 230 had pT1b, 48 had pT3a, and 2 had angiomyolipomas; 226 underwent OPN and 54 underwent MIPN (16 robot-assisted and 37 laparoscopic procedures). Perioperative management was uniform on the clinical pathway. Perioperative data, clinicopathologic variables, complications within 30 d, and oncologic outcomes were reviewed.Measurements: Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Complications were reported from prospectively collected data based on a modified Clavien system. The Fisher exact and Mann-Whitney U tests were used for descriptive statistical analysis. Kaplan-Meier methods were used to estimate survival.Results and limitations: Median follow-up for OPN and MIPN was 29 and 13 mo, respectively. There were no statistically significant differences in age, gender, preoperative American Society of Anesthesiologists score, laterality, histologic subtype, tumor size, tumor stage, or margin status between procedures. Univariate analysis revealed significantly greater values in the OPN group for preoperative eGFR, renal artery clamp time, estimated blood loss, use of renal hypothermia, and length of stay. Differences in overall survival and recurrence-free survival were not statistically significant; however, short median follow-up times limit comparison. There was no significant difference in the number of complications grade ≥3 (p=0.1) or urine leaks requiring intervention (p=0.7). Limitations include the retrospective nature of the study and the possibility of selection bias.Conclusions: OPN and MIPN procedures performed in patients with tumors >4–7cm offer acceptable and comparable results in terms of operative, functional, and convalescence measures, regardless of approach.Take Home Message: Open and minimally invasive partial nephrectomy (PN) for tumors 4–7 cm in size appear to be comparable in terms of operative, functional, and convalescence outcomes. PN for larger renal lesions is an appropriate alternative to radical nephrectomy for many cases when performed by experienced surgeons, regardless of surgical approach.

180-W XPS GreenLight Laser Therapy for Benign Prostate Hyperplasia: Early Safety, Efficacy, and Perioperative Outcome After 201 Procedures

2011-12-05

Abstract: Background: Photoselective vaporisation of the prostate has evolved from the GreenLight 80-W KTP powered laser to the latest 180-W XPS laser involving a MoXy fibre.Objective: Evaluate the prevalence of perioperative complications and short-term outcome for the first time with the XPS laser in men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE).Design, setting, and participants: Prospective data were collected from consecutive patients at seven centres worldwide during June 2010 and March 2011. Indication for surgery was based on the European Association of Urology and the American Urological Association guidelines. Patients receiving anticoagulants or those with retention were included and analysed separately.Intervention: 180-W XPS GreenLight laser prostatectomy using the MoXy fibre.Measurements: Standard parameters associated with transurethral prostate surgery and perioperative prevalence of surgery-associated problems or complications were documented.Results and limitations: A total of 201 patients were included in the study. Mean follow-up was 5.8 mo (standard deviation [SD]: 2.8; range: 1–12 mo). A quarter of the patients had a prostate volume ≥80ml. For prostates between 51 and 60ml, a mean of 300kJ (SD: 112) of energy was applied (lasing time: 35.0min; SD: 15). Statistically significant improvements were noted in all key parameters postoperatively. The prevalence of perioperative complications was low. Limitations of the study are short duration of follow-up and limited number of available patients for the functional follow-up.Conclusions: The 180-W GreenLight XPS laser is a new effective treatment option with a low prevalence of perioperative complications for patients suffering from LUTS due to BPE.Take Home Message: The 180-W XPS GreenLight laser prostatectomy is a new, promising treatment option with a low perioperative complication rate and is suitable for all patients with lower urinary tract symptoms due to benign prostatic enlargement.

