The 8th American Urological Association and the Japanese Urological Association International Affiliate Society Meeting

Abstract

The American Urological Association (AUA) and the Japanese Urological Association (JUA) have been working hard to promote collaboration in the science and art of urology between the two societies. On behalf of JUA, we are pleased to announce the 8th AUA/JUA International Affiliate Society Meeting at the 108th Annual Meeting of AUA (4–8 May 2013, San Diego, CA, USA). We are grateful for the support of AUA to prepare this joint program. We also would like to express our sincere appreciation to all people concerned, including the moderators, speakers and panelists of both societies. This year's program covers two video case discussions and three lectures on up-to-date management of urological cancers and stone. Dr William D Steers, Editor of The Journal of Urology, is invited for a lecture entitled “How to prepare a manuscript for publication in major medical journals”. We are very proud of the outstanding quality of the program. We look forward to the participation of many members of both societies in this joint program. Lastly, we would like to thank Dr Dennis A Pessis, AUA President; Dr Gopal H Badlani, AUA Secretary; and Dr Robert C Flanigan, AUA International Education Consultant, for their dedication to develop and extend mutual relationship between AUA and JUA. Introduction and objectives: Minimally-invasive renal surgery (MIRS) was described over 20 years ago, and its use has continued to increase. Here we will review trends in MIRS for resection of kidney tumors, and evaluate the impact of MIRS on utilization of partial (PN) versus radical nephrectomy (RN). We will also present comparative effectiveness data of MIRS versus open surgery for renal tumors. The role of technological advancements in MIRS, specifically robotic-assisted surgery (RAS), will be discussed as well. Methods: Data from peer-reviewed publications on renal surgery were reviewed. Results: MIRS currently accounts for the minority of overall renal tumor surgeries. Nevertheless, increased adoption of MIRS has shown an interesting interaction with practice patterns over time. That is, data from the early experience with laparoscopy suggest high utilization of laparoscopic RN among small renal tumors. Although PN remains underutilized today, a modest relative increase in this approach has been noted in recent years. Furthermore, continued efforts to improve the ease and efficacy of MIRS have been reported, including the application of RAS to minimize renal ischemia, and facilitate tumor resection and reconstruction during PN. Notably, a paucity of prospective data exist to compare the effectiveness of various approaches to renal surgery. With regard to PN, initial results suggested greater ischemia times and higher complication rates for laparoscopic versus open surgery. More recently, the application of RAS to PN has been associated with decreased warm ischemia times compared with laparoscopic PN, and decreased operative blood loss and length of hospital stay compared with open PN. Cost comparisons across techniques can be particularly challenging given the difficulties with assigning fixed costs and accounting for surgical volumes; however, limited evidence suggest an increased cost associated with RAS for PN in particular. Conclusions: The adoption of MIRS has coincided with changes in utilization of PN versus RN. The potential role of RAS in facilitating an albeit modest contemporary increase in nephron-sparing surgery must nevertheless be balanced against cost implications and relative perioperative safety and oncological efficacy. Introduction: Interest and experience in minimally-invasive surgery for renal tumors has continued to increase. Defining patient and tumor characteristics to identify the optimal candidates for this approach remains critical to ensuring treatment efficacy and safety. At the same time, the challenge remains to carry out tumor resection and reconstruction maintaining maximal renal function while ensuring complete tumor eradication. Objectives: To understand current indications/contraindications for minimally-invasive partial nephrectomy. To show the approach for tumor resection and subsequent parenchymal reconstruction during minimally-invasive and open partial nephrectomy. To discuss techniques for minimizing renal ischemia during partial nephrectomy. Case 1: A 28-year-old male with incidental 2.7 × 2.7 × 2.2 cm left upper pole partially exophytic solid renal mass. No past medical/surgical history. Creatinine 0.8. Question 1: What criteria do you use to recommend a robotic/conventional laparoscopic versus open approach to partial nephrectomy? Would the presence of chronic kidney disease (CKD) impact your choice of surgical approach? Question 2: How do you carry out reconstruction of the renal parenchymal defect robotically/laparoscopically? Case 2: A 62-year-old female with incidental 2.6 × 