Smith Blog

Recently, one of our faculty, Dr. Lee Richstone was honored to be involved as a faculty member at two advanced laparoscopy courses, one in India and the other in Los Angeles. Both courses were held for other physicians who wanted to learn advanced laparoscopic skills. In particular, they wanted to learn more about LESS surgery. LESS stands for Laparoendoscopic Single Site (LESS) surgery. This is a new approach to laparoscopic surgery, where the entire surgery is completed through the umbilicus (belly-button, or navel). The result is nearly scar-less surgery!

Dr. Richstone is one of the few who are leading the way in this exciting field. In fact, we have been pioneers in LESS donor nephrectomy, LESS pyeloplasty for obstructed kidneys, and LESS partial and complete nephrectomy. In particular, our experience with LESS partial nephrectomy is exciting. When patients have small kidney tumors that need to be surgically removed, a partial (not complete) kidney removal is required. This is called a partial nephrectomy. Dr. Richstone’s experience with performing this surgey ONLY through the belly-button may be the largest experience worldwide with this technique.  With time, there’s hope that this technique will offer the best possible cosmetic outcomes while sparing the majority of the remaining kidney, which is so vital.

In December Dr. Richstone was asked to travel to Nadiad, in India, to teach these techniques by giving lectures and performing live LESS surgery. It was a fascinating trip!  Surgeons came from all over the world, including Africa, India, Singapore, Japan, among other nations, to learn. It was a great “meeting of minds”! He performed 2 LESS operations over the 3 day course that helped many patients and their families. Medicine is an amazing occupation, rich with patient experiences, research opportunities, as well as incredible opportunities to work with collegues from across the globe. It is amazing how new technology “diffuses” so quickly to far corners of the world so rapidly! Dr. Manesh Desai was the organizer of the meeting, and the host. To him we are very grateful. More recently, Dr. Richstone was invited to participate in a similar course for the American Urological Association at a course held at the University of Southern California, with doctors from all over the United States, and as far as Korea, in attendance.

When it comes to new surgical approaches in surgery and urology, we need to do a better job of getting advanced techniques “out there” to the community.  For example, far too many patients get their entire kidney taken out when only part of it needs to be removed, and far too few patients are offered the advantages of a laparoscopic approach to surgery (ref 1). This is particularly for kidney surgery where the recovery is considerable shortened, with less pain. It is worthwhile to continue to strive to offer the same success rates for surgery, but strive for a “scarless” approach to improve patient sense of well-being, and cosmetic outcome (ref 2).  We at the Smith Institute for Urology have a long track record on the “cutting edge” of patient care and research, and will continue to do so with passion and vision.

Reference:
1) Richstone L, Kavoussi LR. Barriers to the diffusion of advanced surgical techniques. Cancer. 2008 Apr 15;112(8):1646-9.
2) Richstone L, Kavoussi L.”Less” is more. J Urol. 2007 Sep;178(3 Pt 1):752.

As many of our patients know, Dr. Barbara Shorter, EdD, RD, CDN Associate Professor of Nutrition and  Director of the undergraduate Nutrition Program at Long Island University, has been volunteering her time every other Friday to counsel IC patients.

Well…we are very happy to report that Dr. Shorter has now joined our faculty! She’ll be giving expert advice on the nutritional aspects of many other urological conditions such as kidney disease, kidney stones, interstitial cystitis, prostatitis, and urological cancers.

Barbara Shorter received her Doctorate in Nutrition Education from Teachers College, Columbia University.  She is a registered dietitian with the American Dietetic Association and is a Certified Dietitian/Nutritionist NYS.  Dr. Shorter is an Associate Professor in the Department of Nutrition at the CW Post Campus of Long Island University (LIU) and Director of the Didactic Program in Dietetics.  She recently joined the faculty of the Smith Institute for Urology where she provides nutritional counseling in facets of urology including, pelvic pain, prostate cancer, kidney stone disease, and renal failure.

Prior to Dr. Shorter’s positions in the Academic arena, she was Chief Dietitian for the Catholic Medical Center, and, Senior Nutritionist at the NYU Medical Center Hospital, NYC.

Welcome aboard Barbara!!

Men treated for inflammatory bowel disease with Sulfazalazine have drug related impairment in sperm quality that often persists after cessation of the drug. This had prompted pharmaceutical companies to develop other “sperm friendly” treatment options. The most frequent age of onset of the inflammatory bowel diseases including idiopathic chronic inflammatory bowel disease (IBD), Crohn’s disease (CD) and Ulcerative Colitis (UC) is between 15 to 30 years of age. This range, of course, coincides with the peak reproductive years. Therefore, it makes good sense that the effect on male fertility of any drug treatment should be known. Azathioprine and 6-Mercaptopurine (6-MP) are effective immunosuppressive agents commonly used for the long term control of UC and CD in the steroid dependent patient and are focus of this article.

Azathioprine is converted to 6-mercaptopurine which acts to decrease cell metabolism and DNA biosynthesis. A study by Russell and Hunsicker (Study of the base analog 6-mercaptopurine in the mouse specific-locus test., Mutat Res. 1987 Jan;176(1):47-52.) found that in mice 6-Mercaptopurine caused chromosomal damage (both structural and numerical) in all stages of development of the male germ-cell. This data was again confirmed by Witt and Bishop (Mutagenicity of anticancer drugs in mammalian germ cells., Mutat Res. 1996 Aug 17;355(1-2):209 34). In a study in rats, a dose dependent decrease in sperm concentration, damage to the seminiferous tubules and a lowering of testosterone was found with Azathioprine therapy (Iwasaki M, Fuse H, Katayama T., The effects of cyclosporine azathioprine and mizoribine on male reproduction in rats, Nippon Hinyokika Gakkai Zasshi. 1996 Jan;87(1):42-9). In addition, in a study in mice, spermatogenesis and fertility was also decreased (Sykora I. Dominant-lethal test of 6-mercaptopurine: dependence on dosage, duration and route of administration. Neoplasma. 1981;28(6):739-46).

