Author Reply In this study, a few fertility-focused prompts by a nurse, which were added to an already scheduled nursing education session (covering topics including treatment logistics, chemotherapy side effects, nutrition, and support services), led to a significant increase in sperm banking rates. We believe that the strength in this finding is that it can be broadly applied. Whether from a nurse or physician, even a brief standardized reminder with available pamphlets of information was able to make a significant difference in sperm banking rates.
Editorial Comment Patients with new malignancies have a myriad of urgent therapeutic considerations. The authors demonstrated the value of a separately scheduled nursing counseling session regarding sperm banking and fertility preservation before oncologic therapy is initiated.1 There are many reasons that oncologists may not offer counseling about fertility preservation. Among these reasons are lack of knowledge of options for fertility preservation, discomfort about discussing sperm banking, intense focus on the patient's malignancy while ignoring fertility considerations, and simple disinterest in fertility considerations.
Editorial Comment A decade after the initial clinical reports on robotic radical cystectomy, we now have a preponderance of data to assess potential benefits and harms of this minimally invasive procedure. Multiple studies—ranging from case series to randomized trials to meta-analyses—have demonstrated the potential for the robotic approach to (1) reduce blood loss and transfusion requirements, (2) decrease postoperative pain, (3) reduce 30- and 90-day complications (especially wound complications), and (4) decrease length of stay (LOS) (demonstrated in multiple series including the present study by Borza et al).
Author Reply: Postoperative Urinary Retention and Urinary Tract Infections Predict Midurethral Sling Mesh Complications The authors bring up a relevant point, in that structured followup of patients after a midurethral sling procedure is lacking. It is challenging to do, as most patients do well post-operatively, and wonder why they must attend repeated physician's appointment. However, if a “higher-risk” group could be identified, that would make systematic followup more significant for physicians, cost-effective for the medical system and pertinent to the patient. In our previous work, we found that a large number of women have their midurethral sling complication treated a different physician, highlighting a potential problem with accessing their prior surgeon.
Re: Punjani Et Al: Postoperative Urinary Retention and Urinary Tract Infections Predict Midurethral Sling Mesh Complications (Urology 2017;99:42-48) We read this manuscript with great interest. While the mid-urethral sling is considered by many to be the gold standard treatment for SUI, it is also associated with notable mesh-related complications. Research has sought to evaluate predictive factors for MUS complications. The majority of available investigation focuses on risk factors for post-operative voiding dysfunction, de novo irritative symptoms, or surgical failure.1-3 While this data is important, similar investigation is lacking to help understand risk factors for the most severe adverse events following MUS, including urethral/bladder perforation and fistula.
Clear Cell Renal Cell Carcinoma with Extensive Osseous Metaplasia: Report of a Rare Case A 48-year-old Chinese woman presenting with continuing dull pain in the right lower back and abdomen was found to have a tumor with extensive osseous metaplasia in the the upper-middle pole of the right kidney. The exsected neoplasm specimen revealed a 29×26mm hard tumor with dense ossification. Histopathological examination of the tumor contained lamellar bone forming trabeculae intermingled and showed spherical or polygonal epithelial cells which contained slightly irregular nuclei with small nucleoli and abundant pink to clear cytoplasm.Clear cell renal cell carcinoma with extensive osseous metaplasia is a very rare occurrence.
Radiation with or Without Antiandrogen Therapy in Recurrent Prostate Cancer William U. Shipley, M.D., Wendy Seiferheld, M.S., Himanshu R. Lukka, M.D., Pierre P. Major, M.D., Niall M. Heney, M.D., David J. Grignon, M.D., Oliver Sartor, M.D., Maltibehn P. Patel, M.D., Jean-Paul Bahary, M.D., Anthony L. Zietman, M.D., Thomas M. Pisansky, M.D., Kenneth L. Zeitzer, M.D., Colleen A.F. Lawton, M.D., Felix Y. Feng, M.D., Richard D. Lovett, M.D., Alexander G. Balogh, M.D., Luis Souhami, M.D., Seth A. Rosenthal, M.D., Kevin J. Kerlin, M.D., James J. Dignam, Ph.D., Stephanie L. Pugh, Ph.D., and Howard M.
Beware the Looping Vas Deferens in Orchidopexy A looping vas deferens may be present in up to 20% of undescended testes located within or proximal to the inguinal canal. This associated abnormality is vulnerable to transection during orchidopexy. We present an example of a very long looping vas to emphasize the importance of inspection for this anomaly, and demonstrate the extreme extent that a looping vas may extend. Identification of the vas amongst cord structures may provide false reassurance of normal ductal anatomy. Examination for a looping vas by inspecting structures caudal to the testis should occur at an early opportunity during orchidopexy to avoid inadvertent transection.
Incidental Malignancies identified during staging for Prostate Cancer with Ga -PSMA HBED-CC PET imaging The rapid uptake of 68Ga Prostate-Specific Membrane Antigen (PSMA) HBED-CC PET imaging for prostate cancer staging has led to concerns regarding its specificity, with uptake in both malignant and non-malignant tissues. We describe three separate malignancies identified on 68Ga PSMA HBED-CC PET imaging. The misnomer of “prostate specific membrane antigen” is demonstrated by this case and highlights the importance of continued investigation of the potential role for 68Ga PSMA HBED-CC PET in other malignancies.
A Unique Case of Pentaorchidism Polyorchidism is a rare congenital anomaly with less than 200 case reports in literature. Triorchidism – three testicles – is the most common presentation. We present an unusual case of a patient who was diagnosed with five testicles by magnetic resonance imaging. To the best of our knowledge, this rare presentation has not previously been reported in the medical literature.
Robotic Surgery in Uro-Oncology: a Systematic Review and Meta-Analysis of Randomised Controlled Trials Robotic surgery represents a new horizon in minimally-invasive urological surgery. This systematic review of the literature and meta-analysis examines the effectiveness of robotic surgery compared with laparoscopic or open surgery for major uro-oncological procedures. 25 articles reported findings from 8 trials of prostatectomy (4 trials) and cystectomy (4 trials) including 1033 participants. Robotic surgery is comparable to laparoscopic or open surgery for oncological outcomes, overall complications, and provides somewhat better functional outcome, when compared to laparoscopic and open surgery.