The Inside-Out Transobturator Male Sling for the Surgical Treatment of Stress Urinary Incontinence After Radical Prostatectomy: Midterm Results of a Single-Center Prospective Study

Julie Leruth, David Waltregny, Jean de Leval — 2011-11-14

Abstract: Background: Transobturator slings are currently promoted for the treatment of stress urinary incontinence (SUI) after radical prostatectomy (RP), but data on outcome remain limited.Objective: To assess, at midterm, the efficacy and safety of the inside-out transobturator male sling for treating post-RP SUI and to determine factors associated with failure.Design, setting, and participants: Prospective one-center trial involving 173 consecutive patients without detrusor overactivity, treated between 2006 and 2011 for SUI following RP.Intervention: Placement of an inside-out transobturator sling.Measurements: Baseline and follow-up evaluations included uroflowmetry and continence and quality-of-life (QoL) questionnaires. Cure was defined as no pad use and improvement as a number of pads per day reduced by ≥50% and two or fewer pads. Complications were recorded, and factors associated with treatment failure were evaluated.Results and limitations: Preoperatively, 21%, 35%, and 44% of the patients were using two, three to five, and more than five pads per day, respectively. After a median follow-up of 24 mo (range: 12–60 mo), 49% were cured, 35% improved, and 16% not improved. QoL was enhanced (p<0.001), and 72% of patients were moderately to completely satisfied with the procedure. Maximum flow rates were slightly reduced (p=0.004); postvoid residual volumes were similar (p=0.097). Complications were urinary retention after catheter removal (15%), perineal/scrotal hematoma (9%), pain lasting >6 mo (3%), and sling infection (2%); all were managed conservatively. Severe SUI before sling surgery was not associated with a worse outcome, whereas obesity and a history of pelvic irradiation or bladder neck stenosis were independent risk factors of failure, with risk ratios of 7.9 (95% confidence interval [CI], 3.3–18.9), 3.3 (95% CI, 1.4–7.8), and 2.6 (95% CI, 1.1–6.5), respectively.Conclusions: The inside-out transobturator male sling is an efficient and safe treatment for post-RP SUI at midterm. Patients with prior pelvic irradiation may not be suitable candidates.Take Home Message: The inside-out transobturator sling is safe and efficient at midterm for treating patients with bothersome, including severe, stress urinary incontinence after radical prostatectomy. Obesity and previous pelvic irradiation and bladder neck stenosis were independent risk factors for sling failure.

Diffusion-Weighted Magnetic Resonance Imaging Detects Local Recurrence After Radical Prostatectomy: Initial Experience

Gianluca Giannarini, Daniel P. Nguyen, George N. Thalmann, Harriet C. Thoeny — 2011-11-28

Abstract: Current conventional cross-sectional imaging techniques, such as contrast-enhanced computed tomography and magnetic resonance imaging (MRI), are largely inaccurate in detecting local recurrence after radical prostatectomy. We report on five patients with biochemical recurrence after radical retropubic prostatectomy and pelvic lymph node dissection for whom local recurrence could only be detected with diffusion-weighted (DW) MRI. Prior to DW-MRI, all patients had negative digital rectal examinations, negative or equivocal conventional cross-sectional imaging, and negative bone scans. All suspicious lesions on DW-MRI imaging were histologically proved to be local recurrences of prostate cancer after either transrectal ultrasound–guided or transurethral biopsy. These results should encourage other centres to test our findings.

Re: Stepwise Approach for Nerve Sparing Without Countertraction During Robot-Assisted Radical Prostatectomy: Technique and Outcomes

Jens-Uwe Stolzenburg, Hasan Qazi — 2012-03-01

Kowalczyk KJ, Huang AC, Hevelone ND, et alEur Urol 2011;60:536–47Experts’ summary:These authors present the short- and intermediate-term outcomes on erectile function for reduction of assistant intervention and traction on the neurovascular bundle (NVB) during robot-assisted radical prostatectomy (RARP).

Re: Prediction of Erectile Function Following Treatment for Prostate Cancer

Paul Schellhammer — 2012-03-01

Alemozaffar M, Regan MM, Cooperberg MR, et al.JAMA 2011;306:1205–14Expert's summary:The authors conducted a prospective analysis of 1027 patients from nine US university-affiliated hospitals to assess the impact on sexual function as measured by response to the Expanded Prostate Cancer Index Composite (EPIC-26) validated questionnaire through 24 mo after therapy. The patients had localized prostate cancer and were undergoing treatment by radical prostatectomy (RP; n=524), external beam radiation therapy (EBRT; n=241), and brachytherapy (n=262). A predictive model for sexual function was developed and validated using a cohort of 1655 patients from the CaPSure registry who had 24-mo sexual function recorded by the University of California Los Angeles Prostate Cancer Index.

