Urological Group Research Articles

Etiology, characteristics and management of ureteric injury: experience from a nationwide study.

BackgroundTo investigate the common etiologies, characteristics, and management of ureteric injury.MethodsA nationwide study was performed in 38 medical centers from Mar 2017 to Mar 2019. The data of patients with ureteric injury were retrospectively collected.ResultsOverall, 294 patients were included in this study. Ten cases (3.4%) were due to abdominal injuries, and 284 cases (96.6%) were due to iatrogenic injuries, including 48.6% from urological procedures, 41.9% from gynecological procedures, 6.3% from general surgery, and 3.2% from other treatments. Most urological injuries (79.7%) were caused by endourological procedures. Injury occurred in the distal ureter in 178 cases (60.5%), the mid-ureter in 31 cases (10.5%), and the proximal ureter in 85 cases (28.9%). Only 51 patients (17.3%) were diagnosed immediately during primary surgery. Immediate ureter reconstruction was performed in 30 patients (58.8%), while delayed urinary diversion was performed in 148 patients (60.9%) in the delayed diagnosis group. The side and the location of the injury were different between the urological and nonurological injury groups (P<0.001). Ureteric injuries were diagnosed timelier in the urological group than in the nonurological group (P=0.037).ConclusionsIatrogenic injury was the most common cause of ureteric injury. The majority of iatrogenic injuries were caused by urological procedures and were primarily due to aggressive endourological techniques. Depending on the condition of the patient, the time of diagnosis, and the location and length of the ureteric injury, different management strategies should be applied.

Altmetrics and citations: the impact of journal publications

To assess the correlation between the altmetric attention score and citations as measures of impact for scholarly publications within and outside of the urological field, we compared altmetric attention scores and citations in two groups of journal articles, a urological group ( n=13) and a non-urological group ( n=129). All papers were high altmetric score publications. How researchers can benefit from alternative measures to make their mark.

Re: Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes from a Large Urological Group Practice.

Re: Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes from a Large Urological Group Practice.

Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BackgroundThe definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. AimTo evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. MethodsA database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. Main Outcome MeasureThe primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. ResultsA total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial. Clinical ImplicationsIPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. Strengths & LimitationsThe strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. ConclusionASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk.Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025–1032.

The working time load of specialists and senior physicians in German urology-a critical assessment

The working and continued training conditions of assistant physicians in urology in Germany have already been analyzed. But what about senior urologists in Germany? Under which conditions do they have to work? As far as we know no published data currently exist which illuminate the conditions of this special urological professional group, therefore, the results of this survey are presented. To survey and evaluate the current working conditions of certified and senior urologists in Germany as comprehensively as possible. The working group of employed physicians of the Professional Association of German Urologists (BvDU) carried out a survey within the framework of the urological senior physician forum 2016 and on-line via the e‑mail distributor of the German Society for Urology (DGU). The questions involved the workload, working conditions and satisfaction, overtime performed, working hours and opt out regulations. A total of 176 senior physicians participated in the survey of which 88% were male and 12% female. In Germany there are 1125 senior physicians. The average age of the responders was 44.9years. In more than 80% of the participants the average weekly working hours were over 50 h and 70% signed an opt out regulation. An association between an increasing job dissatisfaction above a working week over 55 h and an average attendance in on-call service over 4 h could be established. The number of on-call services had no influence on job satisfaction. A total of 43% (70 out of 162) of the participants stated that overtime hours were regularly forfeited and 12% (20 out of 162) that all overtime hours were forfeited. Approximately 30% of senior physicians in German urology were dissatisfied with the current working conditions in the present form. Based on the acquired data, adaptation and improvements in the working conditions of senior urologists are necessary in order to maintain the attractiveness of the occupational image and leading positions in German urology.

225 Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes from a Large Urological Group Practice

Erectile dysfunction (ED) is a common problem that may be definitively treated with the implantation of an inflatable penile prosthesis (IPP). The majority of available data on the practice patterns of IPP surgery derives from institutional studies, most notably from academic centers or large single surgeon series, where the majority of procedures are performed in a hospital setting. As insurance companies and health systems look to reduce health care costs, the prospect of IPP surgery in an outpatient freestanding ambulatory surgery center (AS) has gained traction and is becoming more prevalent. Our primary objective was to evaluate the factors which affect utilization of IPP for the treatment of ED in an outpatient freestanding ambulatory surgery center (AS). Secondarily, we examined surgical outcomes in AS compared to contemporaneously-performed hospital IPP surgeries. A database of all patients undergoing inflatable penile prosthesis implantation by practitioners in one of the largest private community urology group practice in the United States, from January 1, 2008-June 1, 2018 was prospectively compiled and retrospectively reviewed. Cohorts of patients having virgin IPP implantation done in the hospital vs. AS setting were compared. We excluded combination (IPP and artificial urinary sphincter or IPP and male sling) and revision cases.

