New Findings in Bladder and Prostate Cancer
Meeting Review
RIU0340_12-12.qxd 12/12/07 8:37 PM Page 214 MEETING REVIEW New Findings in Bladder and Prostate Cancer Highlights of the 22nd Annual Congress of the European Association of Urology, March 21-24, 2007, Berlin, Germany [Rev Urol. 2007;9(4):214-219] © 2007 MedReviews, LLC Key words: Bladder cancer • Prostate cancer • Transitional cell carcinoma • Urothelial tumors • Prostate biopsy • Laparoscopic radical prostatectomy • Human kallikrein he 22nd Annual Congress of the European Association of Urology in Berlin, March 21-24, 2007, offered an array of 1070 posters and 42 videos. Major topics regarding transitional cell carcinoma (TCC) included basic research, prognostic factors and outcome, and management of superficial and muscle-invasive carcinoma. Important new research was presented on diagnosis, biopsy, and surgical approaches for carcinoma of the prostate. T Transitional Cell Carcinoma Basic Research Kramer and colleagues1 assayed the prognostic potential of hyaluronic acid (HA), hyaluronidase (HYAL1), and HYAL1-v1, which is an inactive version of HYAL1, for bladder cancer. Their study included specimens from 179 bladder cancer patients, among Reviewed by Maximilian Rom, MD, Franklin E. Kuehhas, MD, Bob Djavan, MD, PhD, Department of Urology, Medical University of Vienna, Austria. 214 VOL. 9 NO. 4 2007 them cases of superficial and muscleinvasive disease. They found that both HA and HYAL1 were higher in muscle-invasive tumors than in non-muscle-invasive tumors. HYALv1, on the other hand, appeared to be downregulated in bladder cancer. It could be concluded that HA and HYAL1 have prognostic significance because they were able to predict progressiveness with a sensitivity of 81% and a specificity of 70% when combined. Sensitivity and specificity were slightly lower when HA and HYAL1 were measured individually. The screening of telomerase-related genes in bladder cancer was presented by Wang and associates,2 who examined the molecular mechanisms that occur around telomerase in order to increase understanding of the development of bladder cancer. They found that significant up-regulation of 76 genes occurred with telomerasepositive samples, whereas none of these genes were up-regulated in the telomerase-negative tissues. Then again, down-regulation of 71 genes was REVIEWS IN UROLOGY observed in the telomerase-negative samples but not in the positive. Jang and coworkers3 studied the expression of cyclooxygenase-2 (COX-2) in human bladder cancer. Tissue taken from the tumor was compared with cancer-surrounding tissue and completely healthy tissue. The results presented an overexpression of COX-2 in cancer material. The authors expect COX-2 to be involved in tumorigenesis rather than in progression or recurrence. Dubosq and associates4 prospectively evaluated the inactivating mutations of protein 53 (p53) as well as the activating mutations of fibroblast growth factor receptor 3 (FGFR3) in superficial bladder cancer to review their usefulness in the classification of bladder cancer. They found that FGFR3 mutations are common in lowstage and low-grade urothelial cell carcinoma. Tumors with inactivated mutation of p53 have a higher risk of recurrence. The study further showed that mutated FGFR3 is an indicator for little potential of progression. RIU0340_12-12.qxd 12/12/07 8:37 PM Page 215 EAU Congress Highlights Prognostic Factors and Outcome Suttmann and colleagues5 compared different prognostic factors affecting progression and survival of TCC of the ureter. The factors that were observed included laboratory parameters as well as clinical and pathological data. Five-year survival ranged from 96.1% (T1) to 28.6% (T4) and from 100% (G1) to 51.9% (G3). What’s even more interesting is that humoral factors such as elevated alkaline phosphatase in the serum and high white blood cell count indicate a poor prognosis. Other factors that seem to have an impact on the prognosis are platelet count, -glutamyl transferase, creatinine, and blood urea nitrogen. An interesting contribution by Gupta and coworkers6 assessed the outcomes of 171 US patients with T1G3 TCC who were treated with radical cystectomy. Patients were divided postoperatively into 3 subcategories. The first category included those with lower pathological than clinical stage and negative lymph nodes, the second those with the same pathological stage and negative