Chris M. Gonzalez

Update on AUA Guideline on the Management of Benign Prostatic Hyperplasia

PURPOSE To revise the 2003 version of the American Urological Associations (AUA) Guideline on the management of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS From MEDLINE® searches of English language publications (January 1999 through February 2008) using relevant MeSH terms, articles concerning the management of the index patient, a male ≥45 years of age who is consulting a healthcare provider for lower urinary tract symptoms (LUTS) were identified. Qualitative analysis of the evidence was performed. Selected studies were stratified by design, comparator, follow-up interval, and intensity of intervention, and meta-analyses (quantitative synthesis) of outcomes of randomized controlled trials were planned. Guideline statements were drafted by an appointed expert Panel based on the evidence. RESULTS The studies varied as to patient selection; randomization; blinding mechanism; run-in periods; patient demographics, comorbidities, prostate characteristics and symptoms; drug doses; other intervention characteristics; comparators; rigor and intervals of follow-up; trial duration and timing; suspected lack of applicability to current US practice; and techniques of outcomes measurement. These variations affected the quality of the evidence reviewed making formal meta-analysis impractical or futile. Instead, the Panel and extractors reviewed the data in a systematic fashion and without statistical rigor. Diagnosis and treatment algorithms were adopted from the 2005 International Consultation of Urologic Diseases. Guideline statements concerning pharmacotherapies, watchful waiting, surgical options and minimally invasive procedures were either updated or newly drafted, peer reviewed and approved by AUA Board of Directors. CONCLUSIONS New pharmacotherapies and technologies have emerged which have impacted treatment algorithms. The management of LUTS/BPH continues to evolve.

Pathological characteristics of prostate cancer detected through prostate specific antigen based screening.

PURPOSE Since the introduction of PSA testing for CaP, there has been an increase in CaP detection. However, it is uncertain to what extent clinically insignificant tumors are being diagnosed and treated. In a large, community based population we determined the pathological characteristics of screening detected cancers. MATERIALS AND METHODS From 1989 to 2001, 35,661 men were enrolled in a longitudinal prostate cancer screening study. Data were available on 3,492 of the 3,568 men (98%) diagnosed with CaP during this study period. Radical prostatectomy was performed in 2,254 men (63%). Clinical stage, Gleason score and pathological analysis were recorded and analyzed in the context of preoperative PSA, digital rectal examination findings, PSA velocity and the year of cancer detection. RESULTS CaP was detected in 10% of men. Virtually all cases were clinically localized (99.8%) and approximately 70% treated with radical prostatectomy were pathologically organ confined disease. Fewer than 10% of tumors would be considered clinically insignificant based on 2 previously published pathological criteria. CONCLUSIONS Compared to the high prevalence of CaP found in autopsy studies there is a lower detection rate using current screening protocols. Although the outcomes are unknown if these tumors had been left untreated, the majority met pathological criteria for significant cancer.

Characterization and localization of nitric oxide synthase isoforms in the BB/WOR diabetic rat.

PURPOSE Erectile dysfunction is a common pathological development in individuals with diabetes mellitus. Nitric oxide synthase (NOS) is essential for regulation of normal penile erection and NOS protein activity has been shown to be altered with diabetes. Several different isoforms and subtypes of NOS exist. However, little is known about how the distribution and abundance of these isoforms are altered with diabetes. We characterized the distribution and abundance of NOS isoforms and explored how they are altered with diabetes and result in erectile failure. MATERIALS AND METHODS In situ hybridization and quantitative reverse transcriptase-polymerase chain reaction were done to measure the abundance and distribution of NOS-Ia, NOS-Ib, NOS-Ic, NOS-II and NOS-III in control and diabetic (BB/WOR) rats. Protein was localized by immunohistochemical analysis and alterations in protein abundance with diabetes were examined by Western blot analysis. RESULTS NOS-I, NOS-II and NOS-III were observed in the endothelium lining the cavernous spaces and in the epithelium of the urethra. NOS-I protein was also present in the nerves of control and diabetic penes. We observed an increase in NOS-II expression around the dorsal nerves of diabetic penes, a decrease in NOS-III expression in diabetic pelvic ganglia and a decrease in NOS-Ib expression in the diabetic penis. NOS-I protein abundance was significantly decreased in diabetic pelvic ganglia. CONCLUSIONS To our knowledge this is the first report of regional differences in the distribution of NOS-III in the urethra and altered NOS-Ib gene expression with diabetes.

A Prospective Study of Laparoscopic Radical Nephrectomy for T1 Tumors—Is Transperitoneal, Retroperitoneal or Hand Assisted the Best Approach?