2.5 cm left upper pole partially exophytic renal tumor. No significant past medical/surgical history. Creatinine 0.71. Question 1: What is your choice of treatment for the left kidney tumor? Question 2: In doing conventional laparoscopic or robot-assisted partial nephrectomy, what is your routine practice to minimize ischemic time and maximize the restoration of renal function? Case 3: A 59-year-old male status post-right radical nephrectomy. Multifocal small sold lesions within remaining left kidney. Hypertension. Creatinine 1.2. Question 1: Optimal surgical approach for patient with sporadic unilateral multifocal renal tumors? Question 2: Technique for tumor resection during partial nephrectomy: enucleation or resection with margin of “normal” renal parenchyma? Case 4: A 52-year-old female with von Hippel-Lindau (VHL). Left radical nephrectomy 7 years earlier. Now with multifocal right renal tumors. Creatinine 0.78. Question 1: What is your choice of treatment for right kidney tumor(s)? Question 2: What is your choice of treatment for recurrent right kidney tumor(s)? Answer 1: In general, I approach all renal masses with robotic partial nephrectomy, regardless of size unless technically not feasible. The presence of CKD usually does not change my plan of approach, as I try to partial most lesions. Answer 2: I use a double-armed 90-day, 12-inch, 0 and 6-inch 3-0 V-Loc suture (Covidien, Mansfield, MA, USA). I run the 3-0 in the inner layer to close collecting system and vessels. I then exteriorize the 3-0 V-Loc and anchor to a sliding Covidien absorbable Laproclip. I then unclamp early and look for major bleeders that might require additional sutures. I then run a horizontal mattress on the outer layer using 0 V-Loc and use sliding Covidien absorbable Laproclip on all the exiting bites. I rarely use bolsters, but often will use Evicel as a hemostatic agent. Answer 1: Robotic partial nephrectomy, possible off clamp depending on how exophytic and how polar the lesion is. Answer 2: When possible, off clamp partial is carried out. Polar ischemia by providing regional compression can be applied using a (i) robotic non-traumatic 55-mm Grasping Retractor from the fourth arm; (ii) laparoscopic Simon Pole Clamp; (iii) twisting the blue ribbon on the end of an E-tape sponge. Using intravenous indocyanine green and da Vinci Firefly scope, the zero ischemia technique as popularized by Gill is also a great way to minimize renal ischemic injury by dissecting and micro-clamping a branch renal artery. Lastly, if clamping the main renal artery, utilizing V-Loc sutures, sliding clips (Weck or absorbable Laproclip), double armed sutures (minimizing numbers of sutures) and early unclamping techniques have all helped to minimize ischemia time. Using intravenous mannitol might possibly decrease ischemic injury as well. Most importantly, using a very experienced assistant (I use a physician assistant and not residents) is probably my most effective means to decrease ischemia time. Answer 1: Unless they appear to be lesions that can be resected off clamp (superficial, small and polar), they should be resected open on ice. Answer 2: Often this depends upon the lesion. I usually prefer leaving a margin of parenchyma if the lesion appears cystic, infiltrative or multi-lobulated. Finding the enucleation plane on the tumor pseudo-capsule usually results in less bleeding especially when going off-clamp. Answer 1: My treatment choice is no different for left versus right side tumors. In VHL cases with multifocal recurrences, the small tumors could be cryoablated. The lesions should be monitored until they reach about 3 cm. If operative intervention is decided for multiple tumors, in general, I would recommend an open partial nephrectomy using cold ischemia. In very select cases if the lesions are polar and superficial, I might consider off-clamp or zero-ischemia technique robotic partial nephrectomy. Answer 2: If this is a re-do case on the right side for recurrence, I would recommend open partial nephrectomy using cold ischemia. Partial nephrectomy (PN) is now the standard treatment for clinical T1 tumor because of oncological equivalence and functional superiority to radical nephrectomy (RN). Recently, many expert surgeons have been making an effort to minimize the therapeutic invasiveness of PN through laparoscopic and robot-assisted surgical approaches. Here, let me give a short introduction about GasLESS clampless PN, which we have developed as one of the options of minimally-invasive PN, before answering the questions. Since the late 1990s, we have developed gasless laparoendoscopic single-port surgery (GasLESS) for urological tumors as one of the options of minimally-invasive surgery (Kihara et al. Int J Urol 2004, 2009). A wide surgical field is created by dissecting anatomical planes using specialized long retractors and spatulas through a single port, approximately 4 cm in diameter, instead of CO2 gas insufflation. In Japan, GasLESS for