"It is the most congenial city in America that I know of and it is due in large part, I believe, to the fact that here at last on this bleak continent the sensual pleasures assume the importance which they deserve ......" Henry Miller, The Air-Conditioned Nightmare, 1945
Only yesterday, I saw a case of ectopic cryptorchidism. These baseball umpires have their balls right on the hip. The New Orleans Zephyrs beat Omaha in the last inning (9-8).
Every year the death toll due to violence in the US exceeds that of the Vietnam War. Recently, one of the urologists just paid $45 for a shoeshine only to avoid being the next victim. Trauma is the most important cause of death for Americans below the age of 45. AUA President McAninch discussed the results of treatment in 2800 cases of renal trauma. Most important prognostic factor, i.e. to operate or not to operate, is either macroscopic blood loss or microscopic blood loss plus low blood pressure. The diagnostic procedure of choice is CT-scanning, but this is reserved for the categories just mentioned and in cases of perforating trauma. Only persisting hemorrhage is an uncontested indication for surgery, while non-vital renal tissue, extravasation of urine or arterial trauma does not allways need to be treated. Arterial reconstruction can only save the kidney in 20% of cases and then only if the trauma is diagnosed within 6 hours and in young patients. A simple analysis of the extent of the damage in renal trauma can be done by injection of intravenous contrast followed by a plain X-ray 10 minutes later.
Army surgeons are sent to New Orleans to practice trauma surgery, so there was a lot of trauma to be presented in today's sessions. Brooklyn, however, saw 113 penetrating injuries to the kidneys (88% bullet wounds) in 3 years (646): 94% was operated upon. In about half of these, an abdominal approach was used to get to the vessels first in an attempt to stop the bleeding; this procedure did not lead to a better survival of the kidneys. The Swiss Danuser (641) showed that if a patient is hemodynamically stabile in cases of blunt trauma, then conservative treatment is a good option.
DeKernion presented some excellent results of radical prostatectomy and showed us some insights in new developments in the area of tumor therapy, like Liposome IL2 injection into the prostate, or gene-therapy in which a 'new' gene is connected to a virus to deliver it to the cell (P53, an important tumor suppressor gene, is a good candidate to participate in this viral therapy).
"If you are better and not broke: OK!" The closing statement of Darracott Vaughan Jr. about fytoherapy in BPH. Until now, fytotherapy does not show any change in urodynamic parameters, but it does show a decrease in symptom scores, even more than reported when using alfa-blockers or finasteride. Medical treatment of BPH works: the number of operations for BPH has declined in the past 5 years in the US: 272.000 to 170.000. The clinics have, however, shown an evenly rapid rise of number of patients: 2.2 to 3.9 million visitors. Watchful waiting will cause about 25% of patients to come back for operation within the year. The placebo effect in BPH is considerable: after 2 years it is still 3 points down. Even adverse effects like impotence and loss of libido are quite considerable when using placebo: 6 percent.
There are no major differences between the different alfa-blocking agents and none of them is truly uro-selective.
Vaughan stated that medical treatment is only indicated of the symptom score is higher than 11. The higher it gets, the better the results. The choice of medication depends on the size of the prostate. Below 40 grams finasteride does not give much improvement, but it does help some in prostates above 50. A normal prostate grows at a rate of about 2 grams a year in men above 50. Finasteride will cause the prostate not to grow for the first five years.
There were some presentations about cost-effectiveness. Some treatment modalities may get to be too expensive in the managed care organization. Radical prostatectomy and external radiotherapy about equal out. Cryosurgery is much cheaper, if only one treatment is necessary. Laparoscopic nephrectomy and even ESWL may prove to be too expensive. Protocols are being developed for an optimal use of financial resources.
Female stress-incontinence treatment was the topic of one of the bigger poster sessions of today. Vaginal sling procedures, using slings made of cadaveric tissue, fascia or some prosthesis fabrics, was preferred by most, even as a primary procedure for intrinsic sphincter deficiency and hypermobility. In longer follow-ups a success rate of 50-70% (1796, 1797, 1804) was shown, although the posters on retropubic suspension procedures show about equal results (1785, 1787, 1788). Collagen injections show definitely worse results, but are simpler.
BOON signifies the Bladder Outlet Obstruction Number. Prostate volume minus three times maximal flow plus one tenth of the functional bladder capacity predicted urodynamic prostate obstruction in 90%, as was shown by dr.Boon (pure coincidence) (1709). 19 Wallstents used for bulbar urethral strictures showed only good results in 12 after 6.2 years (1552). Dr Klijn (1562) showed a reintervention rate of 45% in sphincter prostheses in 87 patients, but more than 80% are continent. Spontaneous erosions do occur, even after many years, especially in clean intermittent self-catherization.De Boer showed an animal experiment in which the amount of BCG now used in bladder instillations may signify overkill, since the immune response is already started at low concentrations.(1503).
Verhulst presented the results of an enquiry about vasectomies and their results, showing an ever present but minute chance of re-canalization no matter how the vasectomy was performed (1450).
Witjes and De la Rosette found geographic differences in BPH symptoms in the ISC-BPH study (1455).
Noordzij (not related) showed CD44 (a transmembrane adhesion molecule) to be a possible prognostic marker in prostate cancer (1736).
Well, that's it, we're done. After 5 days of AUA all memory banks are full and no more slots remain. The most important news, the rise and eventual fall of complete androgen blockade, was not even presented at this convention, but at the ASCO. No real hot topics this time, but some finishing touches, final blows and stronger footholds. Gene- and immunotherapy are both important developments, especially for prostate cancer, but a lot of work still needs to be done.
Best regards from the Reporter-team, consisting of Egbert Boevé, Renée van de Maesen de Sombreff, Joop Noordzij and Pharmacia & Upjohn representatives Bauke Buwalda en Peter Eklund.
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