Showing papers in "Current Opinion in Urology in 2009"
TL;DR: The designs of existing commercial RMIS systems are not conducive for force feedback, and creative solutions are needed to create compelling tactile feedback systems.
Abstract: Purpose of Review
Robot-assisted minimally invasive surgery (RMIS) holds great promise for improving the accuracy and dexterity of a surgeon while minimizing trauma to the patient. However, widespread clinical success with RMIS has been marginal. It is hypothesized that the lack of haptic (force and tactile) feedback presented to the surgeon is a limiting factor. This review explains the technical challenges of creating haptic feedback for robot-assisted surgery and provides recent results that evaluate the effectiveness of haptic feedback in mock surgical tasks.
551 citations
TL;DR: Antimuscarinic drugs remain the first-line treatment of the overactive bladder and a favorable efficacy/tolerability-safety ratio can be confirmed, and promising new alternatives are emerging.
Abstract: Purpose of reviewTreatment options for the overactive bladder were recently discussed at the 4th International Consultation on Incontinence (ICI) held in Paris, 5–8 July 2008. This article will overview current thoughts on the pharmacological and clinical basis for the different classes of drugs cur
170 citations
TL;DR: At present, high-resolution MRI with pelvic coil appears to offer the most readily available and useful imaging and future studies should work towards helping define standard, reproducible approaches to imaging and image reporting for research and clinical practice.
Abstract: Purpose of reviewTo review the current status of MRI techniques in identification of organ-confined prostate cancer with a focus on their implication for focal therapy and active surveillance.Recent findingsMRI is currently focusing on intraprostatic prostate cancer identification and at 1.5T, it pr
112 citations
TL;DR: The cost of illness for urinary incontinence and OAB is a substantial economic and human burden and is likely to increase further in the future, highlighting the need for effective forms of management.
Abstract: Purpose of reviewTo summarize recent population-based literature on the prevalence and consequences of urinary incontinence and overactive bladder (OAB) symptoms in women and describe our present knowledge regarding known risk factors.Recent findingsThe prevalence of urinary incontinence in women ra
112 citations
TL;DR: The evidence derived from randomized clinical trials does not support a statistically significant incidence of urethral strictures with bipolar compared with monopolar current, but the haemostatic capacity of bipolar current is shown to be superior in ex-vivo studies.
Abstract: Purpose of reviewTo summarize recent knowledge from experimental studies and randomized clinical trials in benign prostate hyperplasia that compare bipolar with monopolar transurethral resection, with an emphasis on morbidity.Recent findingsBipolar transurethral resection of the prostate has a urody
80 citations
TL;DR: Although androgen deprivation therapy appears to increase overall survival in select populations with locally advanced and symptomatic metastatic prostate cancer, their side-effects often lead to secondary short and long-term toxicities that negatively impact patient's quality of life and ultimately affect their survival.
Abstract: Purpose of reviewTo review the current data on adverse effects of androgen deprivation therapy for prostate cancer and to discuss some considerations when choosing therapy and managing side-effects.Recent findingsDespite the existing data supporting the use of androgen deprivation therapy in prostat
78 citations
TL;DR: Prostate biopsy has evolved from a paradigm of a small number of random biopsies to one of systematic, numeric, and anatomic strategy.
Abstract: Purpose of reviewProstate biopsy has evolved from a paradigm of a small number of random biopsies to one of systematic, numeric, and anatomic strategy. Over the past several years, the data have demonstrated the importance of purposeful biopsy strategies for detecting, accurately grading, and stagin
74 citations
TL;DR: The field of bladder cancer tumor markers remains a rapidly evolving area in which newer markers are constantly identified, evaluated, and often discarded if they do not add significantly to the urologists' armamentarium.