Biliary Stent Migration: A Rare Cause of a Bladder Stone Our patient presented with dysuria and pneumaturia without any prior urologic instrumentation. History included choledocolithiasis requiring ERCP and biliary stenting. Imaging showed a large bladder stone. She was taken to surgery and found to have diverticulitis. The sigmoid was resected and the bladder found to have a small fistula tract. The bladder was opened and a large calculus was identified and extracted. The stone was opened and found to contain a biliary stent. While biliary stenting is generally considered safe, migration can occur.
Adding Mirabegron to Solifenacin to Treat Overactive Bladder Has Little Impact on Post-Void Residual Volume or Urinary Retention Risk Urinary retention is a complex and important urological health issue that describes the inability to completely empty the bladder1. The sudden inability to void is termed acute urinary retention, which is usually accompanied by pain and severe urgency, and can have serious consequences if untreated2. Occasionally, acute urinary retention may be precipitated by an event such as infection or medication; thus the definition is further subdivided into precipitated or spontaneous1. Chronic urinary retention describes the persistent inability to completely empty the bladder, and is usually painless and imperceptible to the patient3.
Author Reply Patients remain misinformed or underinformed about the indications and risks associated with testosterone replacement therapy (TRT), despite the Food and Drug Administration's Drug Safety Communications regarding testosterone products.1 Most patients are unaware of the association between low serum testosterone, medical comorbidities, such as obesity, diabetes mellitus, and obstructive sleep apnea, and generally unhealthy lifestyles, characterized by stress, lack of physical exercise, poor sleep hygiene, and poor dietary intake.
Editorial Comment The issue of patient knowledge and or perceptions about a medical condition and treatment is always intriguing. The disconnect between what the medical community knows and where patients get their information; what education level they actually understand their body, and how much they hear and retain this information is the essence of awareness, communication, and compliance with care in medicine. The gap between patient knowledge and best medical information is often vast and requires providers many times to backtrack on what patients know or think they know as the truth based on the best evidence.
Author Reply We agree that there is still a certain controversy about the risks and the efficacy of pregnancy in patients with a history of urinary diversion. However, our study proved that it is safe and showed a good mothers' and children's outcome with a minimum of risks under strict multidisciplinary monitoring. In our study, the main underlying conditions and types of urinary diversion were represented. Nevertheless, we totally agree with the stated objection that the question remains whether these observations and recommendations can be transferred to women in childbearing age with a neobladder.
Editorial Comment Controversy remains about the wisdom and efficacy of pregnancy in women of childbearing age who have a history of urinary diversion. This retrospective study evaluated 37 pregnancies in women with continent diversion, generally for exstrophy or neurogenic bladder.
Re: Cognitive Effects of Androgen Deprivation Therapy in Men with Advanced Prostat Cancer We appreciate the authors' interest on our manuscript and state our opinions about the editorial comment. Statistics is a highly interdisciplinary field concerned with developing and studying methods for collecting, analyzing, interpreting and presenting empirical data. Many statistical methods can be used when designing any work.In general, commonly accepted methods preferred more often to evaluate the results. Our prospective,comparative study was done to evaluate the cognitive effects of hormone therapy.
Cognitive Effects of Androgen Deprivation Therapy in Men with Advanced Prostate Cancer: Methodological Issues We read the article authored by Gunlusoy et al., that was published in the Journal of Urology in 2017, with great interest.1 A case-control study was conducted to examine prostate cancer effects of androgen deprivation therapy (ADT) through a systematic set of methods to determine specific cognitive functions in patients with prostate cancer. The case group included 78 prostate cancer patients who received ADT treatment for 12 months. Also, 78 patients who underwent radical prostatectomy without any additional treatment were included as controls.
Editorial Comment An excellent work by Mayer et al demonstrates the continuing urology gender gap within academic medical centers; men have higher mean h-indices and academic ranks than their female colleagues. Notably, there was no difference in total number publications over career length (m-quotient). Unfortunately, this slower ramp up to equivalent productivity means that women will continue to leave academic positions at higher rates than men,1 that our specialty will continue to lag in women in academic leadership positions.
Reply We appreciate the recognition and support of establishing a cure paradigm for men who present with low-volume metastatic disease that is beyond the limits of curability with any single treatment. Our pilot study shows that an aggressive multi-modal treatment strategy applied with curative intent is both feasible and safe, and that each modality—systemic therapy, surgery, and radiation therapy—plays a key role in eliminating the disease.
Editorial Comment The treatment of oligometastatic prostate cancer is in rapid evolution. In the report by O'Shaughnessy et al, oligometastatic patients were treated with androgen deprivation therapy (ADT) monotherapy, or a combined modality approach involving ADT + surgery for the primary tumor and lymph nodes, or ADT + surgery + hypofractionated stereotactic body radiation (SBRT) to metastases.1 Based on the results of surgery, in some cases conventional fractionation was given to the prostate bed +/− pelvic/para-aortic nodes.
Reply We appreciate the authors' informative comments on our manuscript. We agree with the comment about reliability of results and the requirement of more objective evaluation. Androgen deprivation therapy (ADT) has survival benefits. Mounting evidence has demonstrated extensive adverse effects including metabolic, cardiovascular, bone, and cognitive.1 Among these side effects, interpretation of cognitive dysfunctions is the most difficult because of the most complex findings. Cognitive functions are seriously affected by decreasing testosterone levels naturally with age.
Editorial Comment In the accompanying article the authors present their prospective findings of the cognitive effects of androgen deprivation therapy (ADT) on a cohort of patients receiving therapy for locally advanced or metastatic (non–central nervous system) disease. Their primary finding is that after 12 months of therapy, there is a statistically significant reduction in language ability, short-term memory (as measured by Montreal Cognitive Assessment test), as well as in mental flexibility and inhibition (as measured by frontal assessment battery test) compared with a cohort of age- and comorbidity-matched men with localized prostate cancer treated by radical prostatectomy.
Spontaneous Shrinkage of Testicular Teratoma in a Prepubertal Child Limited numbers of pediatric intratesticular cystic lesions have been reported. Although the majority of pediatric intratesticular cystic masses are benign, natural history of testicular cystic lesion in children has been rarely reported so far. We report a case of intratesticular cystic lesion in a prepubertal child who underwent testis sparing surgery after shrinkage during conservative follow-up. As an initial strategy for intratesticular cystic lesions in prepubertal children, observational approach with serial ultrasonographic evaluations may be a management of choice.
