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CONCOMITANT MANAGEMENT OF RENAL
CALCULI AND PELVI-URETERIC JUNCTION
OBSTRUCTION WITH ROBOTIC
LAPAROSCOPIC SURGERY
Reply,
Taking the logic of Eden et al. [1], if we
persevered with the manual sewing machine
and did not invest in or use the electric sewing
machine, we would not enjoy the wonderful
tailored clothing or commercial merchandise
that is available today. One must invest,
investigate and deploy medical technology
judiciously. The authors of this letter need to
re-read the original article [2]. Clearly, the
‘take-home’ message was not to declare that
our described technique was the only way
forward. Our intent was to merely describe a
technique, never described before, which
could be applicable in a given situation, such
as the availability of the daVinci robotic
system.
Unless our critics have been in hiding, there is
no question that open surgical pyeloplasty is
the dominant method of managing PUJ
obstruction worldwide. This should also be
evident to our critics who claim to have had
travelling ‘laparoscopic shows’ to the
developing world. Even in a market-driven
healthcare arena, such as in the USA,
laparoscopic pyeloplasty is only offered at
selected centres. Because of the reasons
stated in the article and the ready availability
of 300 daVinci robots across the USA, the fact
is that robotic pyeloplasty is rapidly displacing
laparoscopic pyeloplasty. Practice and referral
patterns in the USA vs Europe and the UK are
significantly different and will not change
soon, despite tirades such as those offered by
our critics.
The operative duration is longer than for some
other series because our duration included
cystoscopy, retrograde ureteropyelography,
stent placement and repositioning, re-draping
followed by the pyeloplasty (please re-review
page 1367). The anastomosis time includes
© 2006 THE AUTHORS
JOURNAL COMPILATION © 2 0 0 6 B J U I N T E R N A T I O N A L | 9 8 , 6 8 9 – 6 9 1 | doi:10.1111/j.1464-410X.2006.06459.x
closure of the renal pelvis after reduction
pyeloplasty in a centre dedicated to urology
resident and fellowship education, which
prolongs any procedure time. Unlike the
critics, we do not always hold to the belief
that ‘fastest is the best’.
FATIH ATUG and RAJU THOMAS,
Department of Urology, Tulane University
Health Sciences Center, New Orleans, LA, USA
1 EDEN CG, MOON DA, GIANDUZZO T.
Concomitant management of renal calculi
and pelvi-ureteric junction obstruction
with robotic laparoscopic surgery [letter].
BJU Int 2006; 97: 653–4
2 Atug F, Castle EP, Burgess SV, Thomas
R. Concomitant management of renal
calculi and pelvi-ureteric junction
obstruction with robotic laparoscopic
surgery. BJU Int 2005; 96: 1365–8
THE UROLOGICAL MANAGEMENT
OF THE PATIENT WITH ACQUIRED
IMMUNODEFICIENCY SYNDROME
Sir,
Heyns and Fisher [1] provide an excellent
review on the management of the patient
with HIV/AIDS. However, we would like to
highlight an important point about the
management of LUTS in men with HIV
infection. Although it is right that BOO in
patients with HIV/AIDS can be treated with α-
blockers, clinicians should be aware that
selective α1a-blockers can lead to significant
and potentially dangerous side-effects in
patients on certain anti-retroviral agents. As
up to two-thirds of patients with HIV
infection in developed countries are receiving
highly active anti-retroviral therapy [2], this is
an important consideration.
Ritonavir (also known as Norvir or Kaletra
when combined with lopinavir) is a protease
inhibitor and a potent inhibitor of the CYP3A4
hepatic enzyme, which is also responsible for
alfuzosin metabolism. Co-administration of
ritonavir and alfuzosin causes significant
increases in alfuzosin exposure, and increases
the risk of serious adverse reactions such as
hypotension. The interaction is significant
enough for the co-administration of alfuzosin
with ritonavir to be contraindicated in the
USA by the Food and Drug Administration [3].
As tamsulosin is also metabolized by CYP
enzymes, potential interactions with
tamsulosin cannot be excluded.
