Monday, January 14, 2013

Extended dartos fascial flaps in distal Snodgrass TIP urethroplasties.

Hypospadias Surgery by Professor Ahmed T Hadidi

Surgical Atlas Snodgrass technique for hypospadias repair

Tuesday, January 8, 2013

Cervical Cancer Progression and Staging

Over the past 40 years, the number of deaths from cervical cancer have decreased dramatically. According to the NIH, this decrease is the result of more women receiving regular pap tests to help catch precancer in earlier stages before it turns into cancer. The American Cancer Society estimates that 12,170 cases of cervical cancer were diagnosed in 2012.

The video below explains the criteria doctors use to stage cervical cancer.

Monday, January 7, 2013

Injection therapy for vesicoureteral reflux notes 5

The most common direction of mound shift is medially and caudally towards the bladder neck. Studies have shown that autologous chondrocytes, PTFE, and dextranomer/hyaluronic acid all shift toward the bladder neck if shifting occurs. Diamond et al describe distally shifted mound in 75 % of their technical failures. 10 The mechanism of shifting is thought to be due to the bladder contraction creating pressure gradient toward the bladder neck. Capozza et al found an association between mound shift and those patients with voiding dysfunction symptoms. Twenty-five of 27 patients with treatment failure had voiding dysfunction symptoms including frequency, urgency, and incontinence. 11

10. Diamond DA , Caldamone AA , Bauer SB , Retik AB . Mechanisms of failure of endoscopic treatment of vesicoureteral reflux based on endoscopic anatomy. J Urol 2003 ; 17 : 1556 – 8 ; discussion 1559 .

11. Capozza N , Lais A , Matarazzo E et al. Influence of voiding dysfunction on the outcome of endoscopic treatment for vesicoureteral reflux. J Urol 2002 ; 168 : 1695 – 8 .

Injection therapy for vesicoureteral reflux notes 4

Injection therapy in those patients with neuropathic bladders has been shown to be effective. Perez-Brayfield et al describe a success rate of 78 % . Neuropathic bladder and injection therapy present a certain set of challenges. Neuropathic bladders often have severe trabeculation and fibrosis, and placement of the injectable material in the correct position and with adequate mound configuration
is often more technically challenging. In addition, due to high voiding pressures, neuropathic bladders are at increased risk for mound shifting. These patients should be maintained on a bladder-management regimen including anticholinergic medication and clean intermittent catheterization in order to keep bladder pressures low. 4

4. Perez-Brayfield M , Kirsch AJ , Hensle TW et al. Endoscopic treatment with dextranomer/hyaluronic acid for complex cases of vesicoureteral reflux. J Urol 2004 ; 172 : 1614 – 16 .

Sunday, January 6, 2013

Injection therapy for vesicoureteral reflux notes 3

The mechanism of long-term sustained efficacy of dextranomer/hyaluronic acid (Deflux) is:
Dextranomer/hyaluronic acid is a dual component material. The dextranomer is cross-linked dextran microspheres 80 – 250 µm in diameter in a gel of hyaluronic acid. The dextranomer, the main bulking agent, is slowly degraded by hydrolysis. The hyaluronic acid represents the transport medium and slowly dissipates over 12 weeks. Volume stability over time results from fibroblast migration and collagen ingrowth into the hyaluronic acid matrix between the dextranomer microspheres. Stenberg et al found that histologic samples taken at the time of open reimplantation after failed injection therapy revealed granulomatous reaction of the giant cell type, inflammatory cell infiltration and implant pseudoencapsulation. 3

3. Stenberg A , Larsson E , Lackgren G . Endoscopic treatment with dextranomer/hyaluronic acid for vesicoureteral reflux: histological findings. J Urol 2003 ; 169 : 1109 – 13 .