Author Reply Patients with suspected ureteropelvic junction obstruction (UPJO) and equivocal 99mTc-mercaptoacetyltriglycine (MAG3) diuretic renographic study constitute a diagnostic challenge. The tracer uptake and excretion curve during a nuclear renal scan are functions of complex interactions between renal function, collecting system volume, and outflow obstruction. This creates challenges in translating curve morphology into an easily reported yes or no answer concerning the presence or absence of obstruction.
Editorial Comment Without prompt diagnosis and treatment, ureteropelvic junction obstruction (UPJO) can lead to impaired renal function.1,2 Diagnosis of UPJO is chiefly made on the basis of 99mTc-mercaptoacetyltriglycine (MAG3) diuretic renography revealing a functional obstruction. A clinical dilemma exists in patients with signs and symptoms suggestive of UPJO, but who otherwise lack evidence of obstruction on nuclear imaging. In this study, von Rundstedt and colleagues3 aimed to increase the sensitivity of diuretic renography for diagnosing UPJO by evaluating P40, the percentage of maximal tracer counts present at 40 minutes, with an abnormal P40 identifying anatomical obstruction.
Surgical Technique for Robot-assisted Sacrocolpopexy Performed via a Single Port Sacrocolpopexy is considered the gold standard for the treatment of pelvic organ prolapse (POP). This procedure was the first technique used to treat POP with robotic assistance and has gone a long way since the open procedure was introduced. Originally, 5 trocars were inserted and there remained issues in terms of scarring, morcellation, and possibly an increased risk of infection. The objective of this video was to demonstrate a surgical technique and a few tips and tricks for a robot-assisted sacrocolpopexy performed via a single port in the umbilicus.
Pathological Findings in Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion-guided Biopsy: Relation to Prostate Cancer Focal Therapy The introduction of widespread prostate-specific antigen screening brought about an increase in the detection of clinically low-risk prostate cancer. Many of these patients are overtreated by radical prostatectomy and radiation. Comparatively, focal therapy for prostate cancer offers the advantage of decreased rates of incontinence and impotence. The 12-core extended sextant transrectal ultrasound-guided needle biopsy is unable to safely identify candidates for focal therapy. Multiparametric magnetic resonance imaging (MRI) and MRI/ultrasound fusion-guided biopsy can detect more clinically significant prostate cancers and aid in accurate detection of higher-grade disease.
Reply From Authors We are pleased that our recent publication was the source of discussion at your journal club.1 For the question of tumor sizes listed in table 1, the values listed are medians and interquartile ranges. In other words, “the upper range” listed is actually the 75th percentile value. In fact, the absolute upper limit was 14.5 cm for the partial nephrectomy group and 16 cm for the radical nephrectomy group. For the issue of the survival curves in figure 2, the stages indicated are clinical stage. Some clinical T2 tumors were upstaged to pT3 disease at final pathology, accounting for the higher number at risk in figure 2.
Reply Let me begin by thanking the author for the thoughtful points laid out in the editorial comment. We are in agreement that computerized tomography (CT) is not the only modality available for imaging stones in the urinary tract, and a comparison of CT to other imaging modalities is beyond the intended scope of the current study. However, the superiority of CT imaging specifically for definitive diagnosis of ureteral stones and determination of stone size cannot be disputed. Kanno et al1 evaluated the efficacy of ultrasound (US) for the detection of renal stones and found that CT had a sensitivity of 100%, whereas US was only 70%.
Editorial Comment The authors present a retrospective review of computerized tomography (CT) scans in 150 patients with ureteral stones to demonstrate the clinical relevance of coronal measurements of stone size for predicting stone passage. This work highlights 2 important and clinically relevant aspects of urinary stone disease management: accurate stone size measurement and medical expulsion. What makes these 2 topics particularly confusing is the heterogeneous nature of the literature surrounding each. Diagnostic imaging for kidney stones is a shifting landscape.
Vaginectomy and Buccal Mucosa Vaginoplasty as Local Therapy for Pediatric Vaginal Rhabdomyosarcoma We report a case of vaginal rhabdomyosarcoma where vaginectomy with buccal mucosa vaginoplasty was performed to avoid radiation therapy to the young pelvis.The patient presented at 30 months with an exophytic vaginal mass, found to be botryoid rhabdomyosarcoma. After receiving neoadjuvant vincristine, actynomycin D, and cyclophosphamide chemotherapy with good response, she underwent surgery. It was performed using an anterior sagittal approach on the prone position, which allowed for a safe circumferential dissection of the vagina all the way to the cervix and en bloc resection.
Ureteric Obstruction From Malignant Melanoma in Both Right Double Moiety and Left Single Moiety Ureters We report the first documented case of malignant melanoma obstructing ureters of both moieties of a duplex kidney and contralateral single moiety ureter in a 51-year-old male. The patient presented with fever, coryzal symptoms, and liver function test derangement several years after 2 superficial spreading melanomas were excised with clear margins. Ultrasonography demonstrated hydronephroureter in both moieties of a complete right-sided duplex kidney. Retrograde pyelograms showed bilateral hydronephroureter and filling defects in all 3 ureters.
“Renal Calculi as Big as Eggs”: Urolithiasis and Chronic Kidney Disease of Ludovico I, Marquis of Saluzzo (1406-1475) The Marquisate of Saluzzo in Piedmont (northwest of Italy, close to the French border) was an important and independent territory from 1125 until 1548 when, after the deposition of the last Marquis Gabriel, it was annexed to the crown of Paris and then to the Duchy of Savoy. Saluzzo reached its period of greatest splendor in the 15th century under Marquis Ludovico I Del Vasto (1406-1475) (Fig. 1), who, with a neutral policy toward Italian belligerence, was able to act as mediator in the discord between the emperor and the king of France.
Encountering “Dropped” Gallstones During Robotic-assisted Laparoscopic Radical Prostatectomy We describe a case of an unusual finding during robotic-assisted laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy in a 66-year-old man with stage IIb (T2c, N0, M0) prostate adenocarcinoma. During the operation, intraperitoneal examination of the rectovesical pouch revealed calcifications and stones, which were subsequently identified as gallstones. Although these stones were not noted initially on this patient's preoperative multiparametric magnetic resonance imaging, a retrospective review demonstrated hypointense foci in the rectovesical pouch.
