AUA Convention Orlando - 2002

The history of Orlando goes back to 1860. Since that time the population grew from 84 to about 1.6 million in 2002. Orlando used to be a rather small town, when Walt Disney decided in 1965 to start anew on the East Coast after it became clear that Anaheim's Disneyland became encapsulated by cheap hotels and other buildings and could no longer expand. The bright economic future of such an undertaking was welcomed by the Florida legislature, that allowed construction of roads, canals and settlements. Walt Disney died before the opening, but the themeparks grew in number and, despite some financial setbacks in the eighties, continue to be one of the main attractions of Florida.

Bladder cancer is one of the main topics of todays program, which starts off with a point-counterpoint session. The discussion is - it happened before - without much excitement. It is all about the wellknown T1G3 tumor: primary or delayed cystectomy? Montie (New Harbour, MI, USA, with 12 abstracts a real contributor to this AUA) acts as defendant of the primary cytectomy option. To postpone treatment is like verdedigt de primaire cystectomie, uitstellen noemt hij `walking on a tight rope`, sin. Tensce 20 to 50% of T1 tumors show progression. Droller is took on with the TURT+BCG+close follow-up option, claiming that only 50% of these tumors in indeed G3, while of these only 50% show progression. He doubted whether this group of patients could be cured at all and pointed out that delayed cystectomy was probably as ineffective as the primary version. Alas, the problem remains unsolved: for individual patients, a decision remain a difficult one.
When Soloway enters the arena, all present (the giant hall was fully booked) really get ready for some action. A panel including such celebrities as Debruijne (Netherlands), Snow (UK) and Messing (USA) discuss on topics like follow-up and adjuvant therapy in superficial bladder cancer. Like: is there a place for adjuvant chemotherapy in primary, low grade bladder cancer? Debruijne looked up some EORTC studies and concluded that a single intravesical chemotherapy is mandatory within 24 hours after TUR and weekly in medium and high risk tumors
The nice about Soloway is that he will always try to add some complicating factors, like 'what if the cancer then recurs as high-grade Ta or Cis?' Both Messing and Debruijne then opt for cystectomy, but Soloway firts would like to try BCG plus Interferon. Tumormarkers do not seem to add anything to the discussion. Further analysis of the upper urinary tract is not really indicated in low-grade cancer, but should be done yearly in high-grade tumors.

Incontinence: Wein talked about the history and trends in current surgery. The Burch procedure seems out now, and is replaced by the sling procedure as a golden standard. But `efficacy depends on the hands of the expert`, and `complications depend on who you believe`. In the US, ordinary sling procedures still have a major audience, while abstracts on TVT are only looked upon with curiosity. TVT results are comparable to those of sling procedures, but with a lower complication rate and shorter hospital stay. All panellists stick to their own procedure and their own material.

Schulman (Brussels, Belgium) pointed out that those who are not familiar with laparoscopic radical prostatectomy but do have a fair experience on the open version, should not try to switch sides but stick to their own craft. When you are a beginner, then try laparoscopy, because hospital stay is shorter and blood loss lower, while after an open procedure 2/3 of all patients need Viagra for their erections. Hu (LA, CA, USA) Found out that RP'sin large quantities per hospital (1 RP/wk or >60/yr) and per urologist (3 RP's/month or >40/yr) has advantages in terms of lowering complication rate, less bladder neck tenoses and shorter hospital stay.

Your Reporter wanted to be educated for a change, so he went to a course on 'Male Infertility: Diagnostic and Treatment Strategies'. Although the last EAU In Birmingham showed that therapy for varicocele related to infertility was only indicated in clinical varicocele in prepubertal boys, while no effect on fertility was shown when surgery was done in grown men, this information still has to cross the Atlantic. Everyone in the (nearly All-American) audience did not even as much question the necessity of surgery in these cases and only discussed the type of surgery (the verdict was: microsurgery). According to Nagler and Sandlow, ICSI, possibly in combination with TESE, seems an easy to find solution in many cases of male infertility (even in azoospermia, where often still some spermcells can be found). although one has to be cautious not to pass on genetic defects (like cystic fibrosis) that reprsent the cause of the infertility - and induce inheritence into infertility.

