Urology Update from Jackson Hole

MEETING REVIEW Urology Update from Jackson Hole Highlights from the 3rd Annual Jackson Hole Summer Urologic Conference July 28–August 3, 2001, Jackson Hole, WY [Rev Urol. 2002;4(2):78–86] © 2002 MedReviews, LLC Key words: Anti-androgen monotherapy • Incontinence • Infertility treatments, cost/benefit • Prostate cancer • Prostatectomy • Ureteral stones • Urinary diversion he 3rd annual Summer Jackson Hole Urologic Conference in Jackson Hole, WY once again combined an outstanding educational format with a spectacular venue. Conceived over two decades ago by Ralph Hopkins, a practicing urologist from Riverton, WY, the Jackson Hole meeting combines an internationally recognized faculty with an equally renowned critique panel. The faculty present a series of papers in their areas of expertise and the critique panel is afforded sufficient time to critically analyze and evaluate the presentations. This results in some good-natured ribbing but also allows critical assessment of the data presented. T Reviewed by Michael K. Brawer, MD, Northwest Prostate Institute, Seattle, WA 78 VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY Prostate Cancer TURP-Detected Prostate Cancer Gerald Andriole presented a number of interesting papers, primarily on carcinoma of the prostate, based on his vast experience at Washington University School of Medicine in St. Louis. In a paper on the frequency and histopathologic features of transurethral resection of the prostate (TURP)-detected prostate cancer, he first reviewed the literature on the incidence of transition zone carcinoma (see Table 1).1–7 He went on to describe his experience in the prospective evaluation of 259 men with lower urinary tract symptoms (LUTS) who underwent TURP. All men with either an abnormality on digital rectal examination or elevated prostate-specific antigen (PSA) underwent at least one set of peripheral and/or transition zone biopsies that were negative for cancer. The incidence of cancer and the number of prior negative biopsies are shown in Table 2. These data demonstrate that a considerable portion of patients who have negative peripheral and indeed transition zone biopsy may harbor significant carcinoma of the prostate at the time of TURP. The decrease in incidence of TURP as we move more and more to pharmacologic and alternative therapies for LUTS owing to presumed benign prostatic hyperplasia (BPH) underscores the need to periodically evaluate those patients for prostate cancer. Gleason Score 3+4 Versus 4+3 Dr. Andriole reviewed the differences between Gleason 3+4 and Gleason 4+3 in another presentation. He eval- Jackson Hole Urologic Conference cal margins (P > .10). Dr. Andriole concluded that when controlling for other prognostic parameters a positive margin at the apex is not associated with untoward prognosis. Table 1 Percent Prostate Cancer in Transition Zone Biopsies if Prior Negative Prostate Biopsy Repeat Positive Biopsy Rate Prostate Cancer Only in Transition Zone Author 37% 31% 32% 24% 16% 21% 18% — 10% 15% 3% 10% 9% 12% Lui et al Liu et al2 Babaian3 Bazimet et al4 Keetch et al5 Morote et al6 Onder et al7 uated 133 men with Gleason 3+4 and 24 men with Gleason 4+3 who were followed for a mean time of 38.6 months. Those men with Gleason 4+3 had the higher pathologic stage and larger tumor volume, although these differences were not statistically significant. The incidence of PSA recurrence for those men with Gleason 4+3 was significantly greater than those with Gleason 3+4 (P = .0008). These data confirm the observation from the Stanford group and others that increasing percentage of Gleason grade 4 and/or 5 connotes an adverse prognostic indication. Radical Prostatectomy In a paper addressing the use of selective cavernous nerve resection and sural nerve grafting for men undergoing radical prostatectomy, Dr. Andriole gave a balanced presentation. He noted that, although technically feasible, the indication for wide resection of the nerve vascular bundles is at best obscure. Using preoperative parameters may result in inappropriate nerve resection in 15% to 60% of cases. He concluded that until more is known about the appropriate factors to guide the decision for nerve resection, which hopefully will come from advances in staging Percent of Positive Biopsies as a Predictor of Outcome Gary Grossfeld, Assistant Professor of Urology at the University of California at San Francisco, also focused primarily on carcinoma of the prostate. One paper addressed the use of the percent of biopsies with cancer to predict tumor extent and outcome