Hubert John Peter Wiklund (Eds.) Robotic Urology

Transcription

1 Hubert John Peter Wiklund (Eds.) Robotic Urology

2 Hubert John Peter Wiklund (Eds.) Robotic Urology With 116 Figures and 23 Tables 123

3 Hubert John Zentrum für Urologie Klinik Hirslanden 8032 Zurich Switzerland Peter Wiklund Karolinska University Hospital Stockholm Sweden ISBN e-isbn DOI / Library of Congress Control Number: Springer-Verlag Berlin Heidelberg This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer Verlag. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, estudio, Calamar, Spain Printed on acid-free paper springer.com

4 Preface Urology has traditionally been a technically driven specialty. Minimally invasive surgical procedures aim to reduce collateral surgical damage while optimizing functional and oncological results. Improvement of magnification, 3D imaging, articulated instruments, depth perception, and precise motor control are prerequisites to achieve these goals. Robotic technology has overcome most of these potential limitations and presently allows challenging laparoscopic interventions, not only in a few experts hands but also among a broad spectrum of urologists and patients who can benefit. Robot-assisted surgery presently operates on a master slave relationship basis, and the primary system is the Da Vinci robot (Intuitive Surgical, Sunnyvale, Calif.). Urology is the leading field in robotic surgery, with radical prostatectomy being the most often performed robotic-assisted intervention. The birth of this instructional book is very timely, as many new robotic teams are experiencing their learning curve worldwide with great enthusiasm. The book highlights the standardized robotic procedures in urology. The authors have invested great effort and personal experience in order to support new robotic teams. As editors of this book, we tried to focus on the relevant urological procedures, knowing that the evolution of robotic urology will occur rapidly and involve many other urological operative indications in the kidney, ureter, bladder, and prostate surgery. Our thanks goes to Ms. Meike Stoeck from Springer, who helped to advance the project in a significant way. We are happy that our spontaneous idea to edit a textbook on robotic urology has come to a fruitful conclusion after 2 years of hard work. Personally (H.J.) I thank my teachers Peter Jaeger and Dieter Hauri for their influence and motivation in my clinical and research work during the past 15 years, and I am especially grateful to my wonderful wife, Manuela, for her support. September 2007 Hubert John, Zurich Peter Wiklund, Stockholm

5 VI Preface Hubert John and Peter Wiklund in the Swiss Alps, 4 February 2006, when they decided to edit this book

6 Foreword This book will show that robotic surgery already has a definite place in the daily work of operative urology. The book shows that robotic surgery is increasingly used in operations such as pyeloplasty, nephrectomy, urethral implantation, and, to some degree, in cystectomy. I focus on the most frequently performed operation in urological oncology: the radical prostatectomy (RP). Although I am personally fascinated by the new technology and fully aware that further improvements are forthcoming, I am reluctant to state that robotic radical prostatectomy is superior to open radical prostatectomy. Being involved now for many years in the surgical treatment of localized prostate cancer, I have experienced many alternatives claiming to stop open retropubic radical prostatectomy such as brachytherapy, perineal prostatectomy, and laparoscopic radical prostatectomy. In our prostate cancer center in Hamburg we offer a wide range of therapeutic options to each patient including seed implantation, high dose rate brachytherapy, external-beam radiation therapy, laparoscopic radical prostatectomy, and robotic radical prostatectomy. When patients are objectively informed about long-term side effects and cure rates, however, the majority of patients prefer not to undergo any such therapeutic options. The majority of patients choose open radical prostatectomy. I am aware that this is in contrast to recent developments in the United States, where 40% of all radical prostatectomies were done using the Da Vinci technique in 2006, and it is estimated that this will increase to 60 or 70% in I am also aware of the fact that approximately Da Vinci systems are installed in Europe. If we look at the Web homepages of centers that promote robotic radical prostatectomy, we get the impression that this technique is superior to the open approach. But what scientific evidence do we have for a comparison of the available techniques? Rojas-Cruz and Mulhall presented an abstract at the AUA meeting in May 2007 where they analyzed the stated advantages of robotic RP over open RP [2]. On 93 of 116 (80%) analyzed homepages it was stated that potency and continence rates achieved by the robotic approach are superior to open RP. Yet, only two (!) centers were able to give their own data on functional outcome, which demonstrates that scientific reality and arbitrary statements are presently in conflict with each other. The problem I have with such an approach is that we, as urologists, are able to judge such statements; however, a patient faced with prostate cancer seeking the best treatment is not informed in an ethically ideal way. Furthermore, this attitude will lead to high expectations of the patients, and I am convinced that many of them will be quite disappointed by the postoperative reality. At the same AUA meeting two groups presented a comparison of functional outcome of laparoscopic, robotic, and open RP. In both studies, which

