Stephen S. Steele

A Review of the Current State of the Male Circumcision Literature

INTRODUCTION Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. AIMS The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America. METHODS A literature review of peer-reviewed journal articles was performed. MAIN OUTCOME MEASURES The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations. RESULTS This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on mens sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. CONCLUSION Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America.

Examining Penile Sensitivity in Neonatally Circumcised and Intact Men Using Quantitative Sensory Testing

PURPOSE Little is known about the long-term implications of neonatal circumcision on the penile sensitivity of adult men, despite recent public policy endorsing the procedure in the United States. In the current study we assessed penile sensitivity in adult men by comparing peripheral nerve function of the penis across circumcision status. MATERIALS AND METHODS A total of 62 men (age 18 to 37 years, mean 24.2, SD 5.1) completed study procedures (30 circumcised, 32 intact). Quantitative sensory testing protocols were used to assess touch and pain thresholds (modified von Frey filaments) and warmth detection and heat pain thresholds (a thermal analyzer) at a control site (forearm) and 3 to 4 penile sites (glans penis, midline shaft, proximal to midline shaft and foreskin, if present). RESULTS Penile sensitivity did not differ across circumcision status for any stimulus type or penile site. The foreskin of intact men was more sensitive to tactile stimulation than the other penile sites, but this finding did not extend to any other stimuli (where foreskin sensitivity was comparable to the other sites tested). CONCLUSIONS Findings suggest that minimal long-term implications for penile sensitivity exist as a result of the surgical excision of the foreskin during neonatal circumcision. Additionally, this study challenges past research suggesting that the foreskin is the most sensitive part of the adult penis. Future research should consider the direct link between penile sensitivity and the perception of pleasure/sensation. Results are relevant to policy makers, parents of male children and the general public.

Randomized, controlled trial of laser vs. bipolar plasma vaporization treatment of benign prostatic hyperplasia

INTRODUCTION Prostate vaporization technology is becoming a standard of care for treatment of moderate, symptomatic benign prostatic hyperplasia (BPH). We compared two transurethral prostate vaporization technologies with respect to cost, efficiency, efficacy, safety, and surgical team satisfaction. METHODS Fifty-five patients meeting standardized symptom criteria for BPH were randomized to either Olympus Plasma ButtonTM or Biolitec EVOLVE® diode laser vaporization. Primary outcome of cost with secondary outcomes of clinical efficacy, resection time, surgical team satisfaction, and safety were analyzed. Followup was carried out at six and 12 weeks. Patient factors included baseline, as well as six- and 12-week International Prostate Symptom Score (IPSS) with quality of life (QoL) scores. We recorded surgical team satisfaction with a Likert-style survey investigating ease of set-up, reliability, efficiency, and ability to reach desired endpoint. All complications or side effects detected within three months and the resulting management were included in the cost analysis. RESULTS Mean cost per patient was

Is there still a role for pubovaginal slings in the treatment of SUI in the era of mid-urethral slings?

3418 for the Olympus group and

Botulinum toxin A: First-line therapy for idiopathic detrusor overactivity

4564 for Biolitec (p<0.05). Surgical vaporization time was significantly less for the Olympus group, 24.3 vs. 33.5 minutes (p<0.05). Surgical and nursing staff preferred the Olympus device (p<0.05). IPPS symptom improvement and complication rates were similar between groups. Patients in the Biolitec arm had more intraoperative bleeding episodes requiring conversion to monopolar transurethral resection of the prostate (TURP) (three vs. none). CONCLUSIONS In a head-to-head randomized trial, Olympus Plasma Button transurethral vaporization was more cost-effective, faster, and preferred by surgical staff when compared to Biolitetec Diode Laser vaporization. Both devices showed similar safety and efficacy.

Canadian Urological Association position statement on the use of transvaginal mesh