following radical prostatectomy. He used the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry of patients throughout the United States. Univariate and multivariate analysis demonstrated that PSA at diagnosis, biopsy Gleason score, and the percentage of positive biopsies (number of positive biopsies/total number of biopsies) all were significant predictors of both extracapsular disease and disease recurrence. The percent of biopsies that revealed carcinoma was the most important predictor for the likelihood of extra prostatic disease and disease recurrence for those patients with intermediate or highrisk disease characteristics, based on clinical tumor stage, serum PSA, and 1 methodology, this procedure should be considered investigational. The finding of positive surgical margins at the time of radical prostatectomy continues to occur all too often, and the appropriate intervention remains obscure. Dr. Andriole identified 33 men with isolated positive apical margins and compared them to a cohort of patients matched by age and preoperative PSA and biopsy Gleason parameters who were shown to have pathological T2 disease. Patients were evaluated for PSA failure at 1-, 3-, and 5-year intervals. PSA recurrence for survival at 5 years was 75% and 77%, respectively, for those with positive and negative api- Table 2 TURP-Detected Prostate Cancer No. Patients No prior biopsy No. (%) with Prostate Cancer 40 6 (15) One or more negative peripheral zone biopsy only 105 13 (13) 1 or more negative peripheral + T2 biopsy 144 11 (8) Data from Ornstein et al.26 TURP, transurethral resection of the prostate. VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY 79 Jackson Hole Urologic Conference continued Table 3 Trials Comparing Bicalutamide Monotherapy with Castration Author N Dose Stage of Disease Comparison Result 486 50 mg Stage D2 Castration Longer progression-free with castration Bales and Chodak10 1037 50 mg Stage D2 Castration Longer median survival with castration Tyrrell et al11 1453 150 mg Metastatic and locally advanced Castration Longer survival in M1 patients with castration Boccardo et al12 229 150 mg Metastatic and locally advanced Combined androgen blockade No difference in progression-free or overall survival Iversen et al8 480 150 mg Locally advanced Castration No difference in survival Chodak et al 9 biopsy grade. In a subset of low-risk patients, disease recurrence at 5 years was 15% for those with one third or less of the biopsies positive, as compared to 31% for those that had more positive biopsies. Similar findings were noted with intermediate- and higher-risk disease. The simplicity of simply identifying the number of biopsy cores that are positive renders this approach widely applicable, although certainly not as reproducible as a more sophisticated measurement, such as percent of cancer within a biopsy or millimeters of biopsies that showed carcinomas. Using percent of positive biopsies as a measure obviously has more general appeal. Obviously one confounder is the number of biopsies obtained, and this needs to be standardized for this method to be useful. Intermittent Androgen Deprivation Dr. Grossfeld provided an update on the University of California experience with intermittent androgen deprivation. Sixty-one patients were treated, including 34 patients with clinically localized disease and no prior treatment and 27 patients who had recurrent disease following local 80 VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY therapy. In their study, the University of California group treats patients with 6–9 months of androgen deprivation during the initial cycle. They continue this for 1 to 2 months after PSA either reaches a nadir or becomes undetectable. Patients who achieved a PSA nadir less than 0.1 ng/mL (for those with prior definitive local therapy) or less than 4.0 ng/mL (for those with no prior local therapy) are eligible for going off therapy. Androgen deprivation is then reinstituted when serum PSA reaches a predetermined level either greater than 50% of the pretreatment level or greater than 10.0 ng/mL, or by patient request. With follow-up between 7 and 60 months following the start of treatment, with a mean of 30 months, patients received one to five treatment cycles with a median of 2 cycles and the median cycle length being 14 months. Importantly, patients were off androgen deprivation 45% of the time, although this time interval decreased with the increasing number of cycles. Among a small subset of patients in which quality of life was measured with a variety of instruments, the researchers noted clinically