7 VIII Foreword included more than 1000 patients, open RP achieved slightly better results than the concurrent techniques [3, 4]. (By the way, I have not found this information on any robotic prostatectomy homepage.) Will we ever have the chance to objectively compare surgical approaches? At present, it is not feasible, and I strongly believe that it is the surgeon who is the most important factor for a successful procedure. Multiple single-center experiences are published that do not allow drawing any conclusion as to whether or not a certain technique is advantageous regarding cancer control rates and functional outcome. Cancer control rates are definitely more influenced by tumor selection than by whether we control our instruments by hand or via a console. With regard to functional outcome, again it is the surgical technique and the principles in combination with the experience of the surgeon, rather than the instruments we are using [5]. The nerve-sparing procedure, for example, should be started ventrally, coagulation and tension on the neurovascular bundles should be avoided, etc. [1]. Obeying these principles is what is leading to adequate results regardless of the way we get our instruments down to the prostate. In a recent study from the MSKCC it was furthermore shown that the surgeon s experience is not only associated with postoperative morbidity and functional outcome, but also with cancer control rates [6]. In this study based on 7765 prostate cancer patients, the learning curve for prostate cancer recurrence after RP was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations. The predicted probabilities of recurrence at 5 years were 17.9% for patients treated by surgeons with ten prior operations and 10.7% for patients treated by surgeons with 250 prior operations (difference = 7.2%, <0.001). Again, the surgeon s experience is what counts most. So what are the potential advantages of laparoscopic, robotic, and perineal RP over the open approach? If we look at invasiveness, it has been shown that the open approach is not more invasive than the laparoscopic one [7]. This is due to the fact that we approach the cavum retzii without any muscular incision which is a totally different situation, i.e., compared with kidney or adrenal surgery in which a clear benefit for the patient is shown for the laparoscopic approach [8]. Nevertheless, it is clear that blood loss is reduced in laparoscopic, robotic, and perineal RP compared with open RP; however, due to improvements of surgical technique and improvements in anesthesia (such as restriction in infusion intake), the transfusion rate in modern open series is negligible at present [1]. Hospital stay following RP is instead driven by the health system than by the surgical approach, and again we cannot really find an advantage of any technique. I could cite numerous papers which have investigated one or the other aspect of the various techniques, but such information seems undesirable at this point. Briefly, there is no real advantage of a laparoscopic or robotic approach over the open RP. Data on effectiveness which address long-term outcome comparable to that of open or perineal RP, however, need to be obtained. A clear disadvantage for the robotic approach is obvious: as soon as cost-effectiveness is considered, all other available techniques are by far superior. At least in Germany this will play a major role for the development of this approach, especially in light of the fact that thus far no substantial advantage for the patient is apparent. Where are we going from here? I believe that in the future we will have parallel techniques available. Actually, reflecting the German situation, this is what has already happened. In the past few years, in addition to retropubic and perineal prostatectomy,