urological tumors has been covered by the National Universal Health Insurance System since 2008. Recently, we have applied a new 3-D head-mounted display system (RoboSurgeon system) to GasLESS (Kihara et al. AUA 2013, EAU 2013). We have developed a novel technique of GasLESS “clampless” PN for maximal preservation of renal function, which is applied to a wide range of renal tumors (EAU video library #160204, EAU 2013 video, AUA 2012/2013, EAU 2010/2012/2013 posters, Kihara et al. Int J Urol 2009). The main steps to accomplishing GasLESS clampless PN are: (i) mobilization of the kidney, so that the tumor is located just beneath the single port; and (ii) tumor excision using a “mushroom technique”, which allows clampless tumor excision and ensures negative surgical margin. Tumor excision, assisted with ultrasonography, consists of three parts: (i) creating a circumferential groove around the tumor using an ultrasonic coagulator; (ii) creating a mushroom stalk-like shape in the tumor base and drawing the stalk upward with a thread tying the stalk; and (iii) transecting the mushroom stalk, within which tumor vessels often exist, little by little. Comment: Another reason why PN is recommended for clinical T1 tumors is a relatively high incidence (approximately 20%) of benign neoplasms (i.e. renal oncocytoma, fat-poor angiomyolipoma) at nephrectomy. The predicting factors for benign pathology include female sex, younger age and smaller tumor size (Fujii et al. AUA 2011). Therefore, I believe that state-of-the-art imaging including dynamic computed tomography scan and diffusion weighted magnetic resonance imaging is necessary for this young patient with a small renal mass. Answer 1: Minimally-invasive PN, such as laparoscopic or robot-assisted PN, is recommended for the patient. As aforementioned, we normally carry out GasLESS clampless PN for almost all the patients with clinical T1a tumors, regardless of tumor location or renal function. Recently, the clampless rate is more than 95% in all T1a tumors and 99% in peripheral tumors. Answer 2: In GasLESS clampless PN, after confirmation of hemostasis, reconstruction of the renal parenchymal defect is avoided as much as possible, and the resection bed remains unclosed. It is because there are some concerns that reconstruction using sutures might be the cause of additional impairment of renal function due to loss of nephron units and delayed bleeding. In our experience of more than 200 patients of clampless PN, none developed delayed bleeding or pseudoaneurysm formation after surgery. Only when the collecting system is opened or renal vessels are clamped is the reconstruction carried out as follows: the bed is closed with interrupted sutures with 1-0 threads after placing absorbable hemostats using a ValveGateTM needle holder (Geister, Tuttlingen, Germany). Answer 1: We recommend GasLESS clampless PN carried out retroperitoneally in the patient. The results for endophytic tumors are favorable. The standard of care for small renal cell carcinoma (RCC) is, whether the tumor is exophytic or endophytic, complete surgical resection. Answer 2: We carry out “clampless” PN retroperitoneally. When requiring vascular clamping, although it is very rare, ice slush is used for cold ischemia. Answer 1: Generally, PN should be strongly considered in imperative cases. If PN is technically infeasible, cryotherapy or radiofrequency ablation can be alternatives. I wonder how many tumors the patient has: 10, 20 or more? He has at least eight tumors even on a single-slice magnetic resonance image. I would basically recommend minimally-invasive RN to this patient in the clinical setting; particularly if he is Japanese, because Japanese hemodialysis patients live relatively long life spans with an estimated 10-year survival rate of 40%. Also, hemodialysis is covered by the National Universal Health Insurance System. Answer 2: Once PN is selected, enucleation is recommended to this patient to preserve renal function, because some previous studies have reported that positive surgical margins appear to have little to no impact on survival in patients undergoing PN for RCC. Comment: For VHL patients, the goal is to maintain the patient's own kidney function throughout their lifetime, to minimize the number of surgeries and yet remove tumors before they metastasize. The current consensus is to recommend surgery when the largest tumor is larger than 3 cm. Answer 1: Observation is recommended until the tumor becomes 3 cm. At the time, PN is recommended. We would select GasLESS clampless PN. Answer 2: Open (smaller incision) right PN (and left adrenalectomy?) is my choice of treatment. Cryotherapy or radiofrequency ablation might be added after surgery if necessary. Answer 1: We use two indications for conventional laparoscopic partial nephrectomy (LPN): (i) the tumor is 3 cm or less; and (ii) it is exophytic. Based on these criteria, I recommend using a transperitoneal approach. For most T1b tumors and T1a tumors for