Abstract: Purpose of review Bladder cancer remains a highly prevalent and lethal malignancy. Early diagnosis and prompt treatment have been shown to improve survival at both initial diagnosis and recurrence. A vast number of tumor markers have been identified and rigorously evaluated in attempts to improve noninvasive diagnostic accuracy of bladder cancer. Hematuria was the first tumor marker in a field that has grown to include soluble markers, cell-surface antigens, cell-cycle-related proteins, and genetic alterations. We aim to provide a critical appraisal of newer markers and the current state of research. Recent findings The number of tumor markers identified has been exponentially increasing. For a variety of reasons, many are unsuitable for clinical practice. More promising recent markers include those discovered in the fields of genomics, proteomics, and epigenetics. Much of the recent work is focused on molecular genetic pathways in bladder cancer. Summary The field of bladder cancer tumor markers remains a rapidly evolving area in which newer markers are constantly identified, evaluated, and often discarded if they do not add significantly to the urologists' armamentarium. Newer markers rely on genetic rearrangements, molecular changes, and cell-cycle-related proteins. Work is currently being done to identify the most promising markers.
66 citations
TL;DR: Only prebiopsy MRI can provide best quality of cancer assessment and allows for targeting biopsies, and it is hoped that advances in 3T MRI as well as in radiotracers for PET/computed tomography will further improve diagnosis, treatment selection, planning and outcomes.
Abstract: Purpose of reviewTo review the current status of advanced imaging techniques in identification of organ-confined prostate cancer with a focus on their impact on patient management.Recent findingsTransrectal ultrasound suffers from poor accuracy despite significant technical improvements. Generally u
65 citations
TL;DR: This study focuses on recent developments in epidemiology, pathogenesis, cause, diagnosis, treatment and prevention of uncomplicated UTI and recurrent UTI in women.
Abstract: Purpose of reviewUrinary tract infections (UTIs) in women comprise uncomplicated and complicated UTIs. Uncomplicated UTIs, such as acute uncomplicated cystitis and pyelonephritis, are very common infections in otherwise healthy women, with a high tendency to recur. Although severe complications are
64 citations
TL;DR: Dairy measures and novel probiotic therapy are promising adjuncts for preventing recurrent nephrolithiasis and alternative measures for reducing urinary risk factors show promise in reducing urinary oxalate.
Abstract: Purpose of review Recurrent nephrolithiasis is a burden to the individual patient as well as the healthcare system. A lack of new medications for treatment of stone disease and continued poor compliance with drug therapy has led to a growing interest in dietary manipulation and novel therapies aimed at preventing recurrent stone formation. Recent findings Despite initial enthusiasm for lemonade therapy, recent metabolic studies suggest that beverages with a high potassium citrate content, rather than citric acid, may be more effective in reducing stone risk because of the alkali load and citraturic response. In addition, there is increasing epidemiologic and metabolic evidence that obesity and dietary excess, including fructose-rich and purine-rich foods, are associated with increased stone risk. Finally, alternative measures for reducing urinary risk factors, such as probiotics, show promise in reducing urinary oxalate and may be effective in the treatment of primary and enteric hyperoxaluria or even idiopathic calcium oxalate nephrolithiasis. Although changes in urinary stone risk factors may reduce the need for surgical treatment of stone disease, the best management for recurrent nephrolithiasis is likely a combination of surgical and medical therapy. Summary Dietary measures and novel probiotic therapy are promising adjuncts for preventing recurrent nephrolithiasis.
TL;DR: Robotic adrenalectomy is an acceptable option in high volume robotic centers from standpoints of outcomes, feasibility, and cost as robotic systems further disseminate and the cost disadvantages become less prohibitive.
Abstract: Purpose of review This review assesses the role of robotic surgery in management of benign and malignant adrenal disease. Recent findings Laparoscopic adrenalectomy is considered the standard of care for benign adrenal neoplasms and has been increasingly considered for malignant disease. Robotic techniques have been considered for theoretical advantages in visualizing and dissecting the adrenal and its vasculature. Series of robotic adrenalectomy and limited comparisons with laparoscopic adrenalectomy have shown that robotic adrenalectomy is well tolerated and effective with subjective advantages compared with laparoscopic adrenalectomy. There has been growing interest in adrenal sparing-surgery using minimally invasive techniques and encouraging outcomes for selected benign lesions. Summary Robotic techniques for adrenalectomy have subjective advantages compared with laparoscopic adrenalectomy, but no objective superiority has been demonstrated. Surgical outcomes have been comparable with laparoscopic adrenalectomy though there have been no randomized controlled studies. Robotic adrenalectomy will be increasingly considered in lieu of laparoscopic adrenalectomy as robotic systems further disseminate and the cost disadvantages become less prohibitive. Although laparoscopic adrenalectomy remains the standard of care, robotic adrenalectomy is an acceptable option in high volume robotic centers from standpoints of outcomes, feasibility, and cost.