8 Foreword IX the laparoscopic approach has been established. Few centers (including ours) have gathered their first experience with robotic RP, which is without a doubt a fascinating technique. With all the upcoming developments in robotic surgery, such as haptic feedback, the entire situation might be different 10 years from now, and maybe we will eventually see, in fact, that a surgical approach will make a difference. It is our task for the future to produce objective data which compare equally experienced surgeons for every technique. Our personal feeling, however, is that the surgeon s experience will remain the most important factor for success of RP in the future. Hamburg, September 2007 Prof. Dr. med. Hartwig Huland References 1. Graefen M, Walz J, Huland H (2006) Open retropubic nerve-sparing radical prostatectomy. Eur Urol 49(1):38 2. Rojas-Cruz C, Mulhall JP (2007) Sexual health misinformation on robotic prostatectomy websites. J Urol 177(4): Schwab CW, Fabrizio MD, Given RW et al. (2007) Evaluation of three surgical treatment modalities from a single institution. J Urol 177(4):19 4. Wagner AA, Wei JT, Dunn RL et al. (2007) Patient-reported outcomes after retropubic, laparoscopic, or robot-assisted prostatectomy: results from a prospective, multi-centre study. J Urol 177(4): Bianco FJ Jr, Riedel ER, Begg CB et al. (2005) Variations among high volume surgeons in the rate of complications after radical prostatectomy: further evidence that technique matters. J Urol 173(6): Vickers AJ, Bianco FJ, Serio AM et al. (2007) The surgical learning curve for prostate cancer control after radical prostatectomy. J Natl Cancer Inst 99(15): Fornara P, Zacharias M (2004) Minimal invasiveness of laparoscopic radical prostatectomy: Reality or dream? Aktuelle Urol 35(5): Zacharias M, Haese A, Jurczok A et al. (2006) Transperitoneal laparoscopic adrenalectomy: outline of the preoperative management, surgical approach, and outcome. Eur Urol 49(3):448

9 Contents 1 History of Robotic Surgery in Urology András Hoznek 1.1 Introduction Background Endourology Transurethral Prostate Resection Ablatherm Prostate Biopsy Percutaneous Renal Access Laparoscopic Surgery Robotic Camera Holders Master Slave Systems Clinical Experience with Master Slave Systems in Urological Laparoscopy Radical Prostatectomy Radical Cystectomy and Urinary Diversion Pyeloplasty Live Donor Nephrectomy Future of Robotic Surgery Surgical Anatomy of the Prostate for Radical Prostatectomy Arnauld Villers and Thierry Piechaud 2.1 Introduction Pelvic Fasciae, Parietal and Visceral, and Their Surgical Importance Parietal Fasciae Visceral Fasciae Fascial Surgical Dissection Nerve-sparing Technique Proximal Bladder Neck Sphincter and Detrusor Apron Urethral Stump (Sphincteric Urethra) Preservation Prostatic Capsule Rectourethralis

10 XII Contents 3 Robotic Radical Prostatectomy: Extraperitoneal Approach Hubert John 3.1 Introduction Extraperitoneal Approach: Step by Step Discussion Patient Positioning Trocar Placement Operative Time Avoiding the Intraperitoneal Cavity Conclusion Robotic Radical Prostatectomy: Transperitoneal Access Charles-Henry Rochat and Jean Sauvain 4.1 Introduction Steps of the Transperitoneal Access Preparation Installation of the Patient Access to the Pelvis and Incision of the Anterior Peritoneum Pelvic Lymphadenectomy for Localized Prostate Cancer and Robotic-assisted Radical Prostatectomy Oliver W. Hakenberg and Manfred P. Wirth 5.1 Arguments for and Against Routine Pelvic Lymphadenectomy Morbidity of Pelvic Lymphadenectomy Extent of Pelvic Lymphadenectomy Location of Node-positive Disease and Lymphatic Drainage Purpose of Lymphadenectomy Influence of Lymphadenectomy on Outcome in RP The Likelihood of Nodal Disease Based on the Use of Nomograms PLND or no PLND? Pelvic Lymphadenectomy in Conventional Laparoscopic and Robot-assisted Radical Prostatectomy Use of PLND in Robot-assisted Radical Prostatectomy Technique of PLND in Robotic Radical Prostatectomy Conclusion

11 Contents XIII 6 Bladder Neck Dissection During Robotic-assisted Laparoscopic Radical Prostatectomy Thierry Piechaud and Filippo Annino 6.1 Introduction Anatomy of the Bladder Neck Anatomical Surgical Correlations Median Lobe Previous TURP Functional and Oncological Principles of Bladder Neck Preservation Surgical Technique of Bladder Neck-sparing Dissection During Robotic-assisted Prostatectomy Median Lobe Previous TURP Wide Resection of the Bladder Neck Indications and Choice of Technique Bordeaux Series Conclusion Nerve-sparing Techniques for Laparoscopic and Robot-assisted Radical Prostatectomy Ketul K. Shah, Mario F. Chammas Jr., Kenneth J. Palmer, Rahul Thaly, Vipul R. Patel 7.1 Introduction Neurovascular Anatomy Neurovascular Bundles Nerve-sparing Techniques and Results Athermal Approaches to Nerve Sparing Seminal Vesicle Tip Preservation to Improve Potency Categorization of Approaches to Nerve-sparing Robotic Prostatectomy Nerve Sparing in Robotic-assisted Laparoscopic Prostatectomy The Henry Ford Technique: the Veil of Aphrodite The Ohio State Technique: Athermal Early Retrograde NVB Release During Antegrade Prostatectomy UC Irvine: Antegrade Clamp and Suture Technique University of Chicago: Antegrade Thermal Clipless Approach Nerve Sparing in Laparoscopic Radical Prostatectomy Cleveland Clinic: Clamp-and-Suture Technique with Ultrasound Guidance Heilbronn Technique Discussion Conclusion

