New Urologic Strategies Explored at Jackson Hole

20th Annual Jackson Hole Urologic Conference

MEETING REVIEW New Urologic Strategies Explored at Jackson Hole Highlights From the 20th Annual Jackson Hole Urologic Conference January 22-28, 2000, Jackson Hole, Wyo. [Rev Urol. 2000;2(4):211-220] Key words: Erectile dysfunction • Prostate cancer • Testis • Trauma • Urogynecology T he 20th Annual Jackson Hole Urologic Conference combined an internationally recognized faculty with an equally renowned critique panel. After the faculty presented papers in their areas of expertise, the critique panel analyzed and evaluated the presentations, resulting in constructive critical assessment of the data. Pediatric Urology The nonpalpable testis in an infant must be considered intersex unless proved otherwise, irrespective of the degree of virilization, according to Anthony Caldamone, MD. Figure 1 demonstrates the Brown University approach to evaluation. Using such a template will make evaluation of these difficult cases easier. The role of laparoscopy in pediatric urology continues to emerge. Dr Caldamone reported his extensive experience using laparoscopy to evaluate the undescended testis. He and his colleagues examined 104 patients; 55 were between the ages of 0 and 3 years. In 59%, there were blind-ending cord structures; in 41%, the testis was present (including 23 in the intraabdominal position and 20 below the Reviewed by Michael K. Brawer, MD, Northwest Prostate Institute, Seattle. internal ring). The investigators concluded that 51% of patients derived no benefit from the procedure, because either the gonad or the cord was below the internal ring. Three potential benefits of performing orchidopexy emerge: fertility enhancement; improved cosmetic and psychological status; and perhaps reduction in malignancy risk or increased ability to detect malignancy through improved surveillance. Dr Caldamone noted shortened hospitalization and much faster return to normal activities as benefits of his method of laparoscopically performing a 2-stage Fowler-Stephens orchidopexy. In this approach, the first stage antecedes the second by 6 to 13 months. In the first procedure, the spermatic vessels are clipped well away from the vas. In the second stage, using the 2 laparoscopy ports from the first procedure, the peritoneum reflections are mobilized: the gubernaculum is divided; then the vas-testis-peritoneal complex is dissected from the floor of the abdomen and passed through the native or new internal ring into the scrotum. During procedures on 17 patients, only 1 complication occurred, that of a bowel perforation with the Verres needle. (Dr Caldamone now considers the Verres technique contraindicated.) All testes were successfully placed in the scrotum and remained there for an average of 10 months of follow-up. In the younger child in whom the testis sits just inside the internal ring, Dr Caldamone performs single-stage orchidopexy. Dr Caldamone also provided a simple approach to the evaluation of patients with urinary tract infections that may be the result of vesicoureteral reflux (Figure 2). His choices for antimicrobial therapy are shown in Table 1. His group, which is particularly interested in developing better injectable materials with which to endoscopically correct vesicoureteral reflux, has been using autologous ear chondrocyte. In this procedure, the ear chondrocytes are harvested and cultured for approximately 6 weeks before endoscopic injection. The procedure was successful in 23 of 29 patients, including 4 children with grade 4 reflux. Dr Caldamone also shared his organized approach to the evaluation of patients with urinary incontinence or enuresis (Figure 3). Urogynecologic Disorders It has become a tradition that nonurologists are among the faculty at the Jackson Hole meeting. Outstanding presentations by John DeLancey, MD, a gynecologist, demonstrate the FALL 2000 REVIEWS IN UROLOGY 211 Urologic Strategies continued success of this tradition. During his discussion of the mechanisms of stress urinary incontinence, he noted that urethral support was related primarily to 3 components: the tendinous arch of the levator ani muscle, the pubocervical fascia, and the levator ani muscle. Increased intra-abdominal pressure during coughing forces the urethra and other elements of the pelvic floor downward, compressing the urethra between the abdominal floor and the endopelvic fascia; this results in closure