Correction of Congenital Penile Curvature Using Modified Tunical Plication with Absorbable Sutures: The Long-Term Outcome and Patient Satisfaction

Transcription

1 european urology 52 (2007) available at journal homepage: Sexual Medicine Correction of Congenital Penile Curvature Using Modified Tunical Plication with Absorbable Sutures: The Long-Term Outcome and Patient Satisfaction Ju-Ton Hsieh, Shih-Ping Liu, Yisheng Chen, Hong-Chiang Chang, Hong-Jen Yu, Chung-Hsin Chen * Department of Urology, National Taiwan University Hospital, Taipei, Taiwan Article info Article history: Accepted December 24, 2006 Published online ahead of print on January 9, 2006 Keywords: Penile curvature Tunical plication Chordee Polyglactin Quality of life Abstract Objectives: Although plication of the tunica albuginea with nonabsorbable sutures is an effective method in correcting congenital penile curvature (CPC), suture-related complications may happen. We investigated the long-term outcome and patient satisfaction of a modified tunical plication technique using absorbable sutures. Materials and methods: From January 1999 to July 2005, 114 consecutive patients with CPC treated with a modified tunical plication technique by a single surgeon were retrospectively reviewed. With the modified corporeal plication technique, two, interrupted, U-shaped sutures with 2-zero polyglactin were applied to create bumps on the tunica albuginea. The long-term outcome and patient satisfaction were assessed by a post hoc questionnaire interview. Results: Among the 114 patients, complete straightness of the penis was achieved in 65 (57%) patients, and 33 (29%) patients reported a 15-degree or less residual or recurrent curvature at 6 mo postoperatively. Although 32 (28%) patients experienced suture failure (median time: 38.5 d), only half of them had a residual or recurrent curvature greater than 15 degrees. Younger patients (<24 yr) had a higher chance of suture failure than elder patients ( p = 0.03). Among the 103 patients completing the questionnaire, no palpable suture knots, suture granuloma, erectile discomfort, or erectile dysfunction was reported (median follow-up time: 41.5 mo). Eighty-three (81.5%) patients were either very or moderately satisfied with the surgical outcome. Conclusions: The modified technique using double, interrupted, U-shaped sutures and absorbable suture material is a simple and effective method for treating CPC. Suture-related complications rarely happen. The long-term outcome is satisfactory, and most patients are pleased with the procedure. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan 100. Tel x5248; Fax: address: danduoncin@yahoo.com.tw (C.-H. Chen) /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 262 european urology 52 (2007) Introduction Congenital penile curvature (CPC) is usually due to length disproportion of the tunica albuginea of corpora cavernosa [1]. Patients with CPC usually start to notice deviation of the erect penis when they reach adolescence [2]. The condition is usually mild and causes no symptom or bother [2]. However, severe penile deviation during erection can cause difficulty in intromission, discomfort during sexual intercourse and psychological trauma demanding treatment [3]. The Nesbit procedure and plication of the tunica albuginea are two commonly used methods for correcting CPC [2,4 8]. Compared with the Nesbit procedure, tunical plication has the advantages of being a simpler procedure, causing less postoperative bleeding and erectile dysfunction, and being able to adjust the areas of plication to ensure an optimal result and avoidance of overcorrection [2,4,6 8]. Most surgeons performing tunical plication utilized nonabsorbable sutures, which could cause certain suture-related complications [3,9,10]. We had described a modified technique of tunical plicaiton using absorbable sutures for the treatment of CPC [11]. The current study is to survey the longterm outcome and patient satisfaction in 114 patients with CPC treated by the procedure. 2. Materials and methods 2.1. Patient population From June 1999 through July 2005, 114 consecutive young men with CPC were treated with the modified tunical plication technique by a single surgeon. The age of the patients ranged from 13.2 to 39.4 yr with a mean age of All presented with a 30-degree or more deviation of the erect penis. Difficulty or pain in vaginal penetration had been experienced in all but 17 men who had no sexual experience before but were psychologically bothered by the presence of penile curvature. Autophotographs or office drawings were taken to delineate the degree and direction of the penile curvature. All patients were evaluated with a detailed history and physical examination before surgery. Patients who had Peyronie s disease and had received a previous