12 XIV Contents 8 Vattikuti Institute Prostatectomy: Veil of Aphrodite Nerve-sparing Technique Alok Shrivastava, James O. Peabody, Mani Menon 8.1 Introduction Indications and Patient Selection Setup Operating Room The Surgical Team Instruments Robotic Instruments Laparoscopic Instruments Sutures Technique of VIP Specific Patient Preparation Patient Positioning and Port Placement Development of the Extraperitoneal Space Lymph Node Dissection Bladder Neck Transection Nerve-sparing Technique: the Veil of Aphrodite Exposure of Prostatic Apex and Control of Dorsal Venous Complex Urethrovesical Anastomosis Retrieval of Specimen and Completion of Surgery Postoperative Care Crossing Over the Learning Curve Structured Program Setup Patient Selection Robotic Assisted Radical Prostatectomy: the Apical Dissection Xavier Cathelineau, Jamison Jaffe, Eric Barret, François Rozet, Guy Vallancien 9.1 Introduction Preparation of the Apex Dorsal Venous Complex Completion of the Neurovascular Bundles Urethral Transection and Division of the Rectourethralis Vesicourethral Anastomosis Jean Joseph 10.1 Introduction Semicontinuous Suturing Continuous Suturing

13 Contents XV 10.4 Interrupted Suturing Complications Intraoperative Postoperative Conclusion Outcome Measures After Robot-assisted Laparoscopic Prostatectomy Esequiel Rodriguez, Douglas W. Skarecky, Thomas E. Ahlering 11.1 Introduction Operative Results Operative Time Blood Loss and Transfusions Peri-operative Complications Convalescence Oncological Control Surgical Margins and PSA Recurrence Quality of Life Continence Potency Conclusion Urinary Incontinence After Robotic-assisted Laparoscopic Radical Prostatectomy Kevin G. Chan and Timothy G. Wilson 12.1 Introduction Incidence of Urinary Incontinence Following Radical Prostatectomy Mechanism of Urinary Incontinence Following Radical Prostatectomy Risk Factors for Urinary Incontinence Following Radical Prostatectomy Evaluation for Urinary Incontinence Following Radical Prostatectomy Management of Urinary Incontinence Following Radical Prostatectomy Detrusor Overactivity Urethrovesical Anastamotic Strictures Post-prostatectomy Stress Urinary Incontinence Behavioral Therapy Medical Therapy Transurethral Injection Therapy Male Slings Artificial Urinary Sphincter Conclusion

14 XVI Contents 13 Erectile Function After Robotic Prostatectomy: Anatomical Aspects and Treatment Juan I. Martinez-Salamanca and Ashutosh Tewari 13.1 Introduction Incidence Pathophysiology Anatomical Foundations About Nerve-sparing Surgery Tri-zonal Concept for the Nerve-sparing Robotic Prostatectomy Proximal Neurovascular Plate Predominant Neurovascular Bundles Accessory Distal Neural Pathways The Distribution and Functional Classification of the Autonomic Ganglion Cells Distribution The Functional Classification Robotic Surgical Techniques (Modifications) to Preserve Sexual Function Athermal Robotic Technique (Cornell University) Bladder Neck Transection Seminal Vesicle and Vas Dissection Incision of Denonvillier s Fascia and Posterior Dissection to the Apex Lateral Pedicle Control Release of Neurovascular Bundles Apical Dissection, DVP Ligation and Urethral Transection Veil of Aphrodite Nerve Sparing Cautery-Free Neurovascular Bundle Preservation Modified Clipless Antegrade Nerve Preservation Robotic Series: Sexual Outcomes Weill Medical College (Cornell University) Experience Erectile Dysfunction After Radical Prostatectomy: Treatment Strategies Evaluation Questionnaire-based Assessment Clinical Assessment of Patient with ED After Radical Prostatectomy Nocturnal Penile Tumescence Testing Duplex Doppler Assessment Dynamic Infusion Cavernosometry and Cavernosography Treatment Phosphodiesterase-5 inhibitors Sildenafil Vardenafil Tadalafil Intracavernosal Injections Vacuum Constriction Devices Combination Therapy Treatment Protocol for the Patient with ED After RP