lymph nodes, and the third those with higher pathological stage and/or positive lymph nodes. A large percentage of patients with T1G3 TCC were pathologically upstaged at cystectomy, and survival rates were not very good. Carcinoma in situ (CIS) proved to be the only reliable predictor, indicating a bad prognosis. Management of Superficial Urothelial Tumors CIS is an aggressive type of superficial bladder cancer with very high recurrence and progression. Bacille Calmette-Guérin (BCG) therapy is state of the art, but some tumors are not sensitive to BCG. Witjes and colleagues7 therefore studied the treatment of BCG-refractory CIS with hyperthermia and mitomycin (MMC). An intravesical catheter equipped with a radio-frequency antenna (Synergo® system SB-TS 101; Medical Enterprises Group, Amsterdam, Netherlands) was used to cause hyperthermia (between 41C and 44C), weekly for 6 to 8 weeks, while MMC was instillated with 2 30-minute cycles. The fact that 94% of patients responded completely to the treatment suggests that the combination of MMC and hyperthermia is a good alternative to BCG if the tumor is refractory or if the patient cannot endure the side effects. On the other hand, the recurrence rate after 1 year was around 30%. Rischmann and coworkers8 assayed the protective effect of ofloxacin against the side effects of BCG instillation therapy in patients with super- to be necessary, especially if there is also a CIS. BCG treatment might be offered in non-muscle-invasive disease with no CIS. Horstmann and colleagues10 investigated the differences in bladder cancer between men and women. They compared such factors as age at cancer detection, tumor classification, recurrence, and clinical outcome in 1269 patients. The results showed that women were older than men at the age of detection (67 years vs 62 years) and had lesser and less aggressive tumors. Men had a better overall survival rate than women once a tumor became muscle-invasive. The objective of Alken and coworkers11 was to compare the quality of transurethral detection and resection Ofloxacin may be effective against the side effects of BCG instillation therapy in patients with superficial bladder cancer. ficial bladder cancer. They further wanted to determine whether ofloxacin could improve the effectiveness of BCG. One hundred fifteen patients who received BCG therapy were additionally given either ofloxacin or placebo. BCG therapy had to be stopped because of side effects more often in the group that received the placebo, suggesting that ofloxacin may be effective in this matter. It has not been proved, though, that ofloxacin can enhance the effect of BCG. An extraordinary type of bladder cancer was examined by Gaya and associates.9 Micropapillary urothelial carcinoma (MUC) is a variant of urothelial carcinoma with high metastatic potential. Because few data regarding treatment outcomes exist, patients with non-muscle-invasive MUC often receive intravesical therapy with the purpose of bladder preservation. Because the prognosis is not very good in these cases, the Gaya group concluded that radical therapeutic options seem of bladder carcinomas under 5aminolevulinic acid-induced fluorescence light (FC) with conventional visible white light (VC). They randomized 1048 patients with suspected superficial bladder cancer into a fluorescence group and a conventional group. All received transurethral resection (TUR) of the tumor afterwards. The fluorescence-guided cystoscopy showed significantly better detection rates than conventional cystoscopy. Long-term recurrence could not be investigated because most patients received second-look TUR and underwent fluorescence-guided cystoscopy. Management of Invasive Urothelial Tumors Polyakov and associates12 evaluated the feasibility of radical cystectomy in elderly patients ( 75 years), considering the increase in morbidity and mortality during and after the operation. Patients younger than 75 years VOL. 9 NO. 4 2007 REVIEWS IN UROLOGY 215 RIU0340_12-12.qxd 12/12/07 8:37 PM Page 216 EAU Congress Highlights continued were put into group 1, the older ones into group 2. No difference could be observed regarding pT-stage, surgical time, intra- and perioperative complications, blood loss, hospitalization, and urinary diversion-type specific complications, although the younger group had better outcomes concerning continent urinary diversion, nonsurgical complications, in-hospital