Re: Role of Magnetic Resonance Imaging Before Initial Biopsy: Comparison of Magnetic Resonance Imaging–Targeted and Systematic Biopsy for Significant Prostate Cancer Detection

Nicolas Barry Delongchamps, Marc Zerbib — 2012-03-01

Haffner J, Lemaitre L, Puech P, et alBJU Int 2011;108:E171–8.Experts’ summary:The authors compared magnetic resonance imaging (MRI)–targeted biopsies with extended systematic biopsies for the detection of significant prostate cancer (PCa). A total of 555 consecutive patients with suspicion of PCa had prebiopsy MRI, 10–12 transrectal ultrasound–guided systematic biopsies, plus two targeted biopsies at any MRI area suspicious for malignancy. Significant PCa was defined as >5mm total cancer length, any Gleason pattern >3, or both. The median prostate-specific antigen (PSA) level was 6.75 ng/ml (range: 0.18–100). MRI was positive in 351 patients (63%), and overall, 302 patients (54%) had cancer detected at extended systematic biopsies, targeted biopsies, or both. Of 302 cancers detected, 249 (82%) were significant PCa, and 53 (18%) were nonsignificant PCa. The detection accuracy of significant PCa by targeted biopsies was higher than the detection accuracy of extended systematic biopsies (p<0.001). Targeted biopsies also detected 16% more grade IV/V cases. A targeted biopsies–only strategy without extended systematic biopsies would have necessitated a mean of 3.8 cores performed in only 63% of patients with positive MRI and avoided the potentially unnecessary diagnosis of 13% (53 of 302) of nonsignificant PCa.Experts’ comments:In the era of overdetection of insignificant PCa's, this study is of major interest and draws attractive perspectives. As many as half of the PCa's in men aged >50 yr may be insignificant . As suggested by the authors, MRI-targeted biopsies may avoid unnecessary biopsies in almost 40% of patients and may avoid unnecessary diagnosis in >10% of patients harboring insignificant cancers. Also, decreasing from 12 cores to 3–4 cores in a biopsy procedure may affect morbidity, especially by decreasing the risk of urinary tract infections .

Re: A Prospective, Randomized Pilot Study Evaluating the Effects of Metformin and Lifestyle Intervention on Patients With Prostate Cancer Receiving Androgen Deprivation Therapy

Mark A. Moyad — 2012-03-01

Nobes JB, Langley SE, Klopper T, Russell-Jones D, Laing RWBJU Int. In press. doi:10.1111/j.1464-410X.2011.10555.xExpert's summary:This randomized 6-mo interventional versus standard-of-care (controls) preliminary trial included in each arm 20 men with a mean age of 70 yr who were on androgen deprivation therapy (ADT) for prostate cancer (PCa). The intervention was a combination of metformin (850mg daily for 2 wk and then 850mg twice daily thereafter) with a low glycemic index diet and exercise encouragement.

Re: Dutasteride Improves Outcomes of Benign Prostatic Hyperplasia When Evaluated for Prostate Cancer Risk Reduction: Secondary Analysis of the Reduction by Dutasteride of Prostate Cancer Events Trial

Matthias Oelke — 2012-03-01

Roehrborn CG, Nickel JC, Andriole GL, et alUrology 2011;78:641–7Expert's summary:The Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial, an international multicenter randomized, double-blind 4-yr trial to determine the risk of incident prostate cancer in men treated with dutasteride 0.5mg or placebo once daily, included male volunteers between 50 and 75 yr of age, with a serum prostate-specific antigen (PSA) concentration of 2.5–10 ng/ml, prostate volume ≤80cm3, International Prostate Symptom Score (IPSS) <25 (or <20 when using α1-blockers), and negative biopsies for prostate cancer before trial enrollment . The article reviewed in this section of European Urology was a secondary analysis of men participating in the REDUCE trial. In this particular cohort it evaluated the following benign prostatic hyperplasia (BPH) outcome parameters: changes of prostate volume, lower urinary tract symptoms assessed by IPSS, symptom burden assessed by IPSS question 8, and BPH Impact Index (BII), as well as the incidence of acute urinary retention, BPH-related surgery, and urinary tract infection.