penile operation for conditions like hypospadias, penile curvature, and webbed penis were excluded from the study. Before theoperation, patients received a full explanation about possible occurrence of penile shortening and palpable bumps under the penile skin after surgery. All patients had been followed up for at least 6 mo Collection of clinical data Medical records were retrospectively reviewed to collect the patients data such as the age at diagnosis, the degree and direction of the penile curvature, the reason for surgery, the number of sutures applied, postoperative complications, time of occurrence of suture failure, the degree of the residual curvature, and so on Definitions of suture failure and significant residual or recurrent curvature Suture failure was defined as a patient hearing a sound or having the feeling of a snap from the penis regardless of the change of the status of the penile curvature. A significant residual or recurrent curvature was defined as presence of penile curvature of more than 15 degrees after the correction [12] Long-term outcome and patient satisfaction Long-term outcome and patient satisfaction were determined through a detailed, post hoc, structured questionnaire as detailed in the appendix. The questionnaire was completed and mailed by the patient, or the patient was interviewed by telephone by well-trained personnel. Presence of residual curvature, palpable bumps, palpable suture knots, discomfort during erection, erectile dysfunction, and penile shortening were items used to evaluate the long-term outcome. Patient satisfaction was categorized into very satisfied, moderate satisfied, dissatisfied, and very dissatisfied with the surgical result Surgical techniques of the modified plication [11] A circumferential subcoronal incision was made, and the penis was degloved to the penile root. After a tourniquet was applied at the penile root, an artificial erection was induced by normal saline injection through a butterfly needle into one corporal body. The cusp of the maximal convexity of the penile curvature and plicated areas were then determined. The overlying Buck s fascia and the neurovascular bundle in these chosen areas were then carefully dissected free from the tunica albuginea. The Kelâmi s procedure with the use of Allis clamps was adopted to adjust the plicated tunical bumps intraoperatively [13]. The determined bumps, hence, were maintained by placing double, interrupted, U-shaped sutures with 2-0 synthetic absorbable polyglactin (Vicryl, Johnson & Johnson, NJ, USA). The plication sutures were tied in square knots for six times. Finally, a light compressive dressing with a self-adhesive bandage was applied to the penis. Patients were instructed to abstain from sex for 8 wk postoperatively Statistical method All statistical analyses were performed with Small Stata 8.2 for Windows. A Cox regression was used to predict the suture failure by variables. All statistical tests were two sided with p < 0.05 regarded as statistically significant. 3. Results Among the 114 patients, there were 69 (60.5%) with ventral, 27 (23.7%) with left, 3 (2.6%) with dorsal, and 4 (3.5%) with right penile curvature (Table 1). Penile

3 european urology 52 (2007) Table 1 Demographics and surgical outcomes of the 114 patients with congenital penile curvature treated by the modified tunical plication procedure Characteristics Number Percent Median age, yr (range) 24.2 ( ) Median DCPD, degree (range) 50 (30 90) Deformity Dorsal Ventral Left Right More than one direction a Early postoperative complications Wound infection Temporary numbness Hypersensitive glans penis Suture failure Median failure time (d) (range) 38.5 (3 60) Residual curvature at 6 mo Straight > Follow-up duration, mo (range) 41.5 (13 91) DCPD = the degree of the penile curvature after the prepuce degloved. a Eight patients with ventral and left curvature, two with ventral and right curvature, and one with dorsal and left curvature. curvature with more than one direction was detected in 11 (9.6%) patients. The angle of curvature ranged from 30 to 90 degrees, with a median angle of 50 degrees. After the operation, no erectile dysfunction was reported by the patients, two patients had wound infection, and three patients, who received circumcision at the same time, complained of hypersensitivity of the glans penis. Fifteen (13.2%) patients had temporary numbness over the penile shaft and/or glans penis after the operation. The numbness recovered completely in all patients at a median time of 30 d (range: 7 75). Six months after correction, 65 (57%) patients reported a straight erect penis, and 33 (28.9%) patients reported a residual or recurrent curvature of 15 degrees or less. The rest 16 (14%) patients had a residual or recurrent curvature of more than 15 