Injection therapy for vesicoureteral reflux notes 2

Preinjection skin testing is necessary for the use of cross-linked bovine collagen as 3 % of patients will have a hypersensitivity reaction. However, a negative result does not completely eliminate the risk of an allergic reaction. Leonard et al describe a small subset of patients who developed antibovine collagen antibodies who had negative preinjection skin testing. While those patients became seropositive the clinical relevance is unclear. In only one of those patients a local reaction occurred which may have been immunogenic. 2

2. Leonard MP , Decter A , Hills K , Mix LW . Endoscopic subureteral collagen injection: are immunological concerns justified? J Urol 1998 ; 160 : 1012 – 16 .

Injection therapy for vesicoureteral reflux notes 1

Proper technique for the standard subureteric transurethral injection (STING) therapy involves the following steps:
(1) emptying the bladder to ¾ capacity so as not to displace the ureter laterally;
(2) placement of the needle bevel up into the posterior portion of the ureter;
(3) visualization of the creation of the mound with initial injection of 0.1 – 0.2 ml of material. Multiple injection sites implies there was difficulty in obtaining a proper mound in the correct plane, as well as increasing the possibility of leakage of injectable material. Kirsch et al reported improved results by modifying the standard technique by performing hydrodistention of the ureteral orifice and injection into the submucosa of the ureteral tunnel. 1

1. Kirsch AJ , Perez-Brayfield M , Smith EA , Scherz HC . The modified STING procedure to correct vesicoureteral reflux: improved results with submucosal implantation with the intramural ureter. J Urol 2004 ; 171 : 2413 – 16 .

Friday, January 4, 2013

The Kelalis-King-Belman Textbook of Clinical Pediatric Urology

Pain Management: A Practical Guide for Clinicians, Sixth Edition

Textbook of Laparoscopic Urology

Manual Endourology: Training for Residents

Robotics in Urologic Surgery

Thursday, January 3, 2013

book of Reconstructive Urologic Surgery


Circumcision Reduces HPV-Linked Penile Precancerous Lesions

A Study By University Of North Carolina Has Found That Male Circumcision Can Reduce Prevalence Of Penile Precancerous Lesions Among Men In Kenya.
Human Papillomavirus – HPV – Is A Sexually Transmitted Virus That Plays An Important Role In Genital Cancers In Men And Women, Including Cancers Of The Penis And Cervix.
“Our Data Are The First To Show That Male Circumcision May Reduce HPV-Associated Penile Precancerous Lesions. This Represents An Additional Public Health Benefit Of Male Circumcision,” Said Jennifer Smith, Senior Author.
“The Percentage Of Men With HPV-Associated Precancerous Penile Lesions Was Substantially Higher Among Those Who Were Not Circumcised – 26 Percent- Compared To Those Who Were Circumcised – .7 Percent,” Explained Smith, A Associate Professor Of Epidemiology In The UNC Gillings School Of Global Public Health And A Member Of UNC Lineberger Comprehensive Cancer Center.
“Interventions That Reduce HPV-Associated Penile Lesions Could Be Important To Both Men And Women, Because Such Lesions May Increase HPV Transmission From Men To Their Sexual Partners.
“Circumcision May Also Provide A Useful Intervention To Prevent HPV-Associated Penile Lesions And Ultimately Invasive Cervical Cancers In Less Developed Countries, Since Prophylactic HPV Vaccines May Not Be Readily Available To Men, And Current HPV Vaccines Do Not Include Protection Against All High-Risk HPV Types,” Added Smith.
The Study Has Been Published In The International Journal Of Cancer.