Re: Postfertilization Autophagy of The Sperm Organelles Prevents Paternal Mitochondrial DNA Transmission

B. José Manuel Mayorga-Torres, Walter Cardona-Maya — 2012-03-01

Al Rawi S, Louvet-Vallee S, Djeddi A, Sachse M, Culetto E, Hajjar C, Boyd L, Legouis R, Galy VScience 2011;334:1144–7Experts’ summary:The purpose of this work was to describe the relation between autophagy and the removal of the sperm organelles postfertilization. To accomplish this objective they used different techniques, such as fluorescence microscopy, electron microscopy, immunofluorescence, RNAi, and PCR on a C. elegans model. Rawi et al. found proximity of mitochondria and membranous organelles to paternal DNA during the embryo first cell divisions, and an association of these organelles to proteins involved in autophagosome formation. The researchers evaluated the ubiquitination and autophagy signals pre and postfertilization, and found autophagy marks in paternal mitochondria postfertilization; however, there was no sign of ubiquitination. In addition, when the autophagy pathway was inhibited, it was found the presence of mitochondria and membrane organelles in late embryonic stages and also the male mitochondrial DNA in larval stages. Furthermore, the authors did find autophagy and ubiquitination signals post fertilization in a mouse model, which indicates the close relation between this evolutionary mechanism for the elimination of paternal mitochondria.Experts’ comments:During fertilization, the entire spermatozoa enters the egg and it is widely described that in almost all the animals the mitochondrial genome is inheritance from the mother , but the mechanism underlying in the elimination of the paternal contribution is not fully understood. Autophagy is a process commonly known for being involved in cell death pathways, but it is also implicated in other functions in cellular metabolism such as the reduction of organelles masses in liver cells, a mechanism that provides nutrients under cell starvation condition and as well, as a selective system of elimination mitochondria in the erythrocytes maturation . Sutovsky et al. detected ubiquitination signals in spermatozoa pre and post-fertilization; they have proposed that selective labeling of paternal mitochondria is the cause of the eventual elimination process by the embryós proteasomes and lysosomes. In a recent study Sato et al. found a possible link between this process and the mechanism of autophagy; in this study, it was found an alteration in the elimination process of the paternal contribution when the autophagy pathway was inhibited, and proposed that the oocyte and the sperm are able to promote autophagy activity in embryos.

Aquaporin 3 Protein Expression in Transitional Cell Carcinoma: A Potential Marker With Regard to Tumour Progression and Prognosis?

Peter C. Rubenwolf, Stefan Denzinger, Wolfgang Otto — 2011-12-22

The mechanism by which water passes across biological membranes was a matter of debate until the discovery and elucidation of the aquaporin (AQP) water channels by Peter Agre and associates in the 1990s. AQPs are a family of transmembrane proteins that selectively allow water or water plus other small, uncharged molecules such as urea and glycerol to pass along hydrostatic and osmotic gradients. Situated at specific membrane sites in a variety of epithelia, endothelia, and other tissues, AQPs play a fundamental role in numerous physiologic processes, most notably in fluid absorption and secretion. To date, 13 different mammalian AQPs have been identified at the molecular level and localised to particular tissues . Analysis of several human diseases has confirmed that AQPs are involved in various pathologic conditions and provide promising drug targets . Moreover, there is strong presumptive evidence that AQPs play a role in carcinogenesis, specifically in tumour angiogenesis and cell migration .

iPad-Assisted Percutaneous Access to the Kidney Using Marker-Based Navigation: Initial Clinical Experience

2011-12-22

Preliminary experience exists with computer-assisted surgery (CAS) for laparoscopic procedures of the prostate and the kidney . Based on algorithms developed for inside-out tracking via the laparoscope (endoscopic tracking), we modified this marker-based tracking technique for percutaneous access to the kidney using an iPad (Apple Inc., Cupertino, CA, USA). In percutaneous nephrolithotomy (PCNL), adequate access to the collecting system represents the most important factor for success .