Pelvic exenteration for primary and recurrent malignancies in urology department

Objective The objectives of present study is to investigate the safety and efficacy of pelvic exenteration (PE) for the treatment of pelvic malignancies in urology department. Methods From April 2010 to December 2014, 20 patients with primary or recurrent pelvic malignancy accepted anterior pelvic exenteration (APE) or total pelvic exenteration(TPE) surgery, including 7 males and 13 females, ranged from 35 to 87 years old with an average of 65 years old. Ten case accepted APE and 10 for TPE. The ilium conduit was done in 5 cases for APE and 6 cases for TPE as urinary diversion, cutaneous ureterostomy was done in 5 cases for APE and 4 cases for TPE as urinary diversion. There were 6 cases primary tumor in APE group and 3 primary tumors in TPE. All of the patients had 13 cases of the urinary tract tumor group, and none of the urinary tract tumor group in 7 cases. There were 4 cases received preoperative chemotherapy in the urinary tract tumor group. No case received preoperative radiotherapy. 3 cases received preoperative chemotherapy in none of the urinary tract tumor group, 3 cased received preoperative radiotherapy. After induction of general anesthesia using a laryngeal mask for airway management. All patients took the abdominal incision, then dissected lymph nodes on both sides of the iliac vessels, freed bilateral ureters to the end of the swollen bladder, separated the peritoneal space.The bilateral vas deferens was cutted and ligated, then isolated and ligated the seminal vesicles between the posterior wall of the bladder and the anterior wall of the rectum.Lateral ligaments of bladder was cuted, then cuted ligament of prostate and puboprostatic ligament, sutured and cut deep vein of penis. Urethra of apex prostate was freed and cuted. Female patients needed to free the uterus and the posterior wall, cut the cardinal ligament and round ligament of uterus, isolate the posterior wall of the uterus to the posterior vaginal wall. Rectal resection adopted Miles operation.And sigmoid colostomy was performed on the left side of the abdominal wall. The perioperative characters, pathological results and patients′ survival data were collected and analyzed. Results The average operation time for APE was 3.8 hours and 5.2 hours for TPE (P=0.173). Median length of hospital stay was 17.9 (7-47) days. The median blood loss was 300ml (80-2 500 ml) for APE and 400ml (50-6 000 ml) for TPE (P=0.909). The median follow-up time was 12.5 months (1-41months). The estimated 2-year survival rate for APE was 55.6% and 45.0% for TPE (P=0.642). Urinary system tumors group and non urinary system tumors group were analyzed and compared, The median survival time was 28 months and 13 months (P=0.538) in the two groups.The incidence of gastrointestinal complications of urinary system tumors and non-urinary system tumors was 7.7% and 28.6%, incision complications was 7.7% and 28.6%. Complications of urinary diversion only occurred in the non urologic tumor group, the incidence was 14.3%. The incidence of transfusion in two groups was 46.2% and 28.6%. Conclusions Pelvic exenteration (APE and TPE) could be a safe and reliable choice for local advanced primary and recurrent pelvic malignancy. Even for the recurrent malignancies, the survival results of the patients were satisfactory. Key words: Pelvic malignancy; Anterior pelvic exenteration; Total pelvic exenteration

Urinary quality of life outcomes in men who were treated with image-guided intensity-modulated radiation therapy for prostate cancer