Surprisingly, the significant interaction
between alfuzosin and ritonavir is not listed in
the British National Formulary (BNF) [4]. In
our clinical experience, selective α1a-blockers
administered to patients taking ritonavir have
resulted in severe nausea, vomiting, dizziness
and in one case, collapse. As a result we have
been managing such patients effectively with
doxazosin or terazosin. We have informed the
Committee on Safety of Medicines in the UK
about this significant interaction, and would
anticipate this to be reflected in future
editions of the BNF. In the meantime we
advise caution in the use of selective α1a-
blockers in patients taking ritonavir.
KHURSHID R. GHANI and
FRANCIS CHINEGWUNDOH, Department
of Urology, St Bartholomew’s Hospital,
West Smithfield, London, UK
1 Heyns CF, Fisher M. The urological
management of the patient with acquired
immunodeficiency syndrome. BJU Int
2005; 95: 709–16
2 Rice BD, Payne LJ, Sinka K, Patel B,
Evans BG, Delpech V. The changing
epidemiology of prevalent diagnosed HIV
infections in England, Wales, and
Northern Ireland, 1997 to 2003. Sex
Transm Infect 2005; 81: 223–9
3 USA Food and Drug Administration.
Available at: http://www.fda.gov/
medwatch/safety/2005/nov05.htm.
Accessed July 2006
689
LETTERS
4 BNF. British National Formulary No. 51
March 2006. London: BMJ Publishing
Group Ltd., 2006
MINI-FLANK SUPRA-11TH RIB
INCISION FOR OPEN PARTIAL OR
RADICAL NEPHRECTOMY
Sir,
We read with interest this recent article by
DiBlasio et al. [1] but felt that several issues
invited further comment. The authors clearly
felt that minimising the skin incision was
important in minimising morbidity, but the
length of an open surgical skin incision does
not necessarily reflect the length of incision in
the underlying muscle layer, as there is the
potential for inverted ‘funnelling’. The greatest
predictor of pain is usually the degree of
prolonged muscle bruising after dynamic
retraction using a blunt retractor, and this
is likely to be much greater than when
laparoscopic incisions are ‘joined’ to harvest
the specimen.
It was also interesting that there was no
comment on any health-related quality-of-
life issues or return to normal activity.
Patients tend to recover much more quickly
and return to normal activity sooner after
laparoscopic nephrectomy [2,3] and this
factor is perhaps more important than
absolute days of inpatient stay.
Finally, if the surgeon should choose to use an
8-cm primary incision, this could be better
used for hand-assisted laparoscopy; the dual
advantages of this approach would be better
(magnified) vision and the ability to perform
proprioceptive manipulation (tactile feedback
aids dissection during open partial
nephrectomy). Further, as this is usually a
midline supra- or infra-umbilical incision,
there is the potential for a faster and more
comfortable recovery, without compromising
intact specimen extraction.
ABHAY RANÉ, DECLAN MURPHY and
ALASTAIR HENDERSON, Department of
Urology, East Surrey Hospital, Redhill, UK
1 DiBlasio CJ, Snyder ME, Russo P. Mini-
flank supra-11th rib incision for open
partial or radical nephrectomy. BJU Int
2006; 97: 149–56
2 Kercher KW, Heniford BT, Matthews
BD et al. Laparoscopic versus open
nephrectomy in 210 consecutive patients:
690
outcomes, cost, and changes in practice
patterns. Surg Endosc 2003; 17: 1889–95
3 Patel A, Wilson L, Blick C, Gurajala R,
Rane A. Health-related quality of life
after retroperitoneoscopic and hand-
assisted laparoscopic nephrectomy.
J Endourol 2005; 19: 849–52
INGUINAL METASTASES FROM
TESTICULAR CANCER
Sir,
I read with great interest this article by
Daugaard et al. [1]; it is a good study involving
695 patients with testicular tumour, of whom
14 (2%) developed inguinal metastases during
the follow-up. As reported previously [2,3],
the incidence of inguinal metastases in
testicular cancer is 2% in patients with the
risk factors of previous testicular surgery or
extension of the tumour to the epididymis
and the tunica vaginalis. In this case series,
only two patients had these risk factors.