which LPN is not indicated, we choose to use open partial nephrectomy (OPN). The presence of CKD strongly influences our choice of surgical procedure. If CKD is stage 4 or higher, we choose laparoscopic radical nephrectomy, because the benefit of parenchymal preservation makes no difference in the prognosis of the kidney. Answer 2: I oversaw the opening of the renal sinus with 2-0 Vicryl running sutures if we enter the collecting system or large vessels in the renal sinus. The renal parenchymal is then closed with 2-0 Vicryl running sutures with a sliding Hem-o-Lok clip placed after each suture that is passed through the capsule. Answer 1: We would choose the same strategy as used in the case 1 patient because of the similarity of the location of the tumor and the lack of CKD. Answer 2: We do not use a “specific” technique, but we always make an effort to keep the ischemic time under 30 min. Mannitol is widely used for reducing ischemic renal injury, but our results show no benefit in the preservation of renal function after partial nephrectomy. We do not use cold ischemia or the early unclamping technique. If we need more time for suturing the parenchyma, however, we unclamp the hilum between 25 and 30 min. Answer 1: This patient has a solitary left kidney with multiple lesions. Because the patient is relatively young, it is important not to compromise the oncological outcome, although preservation of renal function is also important. I would choose open partial nephrectomy with under cold ischemia with surface cooling with slush ice. Answer 2: I would avoid enucleation because of the risk of positive surgical margin. I would carry out a conventional partial nephrectomy. Answer 1: For right kidney tumor(s), I would choose open partial nephrectomy under cold ischemia. For patients with VHL, I would excise the tumors with enucleation. Answer 2: I would carry out repeat partial nephrectomy as much as possible. Introduction and objective: The U.S. Preventive Services Task Force (USPSTF) has recommended against routine screening for prostate cancer using prostate-specific antigen (PSA). This lecture will help urologists understand how the USPSTF panel came to this conclusion. Methods: A review of the clinical evidence supporting the efficacy of PSA testing. Results: PSA screening results in significant overdiagnosis of localized prostate cancer. Furthermore, there is no consensus regarding optimal management of men with localized disease. Conclusions: The reduction in prostate cancer mortality 10–14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55–69 years. Unfortunately, the harms of screening include pain, fever, bleeding, infection and, occasionally, urinary difficulties. More importantly, many men diagnosed with localized prostate cancer receive treatments that result in erectile dysfunction, urinary incontinence, bowel dysfunction and a small risk of premature death. Because urologists cannot distinguish between indolent tumors and clinically significant tumors, many men who will not benefit from treatment are exposed to the complications. Therefore, the benefits of PSA based screening do not outweigh the harms over a period of 10–14 years. Although men might experience a greater benefit with longer follow up, this belief has yet to be supported with data from randomized trials. The Göteborg randomized study showed a significant mortality reduction of 44% in the screening group after 14 years of median follow up. The efficacy of cancer screening should be evaluated as the probability of mortality reduction throughout the life. The Swedish study contributes to answering that question. The number of men needed to be detected (NND) amounted to 12, and was very low in comparison with the other cancer screening program. However, fundamentally, NND cannot predict how large drawbacks of screening would be, because it is based on the assumption that any stage of prostate cancer is equal, whereas the socioeconomic and physical damages are not comparable between metastatic and localized prostate cancer. The ERSPC data published in 2012 clearly showed that the initial exposure of PSA screening in men aged 55–69 years might relate with a high likelihood of delay to detect potentially lethal prostate cancer, because 74% of prostate cancer deaths were in cancers diagnosed at the first screening round. In contrast, a significant (38%) decrease in prostate cancer death at 10 and 11 years was found, indicating that long-term PSA screening exposure in the community might substantially decrease life-time risk of prostate cancer death. Although, all-cause mortality was identical between the two arms, any screening or definitive treatment intervention would not significantly affect it. Prostate cancer death could be the defined end-point. Progress in effective primary prevention and a substantial number of medical interventions – the intelligent use of PSA could be at least one of them – can significantly prolong life expectancy. Before