PurposeQuality of life (QoL) outcomes play a major role in the treatment selection for prostate cancer (CaP). We evaluated the urinary QoL outcomes in men who were treated with image-guided intensity-modulated radiation therapy (IG-IMRT) for CaP. Methods and materialsWe enrolled men who were diagnosed with CaP and underwent IG-IMRT in a large urological group practice into a prospectively maintained database. The typical radiation treatment dosage to prostates and seminal vesicles was 8100 cGy in 45 fractions. Urinary QoL was self-assessed using the standardized incontinence grade and International Prostate Symptom Score (IPSS) at baseline and at each follow-up visit. We evaluated the cumulative incidence of urinary incontinence and changes in both continence and IPSS over time. ResultsOf the 3602 men who were eligible for analysis, 3086 (85.7%) had no urinary incontinence; 479 (13.3 %) had minimal incontinence (no requirement for pads), and 37 (1.0 %) had significant urinary incontinence that required the use of pads or interfered with activities of daily living, at baseline. After a median follow-up of 24 months (range: 12.0-41.0 months), these numbers were 80.6%, 17.4%, and 2.0%, respectively. Radiation therapy appeared to have a beneficial effect on some men: 54.1% of men with minimal incontinence became completely continent of urine during follow-up. Of those with significant urinary incontinence, 29.7% reported resolution and 27.0% reported improved symptoms with no requirement for pads. Of the 1276 men with moderate IPSS, the mean IPSS decreased from 12 to 9.8 at the time of the last follow-up (P < .001). Similarly, of the 233 men with severe IPSS, the mean IPSS decreased from 24 to 13 at the time of the last follow-up (P < .001). ConclusionIG-IMRT for clinically localized CaP is associated with a relatively low incidence of urinary incontinence. Although unexplained, IG-IMRT seems to improve symptoms in some men with baseline urinary incontinence and moderate-to-severe IPSS.

Variability of the urological clinical practice in prostate cancer in Spain

ObjectivesTo study the opinion of the Spanish urologists regarding the main points in the diagnosis, prevention, quality of life and treatment of prostate cancer. Material and methodsAn anonymous questionnaire was administered to 290 specialists who represented the urological professional group involved in the management of prostate cancer in Spain. The following were considered in their definition: grade of professional experience, work setting, contractual relation with patient and academic character of the center. The statistical analysis was based on the study of relative frequencies for qualitative variables. The results were interpreted in 2009–2010 and the final report of them was done in 2011. ResultsResponse rate collected and correctly transcribed from the forms was 96.9% (n=281). This accounts for 10–15% of the national group. Median age was 47.7 (29–69) years and 92% were men. Mean years of professional experience were 19.1 (1–43). Responses collected regarding 153 questions were analyzed. These dealt with: (a) how the diagnosis of the disease was carried out in the setting of the surveyed; (b) the opinions given on the disease prevention; (c) treatment of the localized treatment; (d) treatment of the advanced disease; and (e) the definition of the fields of interest for the professional. ConclusionThis survey showed important variability in some points of clinical practice in regard to the recommendations of the experts. It also shows the principal concerns of the professional, defines opportunities for training improvements and detects needs in the national urological group.

Variabilidad de la práctica clínica urológica en cáncer de próstata en España

ObjectivesStudy the opinion of the Spanish urologists regarding the main points in the diagnosis, prevention, quality of life and treatment of prostate cancer. Material and methodsAn anonymous questionnaire was administered to 290 specialists who represented the urological professional group involved in the management of prostate cancer in Spain. The following were considered in their definition: grade of professional experience, work setting, contractual relation with patient and academic character of the center. The statistical analysis was based on the study of relative frequencies for qualitative variables. The results were interpreted in 2009-10 and the final report of them was done in 2011. ResultsResponse rate collected and correctly transcribed from the forms was 96.9% (n=281). This accounts for 10-15% of the national group. Median age was 47.7 (29-69) years and 92% were men. Mean years of professional experience were 19.1 (1-43). Responses collected regarding 153 questions were analyzed. These dealt with: a) How the diagnosis of the disease was carried out in the setting of the surveyed; b) The opinions given on the disease prevention; c) Treatment of the localized treatment; d) Treatment of the advanced disease; and e) The definition of the fields of interest for the professional. ConclusionThis survey showed important variability in some points of clinical practice in regards to the recommendations of the experts. It also shows the principal concerns of the professional, defines opportunities for training improvements and detects needs in the national urological group.

The History and Future of the Urologic Oncology Study Group (UOSG) of the Japan Clinical Oncology Group (JCOG)

The Urologic Oncology Study Group (UOSG) of the Japan Clinical Oncology Group was founded in 2001. At the beginning, 41 collaborative institutions participated, and the first group representative was Kenichi Tobisu, from the Shizuoka Cancer Center. In the last 10 years, three JCOG studies have been conducted. In two of them, patient registration has been closed and they are now in the follow-up period. The third study has just started registration in 2011. At present, we have not yet completed the final data analyses in any of the studies. In the meantime, however, we have performed a few retrospective analyses by collecting clinical data from each of the participating institutions, and the results were published as important Japanese data. All the activities of the investigation were supported by the Health and Labor Sciences Research Grants for Clinical Research in Japan. The UOSG encountered great difficulties in planning the prospective study, completing the sophisticated protocol and recruiting the expected number of patients. It usually took a longer time than expected to achieve the final goal. This was probably due to insufficient experience in conducting sophisticated protocol studies and immaturity in managing a study group. Now, the UOSG consists of 38 institutions and is gradually overcoming these problems. In 2011, the UOSG changed its group representative to Yoshiyuki Kakehi from Kagawa University and continues to strive to meet the challenge of becoming a more active group. In this review, we provide an overview of the history and achievements of the UOSG over the past 10 years, along with a list of participating institutions.

