Viewpoint in 2006

With continually improving imaging techniques, more small renal tumors are detected incidentally, and the management of these tumors is a subject of considerable controversy. In the first of two Viewpoints examining this issue, Beckeret al.discuss the treatment options available and outline the arguments in favor of nephron-sparing surgery as the standard treatment for small renal tumors.

With the popularization of laparoscopic and robotic pyeloplasty has come a resurgence in the debate over the role of crossing vessels in the pathogenesis of ureteropelvic junction obstruction. In this Viewpoint, the authors examine the evidence and argue that crossing vessels do not cause ureteropelvic junction obstruction or compromise the success of endourologic procedures.

Accurate prognostic indicators are of critical importance for patients with renal cell carcinoma. In this article, the authors argue that the arrival and application of new targeted therapies will necessitate a re-evaluation of the current prognostic systems to incorporate emerging molecular markers with existing clinical and pathologic staging constructs.

There is considerable controversy regarding the role of extended pelvic lymph-node dissection (PLND) during radical prostatectomy. In the first of a pair of articles discussing this issue, Burkhard et al. speculate on the potential therapeutic benefit of extended PLND, and argue that it should be performed in the majority of patients undergoing radical prostatectomy.

In our second article discussing the role of extended pelvic lymph-node dissection (PLND) during radical prostatectomy, Hartwig Huland argues that extended PLND is not justified in presently selected patients, is rarely used to guide intraoperative decisions, and has little impact on treatment outcomes.

For patients with high-risk superficial bladder cancer, accurate identification of tumor grade and stage, and appropriate treatment are paramount to achieving durable disease control and long-term survival. In this article, the author highlights the important issues relating to the management of this disease.

Erectile dysfunction is common following radical prostatectomy for localized prostate cancer, but there are indications that early pharmacological intervention could promote return of erectile function. The authors discuss preliminary results with postoperative prophylactic erectile therapy, the rationale behind such an approach, and its potential role in clinical practice.

Radical cystectomy, the gold standard for treatment of muscle-invasive bladder cancer, has traditionally been withheld from elderly patients because of morbidity and mortality concerns. In this Viewpoint, the authors argue that aggressive management is safe and effective in select elderly patients.

For the man suffering from urinary incontinence following prostatectomy, two surgical options are currently available: the bulbous urethral sling and the artificial urinary sphincter (AUS). The authors discuss the literature for the two techniques, and explain why they believe AUS implantation is the preferred option in this patient population.

When the Dornier HM3 lithotriptor was introduced in the early 1980s, shock-wave lithotripsy (SWL) rapidly became the preferred treatment for most upper-tract calculi. A number of second- and third-generation machines have since become available. This Viewpoint discusses the evolution of SWL technology, and highlights concerns over the limitations of modern devices.

Most surgeons no longer use urethral bulking agents for hypermobility-related stress incontinence due to the profusion of new synthetic slings that are more effective and highly durable. Nevertheless, there are situations where bulking agents are preferable. The author comments on the history of injectables, and explains why these agents still have a place in clinical practice.

The use of androgens to treat sexual dysfunction in women remains controversial. In this Viewpoint, the author reviews the reasons behind the widespread off-label use of testosterone products to promote female sexual wellbeing, and the safety and efficacy of these products in this setting.

This Viewpoint provides a timely review of the current status of surgical treatments for men who develop stress urinary incontinence after radical prostatectomy. The author discusses the safety and efficacy of the bone-anchored perineal sling, a procedure that has recently undergone several modifications and is arguably emerging as a viable alternative to the artificial urinary sphincter.

This Viewpoint provides a concise overview of transobturator and retropubic techniques for the surgical treatment of female stress urinary incontinence. The authors focus on a new generation of minimally invasive devices for sling placement, including the transvaginal tape and their own distal urethral polypropylene sling.

Retrograde stone migration during ureteroscopy leads to longer operating times, more-invasive endoscopy, and an increase in residual stones and the need for secondary procedures. In this Viewpoint, the author describes his experience with the various devices developed to prevent stone migration, focusing on the Stone Cone.

Screening for diseases is a fact of modern medicine. For prostate cancer, the issue is complex, as the overall benefit to patients is far from clear. In this Viewpoint, the advantages of early detection and treatment with PSA screening are weighed up against the risks of overdiagnosis and unnecessary treatment.

This Viewpoint documents recent developments in the field of renal cortical tumors, focusing on the current status of open partial nephrectomy. The author argues that nephron-sparing surgery is under-utilized, and that the current trend for urologic surgeons to adopt laparoscopic radical nephrectomy as a minimally invasive alternative could have important consequences for overall renal function.