mortality, and complete postoperative recovery. Thus, it can be said that age, represented by a cut-off at 75 years, does not have a very impressive impact on the outcome of radical cystectomy. The difference between progressive and primary muscle-invasive bladder cancer treated with radical cystectomy was investigated by Cho et al.13 Of the 223 patients who were retrospectively evaluated, 50 had progressive muscle-invasive disease and 173 had primary muscle-invasive bladder cancer. Of the total patients, 45.6% died of the disease. The 5-year disease-specific survival was 36.4% in the group with progressive disease and 61.1% in the primary group. Increased lymph-node involvement and the occurrence of micrometastases are suspected to be the reason for the lower survival rate. It becomes more and more evident that the quality of radical cystectomy has a direct effect on patient outcome. Quality-of-life and functional considerations have led to surgical modifications such as prostate-sparing approaches. Lindenmeir and coworkers14 assayed incidental prostatic cancer prevalence in cystectomy patients. In patients undergoing radical cystectomy, 40% also had prostatic cancer. Sixty percent of them had preoperative PSA levels of less than 4 ng/mL. About 65% of the prostate cancer was clinically significant. The results suggest that prostate-sparing techniques should only be used in a restrictive manner, even if the PSA is below 4 ng/mL. 216 VOL. 9 NO. 4 2007 Krause and colleagues15 evaluated the long-term results of TUR and radiochemotherapy of invasive bladder cancer. The tumors presented in many different stages, notably from T1 to T4 and from G1 to G3 as well as from R0 to R3. It became evident that TUR followed by radiochemotherapy is a good alternative to radical cystectomy, especially as patients are getting older. Still, to have acceptable long-term results, R0 status after TUR is necessary. [Maximilian Rom, MD, Bob Djavan, MD, PhD] Carcinoma of the Prostate Diagnosis One of the new experimental approaches to diagnose prostate cancer is the analysis of human kallikreinlike peptidase (KLK) 14 and 15. The most prominent member of the KLK specimens of patients with prostate cancer suspicion and its potential to spare useless prostatic biopsies.17 The outcome showed that telomerase activity is easily detected in fresh voided urine after prostatic massage, but not in urine voided before massage. Furthermore it was shown that, coupled with a PSA cutoff value of 4 ng/mL, detection of telomerase activity in prostatic fluid specimen would have spared useless prostatic biopsies to 18 of 21 patients (86%). Van Port and coworkers18 studied 542 patients with prostate cancer who underwent radical prostatectomy. The aim was to investigate the clinical significance of small-volume tumors, as many investigators consider them clinically insignificant. Seventy-three specimens fulfilled the study requirements of total tumor volume of 0.5 cm3 Kallikrein-like peptidase 14 and 15 represent suitable new biomarkers with prognostic significance for prostate adenocarcinoma. family is KLK3, commonly called prostate-specific antigen (PSA), which has revolutionized the diagnosis of prostate cancer. Rabien and associates16 examined the suitability of KLK14 and 15 as potential biomarkers for prostate cancer. For both proteins, results of the mRNA analysis did not show any diagnostic or prognostic significance, whereas immunohistochemistry revealed that the expression levels in prostate adenocarcinomas correlated positively with the pathological tumor stage in the Spearman rank test. KLK15 expression was furthermore associated with higher tumor grading according to Gleason (Fisher’s exact test). To sum up the results of this interesting study, KLK14 and 15 represent suitable new biomarkers with prognostic significance for prostate adenocarcinoma. Another study evaluated the role of telomerase activity in prostatic fluid REVIEWS IN UROLOGY or less and a Gleason score 7. Patients were postoperatively followed for a median period of 39.5 months. Biochemical recurrence was defined as 2 consecutive PSA levels 0.10 ng/mL. The conclusion of this investigation is that patients with small-volume prostate cancer have a relatively low risk of an unfavorable long-term outcome. Nevertheless, small tumor volume does not guard patients from developing biochemical recurrences after the radical treatment, and even