The authors concluded that lymph-node
metastases were found in patients with no
previous surgery, probably due to infiltration
to the spermatic cord [1].
In this series, 14 different surgeons from five
different hospitals performed the operations.
From the authors’ admission, the technique of
the surgeons could not be standardised [1]. In
the radical orchidectomy technique [4], great
emphasis must be placed on the high ligation
of the spermatic cord 1–2 cm proximal to the
internal inguinal ring; similarly, the use of a
separate surgical field should be adopted
before opening the tunica vaginalis. A high
ligation of the spermatic cord aids the
pathological diagnosis of stage II tumours; a
separate surgical field prevents tumour
seeding into the wound.
According also to the European Association
of Urology (EAU) Guidelines on testicular
cancer [5], the levels of the serum tumour
markers (βhCG, α-fetoprotein and lactate
dehydrogenase) are important before
orchidectomy for a correct prognostic
classification and suitable treatment
afterward, and not just the levels after
orchidectomy. Patients with stage I seminoma
must receive prophylactic radiotherapy after
orchidectomy. Patients with stage I
nonseminomatous germ cell tumours should
have retroperitoneal lymph-node dissection
unless there is close follow-up surveillance
(and not if staging shows no evidence of
JOURNAL COMPILATION
disease, as described by the authors).
Following the EAU Guidelines minimises the
incidence of recurrence, including inguinal
nodal disease.
GIORGIO BOZZINI and
JAMES G. HUANG, Department of Urology,
Royal Melbourne Hospital, Victoria, Australia
1 Daugaard G, Karas V, Sommer P.
Inguinal metastases from testicular
cancer. BJU Int 2006; 97: 724–6
2 Stein M, Steiner M, Suprun H,
Robinson E. Inguinal lymph node
metastases from testicular tumor. J Urol
1985; 134: 144–5
3 Mianne DM, Barnaud P, Altobelli A,
Masson J, Valeri A. [Inguinal lymphatic
metastasis of cancer of the testis: staging
and therapeutic approach]. Ann Urol
(Paris) 1991; 25: 199–202
4 Sheinfeld J, McKiernan J, Bosl GJ.
Surgery of testicular tumors. In Walsh PC,
Retik AB, Vaughan ED, Wein AJ eds,
Campbell’s Urology, 8th edn. Philadelphia:
Saunders, 2002: 2926
5 Laguna MP, Pizzocaro G, Klepp O,
Algaba F, Kisbenedek L, Leiva O; EAU
Working Group On Oncological
Urology. EAU guidelines on testicular
cancer. Eur Urol 2001; 40: 102–10
FLOW METER URINE TESTING: A
PRACTICAL PROPOSITION IN PATIENTS
ATTENDING FOR URODYNAMICS?
Sir,
We read with interest this recent paper by
Hashim and Abrams [1] on the feasibility of
testing urine directly from the flowmeter
during urodynamics. Their data suggest that
the presence of nitrites in the urine voided
into the flowmeter corresponds well with the
presence of nitrites in urine obtained via a
urethral catheter. However, we respectfully
think that their conclusions oversimplify the
issues. When screening for UTI it behoves the
clinician both to make an accurate diagnosis
and treat with appropriate antibiotics.
As the authors state, 5–10% of patients
presenting for urodynamics will have a
current UTI, but for patients with a recurrent
UTI, who might harbour more unusual urinary
pathogens, a diagnosis based on dipstick
testing alone is inappropriate [2]. Particularly
in these patients, sampling urine only from
the flowmeter deprives the clinician of the
© 2006 THE AUTHORS
© 2006 BJU INTERNATIONAL

opportunity to send a midstream urine (MSU)
sample for microbiological culture.
Screening for UTI before urodynamics is
mandatory, not only to avoid unnecessary
morbidity, but because current infection
might reduce the specificity of the
urodynamics. Importantly, the presence of
asymptomatic bacteriuria does not appear to
compromise the results of urodynamic testing
[3]. Instead of routinely testing only from the
flowmeter, we propose the following more
rigorous protocol, currently in use at our unit.