PURPOSE We designed a prospective, randomized clinical trial to compare 3 common approaches to laparoscopic radical nephrectomy, namely transperitoneal, retroperitoneal and hand assisted. MATERIALS AND METHODS A total of 33 patients with a solid renal mass of 7 cm or less were prospectively enrolled in alternating fashion to a hand assisted procedure, a transperitoneal procedure with morcellation and a retroperitoneal procedure with intact specimen extraction. A single surgeon performed all operations. Preoperative, intraoperative and postoperative criteria were compared among the 3 techniques. RESULTS A total of 11 patients underwent each type of procedure. There was no significant difference in age, American Society of Anesthesiologists class, body mass index or tumor size among the groups. Mean operative time was significantly lower using the hand assisted approach, whereas estimated blood loss was similar in all 3 groups. Incision size, hospital stay and time to normal daily activity were less using the transperitoneal approach. While not significant, there was a trend toward less narcotic use in the transperitoneal group. Hernia formation was seen with increased frequency in the hand assisted group. CONCLUSIONS In our series the hand assisted approach had significantly shorter operative time than the transperitoneal or retroperitoneal approach but it had the greatest risk of hernia formation. The transperitoneal approach was associated with a significantly shorter hospital stay and the earliest resumption of normal activity.

A NOVEL ENDOSCOPIC APPROACH TOWARDS RESECTION OF THE DISTAL URETER WITH SURROUNDING BLADDER CUFF DURING HAND ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY

The experience and use of hand assisted laparoscopic renal surgery continues to expand among urologists.1‐3 Hand assisted laparoscopic nephroureterectomy appears to be a safe, effective technique that provides intact specimen removal and appropriate pathological staging.4 However, as with the standard laporoscopic approach to nephroureterectomy, no consensus has been reached regarding the optimal technique for excising the distal intravesical ureter with an adequate bladder cuff. Classic oncological protocol requires resection o fa1c m. bladder cuff around the involved ureteral orifice to excise and remove completely the distal intravesical ureter. In an attempt to adhere to these oncological principles, a variety of endoscopic techniques have been used for complete resection of the distal intravesical ureter during laparoscopic nephroureterectomy. These approaches include transurethral unroofing of the ureteral orifice before laparoscopic nephrectomy, endoscopic extravesical clipping or stapling of the bladder cuff, combination bladder port/transurethral unroofing of the ureteral orifice, transurethral bladder cuff excision alone and the “pluck” technique with or without transurethral resection.1‐ 6 Since the most safe and effective method to complete distal intravesical ureteral resection has not been agreed upon by laparoscopic urologists, all of these techniques continue to be used, each with their own specific advantages and disadvantages. We describe an alternative approach to the removal of the distal ureter with a surrounding bladder cuff during hand assisted laparoscopic nephroureterectomy. The potential advantages of this approach may facilitate hand assisted laparoscopic nephroureterectomy. METHODS A 62-year-old man initially presented with gross hematuria. Computerized tomography and retrograde pyelography revealed a 3 3 3 3 5 cm. left renal pelvis mass. Left renal pelvic cytology and ureteroscopy confirmed the diagnosis of transitional cell carcinoma. Cystoscopy and cytology of the bladder revealed no evidence of carcinoma, and metastatic evaluation indicated no evidence of distant disease. After informed consent was obtained a general anesthetic was given and the patient was placed in the left lateral position without the use of the kidney rest. Hand assisted laparoscopic nephrectomy was performed through a 6.5 cm. midline, periumbilical incision using a pneumosleeve with 2, 5 to 12 mm. ports, 1 of which was in the midclavicular line

Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease.

PURPOSE We recently demonstrated that radiotherapy induced urethral strictures can be successfully managed with urethroplasty. We increased size and followup in our multi-institutional cohort, and evaluated excision and primary anastomosis as treatment for radiotherapy induced urethral strictures. MATERIALS AND METHODS A retrospective review was performed of 72 patients from 3 academic institutions treated for radiotherapy induced bulbomembranous strictures. Outcome parameters of successful repair included recurrence, incontinence and erectile dysfunction. RESULTS Among the 72 men treated for radiotherapy induced strictures 66 (91.7%) underwent excision and primary anastomosis. Mean followup was 3.5 years (median 3.1, range 0.8 to 11.2). Prostate cancer was the most common reason for radiotherapy (in 64 of 66, 96.9%). External beam radiotherapy and brachytherapy were performed in 28 of 66 men (42.4%) each, and a combination of both was performed in 9 (13.6%). Mean time from radiation to excision and primary anastomosis was 6.4 years (range 1 to 20) and mean stricture length was 2.3 cm (range 1 to 6). Successful reconstruction was achieved in 46 men (69.7%). Mean time to recurrence was 10.2 months (range 1 to 64) with new onset of incontinence observed in 12 men (18.5%). This was associated with stricture length greater than 2 cm (p = 0.013) and treatment center (p <0.001). The rate of erectile dysfunction remained stable (preoperative 45.6%, postoperative 50.9%, p = 0.71). Radiotherapy type did not affect stricture length (p = 0.41), recurrence risk (p = 0.91), postoperative incontinence (p = 0.88) or erectile dysfunction (p = 0.53). CONCLUSIONS Radiotherapy induced bulbomembranous urethral strictures can be successfully managed with excision and primary anastomosis. Substitution urethroplasty with graft or flap is needed infrequently. Patients should be counseled on the potential risks of urinary incontinence and erectile dysfunction.