15 Contents XVII 14 Robotic Pyeloplasty L. Henning Olsen and Yazan F. Rahwashdeh 14.1 Introduction The Retroperitoneal Approach Patient Preparation and Positioning Retroperitoneal Access and Port Placement Docking of the Surgical Cart and Placement of Instruments The Procedure The Transperitoneal Approach Patient Preparation and Positioning Transperitoneal Access and Port Placement Docking of the Surgical Cart and Placement of Instruments The Procedure Follow-up Surgical Outcome Operative Time Success Rates Complications Conclusion Robot-assisted Radical Cystectomy Khurshid A. Guru, Martin N. Jonsson, Peter Wiklund 15.1 Introduction Patient Selection Preoperative Preparation Equipment Port Placement Identification and Dissection of Ureters Male Cystectomy Posterior Dissection Lateral Dissection of the Bladder Nerve-sparing Dissection Apical Dissection Female Cystectomy Technique Where Four Robotic Arms Are Used Control and Positioning of Uterus Control of Vascular Pedicle Vaginal Dissection Mobilization of Bladder and Dissection of Urethra Reconstruction of the Vaginal Wall Pelvic Lymph Node Dissection Robot-assisted Urinary Diversion Robot-assisted Ileal Conduit Intracorporeal Technique Robot-assisted Orthotopic Neobladder, Intracorporeal Technique Discussion

16 XVIII Contents 16 Robotic Kidney Surgery Jorn H. Witt 16.1 Introduction Patient Evaluation and Preparation General Considerations for Robotic Kidney Surgery Surgical Approaches Transperitoneal Approach Patient Positioning and Port Placement Left-side Kidney Preparation Dissection and Securing of the Renal Hilum Right-side Kidney Preparation Retroperitoneal Approach Patient Positioning and Port Placement Kidney Preparation Nephrectomy Simple Nephrectomy Donor Nephrectomy Radical Nephrectomy Nephron-sparing Procedures Nephroureterectomy Other Procedures Postoperative Management Complications and Management Future Perspectives Robotic Adrenal Surgery Elias Hyams and Michael D. Stifelman 17.1 Introduction Indications Operative Technique Right Robotic Adrenalectomy Left Adrenalectomy Results Considerations Conclusion Robotic Antireflux Surgery in Children Piet Callewaert 18.1 Introduction Conventional Laparoscopic Techniques in the Treatment of VUR Robotically Assisted Techniques General Considerations

17 Contents XIX Intravesical Technique Overview Detailed Description of Technique Patient Positioning Port Placement Sequence of Surgical Steps Port-site Closure Postoperative Management Results and First Impressions Extravesical Technique Overview Detailed Description of Technique Patient Positioning Port Placement Sequence of Surgical Steps Postoperative Management Results and First Impressions Discussion and Conclusion Economic Aspects of Starting a Da Vinci Robotic Surgery Program Roland Peplinski and Ryan Rhodes 19.1 Introduction Description of the Technology Hospital Resources: Broad Economic Impact Market Share Growth and Maximizing Efficiency Clinical Validation Urology Procedures Cardiothoracic Procedures Gynecological Procedures General/Pediatric Surgery Procedures Universal Patient Benefits Business Model Market Analysis Cost Analysis Subject Index