For patients with a history of recurrent UTI, or
who are symptomatic for current UTI, we
dipstick-test the urine in the flowmeter. If
positive for nitrites we abandon the test, and
ask the patient to provide a subsequent MSU
sample. If negative for nitrites we proceed
with the test, taking a catheter specimen
for microbiology. For patients who are not
symptomatic for current UTI, we dipstick-test
the catheter specimen alone. If positive
for nitrites we send the specimen for a
microbiological assessment, and provide
empirical antibiotics to cover the procedure.
Making this distinction between symptomatic
and asymptomatic patients avoids both
catheterizing, and possibly under-treating,
those patients who are most likely to have an
infection. Simultaneously it minimises the
number of wasted urodynamic appointments,
a cost saving that more than offsets the
additional cost in catheters and microbiology
laboratory time.
RUFUS CARTWRIGHT and
LINDA CARDOZO, Department of
Urogynaecology, King’s College Hospital,
London, UK
1 Hashim H, Abrams P. Flow meter urine
testing: a practical proposition in patients
© 2006 THE AUTHORS
JOURNAL COMPILATION © 2006 BJU INTERNATIONAL
attending for urodynamics? BJU Int 2006;
97: 1027–9
2 Rahn DD, Boreham MK, Allen KE,
Nihira MA, Schaffer JI. Predicting
bacteriuria in urogynaecology patients.
Am J Obstet Gynecol 2005; 192: 1376–8
3 Moore KH, Simons A, Mukerjee C,
Lynch W. The relative incidence of
detrusor instability and bacterial cystitis
detected on the urodynamic-test day. BJU
Int 2000; 85: 786–92
REPLY
We agree with Cartwright and Cardozo about
the accurate diagnosis of UTIs before
urodynamics. The main aim of a dipstick test
from urine in the flowmeter is to make a
diagnosis of UTI before the patient is
catheterized for urodynamics, and therefore
avoid an unnecessary catheterization. It is not
aimed at diagnosing the pathogen involved. If
the flowmeter dipstick test is positive then the
patient is asked to provide a mid-stream urine
specimen for microscopy, culture and
sensitivity, to diagnose the pathogen and
treat the patient appropriately with
antibiotics. This is the same guideline as
proposed by Cartwright and Cardozo for
symptomatic and/or recurrent UTIs.
Cartwright and Cardozo also mention those
patients who have an asymptomatic UTI after
the catheter specimen is dipstick-tested, and
if positive for nitrites, they send the specimen
for microbiology and provide empirical
antibiotics to cover the procedure. Antibiotic
cover is certainly an option, which we offer
to specific patients. However, they are
counselled thoroughly about the risks of
infection and if it is necessary to proceed,
then we cover the procedure with antibiotics.
However, the aim of the paper was to find a
LETTERS
urine-testing option without losing the free
flow-rate, so that patients can be counselled
before a potentially dangerous
catheterization.
Mr HASHIM HASHIM and
PROFESSOR PAUL ABRAMS,
Bristol Urological Institute, Westbury on Trym,
Britsol, UK
DO STATINS PROTECT AGAINST
PROSTATE CANCER?
Sir,
This Comment [1] made the case for the
protective role of statins in prostate cancer.
Although the authors cited observational
studies that provide some support for this
theory, they neglected to refer to the meta-
analysis by Dale et al. [2], who examined the
effects of statins on cancer risk in 86 000
patients from 27 randomized, prospective
trials of statin use for the primary and
secondary prevention of coronary artery
disease. All reviewed trials included at least
100 patients undergoing treatment for
≥1 year. Statins were shown to have a neutral
effect on both cancer incidence and cancer
death. This was true for all statins, and all
cancer types (including prostate cancer).
RICHARD J. PARKINSON and
SUNJAY JAIN*, Urology, Nottingham City
Hospital, Nottingham, and *Cancer studies
and Molecular Medicine, University of
Leicester, Leicester, UK
1 Goldstraw MA, Amoroso P, Kirby RS. Do
statins protect against prostate cancer?
BJU Int 2006; 97: 1147–8
2 Dale KM, Coleman CI, Henyan NN,
Kluger J, White CM. Statins and cancer
risk: a meta-analysis. JAMA 2006; 295:
74–80
691