of the urethra during stress. In normal women, contraction of the levator ani muscle occurs simultaneously with a cough, increasing this outlet resistance. Repair of fascial detachments, which can occur in patients with stress urinary incontinence, can restore normal anatomy and also cure leakage. Surgical complications can result in permanent fixation of the urethra to the pubic bone. High retropubic urethropexy may result in new enterocele (15%), voiding dysfunction (17%), and new detrusor instability (12%). Kegel exercises help only about 50% of women with stress urinary incontinence; cure is effected in only 6%. Urethral function is a continuous variable involving the intrinsic sphincter and urethral support. The clinical implication of intrinsic sphincter deficiency is gaining increased recognition. Dr DeLancey’s laboratory has demonstrated significant loss of striated muscle with age—approximately 2% of muscle fibers a year. These changes are irreversible. Dr DeLancey commented that the field of surgical gynecology arose largely because of a need to repair the damage that birth caused in the pelvic floor. The well-entrenched beliefs that vaginal delivery results in damage to the pelvic floor because of stretching of the vagina or the cardinal and uterosacral ligaments is implausible. While the cervix dilates from 1 to 10 Figure 1. Algorithm for evaluation of ambiguous genitalia. (PE, physical examination; MGD, mixed gonadal dysgenesis; CAH, congenital adrenal hyperplasia; hCG, human chorionic gonadotropin; DHT, dihydrotestosterone; MIF, müllerian inhibiting factor.) Ambiguous genitalia Chromosomes Genitogram Ultrasound History PE 46 XY 46 XX Sex reversal syndrome 17-OH progesterone Normal True hermaphrodite (ovary/testis/ovotestis) Male pseudohermaphrodite Elevated CAH Maternal androgens Laparoscopy Biopsy X0 X0/XY Streak/ streak Testis/ streak Tumors MGD hCG stimulation Lytes Maternal External androgenic androgens tumor Glucocorticoids Testosterone Mineralocorticoids DHT DHT DHT normal No response Deficiency of androgen synthesis Surgical repair Androgen 5α-reductase MIF deficiency insensitivity deficiency Gonadal dysgenesis 212 REVIEWS IN UROLOGY FALL 2000 Urologic Strategies continued cm, the vagina stretches only from 3 to 10 cm during labor. Although the cervix almost always recovers after birth, the vagina does not seem to recover as well. The cardinal and uterosacral ligaments attach the cervix to the pelvic side wall, suggesting that with labor and dilation of the cervix, there would be less tension on the ligaments. The major injury caused by vaginal delivery is to the pelvic nerves, resulting in pelvic organ prolapse and stress urinary incontinence. With nerve injury, there is loss of tone in the levator ani muscles. There is also tension on the support fasciae, resulting in introital gaps. Both logic and electromyographic studies provide the evidence that pelvic nerve damage can result in prolapse or incontinence. tensive clinical experience at St Bartholomew’s and the Royal Marsden hospitals in London. Topical cooling before conservative renal surgery has long been considered a useful adjuvant. Dr Hendry’s team studied the time it takes to adequately cool a kidney. Realizing that renal metabolism falls exponentially with reduction in temperature, they reviewed the literature suggesting that the metabolism is one third of normal at 27ºC (80.6ºF). After topical cooling with chipped ice and clamping of the renal artery and vein before partial nephrectomy for renal cell carcinoma, they measured renal surface and core temperatures at 1-minute intervals. Kidneys were cooled for 5 to 15 minutes; total ischemia times were 20 to 40 minutes. Time to achieve a core temperature of 27ºC (80.6ºF) ranged from 5 to 12 minutes, depending on the size of the kidney. The team concluded that renal core temperatures should be measured Renal Surgery Mr William Hendry’s many intriguing presentations were based on his ex- Patient aged Patient aged < 6 years or > 6 years (febrile) UTI > 6 years UTI (afebrile) VCU US Negative Positive US Positive Surveillance VCU/ExU ExU/nuclear scan Negative Surveillance Negative Positive ExU/nuclear scan Figure 2. Steps in the evaluation of a patient with urinary tract infection (UTI) and possible vesicoureteral reflux. (VCU, voiding cystourethrography; US, ultrasound; ExU, excretory urography.) 