TL;DR: In this paper, the molecular mechanisms of bladder carcinogenesis in relation to environmental carcinogens in order to provide a given population with a preventive value of bladder cancer was reviewed. But the authors did not consider the role of environmental carcinogenicity in the development of the cancer.
Abstract: Purpose of reviewTo understand the molecular mechanisms of bladder carcinogenesis in relation to environmental carcinogens in order to provide a given population with a preventive value of bladder cancer.Recent findingsCigarette smoking, aromatic amines contained in dyes, chronic inflammation due to
TL;DR: PSA cutoff values provide a reasonable balance between excessive detection rates and the risk of missing relevant prostate cancer, and several of the studies suggest that in following such men, other risk factors such as prostatic volume, previous screens and biopsies, rectal examination, age and family history may be helpful in decision making.
Abstract: Purpose of review Prostate-specific antigen (PSA)-driven testing for prostate cancer is common around the world. There is uncertainty about its proper use in diagnosing prostate cancer. This review describes the background of the addressed problem and summarizes relevant, recent findings reported during 2008. Recent findings Available data suggest that the performance characteristics of PSA do not permit the identification of a valid cutoff value that balances sensitivity and specificity in indicating a biopsy of the prostate. However, biopsy in all men by age would only lead to unacceptably high biopsy and detection rates. Data reported in this study show that within the population of men aged 55-75 years, 80% have PSA values of less than 3.0 ng/ml and 87% below 4.0 ng/ml. Data from European Randomized Study of Screening for Prostate Cancer, Rotterdam suggest that, on the basis of a 12-year follow-up period, biopsy in men with PSA values of less than 3.0 ng/ml can safely be delayed. Several of the studies suggest that in following such men, other risk factors such as prostatic volume, previous screens and biopsies, rectal examination, age and family history may be helpful in decision making. Molecular markers, which may replace PSA or identify selectively indolent, aggressive prostate cancer, are under investigation. Summary At this time, PSA cutoff values (>2.5, 3.0 or 4.0 ng/ml) provide a reasonable balance between excessive detection rates and the risk of missing relevant prostate cancer. Men presenting with PSA values of 2.0-3.0 ng/ml should be reexamined more frequently. Available nomograms applying risk modifiers should be used specifically in this category of men.
TL;DR: In this paper, the authors analyzed the literature regarding incidental finding of renal cell carcinoma (RCC) and found that RCC incidence rates continue to rise among all racial, age, and tumour size categories, with the most rapid increase for localized disease and small tumours.
Abstract: Purpose of reviewTo analyze the current literature regarding incidental finding of renal cell carcinoma (RCC).Recent findingsRCC incidence rates continue to rise among all racial, age, tumour size categories, with the most rapid increase for localized disease and small tumours. In parallel, it seems
TL;DR: In this paper, a growing concern over the acute and long-term adverse effects associated with shock wave lithotripsy calls for treatment strategies to reduce renal injury and improve the efficiency of stone breakage in SHL.
Abstract: Purpose of reviewGrowing concern over the acute and long-term adverse effects associated with shock wave lithotripsy calls for treatment strategies to reduce renal injury and improve the efficiency of stone breakage in shock wave lithotripsy.Recent findingsExperimental studies in the pig model show
TL;DR: The intermediate-term and long-term oncologic outcomes after cryoablation for kidney tumors are satisfactory and combination with new technologies and further development of imaging techniques can potentially expand the range of indications of the procedure.
Abstract: Purpose of review To review the evolution and current status of cryoablation for renal tumors. Recent findings Cryoablation is the most evaluated probe ablative method for the treatment of small renal masses. It is associated with high efficacy and low morbidity. New data on intermediate and long-term oncological outcomes are now available. Five and 10-year cancer-specific survival are 93 and 81%, respectively. Renal cryoablation is most commonly performed percutaneously or laparoscopically. Recently, single-port laparoscopic and natural orifice transluminal endoscopic surgery approaches have also been employed for renal cryotherapy. Summary With careful patient selection, the intermediate-term and long-term oncologic outcomes after cryoablation for kidney tumors are satisfactory. Combination with new technologies and further development of imaging techniques can potentially expand the range of indications of the procedure.
