Is there a clinical role for frozen section analysis during partial nephrectomy? A multicenter experience over 10 years.

BACKGROUND: Frozen section analysis (FSA) is frequently performed during partial nephrectomy (PN). We investigate the utility of intraoperative FSA by evaluating its impact on final surgical margin (SM) status. METHODS: Between January 1995 and December 2005, a series of patients who were treated with open PN for renal cell carcinoma was prospectively analyzed. During PN, each patient underwent a FSA on renal parenchyma distal margin. If FSA was positive for infiltration a deeper excision was performed till obtaining a negative FSA. SM outcome of the FSA was compared with the final pathology report. Recurrence-free survival (RFS) and cost analysis on the FSA performed were analyzed. RESULTS: A total number of 373 patients were enrolled. FSA was performed in all the patients considered for PN. Fifteen patients had a conversion to radical nephrectomy. Positive SMs at the definitive pathological outcome were found in 36 patients (9.6%). FSA was positive in eight patients (2.1%). In that eight cases after a deeper excision the definitive pathological outcome on SM was still positive in two cases. FSA revealed just 14.3% of the positive SM. Patients with positive SM had a worse follow up considering RFS (P<0.05). Kaplan-Meier analysis revealed that FSA did not considerably contribute to prevent recurrence (P=0.35). 1438 euros was the mean cost of performing a FSA during PN. CONCLUSIONS: FSA during PN does not reduce the risk of positive SMs. The use of FSA has also a higher cost related to the procedure.

Delaying Surgical Treatment of Penile Fracture Results in Poor Functional Outcomes: Results from a Large Retrospective Multicenter European Study.

BACKGROUND: Penile fracture is a rare clinical entity that represents a urologic emergency. It involves traumatic rupture of the tunica albuginea of the corpora cavernosa due to twisting or bending of the penile shaft during erection. OBJECTIVE: To determine the differences in preoperative diagnostic evaluation patterns and outcomes of penile fracture patients to investigate the impact of surgical delay on functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed using data obtained from 137 patients presenting with penile fracture at seven different European academic medical centers between 1996 and 2013. Age, imaging modalities used, timing of surgical intervention, length of tunica albuginea defect, and surgical technique were recorded. Postoperative erectile function outcomes were assessed with the International Index of Erectile Function (IIEF-5), and the presence of postoperative penile curvature was noted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The association between timing of surgical intervention and postoperative IIEF-5 results was evaluated with discriminant function analysis. RESULTS AND LIMITATIONS: The median age of the patients was 34.50 yr (interquartile range [IQR]: 28.0-46.5 yr). Of the 137 patients, 82 (59.85%) underwent penile Doppler ultrasound, and 5 patients (3.64%) were evaluated with magnetic resonance imaging. All patients were treated surgically, and the duration between emergency room admission and surgical intervention was 5.0h (IQR: 3.6-8.0h). The median length of tunica albuginea defect was 10mm (IQR: 8-20mm). Postoperative IIEF-5 scores were 21 (IQR: 12-23) and 23 (IQR: 15-24) at the first and third postoperative months, respectively. Discriminant function analysis revealed that if the surgical intervention was performed >8.23hours after emergency room admission, postoperative erectile function was significantly worse (p=0.0051 at first month and p=0.0057 at third month postoperatively). CONCLUSIONS: Our multicenter study showed that delaying surgical intervention results in significantly impaired erectile function. Surgical treatment must be planned as soon as possible to avoid postoperative erectile dysfunction. PATIENT SUMMARY: We looked at sexual outcomes following the repair of penile fracture in a large European population. We found that outcomes worsened if surgical repair was delayed.

Multiparametric [11C]Acetate positron emission tomography-magnetic resonance imaging in the assessment and staging of prostate cancer.