Re: Sven van den Bosch, J. Alfred Witjes. Long-term Cancer-specific Survival in Patients with High-risk, Non–muscle-invasive Bladder Cancer and Tumour Progression: A Systematic Review. Eur Urol 2011;60:493–500

Srijit Banerjee, Vivekanandan Kumar — 2011-12-26

We commend an excellent piece of work that was done by van den Bosch and Witjes on a really complex issue of long-term management of high-risk, non–muscle-invasive bladder cancer (HRNMIBC; G3pT1 bladder cancer). We recently undertook a similar retrospective study of 76 patients who were diagnosed with HRNMIBC with at least a 5-yr follow-up at our institution. Overall survival in our study group was 47.3%. Survival in patients receiving radical treatment was better at 66%. Patients receiving bacillus Calmette-Guérin treatment to start had the survival rate of 45.9% with or without progression.

Re: Tim O’Brien, Eleanor Ray, Rajinder Singh, Bola Coker, Ralph Beard, British Association of Urological Surgeons Section of Oncology. Prevention of Bladder Tumours after Nephroureterectomy for Primary Upper Urinary Tract Urothelial Carcinoma: A Prospective, Multicentre, Randomised Clinical Trial of a Single Postoperative Intravesical Dose of Mitomycin C (the ODMIT-C Trial). Eur Urol 2011;60:703–10

Apul Goel, Sagorika Paul — 2011-12-05

We read with interest this paper on prevention of bladder tumors after nephroureterectomy for primary upper urinary tract urothelial carcinoma (UUTUC) by using single intravesical dose of mitomycin C (MMC) . We compliment the authors for this novel approach. The authors have postulated that MMC possibly reduced successful seeding of cell shed from UUTUC at time of surgery. The authors state that MMC in this study cannot have prevented implantation, as it was administered at least a week after surgery, but it could possibly have prevented cells that did implant themselves from establishing significant new growth.

Reply to Apul Goel and Sagorika Paul's Letter to the Editor re: Tim O’Brien, Eleanor Ray, Rajinder Singh, Bola Coker, Ralph Beard, British Association of Urological Surgeons Section of Oncology. Prevention of Bladder Tumours after Nephroureterectomy for Primary Upper Urinary Tract Urothelial Carcinoma: A Prospective, Multicentre, Randomised Clinical Trial of a Single Postoperative Intravesical Dose of Mitomycin C (the ODMIT-C Trial). Eur Urol 2011;60:703–10

Tim O’Brien — 2011-12-05

The authors’ suggestion of preoperative intravesical mitomycin C (MMC) is interesting but purely speculative. There is not a shred of evidence to support its use in this way. Let's get single-dose postoperative MMC embedded into routine urologic practice first, as it is supported by the level 1 evidence of the ODMIT-C trial, and then start exploring novel approaches.

Re: Marco Roscigno, Maurizio Brausi, Axel Heidenreich, et al. Lymphadenectomy at the Time of Nephroureterectomy for Upper Tract Urothelial Cancer. Eur Urol 2011;60:776–83

2011-12-12

We were interested to read Roscigno et al's retrospective analysis of the role of extended lymph node dissection in upper tract urothelial cancer (UTUC) and the improved pathologic staging perhaps better informing decisions on adjuvant treatment. The authors highlight the uncertainty regarding the use of adjuvant chemotherapy in this setting and the pressing need for clinical trials.