18 List of Contributors T.E. Ahlering University of California, Irvine 101 The City Drive Orange, CA F. Annino University of Modena and Reggio Emilia Hospital Policlinico di Modena L.go del Pozzo Modena Italy E. Barret L institut Mutualiste Montsouris 42 boulevard Jourdan Paris France P. Callewaert University Hospital Maastricht 6202 AZ Maastricht The Netherlands X. Cathelineau L institut Mutualiste Montsouris 42 boulevard Jourdan Paris France M.F. Chammas Jr. Center for Robotics and Computer-assisted Surgery Ohio State University Medical Center 538 Doan Hill, 410 West 10th Avenue Columbus, OH K.G. Chan City of Hope National Medical Center 1500 East Duarte Road Duarte, CA K.A. Guru Roswell Park Cancer Institute School of Medicin and Biomedical Sciences University at Buffalo Elm & Carlton Streets Buffalo, NY O.W. Hakenberg University of Rostock Ernst-Heydemann-Strasse Rostock Germany A. Hoznek Service d Urologie CHU Henri Mondor 51 Av. du Mal. de Lattre de Tassigny Créteil cedex France

19 XXII E. Hyams New York University School of Medicine 151 Lexington Avenue New York, NY J. Jaffe L institut Mutualiste Montsouris 42 boulevard Jourdan Paris France H. John Zentrum für Urologie Klinik Hirslanden Witellikerstrasse Zurich Switzerland M.N. Jonsson Karolinska University Hospital Stockholm Sweden J. Joseph University of Rochester Medical Center 601 Elmwood Avenue, Box 656 Rochester, NY J.I. Martinez-Salamanca Weill Medical College of Cornell University New York Presbyterian Hospital Brady Urologic Health Center 525 East 68th Street New York, NY M. Menon Vattikuti Urology Institute Henry Ford Health System 1 Ford Place Detroit, MI List of Contributors L.H. Olsen Section of Paediatric Urology Aarhus University Hospital Skejby 8200 N Aarhus Denmark K.J. Palmer Center for Robotic and Computer-Assisted Surgery The Ohio State University The James Cancer Hospital 410 W 10th Ave 538 Doan Hall Columbus, OH V.R. Patel Florida Hospital Global Robotics Institute 400 Celebration Place Celebration, FL J.O. Peabody Vattikuti Urology Institute Henry Ford Health System 1 Ford Place Detroit, MI R. Peplinski Urology Marketing Intuitive Surgical, Inc Kifer Road Sunnyvale, CA T. Piechaud Clinique St. Augustin 114 Avenue D Arès Bordeaux cedex France

20 List of Contributors XXIII Y.F. Rahwashdeh Section of Paediatric Urology Aarhus University Hospital Skejby 8200 N Aarhus Denmark R. Rhodes Urology Marketing Intuitive Surgical, Inc Kifer Road Sunnyvale, CA C.-H. Rochat Facharzt FMH für Urologie 12 chemin Beau-Soleil 1206 Geneva Switzerland E. Rodriguez Jr. University of California, Irvine 101 The City Drive Orange, CA F. Rozet L institut Mutualiste Montsouris 42 boulevard Jourdan Paris France J. Sauvain Blv. James Fazy Geneva Switzerland K.K. Shah Center for Robotic and Computer-Assisted Surgery The Ohio State University The James Cancer Hospital 410 W 10th Ave 538 Doan Hall Columbus, OH D.W. Skarecky University of California, Irvine 101 The City Drive Orange, CA A. Shrivastava Vattikuti Urology Institute Henry Ford Health System 1 Ford Place Detroit, MI M.D. Stifelman New York University School of Medicine 151 Lexington Avenue New York, NY A. Tewari Weill Medical College of Cornell University New York Presbyterian Hospital Brady Urologic Health Center 525 East 68th Street New York, NY R. Thaly Center for Robotic and Computer-Assisted Surgery The Ohio State University The James Cancer Hospital 410 W 10th Ave 538 Doan Hall Columbus, OH G. Vallancien L institut Mutualiste Montsouris 42 boulevard Jourdan Paris France

21 XXIV A. Villiers CHU Hôpital Claude Huriez 1 place de Verdun Lille cedex France P. Wiklund Karolinska University Hospital Stockholm Sweden T.G. Wilson City of Hope National Medical Center 1500 East Duarte Road Duarte, CA M.P. Wirth Universitätsklinikum Dresden Fetscherstrasse Dresden Germany J.H. Witt Urology and Pediatric Urology St. Antonius Hospital Möllenweg Gronau Germany List of Contributors