Non-invasive Penile Extenders Are Better Than Surgery

Choosing The Non-Invasive Methods To Increase The Size Of The Penis Is A Better Option For Men Than Surgery, According To A Report.
An Italian Review Published In The April Issue Of The Urology Journal BJUI Found That Penile Extenders Are More Successful Than Techniques Like Vacuum Devices, Exercises And Botox Injections And That Psychological Satisfaction Is Often Just As Important As Physical Changes.
“Urologists Are Constantly Approached By Men Who Are Concerned About The Size Of Their Penis, Despite The Fact That The Majority Of Them Are Normal Sized” Says Associate Urology Professor Paolo Gontero, From The University Of Turin, Who Carried Out The Research Review With Dr Marco Oderda.
“However There Are Also A Number Of Medical And Surgical Conditions That Can Cause Penile Shortening, Such As Radical Prostatectomy For Men With Prostate Cancer, Peyronie’s Disease And Congenital Abnormalities. Then There’s ‘Hidden Penis’, Which Is Caused By Overlying Abdominal Fat And Skin In Obese Aging Men Or A Lack Of Skin Because Of Chronic Inflammation Or An Aggressive Circumcision.
“Surgery Is Characterised By A Risk Of Complications And Unwanted Outcomes And Lack Of Consensus Among The Medical Profession On The Indications For Surgery And The Techniques Used. That Is Why A Non-Invasive Technique Is Preferable.”
The Review Compared Five Evidence-Based Surgical Studies Covering 121 Men And Six Evidence-Based Non-Surgical Studies Covering 109 Men, Published Between 2000 And 2009. Key Findings Included:

Scientists Construct New Penis For Rabbits, Hope For Humans Too

US Researchers Have Successfully Engineered Fully Functional Penises For Rabbits. The Technique May Someday Be Useful For People, It Is Hoped.
In A Study Published In The Proceedings Of The National Academy Of Sciences, The Team Said, Various Reconstructive Procedures Have Been Attempted To Restore A Cosmetically Acceptable Phallus That Would Allow Normal Reproductive, Sexual, And Urinary Function In Patients Requiring Penile Reconstruction. However, These Procedures Are Limited By A Shortage Of Native Penile Tissue. We Previously Demonstrated That A Short Segment Of The Penile Corporal Body Can Be Replaced Using Naturally Derived Collagen Matrices With Autologous Cells. In The Current Study, We Examined The Feasibility Of Engineering The Entire Pendular Penile Corporal Bodies In A Rabbit Model. Neocorpora Were Engineered From Cavernosal Collagen Matrices Seeded With Autologous Cells Using A Multistep Static/Dynamic Procedure, And These Were Implanted To Replace The Excised Corpora. The Bioengineered Corpora Demonstrated Structural And Functional Parameters Similar To Native Tissue And Male Rabbits Receiving The Bilateral Implants Were Able To Successfully Impregnate Females. This Study Demonstrates That Neocorpora Can Be Engineered For Total Pendular Penile Corporal Body Replacement. This Technology Has Considerable Potential For Patients Requiring Penile Reconstruction.
The New Penises Responded Normally To Electrical And Chemical Stimuli, And More Importantly To Biological Imperative. When Given The Chance To Have Sex, Eight Were Able To Ejaculate, And Four Became Fathers.
Indeed, They Became More Aroused Than The Rest. Most Control Rabbits Did Not Attempt Copulation After Introduction To Their Female Partners, Said The Researchers. All Rabbits With Bioengineered Neocorpora Attempted Copulation Within One Minute Of Introduction.

Can Recreational ED Drug Use Lead to ED?