There is some, but unfortunately not much, data available on the effect of these agents on sperm production and sperm function in man. A study by Dejaco et al suggested that men treated with Azathioprine have no change in semen quality and
implied that fertility was also unaffected (Gastroenterology. 2001 Nov;121(5):1048 53. Azathioprine treatment and male fertility in inflammatory bowel disease. Comment in: Inflamm Bowel Dis. 2002 May;8(3):234-5). In this study, paired data wasn’t examined. In contrast, a case study by Sills and Tucker found markedly impaired semen parameters in a single patient who had conceived twice with his partner prior to three months of therapy with 6-MP (First experience with intracytoplasmic sperm injection for extreme oligozoospermia associated with Crohn’s disease and 6-mercaptopurine chemotherapy. Asian J Androl. 2003 Mar;5(1):76-8).

Much more data is needed in humans. Many questions remain unanswered; Are the effects of these drugs in man similar to those found in rodents? Is it the medication used or the underlying disease that has a greater effect on sperm? Are the effects seen reversible, and if so over what time period? Additional research is needed to define the effect of these (and other) drugs used in the treatment of inflammatory bowel disease in reproductive-aged men. Until these studies are done, I feel it is advisable to discuss the potential for impairment in fertility and offer sperm banking to reproductive aged men prior to long term treatment with Azathioprine or 6-Mercaptopurine.

Bruce R. Gilbert, MD, PhD
Director, Reproductive and Sexual Medicine
The Smith Institute for Urology
North Shore LIJ Health System
7/26/09

The American Urological Association Annual meeting in Chicago (April 25th – April 30th) was a huge success for patients suffering from pelvic pain. Some of the latest news…

1.    Various differences may exist in urinary protein expression between interstitial cystitis (IC) patients and those without IC. This suggests that “urinary proteomics” may provide insight into the cause of IC and/or aid in the development of new “markers” for this condition.
2.    Nerve growth factor was found to be elevated in the urine of IC patients and in patients with overactive bladder and even in patients with varied lower urinary tract symptoms.
3.    Patients with IC appear to have significant biosocial impairment as compared to the population at large. Also, conditions such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome were more frequently seen in the IC population.
4.    The Rand Interstitial Cystitis Epidemiology study evaluated almost 100,000 US households and found the prevalence of IC type symptoms in women to be 3-6%, a significantly higher prevalence than previous studies. This suggests that IC symptoms may exist in over 4 million women in the United States!
5.    Botulinum toxin A (100 units) into the bladder base (trigone) improved the symptoms of all 17 patients in one study. At 9 months follow up, 7 patients requested another injection due to return of symptoms.
6.    In another Botulinum toxin A related study, Botulinum toxin A appeared to enhance the clinical effect of bladder hydrodistention.
7.    Antiproliferative factor (APF) is a chemical found in the urine of most IC patients and may be a cause of symptoms. Two new agents have shown promise as APF inhibitors in the laboratory setting.
8.    Both IC patients and patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) had a high prevalence of food sensitivities, but IC patients still had about twice the prevalence as the CP/CPPS patients.
9.     A clinical phenotyping system termed “UPOINT” (Urinary, Psychosocial, Organ specific, Infection, Neurologic/Systemic, Tenderness of pelvic floor muscles) was developed to better understand the cause of and best therapies for CP/CPPS.
10.    In a randomized, double blinded study, pregabalin (Lyrica®)  was not found to be better than a placebo group in the treatment of CP/CPPS…BUT..when evaluating “secondary endpoints” such as global improvements, significant differences where found, suggesting a role for this medication in the treatment of CP/CPPS.

For this information and more, please visit the Pelvic Pain section of this website.

Robert Moldwin, MD
Associate Professor of Clinical Urology
Hofstra University School of Medicine
Director, Pelvic Pain Center
The Arthur Smith Institute for Urology
Long Island Jewish Medical Center

In 1953, John Hunt led a British expedition to climb Mount Everest that unfortunately had to turn around within 300 feet of the summit.  Although the group failed its task, they defined a route and introduced a technique for carrying extra oxygen that allowed the New Zealander Edmund Hillary to reach the summit a few days later. Hillary became Sir Hillary and the accomplishment was celebrated around the globe.

Several steps have been taken in the climb towards a true Natural Orifice Transluminal Endoscopic Surgery (NOTES) nephrectomy. This means removing organs through a natural orifice such as the mouth, rectum, urethra or vagina.  Previous reports demonstrate that kidney removal through the vaginal vault is feasible.

Is NOTES the summit of “Everest” or is it Base Camp? The answer is both. NOTES has fulfilled the dream of eliminating a visable incision for extirpative renal surgery. However, there are growing series of Laparoendoscopic Single-Site Surgery (LESS) nephrectomies that have shown only cosmesis as the advantage to minimizing the incision. Until a series of NOTES nephrectomies is evaluated it is uncertain whether there will be any additional benefit to the patient. The major issues of surgery still remain with postoperative ileus, fatigue and discomfort coming from the actual renal dissection which does not change based on location of trocar placement.

This kind of surgical exploration needs to be supported.  However, the real surgical “Everest” will be a quantum leap, a total replacement of our current notion of invasive extirpative surgery.  We should never take our eyes off this ultimate prize.

Louis R. Kavoussi, M.D.
Professor and Chairman
Smith Institute for Urology
Hofstra School of Medicine
North Shore-LIJ Health System
Long Island, NY