BACKGROUND: The aim of this study was to evaluate whether MP [11C]Acetate PET-MRI enables an accurate differentiation of benign and malignant prostate tumors as well as local and distant staging. MATERIALS AND METHODS: Fifty-six consecutive patients fulfilling the following criteria were included in this IRB-approved prospective study: elevated PSA levels or suspicious findings at digital rectal examination or TRUS; and histopathological verification. All patients underwent MP [11C]Acetate PET-MRI of the prostate performed on separate scanners with PET/CT using [11C]Acetate and 3T MP MR imaging. Appropriate statistical tests were used to determine diagnostic accuracy, local and distant staging. RESULTS: MP imaging with two MRI parameters (T2w and DWI) achieved the highest sensitivity, specificity, and diagnostic accuracy of 95%, 68.8%, and 88%, with an AUC of 0.82 for primary PCa detection. Neither assessments with a single parameter (AUC, 0.54-0.79), nor different combinations with up to five parameters (AUC, 0.67-0.79) achieved equally good results. MP [11C]Acetate PET-MRI improved local staging with a sensitivity, specificity, and diagnostic accuracy of 100%, 96%, and 97% compared to MRI alone with 72.2%, 100%, and 95.5%. MP [11C]Acetate PET-MRI correctly detected osseous and liver metastases in five patients. CONCLUSIONS: MP [11C]Acetate PET-MRI merges morphologic with functional information, and allows insights into tumor biology. MP [11C]Acetate PET-MRI with two MRI-derived parameters (T2 and DWI) yields the highest diagnostic accuracy. The addition of more parameters does not improve diagnostic accuracy of primary PCa detection. MP [11C]Acetate PET-MRI facilitates improved local and distant staging, providing "one-stop" staging in patients with primary PCa, and therefore has the potential to improve therapy. PATIENT SUMMARY: In this report we investigated MP [11C]Acetate PET-MRI for detection, local and distant staging of prostate cancer. We demonstrate that MP [11C]Acetate PET-MRI with two MRI-derived parameters (T2 and DWI) achieves the best diagnostic accuracy for primary prostate cancer detection and that MP [11C]Acetate PET-MRI enables an improved local and distant staging.

Whole body vibration therapy on a treatment bed as additional means to treat postprostatectomy urinary incontinence.

An innovative form of whole body vibration therapy on a treatment bed (Evocell®) to fight against the disabling and isolating symptom of postoperative incontinence in a prostate cancer patient is presented. A supervised program with outpatient active pelvic floor training and a novel form of synchronous high-intensity whole body vibration therapy using the Evocell® device was performed in a patient with postprostatectomy stress urinary incontinence. The patient had previously failed regular pelvic floor exercise. During the intervention, namely a whole body vibration treatment in a lying position on a treatment bed, the patient performed active and passive pelvic floor exercises under professional guidance. Over a period of 6 weeks after starting treatment, the patient regained continence (usage of 1 safety pad). Furthermore, his ability to work increased (return to work) and his ability to attend social activities improved.

The association between maternal hydronephrosis and acute flank pain during pregnancy: a prospective pilot-study.

PURPOSE: Maternal hydronephrosis may cause flank pain during pregnancy. We aimed to investigate the association between maternal hydronephrosis and flank pain intensity. METHODS: From 2014 to 2015, all consecutive women with singleton pregnancies, who presented at our tertiary center due to acute flank pain, were prospectively evaluated by renal ultrasonography and pain questionnaires. A visual analogue scale was used to assess pain intensity. The study had 90% power to detect a significant correlation between hydronephrosis and flank pain (Spearman's test). RESULTS: A total of 51 consecutive women with left-sided (13.7%), right-sided (64.7%) or bilateral (21.6%) pain were enrolled. The mean gestational age of these women, who presented due to their pain, was 27.5 ± 6.8 weeks at the time of consultation. The mean VAS score was 7.6 ± 2.2. In 43/51 (84.3%) women, hydronephrosis was found on renal sonograms. No correlation was found between the grade of hydronephrosis and pain intensity (p = 0.466; r= -0.28). Women delivered at a mean gestational age of 38.1 ± 2.4 weeks and their infants had a mean birthweight of 3138 ± 677 g. CONCLUSIONS: Hydronephrosis is a common finding among pregnant women with acute flank pain. The grade of hydronephrosis does not affect pain intensity. This study suggests normal pregnancy outcomes in these women.

