AUA Convention Orlando - 2002

In 1900, a group of New York surgeons with a special interest in the genitourinary system organized themselves as the New York Genito-Urinary Society. On February 22, 1902, eight members of that society met for dinner in the home of Dr. Ramon Guiteras, and voted to disband the New York GenitoUrinary Society and form the American Urological Association. Thus, the AUA was born.

The Centennial Celebration was opened by Martin I. Resnick, Secretary, and E. Darracott Vaughan Jr., President, and invocated by Pastor William S. Barnes. The latter, ofcourse, has been a patient of Resnick's and was apparently cured of his kidney stones and satisfied with the result.

Senator John Glenn, the first American to orbit the earth in 1962, who still holds the record for being the oldest man in space in a Space Shuttle flight when he was in his late seventies, apparently was not a patient. Or refused to tell us, since he surely is an eligible patient. Heavily guarded, possibly also because of the latest terrorist threats, 82 year old John Glenn told us his tales from outer space, the final frontier. He always wanted to be a doctor, but WWII came in between, and he ended up as an astronaut instead. But he did manage to convince his son, who now is a doctor on the West Coast.

Yesterday brought us a slow start featuring a couple of societies, one of which the Society of Women in Urology. Unfortunately, their breakfast meeting indeed started at 06.45, which is not to the taste of my stomach. So your reporter had to skip 'a great opportunity to meet with female urologists' as stated in the invitation. Maybe we'll meet at the evening reception, which sounds more promising. The Society of Urologic Oncology had a well-visited meeting in the Rosen Centre, just next to the convention centre. Catalona (St.Louis, MO, USA) tried to convince us that the PSA cutoff value for prostate cancer should be lowered to 2.5. Thus, 80 percent of prostate cancer detected is organ confined, while a cutoff of 4.0-6.0 only yields a 60-70% score. In one study, combining a lower cutoff with prePSA (pPSA) determination leads to a 10% increase in cancers detected while biopsy rate is even dropped with 13%. Moul (Rockville, MD, USA), however, figured out that the validity (a statistical combination of sensitivity and specificity) proves that there is no advantage to a lower cutoff than 4.0. In a study by Stamey, it was shown that outcome is no different with initial PSA values between 2 and 9, and the question remains as to what is really detected by lowering cutoff values: coincidental or curable cancer? Moul proved to have the better arguments, while it still remains to be proven what the real value of screening is.

Klotz (Toronto, Canada) reviewed a bunch of studies on the number of prostate biopsies needed to detect cancer. Did you know that 'saturation biopsies' entail taking 32 biopsies under general anaethesia?
He stressed that biopsies should be taken from the lateral aspects of the prostate; 15-30% of cancers are missed in T1c cancers with a PSA below 10 when only medial biopsies are taken. In summary, 10 biopsies, with emphasis on the lateral parts of the prostate seem adequate, while 'saturation biopsies'should be reserved for difficult cases. The traditional sextant biopsies are insufficient, although the yield of more biopsies is minimal, while about 10 percent clinically insignificant cancer is found in that way.
The annual W.F. Whitmore, Jr. lecture was held by von Eschenbach (Bethesda, MD, USA), the director of the National Cancer Instute there. He looked back on the work of Whitmore and urged the audience to draw lessons from the revolution in urology that followed the strategic inflection paved the way towards new insights in medicine and urology in the same way that E=mc² brought us nuclear energy and chiptechnologie. The 'Seek & Destroy' strategy of the 20th century will change to a 'Target & Control' strategy in this one. Especially urology will benefit from new technologies like gene therapy and insight in angiogenesis, among many other emerging technologies. Already, 22% of all cancers are urological, while they account for 10% of cancer deaths. The survival time of prostate cancer has not changed in the past decades.

Back to today. The poster session on epidemiology and natural history of prostate cancer showed that younger patients (<75) benefit more from radical prostatectomy and radical radiation therapy than older patients (Brooks, Iowa City, IO, USA). Younger patients are often under-treated, while more aggressive treatment would lead to better 5 year survival, and older patients over-treated, while their aggressive treatment has no impact on survival. High grade PIN yields a 10% higher chance on developing prostate cancer, which increases to 24% when a new biopsy also shows PIN in a study of 47 patients and 137 controls. If e new set of biopsies shows only BPH, then the chance on cancer diminishes to about 3% in the following 3 years (San Francisco, Boston, MA, USA). Young men with prostate cancer who smoked cigarettes have more aggressive disease, i.e. a higher Gleason score, and the aggressiveness correllates well with the number of cigarettes smoked, according to Roberts, Baltimore, MA, USA. Short Term delays in surgical therapy, i.e. radical prostatectomy, for localized prostate cancer (Nam, Toronto, ON, Canada) reduces cure rate. Until about three months, there is no difference, but after that time, the hazard ratio increases from 1.0 to 1.4 as far as recurrence after one year is considered. Kaplan Meyer curves stay widely apart and continue to do so after 140 months follow-up.

The podium session on Ureteroscopy showed two presentations on the use of the Uromentor device, a computer based virtual reality (VR) simulator for endourological training. The machine (from an Israel based company) combines a normal flexibel scope that is introduced into the urethra and a computer simulation that takes over after that. It can be used to practice cystoscopy, manipulation of the ureteral orifice, insertion of stents and uretroscopy/lithotripsy. Although no testing has been done to compare VR training with real-patient training, the machine seems to work. Another topic was the use of stents after ureteral manipulation, i.e. ureteroscopy/lithotripsy. Netto, São Paulo, Brazil, found no differences in succesrate, pain and complication in stent vs. no-stent, but surgery took longer (64 vs. 45 minutes) in the stent group, while the cost per patient was twice as high (due to the stent). After some discussion from the audience, it was clear that everyone seemed to adopt the no-stenting protocol, but a firm exeption was made for patients living far away.
Winkler(Ramat-Gan, Israel) presented a nice study on the relationship between positive cultures with indwelling stents and the clinical risk on infection and sepsis after ureteroscopy in those cases. If a culture of the stent was negative, then the urine was also negative, while a positive stent culture, which occurred in 36%, resulted in 40% positive bladder urine cultures. Fifty percent of positive stent cultures resulted in urosepsis. He concluded that a negative urine culture was not very well correlated with stent infection and therefore with the risk of sepsis after ureteroscopy. Since about one third of all stents was infected and half of those resulted in urosepsis, he clearly advised broadspectrum antibiotics to be given per-operatively when ureteroscopy was undertaken in those cases.
A nephrovesical subcutaneous ureteric bypass can be used in selected cases of hydronephrosis and kidney insufficiency, particularly in cases of malignant distal ureteric obstruction, when retro- or antegrade insertion of a double pigtail stent proves impossible and nephrostomy is not an option, according to Schmidbauer (Vienna, Austria).

More tomorrow.

ENGLISH version 26 May 2002 27 May 2002 28 May 2002 29 May 2002

DUTCH version 26 Mei 2002 27 Mei 2002 28 Mei 2002 29 Mei 2002