degrees. Four patients with a 30-degree or more residual or recurrent curvature received a second operation. We had discussed with these four patients the advantages and disadvantages of using absorbable or nonabsorbable sutures for the second correction; they all chose to use absorbable sutures. None of them experienced recurrence after the second correction. Suture failure, which usually happened right after the patients heard or felt a snap from their penises, occurred in 32 (28.1%) patients at a median time of 38.5 d (range: 3 60). After suture failure, the erect penis usually deviated to the original direction. Among the patients with suture failure, only half of them had a residual or recurrent curvature of more than 15 degrees. For analyzing factors predicting suture failure, parameters including age, the direction of penile curvature, the degree of curvature after the prepuce degloved (DCPD), and the corrected degree by each bump were further stratified (Table 2). Results of a univariate analyses with Cox regression showed that no factor had statistical significance on predicting suture failure except younger age (Table 2). The younger patients (<24 yr) group had a higher suture failure rate (39%) than the elder group (17%). Via a multivariate Cox regression analysis for suture failure, the younger group still had a higher hazard ratio (2.3; 95% confidence interval: ) than the elder group. The degree of the preoperative penile curvature was not found to be a significant factor to differentiate patients with and without a residual or recurrent curvature of more than 15 degrees (the median degree of the preoperative curvature: 50 degrees in both groups; Wilcoxon rank-sum test, p value = 0.46). Yet, patients having a residual or recurrent curvature of more than 15 degrees were significantly younger than those having a 15 or less degrees of residual or recurrent curvature (median Table 2 Univariate and multivariate analysis of risk factors for suture failures in patients with congenital penile curvature Parameters Pt no. Suture failure Univariate Multivariate Hazard ratio (%95CI) p value Hazard ratio (%95CI) p value Younger age (<24 yr) ( ) ( ) 0.03 Lateral deviation a ( ) ( ) 0.44 DCPD ( ) ( ) 0.55 Corrected degree by each bump > ( ) ( ) 0.55 Pt = patient; CI = confidence interval; DCPD = the degree of the penile curvature after the prepuce degloved. a Lateral deviation versus vertical deviation.

4 264 european urology 52 (2007) Table 3 Long-term outcome and satisfaction of 103 patients responding to questionnaires Complication and satisfaction Number Percent Worsening of penile deviation a 0 0 Late postoperative complications Bump sensation Penile shortening Erectile pain 0 0 Erectile dysfunction 0 0 Palpable suture knots 0 0 Suture granuloma 0 0 Improvement of sexual quality b Satisfaction Very satisfied Moderately satisfied Moderately dissatisfied Very dissatisfied 0 0 a Worsening of the penile curvature after the final assessment at 6 mo after the operation. b Seventeen patients were excluded because of no sexual experience. age: 22.3 and 25.5 yr in each group, respectively; Wilcoxon rank-sum test, p value = 0.02). Among the 114 patients, 103 (90.4%) completed the post hoc questionnaire. The long-term outcome and patient satisfaction of the modified plication procedure in treating CPC is shown in Table 3. Fora median follow-up period of 41.5 mo (range: 13 91), no further recurrence of penile curvature was noted beyond 6 mo after surgery. No suture knots or suture granuloma was felt by the patients. No erectile dysfunction developed postoperatively. Seventynine (91.9%) patients who had difficulty or pain during vaginal penetration reported disappearance of the symptoms after surgery. Bump sensation under the penile skin was experienced in 21 (20.3%) patients, but it became more and more vague afterwards in most of the patients. Twenty-six (25.2%) men noted a certain extent of penile shortening after surgery, but most of the men were not significantly bothered by it. Very or moderate satisfaction with the surgical result was reported by 81.5% of the patients. The rest of the patients were dissatisfied with the surgical result for reasons such as having a residual curvature of more than 15 degrees (n =16), wound dehiscence (n = 2), and wound infection (n = 1). 