July 20, 2012 — Men who use erectile dysfunction (ED) drugs recreationally may be more likely to develop psychogenic ED, the type that originates in the mind, according to new research.
"Recreational use of ED medications increased the chance of psychological dependence on ED medicines,'' says researcher Christopher Harte, PhD, a postdoctoral fellow at the VA Boston Healthcare System.
"Among young, healthy men who used ED medicines recreationally, the more frequent ED medicine use was associated with lower confidence in achieving and maintaining erections, which in turn was associated with lower erectile function," Harte says.
The study is published in the Journal of Sexual Medicine.
The researchers found a link but not cause and effect, Harte tells WebMD.
However, another expert wonders if some of the men who reported ''recreational'' use actually had ED.
ED Drugs and ED: Study Details
ED affects about 34 million men in the U.S., according to Harte.
The condition is more common with age. About 9% of men 18 to 39 are affected. Up to 70% of men 60 and older are.
However, men aged 18 to 45 are responsible for the largest increase in the use of Viagra among U.S. adults, Harte reports. From 1998 to 2002, the use by this age category grew 312%, he says.
For his study, Harte evaluated 1,207 men. Their average age was about 22.
·         72 were recreational users, reporting no diagnosis of ED from a doctor
·         1,111 were non-users of ED drugs
·         24 were prescribed the drugs and used them
The men completed an online survey. It asked about their sexual functioning in the past four weeks. They told whether they used ED drugs and how often.
They answered questions about their erectile function, orgasm, sexual desire, and their satisfaction with intercourse and overall sex.
They reported their levels of confidence in their ability to get and maintain an erection.
ED Drugs and ED: Study Results
Compared to non-users, recreational users reported lower erectile confidence and overall satisfaction.
The decreased confidence, in turn, was linked negatively with erectile functioning, he says.
Harte can't explain the link for sure. "It very well could be that recreational ED medication users may start having unreasonable standards or expectations about their erectile performance," he says.
That, in turn, could lead to men becoming overly sensitive about their performance and more dissatisfied, he says.
ED Drugs and ED: Perspective
The young men who were in the ''recreational'' category may actually have ED, says Irwin Goldstein, MD, editor-in-chief of The Journal of Sexual Medicine and a physician at Alvarado Hospital in San Diego.
"For those people who did use it recreationally, perhaps the explanation is, they were too embarrassed to announce [to their doctor] they have a sexual health problem," he tells WebMD.
They may have bought the drugs over the Internet, he says, without seeing a doctor.
There is no way to know for sure if all the men were honest, Harte says. "However, given that it was an anonymous, online survey, where they could complete the questionnaires in private and at their own pace and discretion, likely buffers, to a degree, any concerns with validity," he says.
If a young man does see a doctor for ED concerns, Goldstein says, some doctors may have trouble believing it could affect someone who doesn't have typical risk factors, such as high blood pressure or diabetes.
"Most 18- to 20-year-olds don't have those risk factors," he says. However, he says, "there can be other reasons for blocked blood flow to the penis."
Goldstein reports consultant work for makers of ED drugs, including Pfizer and Eli Lilly and Company.
ED Drugs and ED: Industry Comments
ED drugs are not meant for recreational use by those who don't have ED, according to spokespersons for the makers of two ED drugs, Cialis and Viagra.
According to Teresa Shewman, spokeswoman for Eli Lilly and Company: "Cialis is approved for use with a prescription only and Lilly does not condone the use of ED medication for off-label or recreational purposes."
"Viagra is approved for use in men age 18 or older who have been diagnosed with erectile dysfunction (ED),'' according to Christopher Loder, spokesman for Pfizer, which makes Viagra. "It should not be used by men who have not been diagnosed with erectile dysfunction."
Christopher Harte, PhD, postdoctoral fellow, VA Boston Healthcare System.
Harte, C. Journal of Sexual Medicine, July 2012.
Christopher Loder, spokesman, Pfizer.
Irwin Goldstein, editor, Journal of Sexual Medicine; sexual dysfunction researcher and physician, Alvarado Hospital, San Diego, Calif.
Teresa Shewman, spokeswoman, Eli Lilly and Company.