Role of Penile Doppler US in the Preoperative Assessment of Penile Squamous Cell Carcinoma Patients: Results From a Large Prospective Multicenter European Study.

OBJECTIVE: To determine the role of penile Doppler ultrasound (PDU) compared with magnetic resonance imaging (MRI) in preoperative diagnostic evaluation of patients with penile squamous cell carcinoma. MATERIALS AND METHODS: A prospective analysis on patients presenting with clinical diagnosis of penile squamous cell carcinoma from 6 different European hospitals between 2012 and 2014 was carried out. Each patient who had planned an organ sparing approach underwent an MRI and PDU both with an artificial erection with prostaglandin E 1. Age, evidence of MRI or PDU corpora cavernosa infiltration, frozen section examination report, definitive pathological report, and surgical approach used per patient were recorded. Accuracy, precision, negative predictive value, sensitivity, and specificity were calculated. Outcomes were statistically evaluated. RESULTS: Two hundred patients were enrolled in the study. The mean age of the patients was 67.35 ± 15.45 (range 51-82). All of the patients were treated surgically. Of the 200 patients, 135 (67.5%) underwent a corpora sparing approach, whereas 65 had a partial penectomy because of the frozen section outcome. About corpora cavernosa infiltration, the definitive outcome confirmed the frozen section examination. PDU vs MRI accuracy was 96.5% vs 90.5%; precision was 92.6% vs 96%; sensitivity was 96.9% vs 73.8%, specificity was 96.2% vs 98.5%. Despite sensitivity (P <.05) no statistical evidence was found between ultrasound and MRI. CONCLUSION: PDU has a statistical similar outcome on detecting infiltration of corpora cavernosa and could be used as a less expensive tool to drive surgical strategy in patient with a diagnosis of penile squamous cell carcinoma.

Multi-institutional validation of the prognostic value of Ki-67 labeling index in patients treated with radical prostatectomy.

OBJECTIVE: Several smaller single-center studies have reported a prognostic role for Ki-67 labeling index in prostate cancer. Our aim was to test whether Ki-67 is an independent prognostic marker of biochemical recurrence (BCR) in a large international cohort of patients treated with radical prostatectomy (RP). METHODS: Ki-67 immunohistochemical staining on prostatectomy specimens from 3,123 patients who underwent RP for prostate cancer was retrospectively performed. Univariable and multivariable Cox regression models were used to assess the association of Ki-67 status with BCR. RESULTS: Ki-67 positive status was observed in 762 (24.4 %) patients and was associated with lymph node involvement (LNI) (p = 0.039). Six hundred and twenty-one (19.9 %) patients experienced BCR. The estimated 3-year biochemical-free survivals were 85 % for patients with negative Ki-67 status and 82.1 % for patients with positive Ki-67 status (log-rank test, p = 0.014). In multivariable analysis that adjusted for the effects of age, preoperative PSA, RP Gleason sum, seminal vesicle invasion, extracapsular extension, positive surgical margins, lymphovascular invasion, and LNI, Ki-67 was significantly associated with BCR (HR = 1.19; p = 0.019). Subgroup analysis revealed that Ki-67 is associated with BCR in patients without LNI (p = 0.004), those with RP Gleason sum 7 (p = 0.015), and those with negative surgical margins (p = 0.047). CONCLUSION: We confirmed Ki-67 as an independent predictor of BCR after RP. Ki-67 could be particularly informative in patients with favorable pathologic characteristics to help in the clinical decision-making regarding adjuvant therapy and optimized follow-up scheduling.

Lower urinary tract symptoms in patients with liver cirrhosis.