4. Discussion The Nesbit procedure used to be the method of choice for the treatment of CPC [5]. Since the Nesbit procedure demands excision or incision of the tunica albuginea, it is time consuming, and postoperative complications such as extensive hematoma formation, penile bulging, overcorrection, new onset of erectile dysfunction, and so forth happen frequently [10]. To avoid such complications and to make the operation simpler, Horton and Devine [8] used tunical plication surgery to treat CPC, and others [6,14] started to adopt the procedure. Although early results of tunical plication surgery were not satisfactory [10], recent modified tunical plication techniques have proven to be at least as effective as the Nesbit procedure in treating CPC [6,7,15,16]. While Thiounn et al with a limited patient number of 25 had reported 100% success, the success rate of the tunical plication procedure in treating CPC generally lies between 80% and 95% [6,7,15,16]. Most surgeons using tunical plication to treat CPC prefer to use nonabsorbable sutures instead of absorbable sutures, because of the possibility of plication breakdown after the suture material was absorbed [6,7,15,16]. However, suture failure still happens, probably from tissue cutthrough, even when using nonabsorbable sutures. In addition, the use of nonabsorbable sutures may cause several suture-related complications such as palpable suture knots, suture granuloma, and discomfort during erection [6,9,10]. Poulsen and Kirkeby [9] had reported 1 of their 23 patients with CPC to have bothering palpable suture knots and one to have suture granuloma; Gholami and Lue [10] had reported bother from suture knots in 12% and pain during erection in 9% of their 132 patients who received tunical plication surgery. In 2001, we suggested a modified tunical plication procedure to treat CPC [11]. Benefits of the modified tunical plication procedure included minimal manipulation of the Buck s fascia and neurovascular bundles to reduce intraoperative bleeding and postoperative penile numbness, the use of double, interrupted, U-shaped sutures to prevent suture failure, and the use of absorbable suture material to avoid certain complications such as palpable suture knots, suture granuloma, and suture-related discomfort during erection. The current report presents the long-term outcome and patient satisfaction of a much larger number of patients treated by the procedure. A total of 84 (81.5%) patients expressed either very or moderate satisfaction with the surgical result. The high satisfaction rate is likely due to the high success rate and the low complication rate of the surgery. Eighty-six percent (98 of 114) of our patients had either a straight erect penis or a residual/ recurrent curvature of less than 15 degrees 6 mo after surgery. The success rate is satisfactory and comparable to other surgeons results. The high

5 european urology 52 (2007) success rate also suggests concern of plication breakdown from suture absorption is not a major issue. The absorbable suture material, polyglactin, is expected to be absorbed at about 8 wk [17]. By that time, the scars formed within the plication should have stabilized and been strong enough to hold the plication. Recurrence of the curvature does happen, and it is probably due to early suture failure from tissue cut-through or suture breakage. Using a more durable absorbable suture such as polydixanone can be attempted. Postoperative suture failure happened in 32 (28.9%) patients at a median time of 38.5 d in our series. Yet, only half of them had a recurrent curvature of more than 15 degrees, and only a few of them considered a second operation necessary. The reason for the discrepancy between the recurrence rate and the suture failure rate is speculated to be due to the use of double, interrupted, U-shaped sutures. When one suture breaks, the other suture offers double security to maintain the plication. In addition, sexual abstinence for 8 wk is of paramount importance in reducing the occurrence of suture failure. In the current study, men younger than 24 yr was found to have a higher suture failure rate ( p =0.01). Musicki et al [18] had described higher intracavernosal pressure in young rats compared with aged rats, and Schiavi and Schreiner-Engel [19] had reported decreased frequency and duration of nocturnal erection with increasing age in men. Accordingly, younger men may have higher intracorporeal pressure and more frequent nocturnal erection, which together may possibly account for the higher suture failure rate. Temporary use of antiandrogens, which had been shown to decrease the nocturnal erection frequency in human males [19], may be one effective option that helps to reduce suture failure in younger patients receiving tunical plication surgery. To achieve a higher success rate and reduce suture failure events, we propose three strategies. First, the use of a more durable absorbable suture such as polydixanone may provide an adequate period and strength against the intracorporeal pressure. This modification may be of help in a patient with a short period of suture degradation. Second, placing one more U-shaped suture in each bump may offer an additional security to maintain the bump structure. However, it is not easy to perform a tunical plication