The treatment of female stress urinary incontinence (SUI) has evolved over the last decade.1 Traditional surgeries for SUI, such as the Burch colposuspension and pubovaginal slings, have slowly been supplanted by mid-urethral slings (MUS). In some centres, retropubic surgeries have become almost obsolete. This has not had a negative impact on the surgical treatment of female SUI. In fact, various databases have demonstrated almost a threefold increase in the overall number of incontinence procedures performed.2,3 The rationale for this shift in surgical procedure and for the increase in surgical volume appears to be related to decreased complication rates, shorter operative time and the simplicity of MUS surgery without compromising objective and subjective cure rates.4,5 Are surgical procedures, such as autologous rectus fascia pubovaginal sling (AF-PVS), history or do they still have a role in female SUI. Welk and Herschorn support that AF-PVS can be a vital tool in the treatment of complex SUI.1 They describe an extremely complex patient population with recurrent SUI that underwent AF-PVS at their centre. Over half of the patient population had mesh erosions, urethral diverticuli or trauma. The remaining patients underwent on average 2 prior surgical procedures to treat their SUI before undergoing an AF-PVS. Their surgical outcomes and patient satisfaction were quite commendable considering the complexity of the patient population. Average pad use decreased from 5 pads per day (PPD) preoperatively to 1 PPD postoperatively. Moreover, the patients’ rating of their overall quality of life was reasonable (62% scored from 4 [mixed] to 7 [delighted]). There is, however, an underlying concern from an education perspective that permeates throughout the paper concerning the shift to MUS.1 Although AF-PVS, Burch colposuspension and other retropubic surgeries may be indicated in various surgical settings for female SUI, graduating urology residents may not have the surgical acumen and experience to perform them. Wu and colleagues found that the number of retropubic suspension surgeries in the United States fell from 52.8% of SUI procedures in 1998 to 13.8% in 2007.2 As the number of pubovaginal slings performed in academic centres continues to fall, graduating urology residents may not be adequately exposed to these procedures to perform them competently and safely. As a result, these operations have the potential to become largely historical procedures or isolated in tertiary referral centres. Alarms have already been sounded concerning graduating Canadian urology residents’ surgical exposure to open radical nephrectomy and open radical retropubic prostatectomy.6 Perhaps these “complex surgical incontinence surgeries,” need to be added to that list.

The role of preoperative urodynamics in stress urinary incontinence surgery

We are well aware that overactive bladder (OAB) is extremely common. The most recent Canadian bladder survey by Herschorn and colleagues demonstrated that OAB symptoms were present in 13.1% of men and 14.7 % of women across Canada.1 In addition, it has been shown to have a tremendous impact on a patient’s quality of life, similar to that experienced by someone with diabetes or rheumatoid arthritis.2,3 Unfortunately, the effectiveness of current OAB treatment protocols in alleviating patient symptoms are not adequate, which is why investigators are looking at new agents, such as BTX A. Currently, there are over 10 different anticholinergic medications on the Canadian market for OAB. The most commonly prescribed medication for this condition, oxybutynin, is fraught with potential problems. The FDA, in 2007, released a warning; this medication is to be used with caution in the elderly and children and common side effects are hallucinations, confusion and cognitive changes.4 Others researchers, such as Kay and colleagues, have documented the potential for serious cognitive decline with this medication.5 As a result, urologists have switched to treating OAB with newer medications to avoid these neurological sequelae. The drawback with these new medications, unfortunately, still revolves around side effects and, ultimately, patient compliance. The significant side effects of dry mouth and constipation, as well as poor patient perceived benefit in symptom reduction, have resulted in extremely poor medication adherence rates. Sears and colleagues examined anti-cholinergic medication compliance in a health care system in which medication was given free to patients; the study demonstrated an adherence rate of only 34%.6 This is similar to earlier research by Shaya and colleagues, which demonstrated only a 32 % adherence rate.7 Secondary to these significant side effects and poor patient compliance, investigators have searched for a better alternative for treating OAB. Urologists were already familiar with BTX A, having used it in a variety of other urologic disorders, such as ureteral stent colic,8 interstitial cystitis,9,10 prostatitis10 and benign prostatic hyperplasia.10,11 As data emerged regarding its effectiveness to treat neurogenic detrusor overactivity,12 it was only natural to consider its use to treat non-neurogenic detrusor overactivity (OAB). Many urologists believe it is a matter of time before BTX A becomes an integral cog in the treatment algorithim for OAB. This change in treatment strategy is fuelled by the inability of the current treatment regimen, primarily anticholinergics, to adequately alleviate symptoms in OAB patients. Current work has established the effectiveness of BTX A in OAB. Sahia and colleagues,13 in a randomized, double-blind placebo control study, demonstrated statistically significant increases in cystometric capacity and reduced frequency, urgency urinary incontinence and urgency with the injection of 200 units of BTX A. The beneficial effects were maintained for at least 24 weeks which, incidentally, is longer than most people stay on anticholinergic medication. Others researchers have demonstrated similar statistically significant amelioration of symptoms with BTX A.14–16 However, with any “new” procedure, patient safety is always extremely important. Detractors of the use of BTX A will express concern regarding urinary retention, urinary tract infections (UTIs), hematuria, distant muscle weakness, as well as the invasiveness of the procedure. There is no doubt that these are legitimate concerns if, in fact, they are truly relevant. It has been clearly demonstrated that BTX A can easily and comfortably be given under local anesthetic in the cystoscopy suite in a matter of minutes with minimal discomfort to the patient and with minimal side effects.17 Hematuria does occur, but to date there is not a single case report of an individual requiring a blood transfusion post-BTX A injection. Urinary tract infections do occur16,18 in the setting of BTX A injection, but there is no data demonstrating an increased risk over cystoscopy alone. Distant muscle weakness has definitely been described with BTX A injections. However, the frequency is extremely low (about 20 reported cases in the literature).18 None of these cases required any intervention and all reports were described in patients with neurogenic detrusor overactivity. Secondary to the small incidence (less than 1%), the association and causation of BTX A in precipitating these events has not been well-established.18 What has been well-established is the risk of urinary retention with BTX A injections.13–16,18 The risk has been shown to be dramatically diminished with decreasing doses of BTX A.19 However, even for individuals who were unfortunate enough to go into retention, researchers have demonstrated that, in properly counselled individuals, quality of life still markedly improved versus before the procedure.20 In fact, quality of life has been extensively studied with regards to BTX A, and, not surprisingly, patients are extremely satisfied with the procedure. A recent study by Sahai and colleagues used the Kings Health Questionnaire (KHQ), which included the following subdomains to measure quality of life: “incontinence impact,” “emotions,” “physical limitations,” “social limitations” and “severity measures.” These subdomains significantly improved in patients who received BTX-A compared with placebo.21 Drug costs in the Canadian health care system will always be a major obstacle. Determining the cost-effectiveness of an intervention, therefore, is a critical undertaking and is more informative than a strict comparison of drug costs. Wu and colleagues assessed the cost-effectiveness of BTX A versus anticholinergic medications for idiopathic urge incontinence.22 The authors discovered that BTX A was much more cost-effective per year than anticholinergic medication. In fact, for anticholinergics to more cost-effective than BTX A injections, the compliance with anticholinergics would have to exceed 75%. Alternatively, the injection costs would have to more than double. The final area of concern for opponents of BTX A involves the possibility of damage to the bladder mucosa with repeated injections every 6 to 9 months. Although the data on this topic are not as robust as that on amelioration of symptoms and quality of life, they are still reassuring. Apostolidis and colleagues biopsied the injection sites and found that BTX A did not appear to be producing significant inflammatory changes, fibrosis or dysplastic changes in urothelium.23 Digesting this plethora of information obviously begs the question: should BTX A be used as a first-line treatment for patients suffering from non-neurogenic detrusor overactivity? Do we continue to use inferior agents with serious significant side effects, poor patient compliance and low success rates? I and others would suggest that the usefulness and success of BTX A make it an excellent candidate to supplant anticholinergics as first-line treatment for OAB. In fact, a recent European Consensus panel reviewed the literature concerning BTX A in the management of neurogenic and non-neurogenic detrusor overactivity; the panel gave a Grade A recommendation to BTX A that it was a safe and effective.24 There are still a few issues that require clarification, most notably the appropriate dose that balances side effects with symptom benefits. Current research places this dose between 100 and 150 units.19 Dose notwithstanding, the age of BTX A for OAB is upon us. Perhaps it is time to stop delaying the inevitable and take the step into the 21st century instead of continuing with old treatment regimens fraught with poor compliance, intolerable side effects and poor cost-effectiveness.