significant improvement in health-related quality of life during the off-treatment episodes in the domains of vitality and fatigue, sexual function, and sexual bother. Anti-Androgen Monotherapy Dr. Grossfeld reviewed the experience with anti-androgen monotherapy in prostate cancer. A number of studies have reported on the use of bicalutamide in either the 50 or 150 mg per day dosing. These demonstrated that castration was superior irrespective of bicalutamide dose. Iversen and associates8 observed that in 480 patients with locally advanced nonmetastatic prostate cancer and a median follow-up of 6.3 years, highdose bicalutamide was reported to be equivalent to castration in terms of time-to-disease progression and overall survival. Significant benefit to the patients randomized to bicalutamide included improvement in sexual interest and physical capacity. Adverse side effects included hot flashes in the castration group and breast pain and gynecomastia in the bicalutamide group. Table 3 depicts several trials in which bicalutamide is compared with surgical or pharmacologic castration.8–12 Jackson Hole Urologic Conference Management of Disease Following Radical Prostatectomy The management of the man with positive surgical markers following radical prostatectomy is, as noted above, a confusing one. No definitive trials have been reported in which patients were properly randomized. Options include delayed radiation or androgen deprivation at the time of disease progression, immediate adjuvant radiation, or androgen deprivation. Each has its proponents. Grossfeld noted that although immediate radiation therapy in an adjuvant setting is certainly advocated by many, if not most, radiation oncologists, data from the University of Colorado and San Francisco demonstrate that if therapeutic radiation is given with a PSA below 2.0 ng/mL, the results are indistinguishable from patients receiving adjuvant radiation before PSA becomes detectable.13 Dr. Grossfeld described a decision analysis model to determine the preferred management of positive surgical margins.14 Using the average probability assessments from the literature, the decision model recommended initial surveillance. Sensitivity analyses demonstrated the model was dependent on the probability of disease recurrence in patients followed expectantly as well as the efficacy of therapeutic radiation. and Director of the Emory Continence Center in Atlanta, presented a number of papers on pelvic anatomy and the mechanisms of cystocele, rectocele, and urinary incontinence. In an illuminating presentation on the evaluation of the incontinent patient, Dr. Galloway cautioned that although traditional medical specialties have divided the organs of the pelvis into the gastrointestinal, gynecologic, and genital urinary “camps," that in fact these organs work together in health and often fail together in disease. He underscored the need for a broader approach to optimum management of patients with pelvic disorders. In addition to the evaluation of the patient, Dr. Galloway emphasized the importance of a full clinical history, a thorough physical examination, measurement of uroflow and postvoid residual volume, and urine analysis. He has his patients keep a bladder diary before their visit. One point that was illuminating to most of the audience was that the foot is innervated by S2 and S3, and thus examination of the feet gives an Urinary Diversion Dr. Grossfeld gave an interesting talk on orthotopic urinary diversion in women requiring cystectomy. He noted that increase in experience demonstrated that this method is a safe and reliable method of urinary diversion in properly selected patients. Examination must include assurance that urethra is not involved in neoplasia. Stein and associates15 noted that the only risk factors for urethral involvement, based on 67 female cystectomy specimens, are tumor involvement of the bladder neck or the anterior vaginal wall. Dr. Grossfeld's summary of the literature may be found in Table 4. Incontinence Niall Galloway, Associate Professor Table 4 Continence Results for Women Undergoing Orthotopic Urinary Diversion Following Cystectomy Author Year N % Continent Stein (personal communication) 2001 88 75% 34% 14% Blute and Gburek 1998 5 80%–100% 20% — Cancrini et al28 1995 7 71%–100% — — Hautman et al 1996 18 85% 70% — Jarolim et al 1997 12 92% 8% — Mills and Studer31 2000 15 80%–100% 7% — Shimogaki et al32 1999 8 50% — Stenzl et al 1997 20 79%–88% 4% — UCSF 2001 25 76% 8% 16% 27 29 30 33 88% % Catheterize % Additional Treatment for Incontinence UCSF data from Gary