some pathological features typical for a poor prognosis were found postoperatively. These findings suggest that new studies are needed to examine the prognostic relevance of small-volume tumors and that focus should be on the development of therapies that are most suited for this group of patients. Haese and colleagues19 evaluated the diagnostic value of percent of free RIU0340_12-12.qxd 12/12/07 8:37 PM Page 217 EAU Congress Highlights PSA (%fPSA) in total PSA ranges below 2.5 ng/mL, the generally accepted cutoff for prostate biopsy, because a substantial number of patients below that cutoff harbor prostate cancer. Total PSA provides limited information within this margin, so that investigation should focus on the detection of new factors that can serve to diagnose prostate cancer. The conclusion is that with total PSA levels lower than 2.5 ng/mL, %fPSA is the most informative predictor, followed by transi- standard to get histopathological information of the prostate, but its mortality rate has never been examined. Gallina and associates21 studied more than 22,000 patients who underwent 1 or more prostate biopsy sessions. Their aim was to identify the mortality rate and risk factors for fatal outcome after prostate biopsies. Results showed an overall mortality of 1.3% 120 days after biopsy. Of men aged 60 years, 0.2% died within 120 days versus 2.5% of men aged 76-80. Risk factors for a fatal outcome Measurement of the amount of intracellular PSA in peripheral blood macrophages enables clear distinction between benign and malignant disease. tional-zone density and PSA density. Total PSA and DRE provide only very limited information. In other words, the Haese group recommends the use of %fPSA in patients with PSA values under the biopsy cutoff of 2.5 ng/mL. A very promising approach to discriminating between benign and malignant prostatic disease is the use of PSA-positive macrophages (Mf) in peripheral blood (imPSA). Results presented in Berlin showed that the measurement of the amount of intracellular PSA in peripheral blood macrophages enables clear distinction between benign and malignant disease. Moreover, localized prostate cancer significantly differed from metastatic disease with regard to the level of circulating Mf. The highest level was found in metastatic prostate cancer and the lowest in levels in controls, suggesting that malignancy correlates with the amount of positive Mf. The study reveals the superiority of imPSA over serum total PSA measurement.20 Prostate Biopsy Transrectal ultrasound (TRUS) guided biopsy of the prostate is the diagnostic are old age and increasing comorbidity Charlson score. Furthermore, first ever biopsy procedures carried a higher mortality risk than subsequent procedures. Another interesting question is whether to use local anesthesia during TRUS-guided prostate biopsy. Findings showed that patients well tolerating initial TRUS do not require local anesthesia during TRUS-guided prostate biopsy. In patients with medium and severe discomfort/pain at TRUS, local anesthesia with intrarectal and anal lidocaine-prilocaine is highly effective in alleviating pain during subsequent TRUS-guided prostate biopsy, with no increase of the complication rate.22 Recent results of the European Prostate Cancer Detection Study (EPCDS) and the 3-dimensional reconstruction of cancers detected on first and repeat biopsy suggested that cancers detected on repeat biopsy were found in more dorsolateral (pararectal) and apical locations. The Vienna Nomograms further identified the optimal number of cores required. Interesting results were presented by Djavan et al.23 In the multi-institutional study (8 European university centers) the value and legacy of saturation biopsies (22 cores) was evaluated versus a novel biopsy protocol using the Vienna Nomograms. The conclusion of the study is that saturation biopsy and modified biopsy protocols using volume/age charts such as the Vienna Nomogram resulted in a 69% to 78% improvement of the cancer detection rate on repeat biopsy as compared with standard repeat biopsy technique. Saturation biopsies were not necessary in all patients with negative initial biopsies. They were beneficial in patients with HGPIN on first biopsy, PSA 8 ng/mL, total Vol 50 cm3, TZ Vol 20-40 cm3, TZ/PZ ratio 0.4, and a negative prior history of biopsies, resulting in a further 37% increase in detection rates. The Surgical Approach