Delayed Radiographic Manifestation of Renal Pseudoaneurysms After Blunt Trauma Pseudoaneurysms may cause recurrent hematuria after blunt renal trauma. We report on an 18-year-old patient with radiographic manifestation of pseudoaneurysm 41 days after blunt renal trauma. Initial and follow-up imaging for recurrent hematuria, including angiography, was without signs of pseudoaneurysm or active bleeding. This case illustrates that recurrent gross hematuria as a typical symptom of pseudoaneurysm may be present initially in the absence of radiographic signs. Repeat angiography should be taken into consideration if recurrent bleeding persists.
Long-term Survival After Resection of Sentinel Node Metastatic Renal Cell Carcinoma We present a case of a patient who took part in a prospective sentinel lymph node (SN) study to investigate the drainage pattern from renal tumors. The patient was treated with laparoscopic radical nephrectomy, for a clinically node negative left renal tumor of 6 cm combined with SN and non-SN lymph node dissection. Histopathologic examination revealed a papillary type 2 pT1b renal cell carcinoma with 2 para-aortic metastatic SNs. No adjuvant treatment was applied. The patient is free of disease at 63 months after surgery.
Pyogenic Granuloma: Possible Cause for Macroscopic Hematuria in Children Pyogenic granuloma (PG) is a benign, vascular tumor that is rarely reported in the urinary tract of pediatric population. Herein we present a case of a child followed up for recurrent painless macroscopic hematuria.We performed ureteroscopy, and a whitish lesion was discovered in the upper calyx of the right kidney. The lesion resected endoscopically, and microscopic examination of the lesion was consistent with PG.It is important for pediatricians and urologists to properly recognize PG as a possible source of hematuria in the pediatric population.
Robot-Assisted Laparoscopic Resection of Renal Vein Leiomyosarcoma Leiomyosarcoma is a rare and aggressive retroperitoneal tumor arising from the smooth muscle of the tunica media. The IVC accounts for > 70% of all leiomyosarcomas, with the renal vein being limited to few case reports 1 2 3 4 5. Accurate pre-operative diagnosis is rare as the origin is unclear and its involvement of the vessels makes biopsy prohibitively dangerous 6. Treatment involves radical nephrectomy followed by adjuvant radiation and/or chemotherapy, with poor prognosis 7 8. Herein, we describe the laproscopic dissection of a retroperitoneal renal vein tumor using a robotic approach.
Editorial Comment for #URL-D-16-02066R1 A biofilm is a structured community of bacterial cells enclosed in a self-produced polymeric matrix, which can adhere to an inert (or living) surface.1 Implantable prostheses such as the artificial urinary sphincter (AUS) are at increased risk for bacterial biofilm colonization as they do not have the protective mechanisms that characterize healthy tissue. Once established, a biofilm is often impossible to eradicate with oral or intravenous antibiotics, due to the protective matrix. Thus, the attraction of antibiotic-coated implantable prostheses—to prevent biofilm formation, and thereby resist device infection.
Cystoscopic Evaluation of Bladder Leiomyoma We report the case of a 40-year-old woman with a history of uterine polyps and 3 months worth of gross hematuria who was found to have a bladder mass on cystoscopy. While this mass appeared benign visually, it demonstrated enhancement on axial imaging with increased internal vascularity on Doppler ultrasound. A transurethral resection demonstrated bladder leiomyoma. This case increases the urologist's recognition of a well-described but previously under-represented condition by showcasing its visual appearance on cystoscopy.
Right-sided InterStim Placement in a Patient With Left Sacral Hypoplasia Sacral hypoplasia is a rare anomaly and the least severe pattern of caudal regression syndrome as described by the Renshaw classification system. These patients may suffer from bladder or bowel dysfunction. Here, we present a successful case of right InterStim placement for the treatment of refractory urinary urgency, frequency, and urinary incontinence in a patient with left sacral hypoplasia.
Aggressive Angiomyxoma of the Penis: The First Case Report in a 9-Month-Old Infant Aggressive angiomyxoma (AA) is a rare, benign, mesenchymal tumor of the pelvis and perineum. It usually occurs in females at reproductive age. However, rare cases have been reported in male children. We present the first case of AA in the penis of a 9-month-old Somalian boy. The infant presented with large, nodular penile mass. The diagnosis was confirmed following complete surgical removal and histopathologic examination. Over a 6-month follow-up period, no recurrence was noticed. Therefore, we recommend complete surgical removal of the mass with wide safety margin and long-term follow-up for cases of AA.
Repair of Urethrovaginal Fistula Secondary to Pelvic Fracture With a Labia Minora Skin Flap in Young Girls The study aims to evaluate the efficacy of transpubic access using a pedicle flap from the labia minora for urethral reconstruction in young girls with urethrovaginal fistula secondary to pelvic fracture. Between January 2011 and January 2016, 4 cases of traumatic urethrovaginal fistula in young girls were treated using a pedicle flap from the labia minora. The mean follow-up was 27 months. All patients voided well and achieved normal urinary control. One patient had recurrent urethrovaginal fistula.
Urothelial Carcinoma of the Ureter and Urinary Bladder With Rectal Linitis Plastica A 62-year-old woman presented with abdominal pain, anorexia, persistent diarrhea, and a 3-month history of dyspepsia. She had no significant medical or surgical history. Laboratory examination revealed high serum levels of carbohydrate antigen 125 (CA 125; 48.5 U/mL) and CA 19-9 (113.4 U/mL). Colonoscopy revealed edematous and irregular mucosal thickening of the rectum, suggestive of rectal cancer. However, the pathology report from the colonoscopic biopsy revealed only chronic inflammation. Abdominal computed tomography (CT) showed circumferential rectal wall thickening with relatively preserved mural stratification, resulting in significant bowel obstruction (Fig. 1A).
Recurrent Urinary Tract Infections in a Female Child With Polydactyly and a Pelvic Mass: Consider the McKusick-Kaufman Syndrome A 3-year-old female child presented with a history of recurrent urinary tract infections. On general examination, polydactyly and a pelvic mass were present. An imperforate hymen was also documented on vaginal inspection. Further inquiry, revealed a positive history of parental consanguinity. A magnetic resonance imaging study defined a hydrometrocolpos responsible for an obstructive cause of the recurrent urinary tract infections. In view of the above, a diagnosis of McKusick-Kaufman syndrome was made.