with triple, interrupted, U-shaped sutures because of the inadequate breadth of a bump. Third, strict sexual abstinence and medications that reduce the intracorporeal pressure and the frequency of the penile erection will eliminate the ultimate source of tissue cutthrough and suture breakdown. The use of absorbable sutures was rewarded since no patient palpated a suture knot, felt erection pain, or developed suture granuloma at the 6-mo and later follow-up. Although bump sensation under the penile skin was experienced in 21 (20.3%) patients and penile shortening was experienced in 26 (25.2%) patients, they did not bother the patients significantly because the problems were not severe and the possibility of occurrence of these complications had been well explained to the patients before the operation. Kirstan et al [1] reported that skin chordee and fibrotic Buck s and dartos fasciae were found in 65% of 87 children with congenital chordee and without hypospadias at a median age of 14 mo. When the chordee was released, no more apparent curvature of the penis was noted. Fifty-four (47.4%) of our 114 patients were found to have chordee during artificial erection, and the penile curvature recovered for more than 10 degrees after the chordee was released in 17 (21%) of them. Nevertheless, all 54 patients still needed the plication procedure to provide adequate correction of the penile curvature. Our observation suggests that chordee-limiting balanced growth of the tunica albuginea of corpa cavernosa may contribute in part to the pathogenesis of CPC in certain patients. 5. Conclusions The modified tunical plication technique using double, interrupted, U-shaped sutures and absorbable suture material is a simple and effective method for the correction of congenital penile curvature. Suture failure occasionally happens and takes place more often in younger patients. Suturerelated complications rarely occur. The long-term success rate is high, and most patients are satisfied with the procedure. Appendix. Questionnaire used for evaluating long-term outcome and patient satisfaction 1. Has the status of your penile deviation changed since the final assessment at 6 months after surgery? (if yes, please answer questions 1a and 1b) 1a. Please describe the degree and direction of your present penile deviation. 1b. Had you heard or felt any snaps from your penis? Yes No

6 266 european urology 52 (2007) Are you feeling a bump or bumps under the penile skin? (if yes, please answer question 2a) 2a. Is the feeling bothering you? 3. Did you notice shortening of your erect penis after the operation? (if yes, please answer question 3a) 3a. Is the penile shortening bothering you? 4. Do you feel suture knots on the penile shaft? (if yes, please answer question 4a) 4a. Are the suture knots bothering you? 5. Have you felt a growing mass around the bump after operation? (if yes, please answer question 5a) 5a. Is the mass bothering you? 6. Have you felt discomfort during erection? (if yes, please answer question 6a) 6a. Does the discomfort bother you? 7. Are you still getting rigid erect penis after the operation? (if no, please answer question 7a) 7a. Is the problem bothering you? 8. How is your sex life after the operation? no sexual life at all, better, no change, worse 9. Are you satisfied with the overall outcome of the operation? very satisfied, moderately satisfied, moderately dissatisfied, very dissatisfied References [1] Donnahoo KK, Cain MP, Pope JC, et al. Etiology, management and surgical complications of congenital chordee without hypospadias. J Urol 1998;160: [2] Ebbehoj J, Metz P. Congenital penile angulation. Br J Urol 1987;60: [3] Van Der HC, Martinez Portillo FJ, Seif C, et al. Treatment of penile curvature with Essed-Schroder tunical plication: aspects of quality of life from the patients perspective. BJU Int 2004;93: [4] Lee SS, Meng E, Chuang FP, et al. Congenital penile curvature: long-term results of operative treatment using the plication procedure. Asian J Androl 2004;6: [5] Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol 1965;93: [6] Baskin LS, Lue TF. The correction of congenital penile curvature in young men. Br J Urol 1998;81: [7] Thiounn N, Missirliu A, Zerbib M, et al. Corporeal plication for surgical correction of penile curvature. Experience with 60 patients. Eur Urol 1998;33: [8] Horton CE, Devine Jr CJ. Plication of the tunica albuginea to straighten the curved penis. Plast Reconstr Surg 1973;52:32 4. [9] Gholami SS, Lue TF. Correction of penile curvature using the 16-dot plication technique: a review of 132 patients. J Urol 2002;167: [10] Poulsen J, Kirkeby HJ. Treatment of penile curvature a retrospective study of 175 patients operated with plication of the tunica albuginea or with the Nesbit procedure. Br J Urol 1995;75: [11] Hsieh