TL;DR: To prove the noninferiority of laparoscopic compared with open surgery regarding outcome, multicenter prospective trials are urgently needed and Laparoscopic RCX must be considered experimental surgery.
Abstract: Purpose of reviewTo compare oncologic outcomes in a contemporary series of patients undergoing radical cystectomy (RCX) by the laparoscopic or open approach.Recent findingsLaparoscopic RCX with extracorporeally constructed urinary diversion is a safe and effective operation for appropriate patients
TL;DR: The response of prostate cancer to thermal therapies with an emphasis on cryoablative techniques is described, and research focused on the development of freeze sensitizing agents that work adjunctively is of central interest in furthering the efficacy of this therapy.
Abstract: Purpose of reviewTo describe the response of prostate cancer to thermal therapies with an emphasis on cryoablative techniques.Recent findingsLong-term follow-up studies demonstrate clearly the effectiveness of the use of modern cryoablative techniques in the management of prostate cancer. Recently p
TL;DR: Cryosurgery has a promising role in primary and salvage treatment of select prostate cancer patients, and focal cryotherapy for unilateral disease offers the added benefit of minimal adverse effects.
Abstract: PURPOSE OF REVIEW Minimally invasive options to treat low-risk prostate cancer are more desirable than radical therapy. Technological improvements in cryotherapy have increased its use, and long-term data on its efficacy are emerging. In this review, we discuss contemporary data on cryotherapy with specific focus on studies using the newest technology. RECENT FINDINGS With respect to biochemical recurrence rates, cryotherapy appears to be as effective for low-risk prostate cancer as other treatment modalities. The definition of recurrence remains problematic, though contemporary studies are more consistently using both the American Society for Therapeutic Radiation Oncology and Phoenix criteria. Erectile dysfunction rates are universally high after whole-gland cryoablation, but incontinence and urethrorectal fistula rates appear to be low with third-generation cryo systems. Focal cryotherapy has encouraging short-term efficacy in terms of biochemical disease-free survival rate for unifocal disease, and rates of erectile dysfunction are dramatically lower than those seen with whole-gland cryoablation. SUMMARY Cryosurgery has a promising role in primary and salvage treatment of select prostate cancer patients. Focal cryotherapy for unilateral disease offers the added benefit of minimal adverse effects. Long-term data are emerging to support cryosurgery, and large multicenter databases have been developed to answer questions regarding optimal treatment outcomes and patterns.
TL;DR: The challenge in the years to come will be to introduce these new gene-based diagnostic and prognostic tests in algorithms integrating the other known risk factors of age, ethnicity, family history and PSA level to better tailor diagnostic and therapeutic strategies.
Abstract: Purpose of review To review the most recent advances in genetic testing for prostate cancer risk and of new molecular diagnostic assays to improve diagnostic accuracy and treatment decision beyond prostate-specific antigen (PSA) testing. Recent findings Multiple independent studies had demonstrated evidence that genetic variations in three regions of chromosome 8q24 and one each at 17q12 and 17q24.3 are independent predictors of prostate cancer risk in addition to family history and serum PSA levels. The small percentage of individuals with several anomalies can have up to 10 times the risk of prostate cancer. Novel molecular urine tests have been studied, and the prostate cancer antigen 3 RNA detection has been studied most extensively and is now commercially available. It provides an independent and synergistic information to predict a higher or lower risk of prostate cancer at given PSA level and can further help predict the tumor volume and Gleason grade found on the prostatectomy specimen. Sensitivity of the prostate cancer antigen 3 test could be improved by the detection of the fusion gene transcripts transmembrane protease serine 2-E26 transformation specific-related gene and serine peptidase inhibitor Kazal type 1 who may in addition allow the identification of prostate cancer patients at higher risk of life-threatening disease. Summary The challenge in the years to come will be to introduce these new gene-based diagnostic and prognostic tests in algorithms integrating the other known risk factors of age, ethnicity, family history and PSA level to better tailor diagnostic and therapeutic strategies.