The Present and Future Challenges Facing Urology Departments at Academic Health Centers Academic health centers (ACHs) represent the pinnacle of health care by providing innovative clinical care, cutting-edge research, and premier education. However, recent changes in health care put their tripartite mission at risk. The coming years will bring immense change to AHCs as they adjust to new market conditions impacting the 3 distinct elements of their mission. Fundamental adaptations are required for AHCs to survive, let alone thrive and continue to represent the best of medical research, education, and health.
In Memoriam—Pablo A. Morales (1918-2016) It is with great sadness that we learned of the death of our founding editor, Dr. Pablo A. Morales, on August 12, 2016 at the age of 97. Dr. Morales was an innovator, starting a second journal in our specialty at a time when the only source of peer-reviewed literature was the Journal of Urology. He worked tirelessly to make it a success, and those of us who have inherited his mantle as well as all our readers honor his memory with a great debt of gratitude.
Treatment of Posttransplant Lymphocele in Children To review our single-center experience in managing posttransplant lymphoceles in pediatric kidney recipients. Lymphoceles are well-known complications after pediatric kidney transplantation (KT). However, there is no standard treatment for lymphoceles, and the literature lacks consensus on which is the most appropriate approach.
Xanthogranulomatous Pyelonephritis Manifesting as a Nephrocutaneous Fistula in a 5-Year-Old Female A 5-year-old girl presented to an outside emergency department (ED) with a lump on her left flank. By report, the lump was noted 3 weeks prior and had been increasing in size. The lump was 3 cm in diameter, flesh colored, hard, and mildly tender to palpation (Fig. 1). The diagnosis was a hematoma, and conservative management with ice and observation was recommended. Two weeks later, the patient presented to the same ED complaining of increasing erythema and pain in the area. Abdominal ultrasound (US) findings were consistent with superficial abscess.
Reply We appreciate the thoughtful comments and would like to further discuss a few of the key points mentioned.
Editorial Comment The authors conducted a retrospective analysis of radical cystectomy patients (cT2N0M0) who received neoadjuvant chemotherapy (NAC), and with an external validation cohort were able to show statistically improved outcomes for patients they termed NAC stable disease compared with NAC progressors.1 The work was carefully done, analyzed, and interpreted. The investigators pointed out in their discussion the need to identify predictive biomarkers to spare non-responding patients the toxicity and delay in definitive treatment.
Clear Cell Papillary Renal Cell Carcinoma: New Clinical and Imaging Characteristics To investigate clear cell papillary (CCP) renal cell carcinoma (RCC), an uncommon tumor of low malignant potential characterized by low-grade, clear cells, showing papillary and tubular architecture. This relatively newly described entity is still being characterized. We present our series of CCP RCC with new clinical and imaging findings.
Adenocarcinoma in Continent Anal Urinary Diversion: Is a Sigma Rectum Pouch a Surgical Option After Failed Ureterosigmoidostomy? To report our experience of radical resection of secondary cancers after ureterosigmoidostomy. Ureterosigmoidostomy was the most common continent urinary diversion before the era of continent cutaneous diversion and neobladders, specifically in children. When performed for bladder exstrophy, patients will live with this kind of diversion for quite a long time. As a result, urologists will be confronted with patients presenting with an adenocarcinoma in their ureterosigmoidostomy. In most cases reported in the literature, an ileal conduit was used for urinary conversion.
Reply The immunomodulatory effect of blood transfusion (BT) has recently garnered significant attention in regard to oncological and perioperative outcomes for bladder cancer patients. Our results were unique in failing to show BT as a significant, prognosticator of worse recurrence, cancer, and overall survival.
Editorial Comment The impact of perioperative blood transfusion (BT) and specifically intraoperative BT on survival outcomes in radical cystectomy (RC) patients has been established in retrospective series.1,2 Whether several theories have been proposed to explain this association, one of the most intriguing is represented by the direct immunosuppressive effect exerted by BT. Specifically, it has been postulated that BT might modulate the immune system due to the presentation of large amounts of antigen.3 Therefore, it is certainly of interest to evaluate if leukocyte-depleted BT impact on survival outcomes in RC patients.
Pelvic Hardware Eroding Into the Bladder: A Rare Case Presentation of Gross Hematuria, Bladder Pain, and Refractory Lower Urinary Tract Symptoms We present a 60-year-old man who presented with gross hematuria, refractory lower urinary tract symptoms, and increasing bladder pain for a duration of 3 months. The patient had a history of a motorcycle accident and pelvic fracture requiring an extensive pelvic open reduction and internal fixation. During evaluation, the patient was found to have an orthopedic screw from his hardware eroding through the left lateral wall of his bladder and irritating his trigone. The patient underwent pelvic exploration with open cystotomy and hardware removal with the orthopedic service.
Adjuvant Sunitinib in High-Risk Renal-Cell Carcinoma after Nephrectomy The main aim of this multi-centre, double-blind phase III trial was to determine the efficacy and safety of 12 months of adjuvant sunitinib treatment versus placebo in patients with loco-regional clear cell renal cell carcinoma (ccRCC) with high risk of disease recurrence after curative nephrectomy.
Injury in Pelvic Fracture Urethral Injury Is Membranobulbar: Fact or Myth Pelvic fracture urethral injuries commonly result from motor vehicle collisions, and the mechanism of injury conventionally thought was a shearing injury at the membranous urethra, which would destroy the striated sphincter. Continence would therefore depend on the bladder neck. Striated sphincter and the site of injury have not been shown clearly on preoperative imaging. We demonstrate our protocol of performing magnetic resonance imaging whereby the membranous sphincter is seen intact and the injury is shown to be at the membranobulbar junction contrary to conventional belief.
Reply The evaluation of asymptomatic microscopic hematuria (AMH) represents a classic struggle to appropriately weigh competing risks and benefits in the face of great uncertainty. This struggle is particularly pronounced when balancing the potential risk of overlooking upper tract urothelial carcinoma (UTUC), a rare, yet potentially lethal finding, with the known harms of unnecessary imaging. Given the results of our study, the indiscriminate use of computed tomography urography (CTU) as the preferred imaging technique for AMH reflects our bias as urologists toward minimizing the former, despite accumulating evidence that greater attention to the latter may be warranted, particularly in regard to direct patient and health system costs, downstream consequences of incidental findings, and radiation exposure with associated risk of carcinogenesis.