PURPOSE: To evaluate the prevalence of lower urinary tract symptoms (LUTS) in men with liver cirrhosis. METHODS: In total, 128 men with known liver cirrhosis were prospectively evaluated using the validated German version of the International Prostate Symptom Score (IPSS) questionnaire. In parallel, all men underwent a detailed examination including medical history; physical examination; Child-Pugh liver function score (CPS) assessment; and measurement of blood levels of prostate-specific antigen (PSA), total and free testosterone, sexual hormone-binding globulin (SHBG), prolactin, luteotropic hormone (LH), and follicle-stimulating hormone (FSH). RESULTS: Mean patient age and mean IPSS was 56 ± 9 years and 8 ± 6, respectively. Mild (IPSS: 1-7), moderate (IPSS: 8-19), and severe (IPSS: 20-35) LUTS were present in 60.2 % (77/128), 31.3 % (40/128), and 7.0 % (9/128) of the patients, respectively. Storage symptoms increased with the CPS (p = 0.04). Voiding symptoms and overall IPSS did not differ between the CPS groups (p = 0.93 and p = 0.67). No correlation was found between ascites volume and IPSS, storage symptoms, voiding symptoms, or quality of life (QoL) (p = 0.46, p = 0.26, p = 0.81, p = 0.87). From CPS groups A to C, mean PSA levels (p = 0.04), total and free testosterone levels (p < 0.001 and p < 0.001), and SHBG levels decreased (p = 0.03); however, prolactin levels increased (p = 0.03). LH and FSH levels did not differ between the CPS groups (p = 0.15 and p = 0.35). CONCLUSIONS: Men with liver cirrhosis commonly have LUTS, with a predominance of storage symptoms. Liver cirrhosis may also affect PSA-based prostate cancer risk assessment. Accurate diagnosis and therapy strategies are warranted to improve the QoL of these patients.

The Link Between Cigarette Smoking and Erectile Dysfunction: A Systematic Review.

CONTEXT: Cigarette smoking is an established risk factor for erectile dysfunction (ED). To what extent smoking affects erectile function, however, remains debated. OBJECTIVE: To integrate the available evidence regarding the impact of smoking status and smoking exposure on prevalence, severity, and progression in patients with ED. EVIDENCE ACQUISITION: A systematic search of the literature was conducted using the Medline, Embase, and Scopus databases limited to articles published in English between January 1998 and October 2014. We selected 13 articles according to predefined inclusion criteria and the Preferred Reporting Items for Systematic Reviews and Meta-analysis. EVIDENCE SYNTHESIS: Most of the studies demonstrated an association between smoking and ED. Evidence was also found supporting the beneficial effect of smoking cessation on the restoration of erectile function. We noted marked heterogeneity in patient populations and smoking categorizations across studies, precluding conduct of a meta-analysis. Considerable evidence exists to support the hypothesis/theory that smoking-related ED is mainly associated with endothelial impairment, reduction in nitric oxide availability, and imbalance between oxidative and antioxidative reactions increasing oxidative stress. Passive secondhand cigarette smoking, especially with a long-term exposure, can also have a negative impact on erectile function. CONCLUSIONS: Smoking is strongly associated with ED. Endothelial dysfunction together with increased oxidative stress represent major pathophysiologic mechanisms, and smoking cessation may mitigate this effect. PATIENT SUMMARY: Current smoking is significantly associated with erectile dysfunction, and smoking cessation has a beneficial effect on the restoration of erectile function.

Gender has no influence on VUR rates after renal transplantation.

The influence of recipient gender on urological complications including vesicoureteral reflux (VUR) after renal transplantation has not yet been established. In this study, post-transplantation voiding cystourethrography and ultrasonography were used to evaluate the upper and lower urinary tract in 598 consecutive renal transplant recipients. Our cohort included 209 females and 389 males, respectively. Gender-specific urological complications and potential confounders were analyzed in relation to long-term allograft outcomes. Postoperative urinary retention occurred more frequently in men (P = 0.004). Urinary tract infections (UTIs) were diagnosed more frequently in women after transplantation (P = 0.05). In a multivariate analysis, gender was not a risk factor for VUR [HR, 1.35 (CI, 0.90-1.96); P = 0.14]. VUR rates were influenced by the surgeon's experience level at the time of transplantation [HR, 0.59 (CI, 0.40-0.87); P = 0.008]. No gender-specific differences were seen for ureteral stenosis, leakage, hydronephrosis, death-censored graft or patient survival, and long-term allograft function. Donor/recipient gender mismatch had no impact on postoperative complication rates. In conclusion, male transplant recipients are at risk for developing postoperative urinary retention, whereas female patients more likely develop UTIs. Surgeon's experience level is a risk factor for developing VUR.