The poster session 'Sexual Function/Dysfunction/Andrology: Evaluation and Surgical Therapy' came up with the following items. Vardi (Haifa, Israel) found good results in penile revascularisationin cases of proven arterial occlusion in young patients (under 28): 73% good results compared to 23% in older patients). Venous leakage showed to have no effect on results, but smokers fared less (29% good results) than did non-smokers (71%). Median follow-up was about 6 years.
The public needs to be better informed on ED as shown in a multicontinent (USA, Europe, Mexico, Brazil) study (Niederberger, Chicago, IL, USA), while tissue engineering may probably lead to corpora cavernosa tissue that can be used to repair Peyronies disease as shown in the rabbit model (Kwon, Boston, MA, USA).
'Female Sexual Dysfunction' has the attention of a number of urologists and is shown in a number of posters. Apparently, Viagra staretd off a revolution in sexual activity that now reaches out beyond the gender borders. Maybe this area shoudl also be claimed by urologists, since gynacologists fail to address it. Costabile (Stanford, CA, USA) showed that topical alprostadil (PGE1) in a dose of 400ug has a subjective and objective response in case of FSAD (Female Sexual Arousal Disorder) in postmenopausal or oophorectised women.
When the seminal vesicles are not removed during radical prostatectomy, that leads to a better sexual Quality of Life compared to 'normal' nerve sparing RP (Sanda, Ann Arbor, MI, USA). The penile bulbus seems pretty vulnarable for radical radiotherpy for prostate cancer. Because of the (possibly only initially) better effect on preservation of erection, radiotherapy is often advised to younger patients. If then ED should still be a post-treatment problem, then therapy is much more difficult and often medication does not help, leaving vacuum devices and prostheses as only remaining options. (McCullough, New York, NY, USA). PGE injections shoudl be started early after non-nervesparing RP, if possible within one month, but not after three months Gontero (Novara, Italië). It was retrospectively shown that ED can be used as a predictive marker fro coronary artery disease (CAD). ED started nearly five years before the onset of CAD symptoms Montorsi, Milaan, Italië). So, after a broadening of the urologic field towards gynecology (see above), we may now also enter the field of cardio-urology!

D'Amico (Boston, MA, USA) reported on a retrospective study of 2254 retropubic radical prostatectomies (RP) and 384 radical radiotherapies (RT, 70 Gy). The RP's always fared as well as the RT's in low, intermediate and high risk groups. Sanda (Ann Arbor, MI, USA) also proclaimed a lack of confidence in RT and brachytherapy. The latter especially showed to be inferior in all domains of a Quality of Life acore in 1172 patints. When you look at the huge differences in brachytherapy practice, one can ask whether all brachytherapies can be heaped together.

Atrasentan is coming and is momentarily tested in faseII studies. It is an endothelium receptor antagonist, with an even stronger affinity for prostate cancer cells. It is manufactured by Abbott. It appears to have a cytostatic effect, not a cytotoxic effect. In one fase II study it showed to have a marked effect on PSA progression when compared to placebo.
Vardenafil is coming. As a direct competitor for Viagra, the Varedafil guys have tried to fit every taxi in town with Disney like rooftop posters. Your Reporter will keep a low profile in this commercial and media explosion.

The end of the day took your Reporter took your Reporetr to Epcot Centre, whcih was fairly quiet despite Memorail Day. In a Disney-like athmosphere, we took a stroll down Mexico, Germany and France and visited Venice in between. The virtual reality of a number of attractions was astounding, far superior to the Zeus machine for virtual reality robotic laparoscopy. A trip not easily forgotten.

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