Reply to Alison J. Birtle, Rebecca Lewis, Emma Hall's Letter to the Editor on Behalf of the POUT Trial Management Group re: Marco Roscigno, Maurizio Brausi, Axel Heidenreich, et al. Lymphadenectomy at the Time of Nephroureterectomy for Upper Tract Urothelial Cancer. Eur Urol 2011;60:776–83

Marco Roscigno — 2011-12-12

In our review article, we aimed to stress the prognostic and staging roles of an accurate lymph node dissection (LND) in patients undergoing radical nephroureterectomy (RNU) for upper tract urothelial cancer (UTUC) . Ideally, LND improves disease staging, thereby identifying patients who could benefit from adjuvant systemic therapy. Nonetheless, whether improved staging results in better outcomes depends on the decision to deliver chemotherapy and on the efficacy of the regimen.

Re: Henk G. van der Poel, Tessa Buckle, Oscar R. Brouwer, Renato A. Valdés Olmos, Fijs W.B. van Leeuwen. Intraoperative Laparoscopic Fluorescence Guidance to the Sentinel Lymph Node in Prostate Cancer Patients: Clinical Proof of Concept of an Integrated Functional Imaging Approach Using a Multimodal Tracer. Eur Urol 2011;60:826–33

Karol Polom, Dawid Murawa, Wojciech Polom — 2011-12-15

We have recently read the work of van der Poel et al. with great interest and would like to congratulate them for it is a very important step forward in near-infrared (NIR) fluorescence navigation surgery. This study was performed based on excellent preclinical laboratory and animal studies ; indocyanine green (ICG) and 99m technetium radioactive colloid (RC) were combined for sentinel node biopsy (SLNB) in prostate cancer. Despite the concurrent administration of the combined mixture in the same syringe, each marker resulted in intraoperative visualization of different sentinel lymph nodes (SLNs). In total, 16 SLNs (59.2%) were detected by both markers, 6 SLNs (22.2%) were detected with ICG only, and 4 SLNs (14.8%) were detected with RC only. One SLN was detected only by single-photon emission computed tomography.

Reply to Karol Polom, Dawid Murawa, Wojciech Polom's Letter to the Editor re: Henk G. van der Poel, Tessa Buckle, Oscar R. Brouwer, Renato A. Valdés Olmos, Fijs W.B. van Leeuwen. Intraoperative Laparoscopic Fluorescence Guidance to the Sentinel Lymph Node in Prostate Cancer Patients: Clinical Proof of Concept of an Integrated Functional Imaging Approach Using a Multimodal Tracer. Eur Urol 2011;60:826–33

2011-12-15

Thank you for giving us the opportunity to respond to the letter of Polom et al concerning our manuscript . First, we would like to thank the authors for their congratulations and for acknowledging the value of our hybrid tracer concept. Polom et al concluded from our data that only 59.2% of the sentinel lymph nodes (SLNs) contained both indocyanine green (ICG) and technetium (99mTc) nanocolloid. However, these percentages (16 of 27 SLNs) were derived from a figure that depicts the intraoperative detectability of the nodes (Fig. 3 in the original manuscript ). For clarity, this percentage illustrates only the ability to surgically identify the SLNs with both radioactive tracing and fluorescence imaging.

Re: Gianluca Giannarini, Thomas M. Kessler, Frédéric D. Birkhäuser, George N. Thalmann, Urs E. Studer. Antegrade Perfusion With Bacillus Calmette-Guérin in Patients With Non–Muscle-Invasive Urothelial Carcinoma of the Upper Urinary Tract: Who May Benefit? Eur Urol 2011;60:955–60

Shiu-Dong Chung, Jeff Shih-Chieh Chueh, Chao-Yuan Huang, Hong-Jeng Yu — 2011-12-15

With great interest, we read the article by Giannarini et al. regarding the efficacy of antegrade bacillus Calmette- Guérin (BCG) perfusion for patients with non–muscle-invasive urothelial carcinoma (NMIUC) of the upper urinary tract (UUT). Based on the results of a retrospective single-center study comprising 55 patients and 66 renal units with a median follow-up of 42 mo, the authors concluded that patients treated with curative intent for Tis disease benefited in terms of local disease control more than those treated with adjuvant intent .