Laparoscopic radical prostatectomy and, more recently, the roboticassisted laparoscopic radical prostatectomy are new treatment options for prostate cancer. It is still not very clear which option is the best to use and what kind of indications have to be fulfilled to use either open, laparoscopic, or robotic-assisted laparoscopic radical prostatectomy. New results from different centers on the experience with these 3 approaches were presented in Berlin. A very interesting study by Hennenlotter and coworkers24 focused on the evaluation of the nerve distribution of the entire prostate surface. Continence and potency rates are highly associated with the nervesparing radical prostatectomy, and it is known that successful outcome depends on the best knowledge of the nerve distribution surrounding the prostate. Recent literature is focused mainly on the anterior aspect of the prostate. This investigation confirmed VOL. 9 NO. 4 2007 REVIEWS IN UROLOGY 217 RIU0340_12-12.qxd 12/12/07 8:37 PM Page 218 EAU Congress Highlights continued the recently discussed notion of the distribution, but it was also shown that notable concurrent increase of nerve fibres in the dorsal localization is also detectable. This conclusion might improve continence and potency rates after nerve-sparing radical prostatectomy. Increasing experience with radical prostatectomy has prompted interest in approaching locally advanced prostate cancer (pT3) with surgical means. Findings showed that radical prostatectomy is a viable option for patients with pT3 tumors, particularly in view of long-term survival. On the other hand, the outcome of men with seminal vesical invasion (pT3b) is associated with a significantly poorer prognosis.25 Another study stated that more than 1 out of 3 patients with clinical pT3 prostate cancer will be free of biochemical recurrence after radical prostatectomy.26 These data strongly confirm the validity of radical prostatectomy as a treatment option in high-risk patients.27 The lack of consensus on how to measure and report continence after radical prostatectomy drove many investigations. The main question is whether patients who are using a pad for occasional urine leak should be reported as continent. Quality-of-life analysis strengthens the argument that definition of continence after radical prostatectomy should stick to an enforced “never wear a pad-never have a leak” rule.28 Since the first description of laparoscopic radical prostatectomy, several modifications have been implemented. There is still doubt if this method can reduce complications, shorten operative time, and reduce positive surgical margin rates with improved preservation of quality-of-life in comparison with the open approach. Diverse results presented in Berlin showed that laparoscopic surgery provides oncological efficacy comparable with that of open surgery.29,30 Rigatti and colleagues31 demonstrated that laparoscopic prostatectomy shows similar results compared with the radical retropubic approach considering lower urinary tract function at a 9-month follow-up. More recently, robotic surgery is increasingly becoming a popular al- ternative to laparoscopy in certain surgical procedures, as it is able to overcome several limitations of traditional laparoscopy. When robotic surgery first was developed, its main purpose was to aid in cardiac surgery by eliminating hand tremor and allowing surgeons to perform bypass operations on a beating heart. More recently, urologic surgeons have utilized and popularized surgical robotics for several operations including radical prostatectomy, nephrectomy, cystectomy, and pyeloplasty. Long-term results are still not available, but the data already presented in the literature dealing with the outcome of robotassisted radical prostatectomy seem to be very promising.32,33 Thaly and associates34 showed that robotic radical prostatectomy is a safe, feasible, and minimally invasive alternative for the treatment of prostate cancer. Mottrie and coworkers35 demonstrated similar results. Another investigation presented the histopathological data of 1200 cases of robotassisted laparoscopic prostatectomy. The overall margin positive rate was 11.2%, and recurrence has only been Main Points • Combined measurement of hyaluronic acid (HA) and hyaluronidase (HYAL1) was able to predict progressiveness of bladder cancer with a sensitivity of 81% and a specificity of 70%. • Ninety-four percent