No Long-Term Harm Seen From Pediatric Shockwave Lithotripsy

NEW YORK (Reuters Health) Sep 17 - The efficacy of extracorporeal shockwave lithotripsy (SWL) in treatment of renal calculi in children is well established, and new research suggests there are no long-term harms from the intervention.
"These findings encourage the treatment of renal calculi in children using SWL technology without fear of development of systemic diseases (such) as diabetes and hypertension," Dr. Ahmed R. EL-Nahas told Reuters Health by email.
In a paper online August 23 in BJU International, Dr. El-Nahas and colleagues at Mansoura University in Egypt note that animal models have shown histological changes in renal tubular and glomerular epithelium and interstitial cells following high energy shockwave exposure. There also have been some reports of alterations of growth rate in pediatric kidneys.
To investigate further, the researchers retrospectively reviewed data on 70 children who underwent shockwave lithotripsy monotherapy from 1990 through 2009. They were followed for at least two years (mean 3.6 years) and their mean age at last follow-up was 11.6 years.
The treated kidney was examined by ultrasonography for measurement of renal length and detection of stones. The measured lengths were then compared with age-calculated normal renal lengths in healthy children.
Only one child had a kidney smaller than one standard deviation of the calculated length. This patient, a girl, had required three lithotripsy sessions to become stone-free. The current problem was brought about by a stone in the pelvic ureter some three years after SWL. She underwent ureteroscopic extraction.
The measured renal lengths of the eight patients aged more than 18 years at follow-up were within normal values for healthy adults.
Estimated blood sugar levels were normal in all children and no patients developed hypertension or diabetes.
The researchers caution that preoperative selective renal function was not estimated and stone analysis and metabolic evaluation were not performed for all patients. In addition, patients who underwent invasive treatment during follow-up were excluded.
Nevertheless, said Dr. EL-Nahas, "This study proved the safety of SWL for treatment of renal calculi in children."
BJU Int 2012.

Primary Severe Hypospadias: Comparison of Reoperation Rates, and Parental Perception of Urinary Symptoms and Cosmetic Outcomes Among 4 Repairs



We compared complication rates, urinary symptoms and cosmetic outcomes, as perceived by parents, among patients undergoing one of four repairs for proximal hypospadias associated with curvature.

Patients and Methods

Ninety-three patients were operated between 2004 and 2010. Repairs included the tubularised incised plate (n=26) or the onlay island flap urethroplasty (n=31) in cases requiring no urethral plate (UP) transection, whereas the onlay island flap on albuginea (n=18) or the 2-stage repair (n=18) in those requiring UP transection.
Complications were assessed by chart review. A customized questionnaire and the Pediatric Penile Perception Score (PPPS) were administered to parents to evaluate their perception of urinary symptoms and cosmetic outcomes, respectively.


After a median (range) follow-up of 4.5 (2.2-8.4) years, complications developed in 21 (23%) patients without any difference among the procedures, or between cases requiring and not requiring UP transection.
Parents of 75 (80%) patients participated in the survey, without difference among repairs (p=0.35). Reported urinary symptoms were not different among repairs. On PPPS, the only difference concerned the question about penile length (p=0.03), which score was significantly better in the techniques requiring UP transection (p=0.05). The 2-stage repair had significantly better scores in the question about penile length and overall PPPS than all the other techniques.


Overall complication rates were comparable among repairs and did not increase after UP transection. Urinary symptoms, as reported by parents, were comparable among the procedures. Perceived penile length was significantly better after UP transection. The 2-stage repair yielded the best cosmetic results.

By Will Boggs, MD
NEW YORK (Reuters Health) - Complication rates and urinary symptoms are similar with four different techniques for repairing primary severe hypospadias, a new study shows.
"The ideal approach strictly depends on the intraoperative findings," Dr. Marco Castagnetti from University Hospital of Padova, Italy told Reuters Health. "If urethral plate transection can be avoided, I generally opt تختار for a TIP (tubularized incised plate) repair unless I am unhappy with the urethral plate (too narrow). When urethral plate transection is deemed necessary, then I would prefer a two-stage approach, but the choice depends also on parental preference."
Dr. Castagnetti and colleagues compared complication rates, urinary symptoms, and cosmetic outcomes (as perceived by parents) in 93 patients with primary proximal hypospadias repaired by one of four techniques. When urethral plate transection was not required for straightening, 26 patients had TIP and 31 had onlay preputial island flap (OIF) urethroplasty. When urethral plate transection was needed, 18 patients had an onlay island flap on albuginea (OIFA) and 18 had a two-stage repair.
Complication rates ranged from 16% for OIF to 27% for TIP but did not differ significantly by technique, according to a November 13th online report in The Journal of Urology.
Urinary symptoms included post-void dribbling (32%), abnormal micturition frequency (25%), deflected stream (16%), hesitation (9%), weak stream (9%), urinary tract infection (8%), and straining to void (3%). Their prevalence was similar after the different procedures.
Parental impression of penile length was significantly better for the two-stage repair compared with all of the other techniques, as was parental impression of penile axis. The two-stage repair also had a significantly higher Pediatric Penile Perception Score.
"Overlying attempts at preserving the urethral plate continuity are unnecessary, and rather than insisting in the use of procedures that shorten the dorsal aspect of the penis, in cases with curvature greater than 30 degrees after ventral dissection, it is better to embark on urethral plate transection," Dr. Castagnetti said. "This does not compromise the results of surgery as previously thought."
"I would be even less keen to preserve the urethral plate in patients with a small penis, as in these cases one should avoid as much as possible to shorten the penis," Dr. Castagnetti said. "Patients with a short penis are best suited for a two-stage repair."
He cautioned, "It is important to remember that the two-stage procedure could become multistage," as 30% to 75% of cases involve additional procedures. "This is an issue and parents should be informed," he added.

