UROLOGY NEWS

We agree that we need to move beyond BMD values alone to predict fracture risk. The WHO fracture risk algorithm (FRAX, www.sheffield.ac.uk/FRAX) is a step forward because it integrates major clinical risk factors as well as BMD to provide better prediction. However, in contrast to our findings, FRAX does not explicitly consider ADT except in the category of secondary osteoporosis and does not consider the presence of dementia as a risk factor for fracture. Whether men on ADT have similar risk factors predicting fracture risk compared to other men is not clear, and future studies are needed to examine this specifically. Meanwhile we agree that tools such as FRAX are definitely a step in the right direction.

The lack of a control group is a weakness of our study but the objective improvements derived from the FVC analyses strongly suggest something more than a placebo effect. Even if a placebo effect contributed to the improvement of nocturia to a certain degree, it can also be considered part of the efficacy of our nondrug therapy. In any case lifestyle modification is the most basic therapy for nocturia. The distinct lack of evidence about lifestyle modification makes this single arm study an important first step. We agree that additional testing is warranted to determine actual cause and effect of the lifestyle modifications in this study.

The treatment of the severely undermasculinized male has always been difficult and, at times, agonizing. In the past it was common to recommend gender conversion when the phallus was small and unresponsive to hormonal stimulation. Now even with a small and nonresponsive phallic structure there is greater reluctance to recommend gender conversion for fear that in utero brain masculinization by testosterone has already occurred and that gender conversion could lead to gender dysphoria. The dilemma remains whether to convert the severely undermasculinized male to a female or to hope for the best, maintaining male sex of rearing with masculinizing genitoplasty on a small penis. Will he be happy, function normally and be well-adjusted as an adult? Other options include observation or phalloplasty, even at an early age. How do we advise the parents? What information can our disorder of sex development (DSD) teams provide to help them confront this overwhelming situation and make an informed decision? Can we present evidence-based information about likely functional and psychological outcomes? How successful have we been in treating these patients in the past and what will future treatments hold?

Urinary incontinence (UI) is far more common in women than in men and its prevalence increases with age. UI, urgency, overactive bladder symptoms, cystitis and urinary tract infections are frequently diagnosed in the female population, and have been estimated as occurring in 5% to 69% of women. The prevalence of male UI ranges between 1% and 39% with urge urinary incontinence the predominant subtype, although the relative proportion shifts toward stress urinary incontinence with increasing age. UI impacts the lives of men and women with detrimental effects on social, professional and recreational activities as well as on sexual health. As described in this issue of The Journal in articles by Soda et al (page 000) and Wing et al (page 000), it may also encourage adaptive changes in the behavior of those affected such as prophylactic urination, urination on first desire and fluid restriction.

Stuck between a rock and a hard place is how a surgeon feels when faced with a ureteral defect that cannot be primarily repaired. If possible, first line therapy when reconstructing the ureter is to bridge the defect with the ureter. The use of this approach depends on the site of the injury (near the kidney, the mid ureter or below the pelvic brim). When the injury is below the pelvic brim, mobilization of the bladder with fixation via psoas hitch may allow for primary ureteral reimplantation, and if not possible a Boari flap can be used to bridge the gap.

Nocturia is a highly prevalent and bothersome condition that often affects elderly patients. Associated sleep deprivation can negatively impact quality of life. The etiology is usually multifactorial. Treatments can be directed toward the bladder, or causative comorbid conditions such as sleep apnea, congestive heart failure and pulmonary or peripheral edema.

ADT increases the fracture risk in men with prostate cancer. In men on ADT denosumab decreases the fracture risk and several bisphosphonates improve bone mineral density, a surrogate for fracture risk. Given a morbid problem and effective treatments, we must now work hard to accurately assess risk in individuals so that treatment can be given to those most likely to benefit.

Despite improvements in surgical techniques, urinary incontinence (UI) is not uncommon after radical prostatectomy (RP) and may dramatically worsen the quality of life of a patient who has been successfully cured of prostate cancer. The real incidence of post-prostatectomy UI remains unknown as it depends on various factors, namely the definition of UI, the methodology used to assess continence, the time of observation, the caregivers involved in followup and, most importantly, the subjective evaluation of continence status by the patient. Some patients are satisfied with their continence status although they require 2 pads daily, while others complain about severe incontinence if they lose a drop during a Valsalva maneuver. Therefore, a proper objective evaluation of post-RP UI is essential not only to properly evaluate incontinence itself but also to evaluate the ability of new surgical techniques or postoperative treatments to improve or hasten continence recovery.

The American Urological Association Foundation launched an ambitious initiative to define national research priorities for the field of urology. This major effort was commissioned by the AUA Foundation Board of Directors to define urology research priorities provided by the urology research community, reverse the decline in urology research funding and progress, and promote an increase in urological disease research funding and activity. The end point is the creation of the AUA Foundation National Urology Research Agenda: 2010 (NURA) which will serve as a roadmap for articulating basic and clinical research as well as the research infrastructure priorities in urology, thereby promoting substantial improvements in patient care. There is a tremendous need for such an initiative and we have much to gain from this effort.

E. Palminteri, M. Gacci, E. Berdondini, M. Poluzzi, G. Franco and V. Gentile Centre for Reconstructive Urethral and Genitalia Surgery, Arezzo, Italy