of patients with Bacille Calmette Guérin therapy-refractory tumors responded completely to the combination of mitomycin and hyperthermia, but the recurrence rate after 1 year was approximately 30%. • Fluorescence-guided cystoscopy showed significantly better detection rates than conventional cystoscopy. • Transurethral resection with following radiochemotherapy is a good alternative to radical cystectomy, especially for older patients. • The most prominent member of the kallikrein-like peptidase (KLK) family is prostate-specific antigen (KLK3), but KLK14 and 15 represent suitable new biomarkers with prognostic significance for prostate adenocarcinoma. • With total PSA levels lower than the biopsy cutoff of 2.5 ng/mL, percent of free PSA is the most informative predictor of prostate cancer, followed by transitional-zone density and PSA density. Total PSA and digital rectal exam provide only limited information. • Saturation biopsy and modified biopsy protocols using volume/age charts such as the Vienna Nomogram resulted in a 69% to 78% improvement of the cancer detection rate on repeat biopsy as compared with standard repeat biopsy technique. • Quality-of-life analysis strengthens the argument that definition of continence after radical prostatectomy should stick to an enforced “never wear a pad-never have a leak” rule. 218 VOL. 9 NO. 4 2007 REVIEWS IN UROLOGY RIU0340_12-12.qxd 12/12/07 8:37 PM Page 219 EAU Congress Highlights seen for Gleason’s grade 7 and above and with extensive T3 and T4 disease.36 It was also shown that robotassisted surgery offers a precise tool that affords the capacity to preserve sexual function in the majority of preoperatively potent patients.37 [Franklin E. Kuehhas, MD, Bob Djavan, MD, PhD] References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Kramer MW, Golshani R, Merseburger AS, et al. Hyaluronic acid and HYAL1 hyaluronidase: prognostic markers for bladder cancer [abstract 383]. Eur Urol Suppl. 2007;6:118. Wang W, Chen S, Liu Y, et al. Screening of telomerase related genes in bladder cancer using complementary deoxyribonucleic acid microarray: preliminary results [abstract 384]. Eur Urol Suppl. 2007;6:118. Jang H, Seo JW, Lee SC, et al. Expression of cyclooxygenase-2 in human bladder tumor [abstract 385]. Eur Urol Suppl. 2007;6:119. Dubosq F, Alanio A, Soliman H, et al. Superficial bladder urothelial cell carcinoma prognostic factors: prospective evaluation of combined FGFR3/p53 genotypes [abstract 498]. Eur Urol Suppl. 2007;6:147. Suttmann H, Lehmann J, Kovac I, et al. Transitional cell carcinoma of the ureter: prognostic factors influencing progression and survival [abstract 16]. Eur Urol Suppl. 2007;6:26. Gupta A, Nielsen M, Bastian P, et al. Outcomes of patients with clinical T1 Grade 3 bladder urothelial cell carcinoma treated with radical cystectomy [abstract 13]. Eur Urol Suppl. 2007;6:26. Witjes JA, Hendricksen K, Gofrit O, et al. Intravesical hyperthermia and mitomycin-c for (BCGrefractory) carcinoma in situ of the urinary bladder [abstract 150]. Eur Urol Suppl. 2007;6:60. Rischmann P, Saint F, Nicolas L, Colombel M. Ofloxacin to prevent BCG-induced toxicity in patients with superficial bladder cancer: results of a randomized prospective, double-blind, placebo-controlled, multicentre study [abstract 152]. Eur Urol Suppl. 2007;6:60. Gaya JM, Palou J, Algaba F, et al. Management of micropapillary carcinoma of the bladder—the case for conservative management of patients with non-muscle invasive and without CIS [abstract 155]. Eur Urol Suppl. 2007;6:61. Horstmann M, Witthuhn R, Falk M, Stenzl A. Sex specific differences in bladder cancer [abstract 591]. Eur Urol Suppl. 2007;6:170. Alken P, Siegsmund M, Gromoll-Bergmann K, et al. A randomised controlled multicentre trial to compare the effects of transurethral detection 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. and resection of bladder carcinomas under 5-Ala induced fluorescence light to conventional white light [abstract 593]. Eur Urol Suppl. 2007; 6:171. Polyakov S, Krasny S, Sukonko O, et al. Radical cystectomy in the elderly—feasible, but strenuous for the patient [abstract 781]. Eur Urol Suppl. 2007;6:218. Cho KS, Cho SY, Lee YH, et al. The difference in prognosis between progressive and primary muscle-invasive bladder cancer treated with radical cystectomy [abstract 783]. Eur Urol Suppl. 