introducing screening for cancer to the community, it should be investigated whether introducing cancer screening in the community improves quality-adjusted life years compared with routine medical care without cancer screening. From a socioeconomic point of view, it might be important to estimate the incremental cost-effectiveness ratio in the screening group. In relation to PSA screening, establishing an optimal screening system, which minimizes overdetection, overtreatment and socioeconomic damage, and maximizes screening effects in terms of mortality reduction and avoiding development of metastatic prostate cancer, must be our mission in focus. Introduction: What distinguishes a very good manuscript worthy of publication from a bad one? A well written article cannot make up for poor research, whereas a badly written article can diminish good research. For international authors for whom English is not their native language, the challenge is often to find editorial assistance so presentation does not diminish the scientific content or distract. Moreover, a local or national clinical study might not be of interest to an international community of academics merely because it replicates findings in another country or institution unless the study is truly novel or the local environment or genetics changes disease phenotype or treatment response. Methods: A stepwise, rigorous approach to preparing a manuscript is the best path to publication. First, determine if the work is ready to publish, is the study complete or will more numbers/key experiments enhance statistical rigor or booster the hypothesis tested? Obviously for an original investigative report, a novel finding offers the best chance of acceptance, whereas, reinterpreting published garners is a lower priority for publication, even if well done and there are no major flaws. Positive findings tend to be published more often, but the negative study might be just as important. Another category of report, the review, is more highly regarded if a formal systemic review follows strict published guidelines (PRISMA) and best evidence-based medicine for a formal meta analysis. A strong manuscript is clear, concise and logically presented. Some authors start with organizing data figures and the Results, then work backwards. Authors often try to review the literature in the Introduction or Discussion and thereby add verbiage that detracts from overall quality. Next, decide on the type of manuscript and target journal by reading Instructions/Guide to Authors. It helps to examine the table of contents for the past several years to see if very similar original reports or reviews have been published, lowering the likelihood of another “me too” paper. English editorial assistance will help sentence construction, tense and grammar, and avoids mixing language. Style matters for top journals, such as presenting in the active voice. A sloppy presentation implies slipshod research. Follow the hierarchy of: Introduction explaining rationale, hypothesis and why important. The Methods section should allow reproduction of data, but if details are published elsewhere, just provide a reference and describe the unique aspects of your experiment/study. Be certain of statistical methods. Present essential findings in the Results section using subheadings, figures and illustrations. If a clinical trial the CONSORT-PRO diagram should be included. Data shown in a graph or figure should not be replicated again in the text. The Discussion is the most important section, where you sell your data yet expose the study's limitations and weaknesses. Selling does not mean overreaching conclusions or language that suggests bias. Cite work that disagrees and present a fair picture. Avoid adjectives, such as “best” or other superlatives. If this is a first observation, then state “first to our knowledge”. The Abstract is written last. Results: Authors want to publish in a journal with a high impact factor, a speedy referee process and a good reputation. Unfortunately, greater than 50% of the urological literature is never cited, raising issues on the quality or relative importance of the work carried out. Studies show that statistics are often erroneously used in urological research. Moreover, the levels of evidence for urological practice tend to be low and their quality average. Editors reviewing clinical trials desire large, randomized trials. Single institution retrospective series are of limited value and thought to be more subject to bias. Basic science studies in clinical journals should possess some clinical relevance. Basic research papers tend to be more rigorously reviewed. Reviews tend to be highly cited if rigorous and timely, but are often redundant. Yet review articles are attractive to editors, because they are more likely to be cited. Within the field of urology, the article's citations often correlate with recent activity in the field (e.g. robotics). Citations also reflect the number of