Reply to Shiu-Dong Chung, Jeff Shih-Chieh Chueh, Chao-Yuan Huang, Hong-Jeng Yu's Letter to the Editor Re: Gianluca Giannarini, Thomas M. Kessler, Frédéric D. Birkhäuser, George N. Thalmann, Urs E. Studer. Antegrade Perfusion With Bacillus Calmette-Guérin in Patients With Non–Muscle-Invasive Urothelial Carcinoma of the Upper Urinary Tract: Who May Benefit? Eur Urol 2011;60:955–60

Gianluca Giannarini, Urs E. Studer — 2011-12-15

We were surprised to read the letter written by Chung et al. about our recent article published in the Platinum Journal reporting on our long-term experience with antegrade bacillus Calmette-Guérin (BCG) perfusion of the upper urinary tract (UUT) in the management of non–muscle-invasive urothelial carcinoma (NMIUC) .

Congress Calendar

2012-03-01

European Urology

Editorial Board

Award pages

Contents

Academic Ranking Score: A Publication-Based Reproducible Metric of Thought Leadership in Urology

Impact Factor for Ranking Academic Urologic Institutions

Reply from Authors re: Manfred P. Wirth, Michael Froehner. Impact Factor for Ranking Academic Urologic Institutions. Eur Urol 2012;61:440–1

Postoperative Radiation Therapy for Pathologically Advanced Prostate Cancer After Radical Prostatectomy

Treat Now or Later: The Dilemma of Postoperative Radiotherapy

Preoperative Prostate-Specific Antigen Isoform p2PSA and Its Derivatives, %p2PSA and Prostate Health Index, Predict Pathologic Outcomes in Patients Undergoing Radical Prostatectomy for Prostate Cancer

PSA is Dead, Long Live PSA

Reply from Authors re: Andrew J. Vickers, Hans Lilja. PSA Is Dead, Long Live PSA. Eur Urol 2012;61:467–8

Evaluation of Multiple Risk–Associated Single Nucleotide Polymorphisms Versus Prostate-Specific Antigen at Baseline to Predict Prostate Cancer in Unscreened Men

It Is Time to Move On

Updated Nomogram Predicting Lymph Node Invasion in Patients with Prostate Cancer Undergoing Extended Pelvic Lymph Node Dissection: The Essential Importance of Percentage of Positive Cores

Updated Nomogram Predicting Lymph Node Invasion in Patients with Prostate Cancer Undergoing Extended Pelvic Lymphadenectomy: Optimizing a Risk-Adapted Surgical Approach

Long-term Renal Function After Urinary Diversion by Ileal Conduit or Orthotopic Ileal Bladder Substitution

Variables Affecting Long-term Maintenance of Renal Function Following Ileal Based Urinary Diversion

Reply from Authors re: Ja Hyeon Ku, Seth P. Lerner. Variables Affecting Long-term Maintenance of Renal Function Following Ileal Based Urinary Diversion. Eur Urol 2012;61:498–500

Should Follow-up Cystoscopy in Bacillus Calmette-Guérin–Treated Patients Continue After Five Tumour-Free Years?

A Plea for Long-Term Surveillance in Bacillus Calmette-Guérin–Treated Non–Muscle-Invasive Bladder Cancer

Laparoendoscopic Single-Site Upper Urinary Tract Surgery: Assessment of Postoperative Complications and Analysis of Risk Factors

Laparoendoscopic Single-Site Surgery for the Upper Urinary Tract: Awaiting Evidence

Reply from Authors re: Jonathan A. Coleman. Laparoendoscopic Single-Site Surgery for the Upper Urinary Tract: Awaiting Evidence. Eur Urol 2012;61:517–8

Efficacy and Safety of Low Doses of OnabotulinumtoxinA for the Treatment of Refractory Idiopathic Overactive Bladder: A Multicentre, Double-Blind, Randomised, Placebo-Controlled Dose-Ranging Study