2007;6:218. Lindenmeir T, Liehr UB, Rau O, et al. Incidental prostate cancer in patients undergoing radical cystectomy for muscle invasive bladder cancer [abstract 789]. Eur Urol Suppl. 2007;6:220. Krause S, Schrott KM, Sauer R. Long-term results of TUR and radiochemotherapy of invasive bladder cancer [abstract 357]. Eur Urol Suppl. 2007;6:112. Rabien A, Fritzsche FR, Jung M, et al. High expression levels of the human kallikrein-like peptidases KLK 14 and KLK 15 in prostatic adenocarcinoma are associated with elevated risk of prostate specific antigen relapse [abstract 105]. Eur Urol Suppl. 2007;6:49. Treuthardt C, Cloutier S, Nguyen P, et al. Detection of telomerase activity in prostatic fluid specimens of patients with prostatic cancer suspicion allows significant sparing of useless prostatic biopsies [abstract 104]. Eur Urol Suppl. 2007;6:48. Van Port IM, Kok DE, Kiemeney LA, et al. Are small-volume prostate cancers insignificant [abstract 103]. Eur Urol Suppl. 2007;6:48. Haese A, Walz J, Gallina A, et al. Accuracy of percent free PSA to predict prostate cancer diagnosis in men with total PSA ranges lower than 2.5 ng/ml [abstract 112]. Eur Urol Suppl. 2007; 6:50. Herwig R, Djavan B, Leers M, et al. Multicenter trial reveals the superiority of imPSA in diagnosis of prostatic disease over conventional serum total PSA [abstract 804]. Eur Urol Suppl. 2007; 6:223. Gallina A, Montorsi F, Walz J, et al. Mortality at 120 days after prostatic biopsy: a populationbased study of 22, 175 men [abstract 404]. Eur Urol Suppl. 2007;6:123. Giannarini G, Mogorovich A, De Maria M, et al. Intrarectal and anal administration of lidocaineprilocaine cream in transrectal ultrasound-guided biopsy of the prostate: a prospective, randomized, single-blind, placebo-controlled trial [abstract 397]. Eur Urol Suppl. 2007;6:122. Djavan B, Rocco B, Zlotta A, et al. Indications for saturation biopsies of the prostate: where do we stand now? [abstract 700] Eur Urol Suppl. 2007;6:197. Hennenlotter J, Laible I, Merseburger A, et al. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. Anatomical distribution of prostatic peripheral nerve tissue- a notable portion located on the dorsal surface of the apex [abstract 115]. Eur Urol Suppl. 2007;6:51. Zwergel U, Suttmann H, Lehmann J, et al. Outcome of patients with locally advanced prostate cancer (pT3pN0) after radical prostatectomy [abstract 123]. Eur Urol Suppl. 2007;6:53. Graefen M, Walz J, Gallina A, et al. Durable cancer control in high risk prostate cancer patients treated with radical prostatectomy [abstract 135]. Eur Urol Suppl. 2007;6:56. Buscarini M, Takeshita K, Stein J, et al. Oncologic outcomes following radical prostatectomy in men with locally advanced disease [abstract 622]. Eur Urol Suppl. 2007;6:178. Tombal B, Castilles Y, Hublet S, et al. Definition of continence after radical prostatectomy (RP): should patient reporting occasional leak or pad wearing be considered continent? [abstract 515] Eur Urol Suppl. 2007;6:151. Touijer K, Romero Otero J, Secin FP, et al. Radical prostatectomy: a non-randomized comparative analysis of outcomes between the open and laparoscopic approach [abstract 750]. Eur Urol Suppl. 2007;6:210. Secin FP, Bianco F, Karanikolas NT, et al. Oncological outcomes of laparoscopic radical prostatectomy: intermediate-term follow up [abstract 751]. Eur Urol Suppl. 2007;6:210. Rigatti L, Guazzoni G, Naspro R, et al. Radical retropubic (RRP) and laparoscopic prostatectomy (LRP): a prospective urodynamic comparison of post-operative continence [abstract 752]. Eur Urol Suppl. 2007;6:210. Herrmann TR, Rabenalt R, Stolzenburg JU, et al. Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter? World J Urol. 2007;25: 49-60. Nelson B, Kaufman M, Broughton G, et al. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol. 2007 Mar;177:929-31. Thaly R, Shah K, Patel V. Robotic radical prostatectomy: peri-operative outcome data of 500 cases [abstract 408]. Eur Urol Suppl. 2007; 6:124. Mottrie A, Van Migem P, De Naeyer G, et al. Robot-assisted laparoscopic radical prostatectomy: oncological and functional results of 184 cases [abstract 407]. Eur Urol Suppl. 2007;6:124. Shah K, Thaly R, Patel V. Robot assisted radical prostatectomy: histopathologic data of 1200 cases [abstract 412]. Eur Urol Suppl. 2007;6:125. Nilsson A, Carlsson S, Jonsson M. Erectile function after robot-assisted laparoscopic radical prostatectomy [abstract 413]. Eur Urol Suppl. 2007;6:126. VOL. 9 NO. 4 2007 REVIEWS IN UROLOGY 219