214 REVIEWS IN UROLOGY FALL 2000 during these surgical procedures. Testis Tumor Mr Hendry reported his extensive experience in surveillance for stage 1 nonseminomatous germ cell tumor (NSGCT) of the testes. Overall, 418 men presented with stage 1 NSGCT during an 18-year observation. Up to 1986, 160 men were managed by surveillance alone, and abdominal relapse occurred in 26. Subsequent to that time, men with at least 3 of 4 risk factors evident in the orchidectomy specimen (lymphatic or vascular invasion, presence of embryonal carcinoma, absence of yolk sac tumor) were offered 2 courses of platinum-based chemotherapy. Only 1 relapse occurred among the 61 men who received this therapy. In contrast, of the 196 men undergoing surveillance without prophylactic chemotherapy, 20 exhibited relapse. He concluded that abdominal relapse decreased from 16% to 8% using the chemotherapy regimen. Interestingly, the mortality from testis tumor has been essentially unchanged (1.2% before and 1.6% after 1986). Mr Hendry not only has a longstanding interest in carcinoma in situ of the testes, but he also has an extensive database, because at the Royal Marsden Hospital, all men with testicular cancer are followed indefinitely. Between 1952 and 1976, a secondary tumor developed in 2.75% of 760 men after an interval of 4 to 15 years from initial orchidectomy. Between 1962 and 1984, secondary tumors developed in 3.1% of 1219 men. In the latter investigation, it was noted that patients with a history of undescended or atrophic testis or of infertility were at increased risk for development of secondary tumors. In 1988, testicular biopsy was offered to men at high risk, and when carcinoma in situ was found, it was treated. When this policy was instituted, 1372 patients were evaluated: 9 had testicular atrophy, a history of undescended testis, or azoospermia; 97 underwent testicular Urologic Strategies Table 1 Common Oral Antibiotics for Childhood UTIs Antibiotic How supplied Treatment Prophylaxis Amoxicillin Suspension: 125 mg/5 mL, 250 mg/5 mL Chewable tablet: 125 mg, 250 mg Capsule: 250 mg, 500 mg Infant (< 8 kg), drops: 50 mg/mL 20 mg/kg/24h q8h 5 mg/kg qhs if used See package instructions See package instructions Sulfisoxazole Suspension: 50 mg/5 mL Syrup: 500 mg/5 mL Tablet: 500 mg 150 mg/kg/24 h q6h 50 mg/kg qhs Nitrofurantoin* Capsule: 25 mg, 50 mg, 100 mg Suspension (Furadantin): 5 mg/mL 5 - 7 mg/kg/24 h q6h 1 - 2 mg/kg qhs TMP-SMX† Suspension: 40 mg TMP/5 mL SS tablet: 80 mg TMP DS tablet: 160 mg TMP 8 mg TMP/kg/24 h q12h 2 mg TMP/kg qhs UTI, urinary tract infection; TMP-SMX, trimethoprim-sulfamethoxazole; SS, single strength; DS, double strength. *Contraindicated in infants under 2 years of age. † Contraindicated in infants under 1 month of age. biopsy. Of these, 10.3% had carcinoma in situ and were treated by a brief course of radiation therapy to the testicle. One patient was found to have seminoma and underwent orchidectomy. Of the remaining patients who were followed at the Royal Marsden Hospital, in only 10 were contralateral tumors detected. Among the 1372 patients, 6 were referred from other hospitals. Mr Hendry concluded that despite relatively short follow-up, these results support a policy of actively searching for carcinoma in situ in high-risk patients. Erectile Dysfunction Tom Lue, MD, a world leader in the field of erectile dysfunction (ED), provided a straightforward approach to the workup required, with a stepwise increase in the complexity and potential morbidity of therapy (Table 2). Every patient should have a complete history (medical, surgical, psychosocial, medications, substance abuse). A careful physical examination and appropriate laboratory tests are also required. Routine laboratory tests should include urinanalysis, complete blood cell count, and blood chemistry profile, plus a determination of a baseline testosterone level. Additional tests may be warranted. Dr Lue emphasized that most patients will undergo a trial with sildenafil first. Good response with sildenafil indicates psychogenic or mild to moderate organic disease. A negative result suggests moderate to severe organic illness and warrants further evaluation. Dr Lue reported on the University of California, San Francisco, experience with a Chinese herbal remedy in a cholesterol-induced rat model of ED. This agent prevented ED in all animals receiving it; all rats in the control group developed ED within 4 months. With respect to cavernous nerve injury, which can occur with radical prostatectomy, his