Ways to celebrate PA Week

Josh Butler practices interventional radiology with Lancaster radiology Associates and is the chairman and founder of the physician Assistant Council at Lancaster General Health, Lancaster, pennsylvania. Katie Butler practices urology with the Lancaster Urological Group.

Should a Complex Uropathy Be a Contraindication for Renal Transplantation in Children?

Background Anatomic and functional disorders of the lower urinary tract represent up to 40% of the causes of renal failure in children. Several centers avoid renal transplantation in these patients because of the high risk of complications and lower graft survival. The aim of this work was to determine the frequency of urinary tract abnormalities (UTAs) among our pediatric series, and to compare the frequency of complications, function, and long-term graft survival among patients without versus with UTA. Methods This single-center, retrospective study compared outcomes between pediatric recipients with versus without UTA. We analyzed demographic features, etiology, pretransplant protocol, urinary tract rehabilitation, incidence of complications, rejection events, as well as graft function and survival. Results Among 328 pediatric cases performed between 1998 and 2008, we excluded nine patients due to incomplete medical records, analyzing 319 procedures in 312 patients. Sixty-seven patients (21%) had UTA. The average age, weight, and height at the time of grafting were significantly lower in the urologic group: 11.1 versus 12.6 years, 28.8 versus 34.4 kg; 125.4 versus 138.4 cm, respectively. There were significantly higher frequencies of a transperitoneal approach and vena cavae and aortic anastomoses among patients with UTA ( P < .001), posing a greater technical challenge in this population. No differences in creatinine levels were observed at 0.5, 1, 2, 5, and 10 years: 1.3 versus 1.6 at 5 years, and 1.4 versus 1.5 at 8 years. Urologic complications, including urinary tract infections (UTIs), occurred among 80.6% of patients with UTA versus 42.1% in the non-UTA group ( P < .001). UTIs appeared predominantly in patients with UTA (62.7% vs 35.3%, P < .001), representing a 2.7-fold risk compared with those children transplanted for other reasons. Rejection incidence was similar in both groups (49.8%). There was no significant difference in 5-y (89.8% vs 85%) or 10-year (83% vs 67%) graft survivals between the groups ( P = .162). Conclusion Our results demonstrated that with proper interdisciplinary care, graft and patient survivals of pediatric recipients with UTAs were not affected; therefore, these patients should not be rejected for transplantation.

Prediction of Survival After Radical Cystectomy for Invasive Bladder Carcinoma: Risk Group Stratification, Nomograms or Artificial Neural Networks?

We compared 3 predictive models for survival after radical cystectomy, risk group stratification, nomogram and artificial neural networks, in terms of their accuracy, performance and level of complexity. Between 1996 and 2002, 1,133 patients were treated with single stage radical cystectomy as monotherapy for invasive bladder cancer. A randomly selected 776 cases (70%) were used as a reference series. The remaining 357 cases (test series) were used for external validation. Survival estimates were analyzed using univariate and then multivariate appraisal. The results of multivariate analysis were used for risk group stratification and construction of a nomogram, whereas all studied variables were entered directly into the artificial neural networks. Overall 5-year disease-free survival was 64.5% with no statistical difference between the reference and test series. Comparisons of the 3 predictive models revealed that artificial neural networks outperformed the other 2 models in terms of the value of the area under the receiver operator characteristic curve, sensitivity and specificity, as well as positive and negative predictive values. In this study artificial neural networks outperformed the risk group stratification model and nomogram construction in predicting patient 5-year survival probability, and in terms of sensitivity and specificity.