worldwide investigators with higher citations for cancer, endorurology and calculus disease papers, and less for andrology, female and pediatric urology. Basic science paper citations often lag clinical papers by years, and thus fail to help a journal's impact factor based on the citations of papers in the preceding 2 years. Some urological journals selectively publish articles that are more likely to be cited based on recent citation indices in order to raise the impact factor, ignoring the value of small subspecialties. Co-authorship has risen over the past several decades, as has the number of authors. However, less than 50% of authors ever publish more than one paper. Editors rarely over-ride their reviewers. Currently, in top journals, such as The Journal of Urology, one vote for rejection will often result in the dismissal of a manuscript for consideration of publication. Accusations of dual publication, self plagiarism and data falsification are increasing, and if suspected the paper will be rejected or retracted. Publishing in two languages given the ubiquity of internet and translation software is not an adequate justification for dual publication. Summary: Preparation is the key to acceptance of a manuscript to a major journal. Preparation starts by careful reading of the Instructions to the Authors and perusal of articles published over past several years to make sure the submission is appropriate and does not replicate recent papers. Although certain subjects and types of manuscripts might get high priority, a well carried out study with significant findings, even if negative, or that is novel, not merely gap filling, should be strongly considered for publication in the major journals. Introduction: Urolithiasis, a complex multifactorial disease, results from interactions between environmental and genetic factors. National surveys in Japan show an increase in the incidence of urolithiasis, nearing that of the USA. Application of medicines in use for associated diseases Certain medications with bearable side-effects are used for urolithiasis. Obesity and insulin resistance are associated with urolithiasis. Pioglitazone, a peroxisome proliferator-activated receptor-γ agonist used for diabetes mellitus decreases renal crystal deposition and oxidative stress in hyperoxaluric rats. Osteoporosis, higher among postmenopausal women, is also associated with urolithiasis. Bisphosphonate, used in bone disease, improves bone mineral density and reduces the risk of calcium stone by reducing calcium excretion. New preventive medicine based on the mechanism of stone formation Renal tubular cell injury induced by oxidative stress through mitochondrial collapse is said to be the initial step of renal calcium crystallization. We elucidated that mitochondrial permeability transition pore opening, which is blocked by cyclosporine A, is associated with mitochondrial collapse, oxidative stress and activation of apoptotic pathway in the initial steps of renal calcium crystallization. New medicines for urolithiasis prevention are expected to target this mechanism. Diagnosis of urolithiasis recurrence risk by using single-nucleotide polymorphism (SNP) analysis If a genetic predisposition to urolithiasis can be detected, prophylaxis can be achieved. Studies show that SNP of genes encoding calcium-sensing receptor, vitamin D receptor and osteopontin are correlated with urolithiasis. Genome-wide association studies show that CLDN14 in Caucasians, and 5q35.3, 7p14.3 and 13q14.1 in Japanese are associated with urolithiasis. Thus, SNP analysis would aid in the prediction of urolithiasis risk and recurrence. Conclusions: New diagnostic methods and preventive medicines along with complete removal of stones will help manage urolithiasis better. Introduction and objectives: Radical retropubic prostatectomy (RRP) provides a long-term cure for patients with clinically localized prostate cancer. However, after a radical prostatectomy, there might be significant postoperative functional sequelae related to urinary continence and erectile function. Widespread prostate-specific antigen (PSA) screening and the consequent diagnosis of prostate cancer in younger and healthier men with organ-confined disease have underlined the importance of urinary and sexual function recovery after surgery. Achieving all three results – rendering patients cancer-free while recovering continence and sexual function – that is, the “trifecta outcome,” has become the hope in men with organ-confined cancer who are continent and potent before radical prostatectomy. Laparoscopic radical prostatectomy (LRP) might provide better functional and oncological outcomes than conventional RRP, as accurate and delicate manipulations can be achieved under expanded laparoscopic vision. However, LRP is a technically difficult procedure that is associated with a long learning curve. The application of robotic technology in surgery has inherent advantages, including binocular 3-D visualiz