Editorial Comment In the absence of clearly identifiable benign causes (ie, urinary tract infection), the American Urologic Association recommends evaluation of microscopic hematuria with cystoscopy in conjunction with upper urinary tract radiological imaging (particularly computed tomography [CT] urography).1 Gross or macroscopic hematuria warrants a similar investigation, particularly owing to a greater likelihood of identifying underlying benign or malignant abnormalities.2 Indeed, CT urography has the highest diagnostic yield in accurate diagnosis of upper tract urothelial carcinoma (UTUC) lesions albeit with inherent cost and radiation exposure.
Author Reply We appreciate Almassi and Goldman's thoughtful commentary and agree with the points that were raised. As noted in the editorial comment, an important question is whether current Enhanced Recovery After Surgery care pathways may facilitate earlier discharge without an increased risk in post-discharge complications and readmissions. Supporting this possibility, a recent prospective study of patients undergoing cystectomy on an Enhanced Recovery After Surgery protocol reported a reduced length of stay and 90-day complication and readmission rates in line with historical data.
Editorial Comment Radical cystectomy is a complex procedure with 90-day complication rates exceeding 60%1 and mortality rates of up to 5%2 in large published series. The median postoperative length of stay exceeds 1 week3 and relates largely to awaiting for return of bowel function and managing perioperative complications, the majority of which occur during the index postoperative hospitalization.1 With an increasing emphasis on optimizing quality of health care while containing cost, significant effort has been invested in standardizing postoperative care paths to optimize outcomes and reduce postoperative length of stay.
Urolithiasis in Children: Metabolic Workup is Essential in All We read the recent paper by Bevill et al1 on pediatric urolithiasis with great interest. Evaluation in children with urolithiasis is considered mandatory,2 as this may reveal modifiable risk factors that can guide preventive therapy. With such prevention, stone recurrence and urolithiasis-associated renal damage may be minimalized.
Our Metabolic Findings in First-time Pediatric Stone Formers Questions the Need for a Full Metabolic Evaluation in Every Child In response, we agree, and the literature would suggest, that there are several different ways to define hypercalciuria.1 We chose to use 250 mg/d, which is the standard value used in adults, as most of our study cohort was older. However, if we were to use >4 mg/kg/d to define hypercalciuria in our study population, we believe that it is better to use actual data, rather than to make assumptions. Within our cohort, we found an average urine calcium level of 1.7 mg/kg/d (0.1-6.2 mg/kg/d), and only 3 (3%) of our patients were found to have hypercalciuria (defined as >4 mg/kg/d).
Villous Adenoma in Renal Pelvis With Manifestation of Percutaneous Fistula and Mucus Secretion A 70-year-old man, complaining of percutaneous fistula with jelly-like yellow mucus in the right kidney for a month, was admitted to our department. From computed tomography, stones and severe hydronephrosis but no suspicious mass was found in right kidney. Nephrectomy of right kidney was performed and pathological examination revealed a villous adenoma in the renal pelvis with moderate to severe atypical hyperplasia of glandular epithelium. Primary villous adenoma in renal pelvis is rare and believed to be related to chronic irritation of stone and inflammation.
Large Prostatic Utricle With Transitional Cell Carcinoma in an Adult A 21-year-old man with pain in the lower abdomen and hematuria of 10 days' duration was evaluated and found to have a large cystic lesion behind the urinary bladder, which was confirmed to be a large prostatic utricle with a solid component on contrast-enhanced computed tomography, magnetic resonance imaging, and transrectal ultrasonography. Postoperative histopathology revealed transitional cell carcinoma.
Author Reply Dorsal onlay reconstruction is the preferred technique and has been performed successfully for more than 20 years.1 Moreover, because of inadequate tissue, support of ventral onlay urethroplasty for penile urethral strictures has lower treatment success and more complication rates when compared to dorsal onlay technique.2,3
Editorial Comment There are several techniques for penile urethral reconstruction, from tubularized incised plate repair for hypospadias, dorsal onlay of buccal mucosa graft, and the Asopa inlay of buccal mucosa graft through a ventral approach.1-3 Ventral placement of buccal mucosa has been described but is relatively less common.4 Ventral placement of grafts in the penile urethra is less common because there is less corpora spongiosum on the penile urethra than in the bulbar urethra.
Bilateral Wilms Tumor With Ureteral Extension Wilms tumor is the most common renal tumor in children. However, tumor extension into the ureter is exceedingly rare. We present a case of bilateral Wilms tumor with unilateral ureteral extension into the bladder. This case illustrates the importance of thoughtful diagnostic evaluation and surgical planning to obtain a good oncologic outcome while preserving renal function.
Re: Changes in Weight and Metabolic Syndrome Are Associated With Prostate Growth Rate Over a 5-Year Period: Methodological Issues We were interested to read the paper authored by Kyung and colleagues published in the Journal of Urology in 2016.1 The authors aimed to evaluate the relationship between changes in weight, waist circumference, metabolic syndrome (MetS), and prostate growth over 5 years in adult population. They concluded that changes in weight, waist circumference, and newly diagnosed MetS affected prostate growth rate during 5 years. Although the valuable study has been done and its findings were very interesting, some methodological issues should be considered.
Reply We appreciate the kind remarks of the above author. Although many studies have demonstrated that prostate magnetic resonance imaging (MRI) is an independent predictor of high-grade prostate cancer (Gleason 7+), and others have found MRI to be superior to clinical risk prediction tools (ie, Prostate Cancer Prevention Trial risk calculator), the added value of MRI over clinical risk determinants had not been objectively measured. Despite the limitations of our study as a result of utilizing clinical outcomes data, rather than data from a prospective trial, we were able to determine the true incremental value of MRI, as it serves as an addition to—not in lieu of—available clinical information.
Editorial Comment We are in an era of change in our approach to the detection and diagnosis of aggressive, potentially lethal, clinically significantprostate cancer. Advances in imaging with multiparametric magnetic resonance imaging (mpMRI), and its acquisition and interpretation using Prostate Imaging Reporting and Data System (PI-RADSv2),2 have led to many exciting new applications of mpMRI in the detection and diagnosis of prostate cancer. PI-RADSv2 was introduced in 2015 and provides standard MR acquisition techniques and uniform definitions of suspicious lesions (PI-RADS 4 or 5).