Ultra-high-risk pregnancies in women after renal transplantation.

OBJECTIVES: This study evaluates pregnancy outcomes in renal transplant recipients who have additional obstetrical, surgical, or urological risk factors. STUDY DESIGN: Data from our transplantation and obstetrical databases were retrospectively analyzed to identify all women of reproductive age who had undergone renal transplantation between 1999 and 2013 at our tertiary referral center and had subsequently become pregnant. Characteristics of pregnancy and perinatal outcome parameters; obstetrical, urological, and surgical risk factors; and graft function were assessed. Descriptive data analysis, Fisher's exact test, unpaired Student's t-test and one-way analysis of the variance were performed. RESULTS: The overall pregnancy rate after renal transplantation was 5% (n=13). 77% of the patients (n=10) had ultra-high-risk pregnancies due to additional risk factors. These included twin pregnancy, placenta previa/percreta, hypertension; previous heart transplantation, previous myocardial infarction; postoperative lymphocele, urinary leakage, hydronephrosis, or vesico-ureteral reflux. Two patients had two consecutive pregnancies. A total of 12 deliveries with 13 newborns were achieved. Cesarean section and preterm delivery rates were 67% and 50%, respectively. Mean gestational week at delivery was 36 ± 3. Mean creatinine levels were higher in women with preterm deliveries and in those of advanced age. Mean time between transplantation and delivery was 79 ± 36 months. All patients had adequate graft function after a mean follow-up of 128 ± 50 months after renal transplantation. CONCLUSIONS: Pregnant women after renal transplantation commonly present with additional risk factors. In these ultra-high-risk pregnancies successful outcomes can be achieved in a multidisciplinary setting. Adequate graft function and urinary tract evaluation is necessary.

Use of self-retaining barbed sutures decreases cold ischemia time in open nephron-sparing surgery.

PURPOSE: In the present study, we aimed to determine whether the use of self-retaining barbed sutures (SRBS) instead of conventional sutures during open partial nephrectomy leads to improved surgical outcomes. PATIENTS, MATERIALS AND METHODS: A retrospective analysis of 50 consecutive patients who underwent open partial nephrectomy for a unicentric renal tumor was performed. In 15 patients, SRBS were used for parenchymal repair during open partial nephrectomy, and in 35 patients, conventional sutures were used. The parameters related to surgical outcomes were recorded and analysis of the total patient population and subgroup analysis according to the preoperative aspects and dimensions used for an anatomical (PADUA) score classification was performed. RESULTS: The preoperative baseline values did not statistically differ between the groups. Analysis of the total patient population showed a significant difference regarding ischemia time (mean ± standard deviation) between the SRBS group (15.2 ± 6.9 min), and the conventional suture group (25.7 ± 11.8 min). There was no significant difference between the barbed and conventional sutures with regard to postoperative hemoglobin levels, decline in hemoglobin percentage, or renal function parameters. In subgroup-analysis, a significant difference in ischemia time was only found for PADUA scores 6 and 7, without any effect on the outcome parameters. CONCLUSIONS: The use of SRBS in parenchymal repair during open partial nephrectomy appears to be a safe and feasible option with decreased cold ischemia time when compared with conventional sutures. In PADUA subgroup-analysis this difference was only observed for PADUA scores 6 and 7.

Intravesical hemostatic gelatin matrix instillation in the management of intractable hematuria.

INTRODUCTION: The objective of the present study was to evaluate the safety and feasibility of a novel and minimally invasive approach, namely, intravesical instillation of a gelatin matrix hemostatic sealant (GMHS) in the management of intractable hematuria. TECHNICAL CONSIDERATIONS: Six consecutive patients with intractable hematuria not responding to standard treatment underwent intravesical instillation of a hemostatic bovine-derived gelatin matrix mixed with a human-derived thrombin component. The technical aspects of this approach are described in detail. The mean age of the patients was 70 ± 4 years (median 71, range 50-79). All patients had pelvic malignancy: 5 had prostate cancer, and 1, cervical cancer. Mean duration of hematuria before intervention was 6 ± 1 days (median 6, range 2-9). Mean preoperative hemoglobin level was 9.2 ± 0.5 g/dL (median 9.0, range 8.0-10.2). Complete control of bleeding was achieved in 5 patients (83%) and all 6 patients (100%) on day 1 and 7, respectively. At a mean follow-up of 10 ± 6 months (median 13, range 1-15), permanent control of bleeding was achieved in 5 of 6 patients (83%). A second GMHS instillation was performed in 1 patient (17%) and it was successful. During the follow-up, there were no complications related to GMHS instillation. Two patients died because of their underlying malignant disease. CONCLUSION: Intravesical GMHS instillation appears to be a safe and feasible option in the management of intractable hematuria in the short-term.