Wednesday, January 2, 2013

Sexual, Urological Disorders Linked to Waist Size

August 2, 2012 — For the first time in a comprehensive way, researchers have associated obesity in men, particularly large waist circumference (WC), with sexual and urologic dysfunction, in addition to metabolic effects. The results of the new studyare published in the August issue of the British Journal of Urology International.
Richard K. Lee, MD, from the Department of Urology, Weill Medical College of Cornell University, New York City, and colleagues analyzed the records of 409 men aged 40 to 91 years who came to the Institute for Bladder and Prostate Health at New York–Presbyterian Hospital/Weill Cornell between January 2006 and June 2008. The men had moderate to severe lower urinary tract symptoms (LUTS), based on scores of 8 or higher on the International Prostate Symptom Score (IPSS).
The researchers divided the men into 3 groups based on WCs of less than 90 cm (<36 inches; 153 men), 90 to 99 cm (36 - 39 inches; 137 men), and more than 100 cm (39+ inches; 119 men), to determine whether WC could be a simple metric to predict LUTS prevalence. Median age for all men was 57.6 years.
"The overall prevalence of lower urinary tract symptoms as measured by the IPSS did not differ significantly among the three WC groups ( P = 0.10), although subgroup analysis showed that the group with WC ≥ 100 cm had a higher proportion of men with severe symptoms (IPSS 20 – 35, P = 0.003); this effect was not seen for the two lower IPSS groups ( P = 0.07 and P = 0.36)," the researchers write.
"Sexual dysfunction significantly differed with WC. The prevalence of erectile dysfunction increased from 32.1% to 74.5% as WC increased ( P = 0.001). The prevalence of ejaculatory dysfunction also increased from 21.4% to 64.7% as WC increased ( P = 0.002)," they continue. In addition, the prevalence of ejaculatory dysfunction went up from 21.4% to 64.7% for the same groupings ( P = .002).
The researchers also found that as WC increased, prevalences increased from 14.5% to 33.5% for hypertension ( P = .02), 8.4% to 29.4% for coronary artery disease ( P =.004), and 11.3% to 32.6% for type 2 diabetes ( P = .001), and that mean serum cholesterol rose from 148 mg/dL to 254 mg/dL ( P = .001) among the same groups.
Using multiple logistic regression modeling, the researchers calculated odds ratios (ORs) for both urological and metabolic associations with WC size. For example, as WC increases from the smallest WC group to the largest WC group, the ORs are 2.32 (95% confidence interval [CI], 1.26 - 3.93; P = .01) for erectile dysfunction, 3.02 (95% CI, 1.31 - 5.78; P = .03) for ejaculatory dysfunction, 2.31 (95% CI, 1.53 - 3.87; P = .001) for hypertension, 2.88 (95% CI, 1.68 - 4.32; P = .002) for type 2 diabetes, and 3.50 (95% CI, 1.32 - 5.12; P = .001) for coronary artery disease.
"The findings demonstrate that obesity in men — part of a growing global epidemic — affects their well-being in profound ways," Steven A. Kaplan, MD, the study's senior investigator, the E. Darracott Vaughan Jr professor of urology at Weill Cornell Medical College, director of the Iris Cantor Men's Health Center, and chief of the Institute for Bladder and Prostate Health at NewYork–Presbyterian/Weill Cornell, said in a Cornell news release. "What we eat can have devastating consequences on more than just our hearts. Quality of life issues, such as sexual and voiding health, can be affected as well in drastic ways."
Study limitations include its confinement to a single, high-volume institution, the researchers write, and randomized trials are needed to validate the results.
The researchers conclude, however, "Waist circumference may represent an easy diagnostic tool to elucidate the presence of occult voiding dysfunction."
"Measuring a man's waistline is easy, noninvasive and does not require extensive testing," Dr. Kaplan said in the press release.
The authors have disclosed no relevant financial relationships.
BJUI. 2012;110:540-545. 