group has studied the use of growth hormone to enhance cavernous nerve recovery in a rat model. In a vasculogenic model in which the internal iliac arteries of the rat are occluded, the investigators demonstrated efficacy with vascular endothelial growth factor (VEGF) as well as a virus VEGF. Regarding gene therapy for ED, Dr Lue said that the penis is an ideal organ for such therapy, because of its external location and slow circulation. He cited, as an example, work in which transfected nitric oxide genes introduced into the penises of aged rats were able to effect improved erections. In his overview of Peyronie disease, Dr Lue emphasized that this disease often causes significant debilitation with penile pain, penile deformity, or shortening during erection as well as ED. Vitamin E, potaba, colchicine, and tamoxifen were reviewed as therapeutic agents; none have been studied sufficiently to provide meaningful data. After reviewing all the surgical options, Dr Lue concluded that the Nesbit technique is a better option for the less experienced surgeon. Prostate Cancer Markers Dan Theodorescu, MD, reviewed molecular markers in localized prostate cancer, including immunohistochemical techniques with expression of P53, retinoblastoma (Rb), chromogranin-A, and loss of E-cadherin. Based on his own studies, he concluded that P53 and Rb expression levels, as well as FALL 2000 REVIEWS IN UROLOGY 215 Urologic Strategies continued Urinary incontinence Hx, PE, UA Determine pattern of wetting Wetting at night only Wetting day and night Maturational delay Patient aged < 10 years Continuous Patient aged > 10 years IVP/VCU Intermittent Dysfunctional voider Ultrasonography Timed voiding; anticholinergic trial Normal Timed voiding; biofeedback; CIC Abnormal Reassurance; enuretic alarm; pharmacotherapy Anticholinergics VCU; urodynamics Ureteral ectopia Normal Surgical correction Urodynamics Observation Neuropathic bladder Incompetent bladder neck or urethra Dysfunctional voider Figure 3. Steps in the evaluation of a patient with incontinence or enuresis. (Hx, history; PE, physical examination; UA, urinalysis; IVP, intravenous pyelography; VCU, voiding cystourethrography; CIC, clean intermittent catheterization.) 216 REVIEWS IN UROLOGY FALL 2000 Urologic Strategies the Gleason score, were the most significant predictors of disease-free and disease-specific survival after radical prostatectomy. In his studies, these were superior to the gold standard pathologic prognostic factors. He suggested that multiple marker analysis was of significant advantage, compared with single-marker determination, but he cautioned that potential biases existed in his studies: there was a small number of patients and many of the men underwent perineal prostatectomy without pelvic lymph node dissection. With respect to the field of prostate cancer marker development, Dr Theodorescu echoed the sentiments of most authorities that the best method of evaluating these tests will be through tissue analysis results from large, prospective, national clinical trials. Standardized protocols specifying technical issues and providing clear definitions of what constitutes a positive test are imperative. Multiple marker comparisons should be performed every time a new marker is developed to see if there is information that can be added to data from historical tests. Dr Theodorescu emphasized that these evaluations are only clinically relevant if they can be performed adequately on material obtained by needle biopsy. Prostate Cancer Staging Dr Theodorescu, in reviewing molecular staging of prostatic carcinoma, observed the inefficiency of metastasis (Figure 4). He reported his results using reverse transcriptase–polymerase chain reaction assay of the tissues of the surgical bed using primers for prostate-specific antigen and prostatespecific membrane antigen to determine whether these findings suggest positive surgical margins. All patients with positive margins had positive molecular assays of periprostatic tissue. In addition, 4 of 16 men with organ-confined disease had positive molecular markers. Intriguingly, 50% of patients with pT3 and negative surgical margins had positive molecular tests. Dr Theodorescu cautioned that the data obtained were very preliminary and that the observations needed further study. Prostate Cancer Therapy In 1990, 34% of Americans reported using at least 1 type of alternative medicine; in 1997, this increased to 