TL;DR: The role of RFA for the management of renal cortical tumors is reviewed and comment on technical considerations for this particular ablative technique, and a summary of contemporary longer-term oncologic outcomes is provided.
Abstract: Purpose of review To provide an overview of the current literature addressing the role of radiofrequency ablation (RFA) for the management of renal cortical tumors. Recent findings As the renal RFA experience continues to mature, longer-term data addressing the oncologic efficacy of this ablative modality are now available. Furthermore, the impact of RFA on secondary clinical endpoints, such as renal function outcomes, has now been addressed in several series. Summary With the stage migration toward diagnosis of smaller renal masses, energy ablative techniques are being increasingly utilized as primary surgical modalities. Here, we review the role of RFA for the management of such masses and comment on technical considerations for this particular ablative technique. In addition, we provide a summary of contemporary longer-term oncologic outcomes and review the impact of RFA on renal function. As more renal masses are diagnosed in the elderly or comorbid patients, it is likely that ablative approaches will assume an increasingly central role in management strategies. In this regard, continued studies are necessary, particularly in regards to oncologic outcomes.
TL;DR: Hereditary kidney cancer syndromes offer valuable insight into the pathogenesis of kidney cancer through identification of the underlying genetic mechanisms common to hereditary and sporadic forms of disease.
Abstract: Purpose of reviewChanging strategies in the evaluation and treatment of renal neoplasms have been fostered by developments in the understanding of the genetics and molecular biology of renal tumors. Many of these discoveries have come from research into hereditary kidney cancer syndromes and the gen
TL;DR: There is a trend in increasing interest and accuracy on the subject of percutaneous biopsy of renal masses as well as a decreasing trend in the rate of nondiagnostic biopsies.
Abstract: PURPOSE OF REVIEW: To review the most recent literature concerning renal mass biopsy with special consideration to three points: variation in results related to the standard used as comparison, biopsy in small renal masses (up to 4 cm in diameter) and the case for nondiagnostic biopsy. RECENT FINDINGS: The overall rate of failed and indeterminate biopsies shows a trend for improvement. However, selection bias and the lack of a uniform index test for comparison preclude a definitive statement. Fine-needle aspiration may equal results of core biopsy, but its role in the diagnostic algorithm is not yet defined. In-vivo accuracy decreases in small renal masses with the same limitations exposed for the overall literature on renal mass biopsy. When nondiagnostic biopsies are considered, there is a need for standardization of the nomenclature in order to compare results. Re-biopsies or surgery after a nondiagnostic biopsy shows malignancy in up to 75% of the cases of renal cell carcinoma. SUMMARY: There is a trend in increasing interest and accuracy on the subject of percutaneous biopsy of renal masses as well as a decreasing trend in the rate of nondiagnostic biopsies. In the small renal masses, most likely to be benign, a diagnostic percutaneous biopsy may have a definitive role. However, the higher rate of nondiagnostic results in this population calls for prospective studies with standard definitions and when possible homogenous index test to properly assess the diagnostic performance of the biopsy.
TL;DR: CXCL16 is one of the newest biomarkers, is significantly expressed in papillary renal cell carcinoma and is an independent prognostic marker for better patient survival and the use of novel molecular biomarkers are being incorporated into clinical practice.
Abstract: PURPOSE OF REVIEW: To review the latest information on biomarkers in renal cell carcinoma and their use in integrated staging systems.
RECENT FINDINGS: The discovery of the Von Hippel-Lindau defect and the hypoxia inducible factor-1alpha transcripted genes has led to an explosion in the understanding of molecular pathways in renal cell carcinoma. The two most prominent biomarkers are carbonic anhydrase IX and vascular endothelial-derived growth factor. Carbonic anhydrase IX has demonstrated excellent specificity and ability to predict treatment response. Vascular-derived growth factor has good correlation with stage, grade and increased levels with adverse survival. Markers such as CXCL16, ADAM10, B7-H1, Ki-67, survivin, P53, GLUT-1, calveolin-1 and endoglin are continuously being validated. CXCL16 is one of the newest biomarkers, is significantly expressed in papillary renal cell carcinoma and is an independent prognostic marker for better patient survival. The incorporation of biomarkers into integrated staging systems such as UCLA Integrated Staging System, SSIGN and Bioscore are discussed and compared.