Finding the Correct Starting Dose for OnabotulinumtoxinA

Reply from Authors re: Christopher R. Chapple. Finding the Correct Starting Dose for OnabotulinumtoxinA. Eur Urol 2012;61:530–2

The Future of Urology

Systematic Review of Methods for Reporting Combined Outcomes After Radical Prostatectomy and Proposal of a Novel System: The Survival, Continence, and Potency (SCP) Classification

Biomarkers in the Management and Treatment of Men with Metastatic Castration-Resistant Prostate Cancer

The Correlation Between Metabolic Syndrome and Prostatic Diseases

The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy

Prediction of Prostate Cancer Risk: The Role of Prostate Volume and Digital Rectal Examination in the ERSPC Risk Calculators

Identifying the Best Candidate for Radical Prostatectomy Among Patients with High-Risk Prostate Cancer

Comparison of Open and Minimally Invasive Partial Nephrectomy for Renal Tumors 4–7 Centimeters

180-W XPS GreenLight Laser Therapy for Benign Prostate Hyperplasia: Early Safety, Efficacy, and Perioperative Outcome After 201 Procedures

The Inside-Out Transobturator Male Sling for the Surgical Treatment of Stress Urinary Incontinence After Radical Prostatectomy: Midterm Results of a Single-Center Prospective Study

Diffusion-Weighted Magnetic Resonance Imaging Detects Local Recurrence After Radical Prostatectomy: Initial Experience

Re: Stepwise Approach for Nerve Sparing Without Countertraction During Robot-Assisted Radical Prostatectomy: Technique and Outcomes

Re: Prediction of Erectile Function Following Treatment for Prostate Cancer

Re: Role of Magnetic Resonance Imaging Before Initial Biopsy: Comparison of Magnetic Resonance Imaging–Targeted and Systematic Biopsy for Significant Prostate Cancer Detection

Re: A Prospective, Randomized Pilot Study Evaluating the Effects of Metformin and Lifestyle Intervention on Patients With Prostate Cancer Receiving Androgen Deprivation Therapy

Re: Dutasteride Improves Outcomes of Benign Prostatic Hyperplasia When Evaluated for Prostate Cancer Risk Reduction: Secondary Analysis of the Reduction by Dutasteride of Prostate Cancer Events Trial

Re: Postfertilization Autophagy of The Sperm Organelles Prevents Paternal Mitochondrial DNA Transmission

Aquaporin 3 Protein Expression in Transitional Cell Carcinoma: A Potential Marker With Regard to Tumour Progression and Prognosis?

iPad-Assisted Percutaneous Access to the Kidney Using Marker-Based Navigation: Initial Clinical Experience

Re: Sven van den Bosch, J. Alfred Witjes. Long-term Cancer-specific Survival in Patients with High-risk, Non–muscle-invasive Bladder Cancer and Tumour Progression: A Systematic Review. Eur Urol 2011;60:493–500

Re: Marco Roscigno, Maurizio Brausi, Axel Heidenreich, et al. Lymphadenectomy at the Time of Nephroureterectomy for Upper Tract Urothelial Cancer. Eur Urol 2011;60:776–83

Reply to Alison J. Birtle, Rebecca Lewis, Emma Hall's Letter to the Editor on Behalf of the POUT Trial Management Group re: Marco Roscigno, Maurizio Brausi, Axel Heidenreich, et al. Lymphadenectomy at the Time of Nephroureterectomy for Upper Tract Urothelial Cancer. Eur Urol 2011;60:776–83

Re: Gianluca Giannarini, Thomas M. Kessler, Frédéric D. Birkhäuser, George N. Thalmann, Urs E. Studer. Antegrade Perfusion With Bacillus Calmette-Guérin in Patients With Non–Muscle-Invasive Urothelial Carcinoma of the Upper Urinary Tract: Who May Benefit? Eur Urol 2011;60:955–60

Congress Calendar