New ablative treatments for small renal masses: HIFU ablation.

Solid renal tumours with a diameter <4cm comprise up to half of all renal tumours coming for a therapeutic decision in tertiary care centres today. ∼80% are renal cell cancers, and nephron-sparing excision is standard therapy. The approach has considerable morbidity , and as many of these tumours are diagnosed in elderly ,infirm patients less invasive focal ablation appears attractive. This is usually achieved with radiofrequency or cryoablation, either percutaneously under image guidance or by a laparoscopic approach. The quality of reports on the outcome with this treatment is moderate, with no prospective comparative studies, and in general short follow-up. Metanalyses suggest more reliable results with cyro- than with radiofrequency ablation . Morbidity is lower than with nephron-sparing surgery, but still substantial and almost entirely due to the perforating trauma at ablation. This would be avoided by energy ablation with high-intensity focused ultrasound from an extracorporeal energy source. Phase 1 clinical studies with several prototoypes have been disappointing, as multiple acoustic interphases and target mobility obviously render adequately precise focusing unreliable. New HIFU transducers that can be approximated directly to the tumour via a laparoscopic approach circumvent these problems. A phase 1 study with this technique in 31 patients demonstrates that complete ablation of tumours can be achieved in this manner, at least for tumours <3cm and in a peripheral position in the lower and middle third of the kidney. Perforating trauma to the kidney is avoided, and morbidity is minimized. Of course patients still need long - term follow-up with sequential imaging and even biopsies, and tumour control is most likely less reliable than with standard nephron-sparing surgery.

Nuevos tratamientos ablativos de las masas renales pequeñas: Ablación con HIFU / New ablative treatments for small renal masses: HIFU ablation

Los tumores renales con un diámetro < 4 cm comprenden la mitad de todos los tumores renales que vienen a centros terciarios buscando una decisión terapéutica hoy en día. Aproximadamente el 80% son cánceres renales y la escisión conservadora es el tratamiento estándar. El abordaje tiene una morbilidad considerable y como muchos de estos tumores son diagnosticados en pacientes ancianos, enfermos, la ablación focal parece atractiva. Esto se consigue generalmente con radiofrecuencia o crioablación, bien por vía percutánea guiada por imagen, bien por un abordaje laparoscópico. La calidad de las publicaciones sobre el resultado con este tratamiento es moderada, sin estudios comparativos prospectivos, y en general seguimientos cortos. Los metanálisis sugieren resultados mas fiables con crioablación que con radiofrecuencia. La morbilidad es menor que con la cirugía conservadora, pero aún substancial y casi enteramente debido al trauma durante la perforación de la técnica de ablación. Esto podría evitarse con la ablación mediante energía con ultrasonidos de alta frecuencia focalizados desde una fuente de energía extracorpórea. Los ensayos clínicos fase I con varios prototipos han sido decepcionantes porque las múltiples interfases acústicas y la movilidad del objetivo obviamente vuelven poco fiable el enfoque adecuadamente preciso. Los nuevos transductores de HIFU que pueden aproximarse directamente al tumor por vía laparoscópica eluden estos problemas. Un estudio fase I con esta técnica en 31 pacientes demuestra que se puede conseguir la ablación completa de tumores de esta manera, al menos en tumores de < 3 cm y en posición periférica en el tercio medio e inferior del riñón. Se evita el trauma por perforación del riñón y la morbilidad se minimiza. Por supuesto los pacientes todavía necesitan seguimiento a largo plazo con pruebas de imagen secuenciales e incluso biopsias, y el control del tumor es más probablemente menos fiable que con la cirugía conservadora estándar(AU)