SUMMARY: The use of novel molecular biomarkers are being incorporated into clinical practice. The understanding of molecular pathways will lead to tailored treatment to the individual patient.
TL;DR: HoLEP seems to represent a valid alternative to both transurethral resection of the prostate and open prostatectomy, with valid long-term functional results, a low rate of short-term and long- term complications, and very low rates of reintervention.
Abstract: Purpose of reviewHolmium laser enucleation of the prostate (HoLEP) has been proposed as an alternative to transurethral resection of the prostate and to open prostatectomy for patients with lower urinary tract symptoms because of large benign prostatic enlargement. The aim of this review is to criti
TL;DR: The final goal of robots is to allow safer and more homogeneous outcomes with less variability of surgeon performance, as well as new tools to perform tasks on the basis of medical transcutaneous imaging, in a less invasive way, at lower costs.
Abstract: PURPOSE OF REVIEW: Robot-assisted laparoscopic surgery in urology has gained immense popularity with the daVinci system, but a lot of research teams are working on new robots. The purpose of this study is to review current urologic robots and present future development directions. RECENT FINDINGS: Future systems are expected to advance in two directions: improvements of remote manipulation robots and developments of image-guided robots. SUMMARY: The final goal of robots is to allow safer and more homogeneous outcomes with less variability of surgeon performance, as well as new tools to perform tasks on the basis of medical transcutaneous imaging, in a less invasive way, at lower costs. It is expected that improvements for a remote system could be augmented in reality, with haptic feedback, size reduction, and development of new tools for natural orifice translumenal endoscopic surgery. The paradigm of image-guided robots is close to clinical availability and the most advanced robots are presented with end-user technical assessments. It is also notable that the potential of robots lies much further ahead than the accomplishments of the daVinci system. The integration of imaging with robotics holds a substantial promise, because this can accomplish tasks otherwise impossible. Image-guided robots have the potential to offer a paradigm shift.
TL;DR: Targeted focal therapy using the modalities of cryotherapy or high intensity focused ultrasound as an alternate treatment for low-risk prostate cancers provides an alternative to active surveillance and more aggressive treatments for patients with low- risk tumors.
Abstract: Purpose of review Prostate cancer screening has shifted the diagnosis of prostate cancer to lower grade, organ confined disease. Radical prostatectomy or radiation therapy has been shown to be overtreatment in 30% of patients. In this review, we will discuss targeted focal therapy (TFT) using the modalities of cryotherapy or high intensity focused ultrasound as an alternate treatment for low-risk prostate cancers. Recent findings TFT uses 3-D mapping biopsies to guide treatment so lesions of interest are ablated whereas sparing surrounding healthy tissues, avoiding the side-effects associated with more invasive treatments. In recent years, improvements in cryotherapy and HIFU have increased efficacy whereas decreasing complications. Prostate cancer control reported following TFT is promising. Summary With data demonstrating effective treatment in select patients, physicians can better inform their patients of the options available to eradicate their prostate cancer. TFT provides an alternative to active surveillance and more aggressive treatments for patients with low-risk tumors. As studies mature, more information regarding long-term survival and benefit will become more evident.
TL;DR: Current data suggest that cryoablation results in lower retreatments, less local tumor progressions, and may be associated with a decreased risk of metastatic progression compared with RFA, but it is unclear whether these differences are a function of the technologies or their application.
Abstract: Purpose of reviewSurgical excision remains the standard of care for treatment of localized small renal masses (SRMs). Laparoscopic and percutaneous minimally invasive ablative technologies are being increasingly employed in current urologic practice. We review recent literature regarding focal ablat
TL;DR: Noninvasive measurements of bladder/detrusor wall thickness, intravesical prostatic protrusion, or isovolumetric bladder pressure might replace invasive pressure-flow studies in the future if only information about BOO is needed.
Abstract: Purpose of reviewTo provide evidence of promising tests to noninvasively diagnose bladder outlet obstruction (BOO) in men with benign prostatic hyperplasia.Recent findingsPressure-flow studies are usually performed to prove BOO prior to prostatectomy. However, pressure-flow studies are invasive, exp