D. Grossfeld, MD. VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY 81 Jackson Hole Urologic Conference continued Table 5 Spontaneous Passage Rates for Ureteral Stones Size Rate Location Rate <4 mm 57% Proximal 12% 4–6 mm 35% Middle 22% >6 mm 8% Distal 45% Data from Hubner et al.16 indication of the neuronal health or lack thereof of the pelvic floor and sphincters, which are innervated by S3, S4, and S5. Another physical finding that may demonstrate underlying pathology is asymmetry of the buttocks and gluteal folds in the standing position. Two-point discrimination, he feels, should be evaluated in the peri-anal and post-anal dermatomes and muscle tone and group of the circum-vaginal and anal sphincter muscles. The perineum should be examined with a full bladder in the standing as well as the supine position. The bladder scan provides an easy method of evaluating a post-void residual volume, which can be measured repeatedly. Dr. Galloway advocates non-surgical treatments for all patients initially. These include fluid and bowel management, skin care, and containment issues. Careful drug history is important, and agents such as -blockers should be avoided, as they result in incontinence. Dr. Galloway recommends a natural conservation management and evaluation. However, if the symptoms are moderate or severe, or if anatomical defects are present, urodynamic evaluation is important. Endourology Distal Ureteral Stones Dr. Margaret Pearle, Associate Professor of Urology at the University of Texas Southwestern Medical Center, provided an update on a number of 82 VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY endourologic advances. Perhaps no field of urology is today more controversial than the option of therapy for distal ureteral stones. She noted that observation is appropriate in select cases, and with ureteral stent placement to dilate the ureter, spontaneous passage is common. Ureteroscopy (URS) and shockwave lithotripsy (SWL) are both highly successful with low complication rates. Salvage therapy, either laparoscopic or open ureterolithotomy, are rarely needed. The rates for spontaneous passage of stones have been reviewed by Hubner et al16 (see Table 5). The use of a stent as definitive management is demonstrated by Leventhal et al.17 He randomized men to URS versus stent placement. Seventeen patients were initially managed with a ureteral stent. Eighty-three percent passed the stone at a mean of 6.6 days. There was no difference in stone size between groups. Dr. Pearle made the point that when SWL is considered for ureteral stone management, if a stent needs to be passed it may be just as easy to pass a 7 French ureteralscope and treat the stone definitively. Complications associated with SWL are primarily related to fragment passage, with sepsis occurring in 1% to 1.5%. No ureteral injury or stricture has been reported with SWL in the absence of manipulation or stem placement. Complications from URS include a perforation rate that is now less than 4% and late ureteral stricture formation in 2%. Wollin and Denstedt18 randomized 58 patients with ureteral stones to receive a stent or not. At 1 week, flank and bladder symptoms were greater in patients with a stent. One hundred percent stone-free status was achieved in all patients, and one patient in each group required an emergency room visit or admission. These authors concluded that routine stent placement after uncomplicated URS for distal ureteral stones may be unnecessary. A number of studies have been reported in which patients were randomized to URS versus SWL for distal ureteral stones. A report by Deliveliotis et al19 randomized patients equally to URS versus SWL. For distal stones, stone-free rates were 100% in the URS group and 98% in the SWL group, with a 6% retreatment rate. SWL operating room time was 10 minutes shorter, and there was a 4% stricture rate in Faculty, 3rd Annual Jackson Hole Summer Urologic Conference Gerald L. Andriole, MD Washington University, School of Medicine St. Louis, MO Margaret S. Pearle, MD Associate Professor of Urology University of Texas Southwestern Medical Center at Dallas Dallas,TX Gary D. Grossfeld, MD Assistant Professor of Urology University of California at San Francisco San Francisco, CA Niall T.M. Galloway, MD, FRCS Associate Professor, Medical Director The Emory Continence Center, Department of Urology Atlanta, GA Lawrence S. Ross, MD Clarence C. Saelhof Professor and Head, Department of Urology University of Illinois at Chicago Chicago, IL Jackson Hole Urologic Conference Table 6 Balloon Dilation: Review of the Literature Author