Editor’s Choice
Magic bullet in management of Peyronie's Disease An exciting article in this edition describes a paradigm shift in the management of Peyronie’s disease (PD) [1]. Reconstructive surgery for PD has been mostly palliative and fraught with unsatisfactory outcomes either in terms of penile length, function or both. This article [1] describes the use of collagenase to effectively dissolve the offending plaque without the side-effects associated with surgery. The results are impressive albeit not entirely curative. The advantage of this strategy is that men can be treated irrespective of the phase of the condition. This means that men can be referred on to a specialist as soon as the diagnosis of PD is made rather than awaiting stabilisation. This will also facilitate disease modifying drugs, such as potassium para-aminobenzoate (Potaba, which has level 1 evidence supporting its use) [2] or pentoxifylline, to be used during the acute phase. These drugs do not appear to be popular among andrologic surgeons, perhaps due to their gastrointestinal side-effects. However, Potaba capsules seem better tolerated than in the sachet form. Collagenase has already been used in Dupuytren’s contracture, which has strong correlations with PD. The studies described in this article have led to its acceptance by licensing bodies in several countries. It would appear to have better results when combined with penile modelling, such as with a vacuum erectile device. The treatment is quite intensive with several
outpatient visits required. The side-effects are rare but can be serious. It would appear that corporal rupture occurs when sexual intercourse is attempted too early, which emphasises the need for clear instructions and management of expectations. It will be interesting to see if there is a limit to the amount/extent of repeat treatments, as we strive to restore length and contour fully. Many patients are eager to undergo this novel therapy. It should be introduced in a controlled and audited system.
Conflict of Interest None declared. Paul K. Hegarty Mater Private Hospitals, Dublin and Cork , Ireland
References 1 2
Jordan GH, Carson CC, Lipshultz LI. Minimally invasive treatment of Peyronie’s disease: evidence-based progress. BJU Int 2014; 114: 16–24 Weidner W, Hauck EW, Schnitker J, Peyronie’s Disease Study Group of Andrological Group of German Urologists. Potassium paraaminobenzoate (POTABA) in the treatment of Peyronie’s disease: a prospective, placebo-controlled, randomized study. Eur Urol 2005; 47: 530–5
Robot-assisted nephrouretectomy: is LESS more? In this small non-randomised prospective single-surgeon series, Lim et al. [1] compare laparoendoscopic single-site robot-assisted nephrouretectomy (LESS-RALNU) with multiport RALNU (M-RALNU) for operative technique and oncological outcomes. The authors should be congratulated on reporting in an area of urology where there is paucity of data and techniques are constantly evolving. LESS procedures were developed to make minimally invasive procedures even less invasive. We have previously reported on a multi-institutional comparative analysis of LESS and conventional laparoscopy for commonly performed urological operations [2]. In our comparative analysis, overall perioperative outcomes were similar to conventional laparoscopy, with a trend toward improved cosmesis, lower perioperative pain scores, and faster convalescence.
However, LESS is technically challenging and requires a high level of laparoscopic surgical skills and experience [3]. Introduction of robotic LESS (R-LESS) was promising to resolve some of the difficulties and challenges associated with single-port minimally invasive surgery. Although since its birth in 2009 R-LESS has evolved significantly, the large size of the robotic arms and the lack of specific instruments designed for LESS pose on-going challenges to the urologists in its widespread use [4]. LESS-RALNU carries all the inherit issues associated with a LESS procedure. In addition to that working in two different abdominal compartments and the need for suturing of the bladder cuff excision site will add to the technical challenges faced by the operating surgeon. RALNU was first reported in 2006 and since then multiple groups have published several small series on the operative © 2014 The Author BJU International © 2014 BJU International
7
Editor’s Choice
technique and perioperative outcomes of this procedure. Long-term oncological outcome for this procedure are lacking and only a few published series have provided any follow-up data in this respect. In this paper by Lim et al. [1], patients were relatively homogenous between the two non-randomised arms. However, patients in LESS-RALNU cohort were significantly older (71 vs 62 years). Both these factors plus the small size of the sample are sources of bias and make drawing any meaningful conclusion from the paper difficult. Both described techniques are relatively new and a comparison between two ‘non-gold standard’ surgical techniques may be too early at this point in their evolution. Despite this, the authors provide us with good intermediate oncological data and insight into the risks and benefits of both procedures. There was a trend toward more blood loss and need for blood transfusion in the LESS-RALNU group. These are consistent with the constraints associated with the LESS approach. The operating time is reported to be comparable between the two groups but only two patients in LESS-RALNU group had pelvic node dissection as compared with nine patients in the M-RALNU cohort, and this is likely to have reduced the mean operating time in the LESS-RALNU cohort. Due to lack of standardised indication or a template for lymphadenectomy from prospective data, lymph node dissection in upper tract urothelial cancer remains controversial [5]. Table 1 in the manuscript shows that there were 17 patients with clinical stage T2 in the cohort (eight in M-RALNU and nine in the LESS-RALNU group). Table 2 shows the number of patients who received lymphadenectomy (nine in M-RALNU and two in the LESS-RALNU group). What needs to be further clarified is why lymph node dissection was carried out in all T2 patients in the M-RALNU group and possibly in one patient with a lower stage disease but only in two patients in the LESS-RALNU group. Is this difference due to technical difficulties associated with LESS-RALNU approach?