Robot Prostatectomy Cuts Incontinence, Surgeon Finds

NEW YORK (Reuters Health) Aug 08 - Robot surgery for prostate cancer lowered the rate of urinary complications compared with hands-on surgery in a new Italian study.
While the study was small and contradicts earlier results, it's important because surgery has quickly overtaken cheaper alternatives in the U.S., helped by hospitals aggressively marketing the technology.
Yet there is no ironclad science showing it's any better, and many doctors have voiced concerns about the higher costs.
In the randomized Italian study, a single surgeon performed laparoscopic radical prostatectomy on 120 men, with or without the help of a robot.
He and his colleagues found no reliable difference in blood loss, operating time, length of hospital stay or cancer outcomes at one year.
However, men reported less use of diapers after the robot procedure. At one year, for example, 95% of the robot-assisted group used no or at most one safety diaper a day, compared to 83% of the others.
Also, of the men who were able to achieve an erection before their surgery and were treated with nerve-sparing techniques, 80% in the robot group had recovered that ability within a year vs just 54% in the control group.
"This is certainly the strongest evidence to date (that) laparoscopic surgery done with robotic assistance is going to yield better outcomes than traditional laparoscopy," said Dr. Matthew Cooperberg, a urologist at the University of California, San Francisco.
"Nobody is saying this is definitive, but it is probably the best study we will get answering this question."
According to Dr. Cooperberg, few surgeons in the U.S. today offer laparoscopic surgery without robot assistance, despite the lack of good evidence that using the machine is better.
Dr. Francesco Porpiglia of San Luigi Gonzaga Hospital in Turin, who did all the surgeries in the study, did not respond to a request for comments.
But in their report online July 20th in European Urology, he and his colleagues say the better results with the robot could be due to higher surgical precision given the 3D magnification and wide range of movement of the machine.
They also recognize that their study is limited by the small number of men who participated. Also, they caution, "Our results depend strictly on the single surgeon and do not represent a real-life situation."
Dr. Cooperberg, who uses the technology himself, said skill and experience are more important than technology.
Perhaps the strongest conclusion from the new report, Dr. Cooperberg said, is that patients should not be afraid to ask surgeons about their outcomes. In that vein, he added, "If you are going to see Dr. Porpiglia for prostatectomy, definitely get the robot."
Eur Urol 2012.

Dutasteride Treatment Over 2 Years Delays Prostate-specific Antigen Progression in Patients with Biochemical Failure After Radical Therapy for Prostate Cancer: Results from the Randomised, Placebo-controlled Avodart After Radical Therapy for Prostate Cancer Study (ARTS).