Editorial Comment Active surveillance (AS) has become a pivotal management strategy for patients with cT1 renal mass. Yet even with the oncological safety of AS documented,1-3 critical decision-making in clinical practice and counseling of patients can be challenging, given issues with illness uncertainty and reluctance to forgo treatment for a diagnosis such as “cancer.”4 Thus, appropriate patient education regarding risk balances that surround management strategies for renal mass is critical to high-quality patient care.
Reply We applaud the authors for their fine commentary and for highlighting our contention that validation of all new technology requires data from both centers of excellence and from early clinical adopters before widespread dissemination.
Editorial Comment The accompanying article shows that the new method of prostate biopsy is gaining traction. Most studies evaluating prostate magnetic resonance imaging (MRI) have been performed at a handful of academic institutions, where 1 or 2 experienced radiologists supervise and interpret the imaging, and biopsy is MRI guided.1-4 The academic institutions have developed specialized resources in urology, radiology, and pathology to make the new approach possible. Thus, most information currently in the medical literature may be difficult to apply in settings where such resources are not available.
Author Reply In reply to the submitted commentary, we would like to clarify a few points that we believe are important to the discussion regarding pelvic disease in germ cell tumors.
Editorial Comment In this issue of Urology, Jacob et al present their experience at Indiana University with pelvic lymph node dissection (PLND) for germ cell tumor (GCT). The authors provide several insights with important clinical implications.
Editorial Comment Bladder cancer is the fifth most common cancer diagnosed in the United States and can display a diverse array of histologic variants. Plasmacytoid urothelial carcinoma (PUC) is a rare histologic variant that is characterized by malignant cells growing in an infiltrating discohesive pattern with minimal stromal reaction. Clinically, PUC is associated with upstaging at cystectomy, high rates of surgical margin positivity and lymph node involvement, predilection for peritoneal recurrence, and poor outcomes when compared with urothelial carcinoma, not otherwise specified (UC, NOS).
Editorial Comment The history of urethral catheterization dates back to 3000 years.1 During the last century, several advances have been made both in design and the catheter material to mitigate the patient discomfort and reduce potential complications related to catheterization. Despite these advances and the usage of anesthetic lubricants, introduction of the catheter tip through the bulbourethral junction into the prostate and bladder can sometimes be painful and can lead to false passages in the vicinity of the bulbous urethra.
The Role of the Urologist in the Era of In Vitro Fertilization-Intracytoplasmic Sperm Injection The use of in vitro fertilization and intracytoplasmic sperm injection has dramatically increased. In spite of this, the male partner in the couple is often not evaluated for fertility status or other general health conditions associated with male infertility. Such an approach goes against established guidelines recommending dual partner evaluations and does not address longer term male health risks. In this review, we discuss the urologist's role in the era of in vitro fertilization-intracytoplasmic sperm injection, which includes diagnosing serious conditions associated with infertility, treating reversible causes of infertility, defining untreatable causes of testis failure, and, when appropriate, facilitating sperm retrieval.
A 72-Year-Old Man With Obstructive Voiding Symptoms, Elevated Prostate-specific Antigen Level, and Nodular Digital Rectal Examination A 72-year-old Caucasian man presented to a multidisciplinary genitourinary cancer clinic for evaluation of lower urinary tract obstructive voiding symptoms. He had elected to stop taking tamsulosin due to associated side effects. The patient reported a prior transrectal ultrasound (TRUS)-guided prostate needle biopsy 10 years ago due to an elevated prostate-specific antigen (PSA) level. The previous biopsy was reported to be benign. Additional pertinent medical history is significant for hypertension and congenital hip dysplasia.
Reoperation for Urinary Incontinence: A Nationwide Cohort Study, 1998-2007 The authors of this study examined the incidence of reoperation within a 5-year period after 6 varying procedures for urinary incontinence (UI). These procedures were retropubic midurethral tape, transobturator tape, urethral injection therapy, Burch colposuspension, pubovaginal slings, and miscellaneous operations. The subjects comprised 8671 women from the Danish National Patient Registry, each of whom had undergone surgical treatment for UI from 1998 to 2007 and had not had a UI-related surgery in the 2 years preceding enrollment in the study.
Reply The aim of the present study is to compare the outcomes of intracytoplasmic sperm injection (ICSI) using sperm retrieval (testicular sperm aspiration [TESA] or testis dissection sperm extraction [TESE]) with those using ejaculated sperm in patients with cryptozoospermia. Seventeen couples who had no mature eggs or sperm were not included in statistical analysis, and as a result intention-to-treat analysis was not performed.
Editorial Comment The authors have presented provocative data on a series of 302 patients with cryptozoospermia who were managed with intracytoplasmic sperm injection (ICSI) using either sperm retrieval (testicular sperm aspiration [TESA] or testis dissection sperm extraction [TESE]) or from ejaculated sperm.1 The overall results are presented with a strong suggestion that men who used testicular sperm had far better results than couples where ejaculated sperm were used for ICSI. Unfortunately, this study has substantial bias in its presentation of data as it is an experiential, retrospective analysis of treatment of couples rather than an effective, direct comparison of use of testicular versus ejaculated sperm.
Editorial Comment The authors indeed describe an elegant system for essentially automatically updating their web-based statistical prediction models. Most other authors, when they update models, simply do this periodically, as we have done1,2 with the original preoperative nomogram.3 The net result seems practically the same, because, as the authors point out, the rapid updates can have negligible effects themselves and must be accumulated before a noteworthy difference occurs. The periodically published updates, which are more typical, would seem to be easier for others to externally validate as opposed to a constantly moving target.
Editorial Comment The authors present a small series of 5 patients with mesh erosions into the bladder following midurethral sling surgery.1 As this is a common procedure performed by the urologic surgeon, one should be familiar with the complications that may arise from this minimally invasive technique. Vaginal erosions are more commonly seen and are typically diagnosed rather early in the postoperative period. However, intravesical exposure of the mesh tape is far less common and not as easily diagnosed. One must have a high index of suspicion, despite a negative cystoscopic examination at the time of sling placement, as a tape may erode into the bladder well beyond the normal postoperative period.
Percutaneous Renal Surgery by David R. Webb is a thoughtful and well-written practical handbook. It is well established that percutaneous nephrolithotomy (PCNL) is the gold-standard procedure for large or complex renal stones, and is the most technically challenging stone-related surgery, with the attendant risk of serious complications. As urologists are most often trained in open or minimally invasive surgical techniques, percutaneous surgery can often evoke anxiety owing to a lack of familiarity and comfort, especially given that most of the critical steps must be performed under image guidance.