46%. Based on 1990 statistics, alternative medicine was a 13.7 billion dollar industry. This expenditure increased to 21.2 billion dollars in 1997, clear evidence of the interest among our patients. In men with prostate cancer, it is estimated that about 33% use some form of alternative therapy. A major concern is the fact that 72% of patients using alternative therapy do not inform their physicians. In Dr Theodorescu’s study of 190 men with clinically localized prostate cancer undergoing radical prostatectomy, Table 2 Diagnostic Tests for Chosen Treatment Options for Erectile Dysfunction Treatment options Diagnostic tests Oral, transurethral therapy; vacuum constriction device None (CIS or duplex ultrasonography optional) Intracavernous injection CIS (duplex ultrasonography optional) Penile prosthesis NPT (Rigiscan) or CIS or duplex ultrasonography Venous surgery CIS + duplex ultrasonography + cavernosography (or DICC) (NPT optional) Arterial surgery CIS + duplex ultrasonography (or DICC) + arteriography (NPT optional) CIS Test 1. Consent (including possible complications and second injection if erection lasts longer than 1 hour) 2. Intracavernous injection of 10 µg of prostaglandin E1 and observation for 15 minutes 3. Good erection lasts longer than 45 minutes; phenylephrine* injection to prevent priapism Partial erection, add manual genital stimulation • Good erection lasts longer than 30 minutes, phenylephrine* injection • Partial erection, second injection of 0.5 mL of Trimix 4. Adequate erection, advise intracavernous injection therapy Inadequate erection, apply vacuum erection device 5. Additional vascular workup if the patient wishes CIS, Combined intracavernous injection and stimulation test; NPT, nocturnal penile tumescence; DICC, dynamic infusion cavernosometry and cavernosography. *Phenylephrine solution: 250- to 500-µg intracavernous injection every 5 minutes until detumescence. FALL 2000 REVIEWS IN UROLOGY 217 Urologic Strategies continued Main Points • In selected patients, a 2-stage Fowler-Stephens orchidopexy can be successful. • About 2% of the striated muscle of the intrinsic sphincter is lost each year. • The major birth injury is to the pelvic nerves, which can result in pelvic organ prolapse and stress urinary incontinence. • Platinum-based chemotherapy following orchidectomy for nonseminomatous germ cell tumor of the testis can help reduce abdominal relapse. • Patients who are at high risk for carcinoma in situ of the testis should be evaluated regularly. • About 33% of patients with prostate cancer use some form of alternative medicine. • Nonmeshed split-thickness skin grafts are recommended for penile skin repair. • In patients with renal trauma, operative decisions should be based on the likelihood of acute or delayed complications. brachytherapy alone, or combination brachytherapy and external beam therapy, 43% used alternative medicine. Prayer or other religious practices and herbal medicines were the most commonly used therapies. A higher Gleason score was associated with greater use of alternative medicine, and younger patients were more inclined to seek such therapy. Primary tumor Urinary Incontinence Postprostatectomy Perineal or retropubic approach to radical prostatectomy to maintain urinary continence? The literature seems to suggest a more rapid return of urinary continence following the perineal approach, although methodology of data collection in some of these studies may be a problem. In a retrospec- Lymph nodes Distant organs tive, cross-sectional study from Dr Theodorescu’s group, the prevalence of urinary incontinence following radical prostatectomy was 43%. This is consistent with investigations using a written instrument to determine urinary incontinence following radical prostatectomy but higher than in investigations using retrospective chart analysis. When continence is scored as no or minimal leakage, continence rates are similar to those obtained using retrospective chart analysis or nonstructured interviewing techniques by the operating surgeon. This is supported by the observation that minor incontinence is associated with only minimal impact on patient lifestyle. During the first 2 postoperative years, the likelihood of reported complete continence was similar between retropubic or perineal approaches, but subsequent continence favored a perineal approach. Dr Theodorescu noted several limitations of his study, including the retrospective, cross-sectional design. He also explained that Clinical metastasis Circulation Metastatic inefficiency (cell numbers) Requirement to proceed to next step 100,000 Detach from prostate Survival • In circulation • In lymphatics Figure 4. The metastatic inefficiency concept in prostate cancer. 