N Caliber Balloon Size Stent (Fr) Duration of Stent Success Follow-up Johnson et al34 31 4–10 mm 5–14 ≥2 d 58% (18/31) ≥6 mo — — — 39% (7/18) — Smith35 5 Chang et al22 10 5–8 mm 8–16 4–8 wk 70% (7/10) — O'Brien et al 14 4–6 mm 8.5 — 57% (8/14) 14 mo Beckmann and Roth37 17 4–10 mm 7–10 4–8 wk 82% (14/17) 15 mo Kramolowsky et al38 14 — — — 64% (9/14) 27 mo Netto et al 21 4–6 mm 8.5 Average 40 d 57% (12/21) 21 mo Ravery et al40 11 10 mm 8 2.1 mo 40% (4/10) 16 mo — — — 59% (79/135) — 36 39 Total 123 the URS group, with none in the SWL group. Peschel et al20 reported on 80 patients with distal ureteral stones that failed to pass in 3 weeks. They were randomized to SWL or URS. Stone-free rates were 90% in the SWL and 100% in the URS group. Operating room times were shorter for URS, as was time to becoming stone-free. Ureteral Strictures Dr. Pearle reviewed the endourologic management of ureteral strictures. She notes that URS is the most common cause today for these. Treatment options include balloon dilation, endoureterotomy, and ureteroneocystostomy. She reviewed the literature with respect to balloon dilation, as is shown in Table 6. Diagnostic factors associated with stricture duration have been reported by Beckmann21 for strictures of less than 3 months’ duration. There was an 88% success rate, compared to 67% for those of longer status. Chang et al22 noted 91% success for strictures of less than 3 months versus 25% for those greater than 3 months. Chang22 also noted the length of stricture would offer prognostic information, with 100% of stricture success with balloon dilation for those less than 1.5 cm versus 12.5% for those greater than 1.5 cm. Endoureterotomy technique was discussed. Dr. Pearle recommends a transmural endoscopic incision through the stricture extending into normal ureter proximally and distally. Stent placement for 6 weeks is required. A review of the literature with respect to endoureterotomy may be found in Table 7. Complications from endoureterotomy include rare urinoma formation and ureteroenteric fistula. Vascular injuries also are rare but must be considered as a potential outcome. Dr. Pearle concluded that endourologic management of benign ureteral and ureteroenteric strictures provides reasonable first-line therapy. Endoureterotomy has a higher success rate than balloon dilation and the Table 7 Endoureterotomy: Results Author N Modality Follow-up Schneider et al41 12 Cold knife 15 mo 67% (8/12) Meretyk et al42 13 Electrified cut 20 mo 62% (8/13) Yamada et al 20 Cold knife 18 mo 85% (17/20) Cornud et al44 31 Electrified cut >12 mo 71% (22/31) Preminger et al45 40 Acucise 8.7 mo 53% (21/40) Singal et al 12 Ho:YAG ≥9 mo 75% (9/12) Wolf et al47 38 Variety 28 mo 82% (31/38) 43 46 Total 166 — — VOL. 4 NO. 2 2002 Success 70% (116/166) REVIEWS IN UROLOGY 83 Jackson Hole Urologic Conference continued latter is exceedingly prone to failure for ureteroenteric strictures. She underscored the need for prospective randomized trials to optimize treatment methods. Lower Pole Ureteral Stones Management of the lower pole ureteral stone remains controversial. Perhaps the most important study in this regard was the meta-analysis performed by Lingeman et al.23 Thirteen shockwave studies and three percutaneous nephrolithotomies were evaluated. This study demonstrated that, controlling for stone size, patients with lower pole stents are 6.27 times more likely to be rendered stone-free with percutaneous approaches as compared to SWL. The Critique Panel, 3rd Annual Jackson Hole Summer Urologic Conference Michael K. Brawer, MD Director, Northwest Prostate Institute Northwest Hospital Seattle,WA Elspeth M. McDougall, MD Professor of Urologic Surgery Vanderbilt University Medical Center Nashville,TN Randall B. Meacham, MD Associate Professor Residency Program Director & Chief, Division of Urology Director of Male Reproductive Medicine and Surgery University of Colorado Health Science Center Denver, CO Ian M.Thompson, MD Professor and Chief Division of Urology University of Texas Health Science Center San Antonio,TX Hunter Wessells, MD Associate Professor Department of Urology University of Washington Harbor View Medical Center Seattle,WA 84 VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY Stone Size < 10 mm 11– 20 mm >20 mm Narrow infundibulum Infundibular angle <70 Multiple calyces Narrow infundibulum Infundibular angle <70 Multiple calyces PCNL YES URS SWL NO SWL YES URS PCNL NO SWL URS PCNL Figure 1. Algorithm for management of lower pole stones. URS, ureteroscopy; SWL, shockwave lithotripsy; PCNL, percutaneous nephrolithotomy. prospective