© 2014 The Authors 8 BJU International © 2014 BJU International
Overall the results of this series are similar to other robotic series and to laparoscopic nephrouretectomy (LNU). Despite this due to lack of long-term data and comparative studies with open/laparoscopic approaches, no definitive conclusion can be made about the utility of either approach. RALNU follows similar principles to the laparoscopic approach and the robotic platform is likely to address some of the surgical difficulties encountered with LNU.
Conflict of Interest Jihad H. Kaouk is a consultant for Intuitive Surgical and a speaker for Ethicon/Endocare. Homayoun Zargar has nothing to disclose. Homayoun Zargar and Jihad H. Kaouk Cleveland Clinic, Glickman Urologic Institute, Cleveland, OH, USA e-mail: [email protected]
References 1
2
3
4
5
Lim SK, Shin TY, Kim KH et al. LESS robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma. BJU Int 2014; 114: 90–7 Kaouk JH, Autorino R, Kim FJ et al. Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases. Eur Urol 2011; 60: 998–1005 Autorino R, Kaouk JH, Stolzenburg JU et al. Current status and future directions of robotic single-site surgery: a systematic review. Eur Urol 2013; 63: 266–80 Autorino R, Cadeddu JA, Desai MM et al. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011; 59: 26–45 Rouprêt M, Zigeuner R, Palou J et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol 2011; 59: 584–94
Magic bullet in management of Peyronie's Disease An exciting article in this edition describes a paradigm shift in the management of Peyronie’s disease (PD) [1]. Reconstructive surgery for PD has been mostly palliative and fraught with unsatisfactory outcomes either in terms of penile length, function or both. This article [1] describes the use of collagenase to effectively dissolve the offending plaque without the side-effects associated with surgery. The results are impressive albeit not entirely curative. The advantage of this strategy is that men can be treated irrespective of the phase of the condition. This means that men can be referred on to a specialist as soon as the diagnosis of PD is made rather than awaiting stabilisation. This will also facilitate disease modifying drugs, such as potassium para-aminobenzoate (Potaba, which has level 1 evidence supporting its use) [2] or pentoxifylline, to be used during the acute phase. These drugs do not appear to be popular among andrologic surgeons, perhaps due to their gastrointestinal side-effects. However, Potaba capsules seem better tolerated than in the sachet form. Collagenase has already been used in Dupuytren’s contracture, which has strong correlations with PD. The studies described in this article have led to its acceptance by licensing bodies in several countries. It would appear to have better results when combined with penile modelling, such as with a vacuum erectile device. The treatment is quite intensive with several
outpatient visits required. The side-effects are rare but can be serious. It would appear that corporal rupture occurs when sexual intercourse is attempted too early, which emphasises the need for clear instructions and management of expectations. It will be interesting to see if there is a limit to the amount/extent of repeat treatments, as we strive to restore length and contour fully. Many patients are eager to undergo this novel therapy. It should be introduced in a controlled and audited system.