218 REVIEWS IN UROLOGY FALL 2000 100 Survival in circulation Attachment to distant site Invasion at distant site Survival at distant site 1 Growth at distant site • Growth stimuli • Angiogenesis Urologic Strategies Table 3 Traumatic Injuries Associated With Erectile Dysfunction Mechanism Likelihood of ED Etiology of ED Treatment Penile fracture 0% - 2% Pseudoaneurysm; AV fistula; site-specific CVOD Exploration and repair Penetrating injuries Variable Arterial injury; site-specific Exploration and repair CVOD Penile amputation Very low Lack of sensation; penile loss Immediate replantation Pelvic fracture 19% - 56% Neurogenic; arteriogenic; site-specific CVOD Delayed evaluation of ED Blunt injury to perineum or flaccid penis Unknown, but a potentially Arterial injury; site-specific Delayed evaluation of ED important cause CVOD; postembolization for priapism ED, erectile dysfunction; AV, arteriovenous; CVOD, cavernous veno-occlusive dysfunction. patients were not randomly assigned to the form of prostatectomy and, therefore, subtle unknown factors may have skewed the results. Whether the perineal approach to prostatectomy offers potential advantages (primarily related to the excellent visualization of the bladder neck and proximal urethra) remains unclear. Recent reports suggest an increased rate of fecal incontinence following the perineal approach, however. Genitourinary Trauma Hunter Wessells, MD, has a particular interest in reconstruction of the urinary tract and in genitourinary trauma. A diffuse group of diseases, including trauma-induced infections and lymphatic problems, may give rise to genital skin loss. Morbidity and, indeed, mortality may be significantly impacted by prompt and correct decision making. Once the wound is ready for coverage, either acutely (certain burns and trauma) or delayed (infection or constriction injuries), its origin loses importance. Of course, overall patient status is critical in the decision-making process. Additional factors include the size of the defect, presence of the testes, degree of sexual function, and presence of remaining transferable genital skin. In the setting of isolated penile skin loss, either an advancement flap or a split-thickness skin graft may be used. The contraction associated with mesh graft makes it contraindicated in sexually active patients. On the penile shaft, Dr Wessells recommends nonmeshed splitthickness skin grafts, rather than fullthickness grafts. Another option is to bury the penis within the scrotum, with the glans brought out through a buttonhole opening. Scrotal reconstruction, in his opinion, is a more significant problem. If there is a small amount of scrotal skin remaining, tissue expanders can be used before reconstruction of a 2compartment scrotum. With extensive skin loss, closure is not possible. Flaps and meshed split-thickness skin grafts are the options (Dr Wessells prefers the meshed skin grafts option). If the wound bed is clean, skin grafts obviate the need for thigh pouches for the testis. He emphasized that the clinician should not forgo necessary debridement in the acute setting in the hopes of reducing the skin deficiency. Dr Wessells reviewed mechanisms of penile injury and suggested likely status of erectile function postinjury (Table 3). Acute injuries to the tunica albuginea, regardless of mechanism of injury, are best managed by immediate repair. If these injuries are not repaired promptly, there may be ensuing angulation and ED. Penile amputation, if followed by reattachment within 24 hours, has a remarkably good outcome, both cosmetically and functionally. Even in the absence of microsurgical reanastomosis, corporal reattachment should preserve erectile function. Blunt injuries to the penis, perineum, and pelvis represent an important clinical entity; they may be a significant cause of ED. Renal Trauma Significant changes in the management of renal trauma have occurred over the last decade. The approach now is that the majority of injuries should be managed nonoperatively. For example, current guidelines suggest that only 1.7% of blunt injuries and 57% of penetrating injuries require surgical exploration. CT, selective