randomized trial by Lingeman, in which 160 patients were randomized to SWL versus percutaneous nephrolithotomy (PCNL) and stratified with stone size, demonstrated that lithotripsy resulted in stone-free status in only 37%, compared to 95% of those having a percutaneous approach. Dr. Pearle's algorithm for the management of lower pole stones is shown in Figure 1. Dr. Pearle's conclusion as to the outcome and management of lower pole calculi is that for small stones (<10 mm), SWL is reasonable first-line therapy. For larger stones (>20 mm), PCNL is preferred. For stones intermediate in size (11–20 mm), the main treatment decision is based on renal anatomy and stone composition. She added that ureterorenoscopy is a reasonable option for small to mid-size stones or stones that have failed SWL. Infertility Lawrence Ross, Professor and Chairman of the Department of Urology at the University of Illinois, presented a number of papers on the management of infertility. In an informative lecture on the role of testis biopsy in the modern manage- ment of infertility, Dr. Ross said there is little role for same. The differential of obstructive versus nonobstructive azoospermia can not be determined by physical examination of the testis and endocrine profiles. In a very interesting paper, Dr. Ross reviewed the cost/benefit analysis of the management of male infertility. He noted that in cases of severe male factors, such as azoospermia and severe oligospermia, the only treatment approach may be in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). But in the more common, treatable forms of male infertility, including varicocele, obstructive azoospermia, endocrine dysfunction, and infection, definitive therapy of these conditions may be more costeffective. In a study by Neumann and associates,24 charges per cycle for IVF from six facilities in the United States and estimated delivery rates from the published literature were evaluated. They observed that the cost per success for delivery with IVF was $66,667 for the first cycle, increasing to $114,286 by the sixth cycle. The cost was considerably greater in older women and if there was a male factor contributing to the Jackson Hole Urologic Conference infertility. The Society for Assisted Reproductive Technology has reported that for the most recent reporting period (1998), when three embryos are transferred in an IVF cycle, the live birth rate is 37.7% for a woman 20 to 29 years of age, diminishing to 8.3% for women 40 to 44. The overall birth rate per cycle for all patients undergoing IVF remains at 25% and unfortunately has not changed over the last 5 years. Schlegel25 did a cost-effectiveness comparison of varicocele ligation to IVF/ICSI. The cost for varicocelectomy was $26,268 versus $89,091, based on figures from Cornell University. They noted that the average published delivery rate for ICSI was 28% versus 30% for vericocolectomy. Comparing similar results for vasectomy reversal, the cost for delivery was $72,521 for sperm retrieval and ICSI versus $25,475 for vasovasostomy. These data suggested that in cases of male-factor infertility procedures directed to the male generally are more cost effective and allow natural conception. Upcoming Meetings at Jackson Hole The 2002 Jackson Hole Summer Meeting will be held July 27–August 2. Interested readers should contact Kay Christensen, Conference Coordinator, for more information at 307-856-5758. 7. 8. 9. 10. References 1. 2. 3. 4. 5. 6. Lui PD, Terris MK, McNeal JE, Stamey TA. Indications for ultrasound guided transition zone biopsies in the detection of prostate cancer. J Urol. 1995;153:1000–1003. Liu IJ, Macy M, Lai Y, Terris MK. Critical evaluation of the current indications for transition zone biopsies. Urology. 2001;57:1117–1120. Babaian RJ. Extended field prostate biopsy enhances cancer detection. Urology. 2000;55:453–456. Bazinet M, Karakiewicz PI, Aprikian AG, et al. Value of systematic transition zone biopsies in the early detection of prostate cancer. J Urol. 1996;155:605–606. Keetch DW, Catalona WJ. Prostatic transition zone biopsies in men with previous negative biopsies and persistently evaluated serum prostate specific antigen values. J Urol. 1995;154:1795–1797. Morote J, Lopez M, Encabo G, de Torres I. Value of routine transition zone biopsies in patients undergoing ultrasound-guided sextant biopsies 11. 12. 13. 14. 15. for the first time. Eur Urol. 1999;35:294–297. Onder AU, Yalcin V, Arar O, et al. Impact of transition zone biopsies in detection and evaluation of prostate cancer. Eur Urol. 1998;33:542–548. Iversen P, Tyrrell CJ, Kaisary AV, et al. Bicalutamide monotherapy compared with castration in patients with nonmetastatic locally advanced prostate cancer. 