Choosing the right sling for your patient

Stress incontinence (SUI) and pelvic organ prolapse (POP) are common conditions. There is high-level evidence that midurethral mesh slings for stress incontinence are effective and safe; however, the rare but serious potential risks of this surgery must be discussed with the patient. The use of transvaginal mesh for prolapse repair does not appear to be supported by the current evidence, and its use should be restricted to specialized pelvic floor surgeons and specific clinical situations.

Percutaneous antegrade nephroscopic holmium laser pyelotomy: Novel endourologic technique for removal of extruded ureteral stent

The routine use of urodynamics prior to incontinence surgery continues to be debated. The evidence available from randomized, control trials suggests that preoperative urodynamics do not improve surgical outcomes and are not cost-effective.

Sacral nerve stimulation: 50 years in the making

Recent data has demonstrated a one in five lifetime risk of a woman requiring stress urinary incontinence (SUI) surgery. Currently, most women opt for a synthetic midurethral sling (MUS), with over 3.6 million placed worldwide. This article attempts to identify whether a gold standard exists with regards to surgical correction of female SUI. When considering which sling type to use for which incontinent woman, the published data demonstrates excellent results for both synthetic mesh (retropubic or transobturator routes) and fascial pubovaginal slings for most patients. Intrinsic sphincter deficiency does appear to be better treated with the use of a retropubic approach, although still with less than stellar results. With little to differentiate, the treatment of most female SUI may be solely based on which sling the surgeon feels most comfortable performing. Currently, most urologists and gynecologists favour synthetic MUS over fascial slings in surgical-naïve patients; however, recent U.S Food and Drug Administration (FDA) warnings concerning the use of mesh in transvaginal surgery have patients questioning the safety of synthetic MUS for the treatment of SUI.