Solid renal tumours with a diameter < 4 cm comprise up to half of all renal tumours coming for a therapeutic decision in tertiary care centres today. Aprox. 80% are renal cell cancers , and nephron-sparing excision is standard therapy. The approach has considerable morbidity , and as many of these tumours are diagnosed in elderly ,infirm patients less invasive focal ablation appears attractive . This is usually achieved with radiofrequency or cryoablation, either percutaneously under image guidance or by a laparoscopic approach. The quality of reports on the outcome with this treatment is moderate, with no prospective comparative studies, and in general short follow-up. Metanalyses suggest more reliable results with cyro- than with radiofrequency ablation . Morbidity is lower than with nephron-sparing surgery, but still substantial and almost entirely due to the perforating trauma at ablation. This would be avoided by energy ablation with high-intensity focused ultrasound from an extracorporeal energy source. Phase 1 clinical studies with several prototoypes have been disappointing, as multiple acoustic interphases and target mobility obviously render adequately precise focusing unreliable. New HIFU transducers that can be approximated directly to the tumour via a laparoscopic approach circumvent these problems. A phase 1 study with this technique in 31 patients demonstrates that complete ablation of tumours can be achieved in this manner, at least for tumours <3cm and in a peripheral position in the lower and middle third of the kidney. Perforating trauma to the kidney is avoided, and morbidity is minimized. Of course patients still need long - term follow-up with sequential imaging and even biopsies, and tumour control is most likely less reliable than with standard nephron- sparing surgery (AU)

Urethral buttressing in patients undergoing artificial urinary sphincter surgery.

PURPOSE: We evaluated the safety and feasibility of what we believe to be a novel technique of buttressing the urethra with a fibrin coated collagen fleece in patients undergoing artificial urinary sphincter surgery in the presence of urethral atrophy. MATERIALS AND METHODS: A total of 17 consecutive men were treated with urethral buttressing for urethral atrophy during artificial urinary sphincter surgery. Continence, complications and patient reported outcomes were assessed by preoperative and postoperative pad use, chart review, patient interview and validated questionnaires. RESULTS: Mean ± SD followup was 38 ± 3.0 months (median 34, range 23 to 71). One patient was excluded from further evaluation due to accidental iatrogenic urethral injury elsewhere. At 3-month followup the mean improvement in pad use was 5 ± 0.5 pads (median 5, range 2 to 9). Of 16 patients 9 (56%) and 2 (13%) used 1 and 0 pad per day, respectively. According to the Patient Global Impression of Improvement questionnaire, 12 of 16 patients (75%) described their condition as much or very much better after surgery. Mean ± SD postoperative Incontinence Impact Questionnaire and Urogenital Distress Index scores were 2 ± 0.8 (median 1, range 0 to 11) and 4 ± 1.0 (median 3, range 0 to 11), respectively. No intraoperative complications were observed. During followup 2 of 16 patients (13%) underwent placement of a second cuff due to unsatisfactory postoperative continence, 1 (6%) underwent artificial urinary sphincter revision for clean urethral erosion and 1 (6%) underwent revision for pump malfunction. CONCLUSIONS: Urethral buttressing with a collagen fleece appears to be a safe, feasible option for urethral atrophy in patients treated with artificial urinary sphincter implantation or revision.

Partial nephrectomy: is there still a need for open surgery?

Long-term outcome data indicate that open partial nephrectomy has cancer-free survival rates comparable to those of radical surgery, with better preservation of renal function, decreased overall mortality and reduced frequency of cardiovascular events. Open partial nephrectomy is increasingly being challenged by laparoscopic and/or robot assisted partial nephrectomy, which in the hands of experts appears to achieve comparable oncological results, albeit at a higher complication rate. We report a review based on literature published over the past years, which may provide insight into the role of open partial nephrectomy in the present urological practice and in years to come.

Urinary continence after radical prostatectomy: the patient perspective.