A geographic analysis of male urethral stricture aetiology and location.

The incidence of specific aetiologies of urethral stricture disease has been reported from a variety of series throughout the world. Most reported urethral stricture series are from single institutions or from a specific region of the world. We provide a multi‐centred series to compare aetiologic incidence between differing regional populations.

Hand-Assisted Laparoscopic Radical Nephrectomy: The Experience of the Inexperienced

PURPOSE We retrospectively examined the experience of novice laparoscopic surgeons performing hand-assisted laparoscopic radical nephrectomy. The purpose was to determine if urologists with minimal laparoscopic training could perform hand-assisted laparoscopic nephrectomies in a safe and efficient manner. MATERIALS AND METHODS The first six hand-assisted laparoscopic radical nephrectomies performed by four different urology residents at the Chicago Lakeside VA hospital were reviewed. The residents included three chief urology residents and one postgraduate year 3 urology resident. None of the residents had taken any laparoscopic course, and all had limited exposure to the hand-assisted technique. In all cases, the residents performed the entire operation. The patients were evaluated for operative time, tumor size, body mass index, and ASA score. RESULTS All six procedures were completed without conversion to the open technique. The average operating time was 215.8 minutes, and the time from incision to organ removal averaged 140.8 minutes. The average estimated blood loss was 166 mL. Complications included an intraoperative diaphragmatic injury (recognized and repaired laparoscopically) and one postoperative ileus. CONCLUSION Hand-assisted laparoscopic radical nephrectomy can be performed safely and efficiently by urologists with minimal laparoscopic experience.

Urethroplasty for Radiotherapy Induced Bulbomembranous Strictures: A Multi-Institutional Experience

PURPOSE Radiotherapy induced urethral strictures are often difficult to manage due to proximal location, compromised vascular supply and poor wound healing. To determine the success of urethroplasty for radiation induced strictures we performed a multi-institutional review of men who underwent urethroplasty for urethral obstruction. MATERIALS AND METHODS A total of 30 men (mean age 67 years) underwent urethroplasty at 3 separate institutions. Excision with primary anastomosis was used in 24 of 30 patients (80%), with 4 of 30 requiring a genital fasciocutaneous skin flap and 2 a buccal graft. Hospitalization was less than 23 hours for 70% of the patients. Recurrence was defined as cystoscopic identification of urethral narrowing to less than 16Fr in diameter. RESULTS All strictures were located in the bulbomembranous region. Mean stricture length was 2.9 cm (range 1.5 to 7). External beam radiotherapy for prostate cancer was the etiology of stricture disease in 15 men (50%), with brachytherapy in 7 (24%) and a combination of the 2 modalities in 8 (26%). Successful urethral reconstruction was achieved in 22 men (73%) at a mean of 21 months. Mean time to stricture recurrence was 5.1 months (range 2 to 8). Two men required balloon dilation after stricture recurrence and none required urinary diversion. Incontinence was transient in 10% and persistent in 40%, with 13% requiring an artificial urinary sphincter. The rate of erectile dysfunction was unchanged following urethroplasty (47% preoperative, 50% postoperative). CONCLUSIONS Urethroplasty for radiation induced strictures has an acceptable rate of success and can be performed without tissue transfer techniques in most cases. Almost half of men will experience some degree of incontinence as a result of surgery but erectile function appears to be preserved.

Presenting symptoms of anterior urethral stricture disease: a disease specific, patient reported questionnaire to measure outcomes.

PURPOSE We evaluated the spectrum of symptoms in men with urethral stricture presenting for urethroplasty. MATERIALS AND METHODS We identified 214 men who underwent anterior urethroplasty by a single surgeon (CMG) from March 2001 to June 2010. We retrospectively reviewed the initial patient history. All voiding and sexual dysfunction symptoms were recorded. RESULTS The most common presenting voiding complaints were weak stream in 49% of cases and incomplete emptying in 27%. Overall 21% of men did not present with voiding symptoms specifically addressed by the American Urological Association symptom index. The most common of these symptoms were spraying of urinary stream in 13% of men and dysuria in 10%. No symptoms were reported in 10% of men. Men with lichen sclerosus were more likely to present with obstructive symptoms (76% vs 55%) while men with penile urethral stricture were more likely to present with urinary stream spraying (17% vs 6%, each p <0.05). Sexual dysfunction was reported by 11% of men, most commonly in those with failed hypospadias repair (23% vs 9%) and lichen sclerosus (24% vs 10%, each p <0.05). CONCLUSIONS While the American Urological Association symptom index captures the most common voiding complaints of men with urethral stricture, 21% of those who presented for urethroplasty did not have voiding symptoms assessed by the index. A validated, disease specific instrument is needed to fully capture the presenting voiding symptoms and sexual dysfunction complaints of men with urethral stricture disease.