Prostate Biopsy-related Infection: A Systematic Review of Risk Factors, Prevention Strategies, and Management Approaches A systematic review to identify risk factors for prostate biopsy-related infection, preventative strategies, and optimal management of infectious complications was conducted. Significant risk factors for postbiopsy infection include urogenital infection, antibiotic use, international travel, hospital exposure, bacteriuria, previous transrectal biopsy, and resistance of fecal flora to antibiotic prophylaxis (especially fluoroquinolones). Patients at risk may benefit from an adjusted biopsy protocol comprising transrectal biopsy under targeted prophylaxis, and/or the use of rectal disinfection techniques or using a transperineal approach.
Castleman's Disease Presenting in the Pelvis Castleman's disease (CD) is a rare benign lymphoid disorder with unknown etiology. There are 2 major forms of this disease, unicentric (ie, localized CD) and multicentric, which play a major role in determining therapy. The mediastinum is the most common localization for the localized CD, whereas its occurrence in the pelvis is even rarer. We report the case of a 22-year-old woman who had a pelvic mass located in the region of the left iliac fossa. The patient subsequently underwent a robotic-assisted laparoscopic tumorectomy.
Changes in Weight and Metabolic Syndrome Are Associated with Prostate Growth Rate Over a 5-Year Period: Reply We appreciate your comments and understand your question. The variables were statistically evaluated based on the assumption of normality (Fig. 1). There were no interactions between most variables in the multivariable regression model. However, weight, body mass index, and waist circumference were found to have multicollinearity. Thus, we selected the weighted variables and removed body mass index and waist circumference because we focused on the correlation between weight status and prostate volume.
Implementation of Dynamically Updated Prediction Models at the Point of Care at a Major Cancer Center: Making Nomograms More Like Netflix Prediction models have been widely advocated to aid patient counseling and clinical decision making. There are 2 major advantages of statistical predictions in comparison to more traditional approaches such as clinical judgment or general risk categorization. First, there are good empirical data that statistical models outperform clinicians and risk groups. For example, Kattan et al asked 24 clinicians to predict the risk of a positive bone scan based on the case histories of 25 men who experienced recurrence of prostate cancer after radical prostatectomy but had not received hormone therapy.
Coenzyme Q10 Intake From Food and Semen Parameters in a Subfertile Population To assess the association between coenzyme Q10 (CoQ10) intake from food sources and semen quality. We assessed this association in a prospective cohort of men attending a fertility clinic. CoQ10 supplementation has been associated with improvements in semen parameters. However, the impact of CoQ10 intake from food sources on semen quality has not been investigated.
Feasibility of Long-term Tibial Nerve Stimulation Using a Multi-contact and Wirelessly Powered Neurostimulation System Implanted in Rats Implant-driven tibial nerve stimulation therapy is an effective technique for treating overactive bladder. However, the monopolar lead design in the currently available implantable devices pose long-term therapeutic challenges in terms of efficiently and selectively delivering electrical pulses to the target. Hence, the purpose of this study was to (1) characterize the tibial nerve (TN) activation properties using a multi-contact implantable system and (2) evaluate the long-term stability of using such a neural interface in a preclinical model.
Percutaneous Nephrolithotomy for Stones in Solitary Kidney: Evidence From a Systematic Review Stones in solitary kidney represent a management dilemma for the endourologist. The advantage of bilateral fully functioning kidneys is not present. Therefore, any insult to either the solitary kidney itself or drainage system can lead to significant morbidity. Key clinical objectives include maximum preservation of existing renal function, high stone clearance, and minimizing post-procedure complications. To date, there exists no Level 1 evidence on this subject. This systematic review serves to evaluate the safety and efficacy of percutaneous nephrolithomy for patients (adults only) with stones in a solitary kidney.
A 57-Year-old Woman With Hematuria and Headaches A 57-year-old Caucasian woman presented to the emergency department as an outside hospital transfer for a 2-month history of gross hematuria and 1-day history of passing blood clots in her urine. She was given prophylactic antibiotics and had a hematuria workup while at the outside hospital, but the workup had not been initiated. She had no significant medical history, 2 previous surgeries involving a benign hysterectomy and a back surgery done in her 30s, no family history of malignancies, a 40 pack-year history of smoking, moderate alcohol use, and no other drug use.
Challenges in the Diagnosis of Urothelial Carcinoma Variants: Can Emerging Molecular Data Complement Pathology Review? Urothelial carcinoma can exhibit a wide variety of histopathologic phenotypes or variant morphologies, classifications of which have recently been revised in the 2016 World Health Organization Classification of Tumours of the Urinary System and Male Genital Organs. Many of these variants not only present diagnostic challenges, but also have clinical implications that affect patient prognosis and treatment strategies. This review will discuss these variant morphologies and their relationship to current understanding of the underlying biology of urothelial carcinoma and molecular classification paradigms.
T-Shaped Shunt with Intracavernosal Tunneling, for a Pediatric Case of Refractory Ischemic Priapism We present the first reported case of refractory pediatric priapism treated by intracavernosal tunneling T shunt. A 12 year-old male, with sickle cell disease, presented with 72 hrs of painful erection. The patient failed conservative measures including aspiration, injection of phenylephrine, as well as distal shunt procedure. A T-T shunt was performed, as previously described in the adult literature. There was immediate resolution of the erection with no complications. At 1 year follow-up, he reports no subsequent episodes of priapism and normal erections.
C. Everett Koop: Pioneer in Pediatric Surgery, U.S. Surgeon General and Early Contributor to Pediatric Urology Charles Everett Koop (1916-2013) was born in Brooklyn, New York in 1916. He received his A.B. degree from Dartmouth in 1937, where he was given the nickname “Chick” (an allusion to “chicken coop”). (1) While attending Dartmouth College he met his wife, Elizabeth Flanagan, a student at Vassar College. (1) They were married in 1938 and would go on to have 4 children together (Allen, Norman, David and Elizabeth). He earned his medical degree from Cornell University Medical College in 1941. He completed his residency at the University of Pennsylvania Hospital in 1946 working under Dr Isadore S.
WITHDRAWN: Reply The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2015.08.053. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
WITHDRAWN: Editorial Comment The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2013.02.086.The duplicate article has therefore been withdrawn.
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