INTRODUCTION: To compare the commonly used 0-1 pad definition of urinary continence for postoperative functional outcome after radical prostatectomy and the correlation with self-reported urinary continence and to determine whether a patient questionnaire can deliver more accurate continence status rates. MATERIAL AND METHODS: We evaluated a cohort of 873 men who underwent radical prostatectomy (RP) at the General Hospital in Vienna between 1998 and 2006. Patients were surveyed with a questionnaire regarding their postoperative outcome and postoperative urinary incontinence. Baseline and pathological factors were examined to determine whether or not they had an impact on the continence status. RESULTS AND LIMITATIONS: A total of 65.2% of men (n = 337) reported themselves to be continent, in contrast 85.1% were continent if the pad definition was applied. Of those using no pads, 93.4% considered themselves continent, while 24.5% of patients using one pad/day did. Overall, 86.5%, 9.8% and 3.7% of continent patients regained continence within 6 months, 6 to 12 months and after 1 year of RP, respectively. A total of 71.5% of men under 65 years old reported full urinary continence, while only 57.0% of men older than 65 considered themselves continent. Men < 65 years recovered full urinary control significantly faster than men older than 65 years- 3.6 versus 4.7 months. Neurovascular bundle resection has a negative effect on continence. CONCLUSIONS: The ultimate continence status should be measured with self-administered disease specific questionnaires at 24 months after RP, as it differs from standard physician reported methods. Age and neurovascular bundle resection are variables affecting continence. We believe that patients' subjective reports of their continence are crucial and that multiple outcomes should be objectively measured. Therefore we suggest that validated questionnaires dealing with the patients' perspective postoperatively should be included in routine follow up.

New findings in bladder and prostate cancer: highlights from the 26th annual congress of the European Association of Urology, March 18-22, 2011, Vienna, Austria.

At the recent annual congress, of the European Association of Urology (EAU), urologists from around the world presented their exciting discoveries related to an array of topics. Besides the huge variety of different sessions and courses, the EAU Section of Uro-Technology (ESUT) transmitted live broadcasts of surgeries from the medical universities of Vienna and Heilbronn, focusing on novel surgical techniques. Unfortunately, this year's congress was clouded by the environmental disaster and nuclear accident in Japan, which prevented a number of Japanese urologists to attend the congress due to obstacles in travelling. In this brief update, we will highlight some of the findings and the clinical significance of a few of this year's important abstracts in bladder and prostate cancer.

Diagnosis of the gr/gr Y chromosome microdeletion does not help in the treatment of infertile American men.

PURPOSE: The phenotypic effects of the gr/gr partial azoospermia factor c deletion vary geographically and to our knowledge have not been reported in the American population. We evaluated the clinical characteristics of infertile American men with the gr/gr deletion. MATERIALS AND METHODS: We retrospectively reviewed clinical data on 1,410 infertile men tested for the gr/gr deletion. We analyzed sperm concentration and the outcome of microdissection testicular sperm extraction with respect to gr/gr status. RESULTS: We identified 73 men with gr/gr deletions, including 43 of 989 (4.3%) with azoospermia, 18 of 317 (5.7%) with severe oligospermia (less than 5 million sperm per ml), 6 of 61 (9.8%) with oligospermia (5 to less than 20 million sperm per ml) and 6 of 43 (14%) infertile men with normospermia (greater than 20 million sperm per ml). A gr/gr deletion correlated with higher sperm production. The gr/gr deletion rate was higher in men with normospermia than in those with a sperm concentration of less than 20 million and less than 5 million per ml (p = 0.021 and 0.006, respectively). Microdissection testicular sperm extraction was done in 22 azoospermic men with gr/gr deletions and sperm were retrieved in 14 (64%). This retrieval rate was similar to that at our center in men with idiopathic nonobstructive azoospermia (p = 0.13). CONCLUSIONS: Diagnosis of the gr/gr deletion did not predict impaired sperm production in our patient population and did not appear to alter the prognosis for surgical sperm retrieval. Despite the established modulatory impact of the gr/gr deletion on sperm production in some populations at this time the clinical value of testing infertile American men for the gr/gr deletion is not clear.