Die Nephrektomie bei Nierenzellkarzinom, kombiniert mit anderen viszeralchirurgischen Eingriffen in der chirurgischen Klinik eines Krankenhauses der Grund- und Regelversorgung

Renal cell carcinoma appears in a certain percentage of patients combined with other abdominal disorders. Their simultaneous operative treatment is not widely reported in the literature. In this retrospective study, we have looked for the advantages of simultaneous operative procedures and whether these can be done safely in a primary surgical hospital. From 1991-2007 we reviewed 14 cases. We compared the results with those of patients who underwent nephrectomy in our urological department and from the actual literature. The overall operation times in the combined surgical and the urological group were nearly identical (135 versus 131 min). The postoperative hospital stay was slightly longer in the combined surgical group (16.6 versus 13.3 days). The morbidity was higher in the combined surgical group. These patients had also a higher comorbidity. We can see clear advantages in simultaneous operations for renal cell carcinoma and other major surgical procedures in the abdomen. This study shows that an experienced surgeon in a primary surgical hospital can perform nephrectomy with simultaneous major abdominal procedures with advantages for the patient as far as operation time and hospital stay are concerned.

Pediatric kidney transplantation is safe and available for patients with urological anomalies as well as those with primary renal diseases

The aim of the current study was to evaluate long-term outcomes of pediatric live kidney transplantation in patients with genitourinary anomalies relative to those with primary kidney diseases. The study included 35 pediatric patients who received a live kidney transplantation during the last 25 yr (28 males, six females). Median age at the time of transplantation was nine yr (range 1-15 yr), and the median follow-up period was 151 months (range 6-239 month). The patients were divided into two groups. The urological group (n = 14) included patients with primary obstructive/reflux nephropathy. The renal group (n = 20) included patients with primary renal disorders. Differences between groups in graft survival, clinical course, and final graft function were evaluated. Original diseases represented in the urological group included five cases with primary VUR and eight cases with secondary VUR. Diseases in the renal group included eight cases with bilateral hypo-dysplastic kidney, three cases with focal/segmental glomerular sclerosis, two cases with membranous proliferative glomerulonephritis, two cases with congenital nephrotic syndrome and five cases with other forms of chronic nephritis. Ten of 14 cases in the urological group, relative to six of 20 in the renal group, were preemptive. Median age at transplantation was 7.5 or 10 yr old, respectively, in the urological or renal group. Twelve kidney recipients in the urological group had also undergone other urinary surgeries, including upper urinary tract drainage, ureteroneocystostomy, augmentation cystoplasty, endoscopic incision of posterior-urethral valve, urethroplasty, etc. Cumulative post-operative complications occurred in nine or 16, respectively, in the urological or renal group. The acute rejection free and overall graft survival were similar in both groups. One patient in the urological group lost his graft while six patients in the renal group lost their grafts. Thus, the post-transplant clinical outcome of pediatric transplantation in patients with urological anomalies is comparable to that of recipients with primary renal disease. Appropriate urinary tract reconstruction and management is essential to reduce the risk of graft dysfunction because of urinary problems.

Editorial Comment

The authors performed a prospective study assessing the long-term clinical effectiveness of TURP. They conclude that TURP results in long-term, high patient-rated satisfaction in a large cohort of patients (n = 280) who underwent surgery during a 20-month period starting January 1993. With the dramatic decline in the number of TURPs being performed, this is a large clinical experience, particularly because it was done at a single site by a single urologic group. This large volume is even more striking, because patients with urinary retention and prostate cancer were excluded.

Randomized Controlled Trial to Evaluate Radiotherapy Endocrine Therapy Versus Endocrine Therapy Alone for PSA Failure after Radical Prostatectomy: Japan Clinical Oncology Group Study JCOG 0401

A randomized controlled trial has started in Japan to evaluate radiotherapy and endocrine therapy for prostate-specific antigen (PSA) failure after radical prostatectomy. Patients who have PSA failure after radical prostatectomy for localized prostate cancer (T1-2N0M0) are randomized into treatment groups of either radiotherapy +/- endocrine therapy or endocrine therapy alone. The Urologic Oncology Study Group (UOSG) in the Japan Clinical Oncology Group (JCOG) composed of 36 specialized institutions will recruit 200 patients. The primary end-point is time to treatment failure (TTF) of bicalutamide, and secondary end-points are TTF of protocol treatment, progression-free survival, overall survival, adverse events and quality of life (QOL). The Clinical Trial Review Committee of the JCOG approved the protocol on April 13, 2004, and the study was activated on May 17, 2004.