Conflict of Interest None declared. Paul K. Hegarty Mater Private Hospitals, Dublin and Cork , Ireland
References 1 2
Jordan GH, Carson CC, Lipshultz LI. Minimally invasive treatment of Peyronie’s disease: evidence-based progress. BJU Int 2014; 114: 16–24 Weidner W, Hauck EW, Schnitker J, Peyronie’s Disease Study Group of Andrological Group of German Urologists. Potassium paraaminobenzoate (POTABA) in the treatment of Peyronie’s disease: a prospective, placebo-controlled, randomized study. Eur Urol 2005; 47: 530–5
Robot-assisted nephrouretectomy: is LESS more? In this small non-randomised prospective single-surgeon series, Lim et al. [1] compare laparoendoscopic single-site robot-assisted nephrouretectomy (LESS-RALNU) with multiport RALNU (M-RALNU) for operative technique and oncological outcomes. The authors should be congratulated on reporting in an area of urology where there is paucity of data and techniques are constantly evolving. LESS procedures were developed to make minimally invasive procedures even less invasive. We have previously reported on a multi-institutional comparative analysis of LESS and conventional laparoscopy for commonly performed urological operations [2]. In our comparative analysis, overall perioperative outcomes were similar to conventional laparoscopy, with a trend toward improved cosmesis, lower perioperative pain scores, and faster convalescence.
However, LESS is technically challenging and requires a high level of laparoscopic surgical skills and experience [3]. Introduction of robotic LESS (R-LESS) was promising to resolve some of the difficulties and challenges associated with single-port minimally invasive surgery. Although since its birth in 2009 R-LESS has evolved significantly, the large size of the robotic arms and the lack of specific instruments designed for LESS pose on-going challenges to the urologists in its widespread use [4]. LESS-RALNU carries all the inherit issues associated with a LESS procedure. In addition to that working in two different abdominal compartments and the need for suturing of the bladder cuff excision site will add to the technical challenges faced by the operating surgeon. RALNU was first reported in 2006 and since then multiple groups have published several small series on the operative © 2014 The Author BJU International © 2014 BJU International
7
Editor’s Choice
technique and perioperative outcomes of this procedure. Long-term oncological outcome for this procedure are lacking and only a few published series have provided any follow-up data in this respect. In this paper by Lim et al. [1], patients were relatively homogenous between the two non-randomised arms. However, patients in LESS-RALNU cohort were significantly older (71 vs 62 years). Both these factors plus the small size of the sample are sources of bias and make drawing any meaningful conclusion from the paper difficult. Both described techniques are relatively new and a comparison between two ‘non-gold standard’ surgical techniques may be too early at this point in their evolution. Despite this, the authors provide us with good intermediate oncological data and insight into the risks and benefits of both procedures. There was a trend toward more blood loss and need for blood transfusion in the LESS-RALNU group. These are consistent with the constraints associated with the LESS approach. The operating time is reported to be comparable between the two groups but only two patients in LESS-RALNU group had pelvic node dissection as compared with nine patients in the M-RALNU cohort, and this is likely to have reduced the mean operating time in the LESS-RALNU cohort. Due to lack of standardised indication or a template for lymphadenectomy from prospective data, lymph node dissection in upper tract urothelial cancer remains controversial [5]. Table 1 in the manuscript shows that there were 17 patients with clinical stage T2 in the cohort (eight in M-RALNU and nine in the LESS-RALNU group). Table 2 shows the number of patients who received lymphadenectomy (nine in M-RALNU and two in the LESS-RALNU group). What needs to be further clarified is why lymph node dissection was carried out in all T2 patients in the M-RALNU group and possibly in one patient with a lower stage disease but only in two patients in the LESS-RALNU group. Is this difference due to technical difficulties associated with LESS-RALNU approach?
© 2014 The Authors 8 BJU International © 2014 BJU International
Overall the results of this series are similar to other robotic series and to laparoscopic nephrouretectomy (LNU). Despite this due to lack of long-term data and comparative studies with open/laparoscopic approaches, no definitive conclusion can be made about the utility of either approach. RALNU follows similar principles to the laparoscopic approach and the robotic platform is likely to address some of the surgical difficulties encountered with LNU.
Conflict of Interest Jihad H. Kaouk is a consultant for Intuitive Surgical and a speaker for Ethicon/Endocare. Homayoun Zargar has nothing to disclose. Homayoun Zargar and Jihad H. Kaouk Cleveland Clinic, Glickman Urologic Institute, Cleveland, OH, USA e-mail: [email protected]
References 1
2
3
4
5
Lim SK, Shin TY, Kim KH et al. LESS robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma. BJU Int 2014; 114: 90–7 Kaouk JH, Autorino R, Kim FJ et al. Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases. Eur Urol 2011; 60: 998–1005 Autorino R, Kaouk JH, Stolzenburg JU et al. Current status and future directions of robotic single-site surgery: a systematic review. Eur Urol 2013; 63: 266–80 Autorino R, Cadeddu JA, Desai MM et al. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011; 59: 26–45 Rouprêt M, Zigeuner R, Palou J et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol 2011; 59: 584–94