6.3 years of followup. J Urol. 2000;164:1579–1582. Chodak G, Sharifi R, Kasimis B, et al. Singleagent therapy with bicalutamide: a comparison with medical or surgical castration in the treatment of advanced prostate carcinoma. Urology. 1995;46:849–855. Bales GT, Chodak GW. A controlled trial of bicalutamide versus castration in patients with advanced prostate cancer. Urology. 1996;47:38–43. Tyrrell CJ, Kaisary AV, Iversen P, et al. A randomized comparison of 'Casodex' (bicalutamide) 150 mg monotherapy versus castration in the treatment of metastatic and locally advanced prostate cancer. Eur Urol. 1998;33:447–456. Boccardo F, Rubagotti A, Barichello M, et al. Bicalutamide monotherapy versus flutamide plus goserelin in prostate cancer patients: results of an Italian Prostate Cancer Project study. J Clin Oncol. 1999;17:2027–2038. Nudell DM, Grossfeld GD, Weinberg VK, et al. Radiotherapy after radical prostatectomy: treatment outcomes and failure patterns. Urology. 1999;54:1049. Grossfeld GD, Tigrani VS, Nudell D, et al. Management of a positive surgical margin after radical prostatectomy: decision analysis. J Urol. 2000;164:93–99;discussion 100. Stein JP, Cote RJ, Freeman JA, et al. Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a patholog- Main Points • A prospective evaluation of 259 men with lower urinary tract symptoms (LUTS) who underwent transurethral resection of the prostate (TURP) demonstrated that a considerable portion of patients who have negative peripheral and transition zone biopsy may harbor significant carcinoma of the prostate at the time of TURP. • A study comparing 33 men with isolated positive apical margins following radical prostatectomy to a cohort of controls concluded that, when controlling for other prognostic parameters, a positive margin at the apex is not associated with untoward prognosis. • Univariate and multivariate analysis of the CaPSURE registry of patients in the United States showed that percentage of biopsies positive for cancer following radical prostatectomy is a significant predictor of both extracapsular disease and disease recurrence. • A presentation on orthotopic urinary diversion in women requiring cystectomy noted that increase in experience has demonstrated this to be a safe and reliable method of urinary diversion in properly selected patients. • After reviewing treatment options for ureteral strictures, one presenter concluded that endourologic management of benign ureteral and ureteroenteric strictures provides reasonable first-line therapy. Endoureterotomy has a higher success rate than balloon dilation, and the latter is exceedingly prone to failure for ureteroenteric strictures. • A presentation regarding the outcome and management of lower pole calculi concluded that for small stones (<10 mm), shockwave lithotripsy is reasonable first-line therapy. For larger stones (>20 mm), percutaneous nephrolithotamy is preferred. For stones intermediate in size (11–20 mm), the main treatment decision is based on renal anatomy and stone composition. • A review of cost/benefit analyses of the management of male infertility concluded that in cases of severe male factors, such as azoospermia and severe oligospermia, the only treatment approach may be in vitro fertilization or intracytoplasmic sperm injection; but in the more common, treatable forms of male infertility, including vericocele, obstructive azoospermia, endocrine dysfunction, and infection, definitive therapy of these conditions may be more cost-effective. VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY 85 Jackson Hole Urologic Conference continued 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 86 ical review of female cystectomy specimens. J Urol. 1995;154:1329–1333. Hubner WA, Irby P, Stoller ML. Natural history and current concepts for the treatment of small ureteral calculi. Eur Urol. 1993;24:172–176. Leventhal EK, Rozanski TA, Crain TW, Deshon GE Jr. Indwelling ureteral stents as definitive therapy for distal ureteral calculi. J Urol. 1995;153:34–36. Denstedt JD, Wollin TA, Sofer M, et al. A prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy. J Urol. 2001;165:1419–1422. Deliveliotis C, Stavropoulos NI, Koutsokalis G, et al. Distal ureteral calculi: ureteroscopy vs. ESWL. A prospective analysis. Int Urol Nephrol. 1996;28:627–631. Peschel R, Janetschek G, Bartsch G. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study. 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