JT, Huang HE, Chen J, et al. Modified plication of the tunica albuginea in treating congenital penile curvature. BJU Int 2001;88: [12] Popken G, Wetterauer U, Schultze-Seemann W, et al. A modified corporoplasty for treating congenital penile curvature and reducing the incidence of palpable indurations. BJU Int 1999;83:71 5. [13] Kelami A. Congenital penile deviation and its treatment with the Nesbit-Kelami technique. Br J Urol 1987;60: [14] Essed E, Schroeder FH. New surgical treatment for Peyronie disease. Urology 1985;25: [15] Chien GW, Aboseif SR. Corporeal plication for the treatment of congenital penile curvature. J Urol 2003;169: [16] Baskin LS, Ebbers MB. Hypospadias: anatomy, etiology, and technique. J Pediatr Surg 2006;41: [17] Conn Jr J, Oyasu R, Welsh M, et al. Vicryl (polyglactin 910) synthetic absorbable sutures. Am J Surg 1974;128: [18] Musicki B, Kramer MF, Becker RE, et al. Age-related changes in phosphorylation of endothelial nitric oxide synthase in the rat penis. J Sex Med 2005;2: [19] Schiavi RC, Schreiner-Engel P. Nocturnal penile tumescence in healthy aging men. J Gerontol 1988;43:M

7 european urology 52 (2007) Editorial Comment on: Correction of Congenital Penile Curvature Using Modified Tunical Plication with Absorbable Sutures: The Long-Term Outcome and Patient Satisfaction Armin J. Becker Urologischen Klinik Grosshadern, Ludwig-Maximilians-Universität (LMU), Marchioninistrasse 15, München, Germany Penile curvatures are most often caused by disproportional growth of the corpora cavernosa congenitally, Peyronie s disease, or trauma to the penis. Penile deviation can be corrected by surgical means. In 1965, Nesbit described the first technique for shortening the elongated tunica albuginea on the convex side of the penis by elliptical excision of tunica albuginea tissue. Essed and Schröder simplified the technique by plicating the convex side of the penis with nonresorbable sutures in The cause of congenital penile deviation is an asymmetry in compliance of the tunica albuginea due to developmental arrest during embryogenesis that not only results in sexual dysfunction but also leads to severe psychological problems. The indication for surgical correction of penile deviation is painful cohabitation for both sexual partners or disability of vaginal penetration depending on the degree of the deviation. The aim of surgery has to be the cosmetic correction under maximum protection of erectile function. Reported success rates for Nesbit or modified Nesbit procedures range from 53% to 100%, and success rates for the plication techniques range from 29.5% to 100% [1]. Most authors report a higher risk for recurrent deviation in patients with Peyronie s disease than in patients with congenital deviation [2]. Nevertheless, postoperative failure also appears in patients with congenital deviation. Insufficient suture and knot technique and suture loosening and breakage, partly due to granuloma formation using nonabsorbable sutures have been discussed as potential reasons [2]. Chung-Hsin Chen and coworkers provide new information on the long-term outcome and patients satisfaction describing a modified plication technique using double-interrupted, U-shaped sutures and absorbable suture material in patients with congenital penile curvature [3]. Criteria to evaluate the outcome were presence of residual curvature, palpable bumps or suture knots, discomfort during erection, and postoperative erectile dysfunction. The authors state that the high satisfaction rate of 81.5% is likely due to the high success rate and the low complication rate of the modified surgery technique applied. The concern of plication breakdown from suture absorption is not a major issue due to the stabilisation of scars formed at the absorption time point of 8 wk [3]. The article is of great interest and relevance to practising surgical urologists because it gives insight into a very convincing form of modification of a well-known plication technique. The results given are convincing because they are based on a cohort of a large group of men, in a long-term follow-up assessing functional aspects and the patient s satisfaction. References [1] Friedrich MG, Evans D, Noldus J, Huland H. The correction of penile curvature with the Essed-Schröder technique: a long-term follow up assessing functional aspects and quality of life. BJU Int 2000;86: [2] Schultheiss D, Meschi MR, Hagemann J, Truss MC, Stief CG, Jonas U. Congenital and acquired penile deviation treated with the Essed plication method. Eur Urol 2000;38: [3] Hsieh J-T, Liu S-P, Chen Y, Chang H-C, Yu H-J, Chen C-H. Correction of congenital penile curvature using modified tunical plication with absorbable sutures: the long-term outcome and patient satisfaction. Eur Urol 2007;52: DOI: /j.eururo DOI of original article: /j.eururo