Transurethral Resection For Bladder Cancer Using 5-Aminolevulinic Acid Induced Fluorescence Endoscopy Versus White Light Endoscopy

Endoscopy done under fluorescence induced by 5-aminolevulinic acid has proved to be a procedure with high sensitivity for detecting transitional cell carcinoma of the bladder. In this multicenter, parallel group, phase III study we compared 5-aminolevulinic acid fluorescence endoscopy guided transurethral bladder resection with transurethral bladder resection done using only white light endoscopy. The proportion of tumor-free resected cases in the 2 groups was evaluated. After patient stratification according to participating centers and European Organization for the Research and Treatment of Cancer risk score 65 and 64 were randomized to the 5-aminolevulinic acid fluorescence and white light endoscopy groups, respectively. Residual tumor was evaluated in the 2 groups by repeat transurethral resection 10 to 14 days later. Analysis was performed according to the intent to treat principle with all patients randomized, followed by per protocol analysis. Intent to treat analysis revealed that in the white light endoscopy group 40.6% of cases were resected tumor-free at primary resection, whereas with 5-aminolevulinic acid fluorescence endoscopy guided transurethral resection 61.5% were resected tumor-free (p <0014). On protocol analysis 46.9% patients in the white light and 67.3% in the 5-aminolevulinic acid fluorescence endoscopy groups were resected tumor-free (p <0.031). No difference was noted in the 2 groups in regard to side effects or laboratory findings. The risk of residual tumor after transurethral resection of transitional cell carcinoma is significantly decreased by 5-aminolevulinic acid fluorescence endoscopy.

Surgery of the adrenal gland.

The features of modern medicine consist of minimal invasiveness and promoting the quality of life. The Niigata University Urological group in Japan performed the first successful laparoscopic removal of the adrenal tumor in 1992 [1]. That success was quickly followed by the Tokyo [2], Hamamatsu [3], Kyoto [4], and Kitazato [5] groups, all of which were located in Japan. Immediately after the successful laparoscopic adrenalectomy, we realized that, compared wi th open adrena lec tomy, l aparoscopic adrenalectomy was much less invasive, induced much less postoperative pain, and involved a much shorter convalescence, resulting in quicker recuperation to preoperative daily activity [6]. Therefore, laparoscopic adrenalectomy has become widely accepted around the world and is popular today. The incidence of adrenal incidentaloma has increased with the advent of many innovative diagnostic tools. Do we have to remove all adrenal incidentalomas? Obviously the answer is “no.” In that case what are the indications and limitations of laparoscopic adrenalectomy? According to Michel et al. [7], the indications of laparoscopic adrenalectomy for incidentalomas include the following: 1) functioning tumors; 2) tumors measuring larger than 4 cm in diameter or growing in size during the follow-up course; 3) tumors showing necrosis, bleeding, or irregular contour on computed tomography; and 4) cases with the higher concentration of serum dehydroepiandrosterone sulfate. I presume that most of the laparoscopists performing adrenalectomy will agree with the authors’ criteria, although exact size of the tumor as an indication is varied. In our observation of 210 cases with incidentalomas [8], 14 cases (6.7%) were malignant. All of the tumors were larger than 6.5 cm in diameter. The fourth category suggests that pre-Cushing’s syndrome can exist among the patients with incidentaloma, even if they do not show clinical symptoms of Cushing's syndrome despite serum or urinary abnormal endocrinologic data. Up until the present time, nobody knows whether these cases will develop Cushing's syndrome in due course. Besides the previous indications, there are some technical limitations in laparoscopic adrenalectomy. These include marked adhesion and infiltration surrounding the tumor probably due to previous surgery or malignancy, and extreme obesity (more than 35 in the body mass index). The indication for pheochromocytoma [9] was controversial because pneumoretroperitoneum or pneumoperitoneum caused great or unstable increase of the blood pressure and because of possible multiple tumors. With the advance of the cardiocirculatory control technique and the image diagnostic procedures, at present most laparoscopists include pheochromocytoma as an indication. However, laparoscopic removal of adrenal malignancy is still controversial, because these malignancies are usually large and intraoperative dissemination or port site recurrence is always possible. Although Heniford [10] reported 10 successful cases, with only one failure in malignancy accompanied by caval invasion, I personally do not perform laparoscopic removal of a malignancy that is mostly large and might be associated with lymph node metastases. The retroperitoneal approach to the adrenal gland showed less postoperative complications in one report [11]. However, I believe that both approaches are excellent and that the outcomes are just a matter of the learning curve. Laparoscopic adrenalectomy is one of the most prominent areas in which urologists have pioneered and significantly contributed to the progress of medicine for the past decade. I recommend that all the urologic laparoscopists acquire full command of laparoscopic adrenalectomy.