arterial embolization, and ureter- FALL 2000 REVIEWS IN UROLOGY 219 Urologic Strategies continued al stenting allow identification and observation of significant injury. In almost all situations, CT provides more information than an intravenous pyelogram, the exception being in vascular injuries. Dr Wessells favors CT as the first choice for imaging, but with a caveat: if CT imaging follows administration of contrast material too soon, extravasation and upper ureteral injuries may be missed. If contrast is never seen in the distal ureter, ureteropelvic junction disruption must be ruled out. The mechanism of renal injury is less important than the extent of damage, according to Dr Wessells. Operative decisions should be based on the likelihood of an acute or delayed complication developing. In grade 1 and 2 injuries, there are usually no indications for surgical intervention. In grade 3 and 4 injuries, Dr Wessells recommends nonoperative management as long as the patient remains hemodynamically stable. Grade 4 vascular injuries, in which there is injury to the main renal artery or vein or segmental branches, and grade 5 trauma generally warrant surgical exploration. So-called relative indications for surgery, such as parenchymal lacerations associated with urinary extravasation and devitalized fragments, are no longer considered an absolute requirement for surgery. Most extravasation resolves with internal stenting. Dr Wessells underscored the importance of correctly identifying renal pelvis and ureteral trauma, because these injuries are unlikely to resolve spontaneously, and failure to recognize them can lead to urinoma, abscess, and sepsis. He recommends exploration and repair for grade 3 and 4 renal lacerations in patients already undergoing laparotomy for associated injury. In the face of major pancreatic and colon injuries, renal reconstruction can be accomplished without excessive risk. In the absence of associated intraperitoneal injuries, close 220 REVIEWS IN UROLOGY FALL 2000 hemodynamic monitoring, serial hematocrit measurements, and bed rest are instituted. Selective segmental renal arterial embolization can effectively control acute or delayed hemorrhage. ■ Faculty Anthony A. Caldamone, MD, Professor of Urology and Pediatrics, Brown University School of Medicine; Head, Pediatric Urology, Hasbro Children’s Hospital, Providence, RI John O. L. DeLancey, MD, Norman F. Miller Professor of Gynecology, Associate Chair of Gynecology, University of Michigan Medical Center, Ann Arbor William F. Hendry, MD, ChM, FRCS, Genitourinary Surgeon, St Bartholomew’s and Royal Marsden Hospitals, London Ronald Kodama, MD, FRCSC, Assistant Professor, Department of Surgery, Department of Urology, University of Toronto, Ontario Tom F. Lue, MD, Professor of Urology, University of California, San Francisco; Chief of Urology, UCSF/Mt Zion Medical Center, San Francisco Dan Theodorescu, MD, Associate Professor of Urology and Molecular Physiology, Paul Mellon Chair in Urologic Oncology, University of Virginia, Charlottesville Hunter Wessells, MD, Assistant Professor, Section of Urology, University of Arizona College of Medicine, Tucson Members of the Critique Panel and Alternates Michael K. Brawer, MD, Director, Northwest Prostate Institute, Northwest Hospital, Seattle Michael Coburn, MD, Associate Professor, Scott Department of Urology, Baylor College of Medicine, Houston Jay Gillenwater, MD, Professor, Department of Urology, University of Virginia School of Medicine, Charlottesville Gerald Jordan, MD, Professor of Urology, Eastern Virginia Medical School; Director, Adult Reconstruction, The Devine Center for Genitourinary Reconstruction at Sentara Norfolk General Hospital, Norfolk, Va Martin A. Koyle, MD, Chairman, Department of Pediatric Urology, The Children’s Hospital; Professor of Surgery/Urology, University of Colorado School of Medicine, Denver Edward J. McGuire, MD, Professor of Surgery, Section of Urology, University of Michigan Medical Center, Ann Arbor Randall Meacham, MD, Associate Professor, Surgery/Urology; Director of Male Reproductive Medicine and Surgery, University of Colorado Health Sciences Center, Denver Patrick C. Walsh, MD, David Hall McConnell Professor; Director, Department of Urology, Johns Hopkins University School of Medicine; Urologist-in-Chief, James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore Jackson Hole 2001 Meetings Winter: January 27-February 2 Summer: July 28-August 3