Rising prostate-specific antigen (PSA) levels after radical therapy are indicative of recurrent or residual prostate cancer (PCa). This biochemical recurrence typically predates clinically detectable metastatic disease by several years. Management of patients with biochemical recurrence is controversial.
To assess the effect of dutasteride on progression of PCa in patients with biochemical failure after radical therapy.
Design, setting, and participants
Randomised, double-blind, placebo-controlled trial in 294 men from 64 centres across 9 European countries.
The 5α-reductase inhibitor, dutasteride.
Outcome measurements and statistical analysis
The primary end point was time to PSA doubling from start of randomised treatment, analysed by log-rank test stratified by previous therapy and investigative-site cluster. Secondary end points included time to disease progression and the proportion of subjects with disease progression.
Results and limitations
Of the 294 subjects randomised (147 in each treatment group), 187 (64%) completed 24 mo of treatment and 107 discontinued treatment prematurely (71 [48%] of the placebo group, 36 [24%] of the dutasteride group). Dutasteride significantly delayed the time to PSA doubling compared with placebo after 24 mo of treatment (p < 0.001); the relative risk (RR) reduction was 66.1% (95% confidence interval [CI], 50.35–76.90) for the overall study period. Dutasteride also significantly delayed disease progression (which included PSA- and non-PSA-related outcomes) compared with placebo (p < 0.001); the overall RR reduction in favour of dutasteride was 59% (95% CI, 32.53–75.09). The incidence of adverse events (AEs), serious AEs, and AEs leading to study withdrawal were similar between the treatment groups. A limitation was that investigators were not blinded to PSA levels during the study.
Dutasteride delayed the biochemical progression of PCa in patients with biochemical failure after radical therapy for clinically localised disease. The safety and tolerability of dutasteride were generally consistent with previous experience.

Fritz Schröder, Chris Bangma, Javier C. Angulo, Antonio Alcaraz, Marc Colombel, Tom McNicholas, Teuvo L. Tammela, Indrani Nandy, Ramiro Castro.
Accepted 4 November 2012, Published online 23 November 2012

Rising PSA After Prostatectomy: What to Do?

What should we do for men who have a rising prostate-specific antigen (PSA) level after radical prostatectomy? A study by Schroder and associates [1] in European Urology addressed this question with a prospective, randomized, placebo-controlled trial aimed at preventing PSA progression. The study was done using dutasteride, which was compared with placebo. Men were randomly assigned to receive either of the 2 treatments for 2 years. The primary outcomes were time to PSA doubling as well as other parameters of progression. The results were very encouraging in that they found a very significant reduction in progression rates for men who were given dutasteride.
The treatment was well controlled, but there were limitations in this study. First, nearly a third of the almost 300 men discontinued the study prematurely, and nearly twice as many patients discontinued it in the placebo group compared with the treatment group, so it may have created a significant bias. Another problem was that the men and the doctors knew the PSA levels as the treatment was proceeding, so there could have been a bias in selecting the men who stayed on the trial and those who did not. Lastly, we have to ask ourselves how important PSA progression is in terms of accurately predicting long-term survival, and there we have more uncertainty.
In the United States, the Food and Drug Administration does not recognize PSA parameters for giving approval for treatments. This leaves us with a question: What should we do with these data in terms of counseling men who have biochemical progression after undergoing a radical prostatectomy? Is it reasonable to offer them dutasteride at the present time even though it is not approved? It is certainly available. Or is it possible that, by affecting PSA in some way, we are preventing patients from being offered other therapies that may indeed affect survival? These are questions that we cannot answer at this time, but I would urge caution in saying to men that, at this time, dutasteride is an appropriate thing to use if your PSA is rising.
We need more information, and without other measures of disease progression besides PSA, it is possible that we are making the wrong conclusion. For now, it would be nice to have additional data, and I expect that this study will continue to report on further follow-up. The bottom line at this time is that I don't think there is enough information yet to recommend dutasteride to men with a rising PSA level, but it certainly can be discussed. I look forward to your comments.


1.      Schroder F, Bangma C, Angulo JC, et al. Dutasteride treatment over 2 years delays prostate-specific antigen progression in patients with biochemical failure after radical therapy for prostate cancer: results from the randomized, placebo-controlled Avodart After Radical Therapy for Prostate Cancer Study (ARTS). Eur Urol. 2012 Nov 23. [Epub ahead of print] Accessed December 19, 2012.

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