Correspondence

Benign lateralizing haematuria: the impactof upper tract endoscopy

Sir,

This paper provided a comprehensive review of benign

lateralizing haematuria, which is a relatively common dilemma

facing current urologists [1]. The authors suggest a revision

of the algorithm of McMurty et al. [2] for managing patients

who present with this condition. By following the algorithm

patients with persistent or recurrent haematuria would proceed

to helical CT and angiography. Both these investigations are

time-consuming and expensive; before reaching this step in

the algorithm we recommend the use of colour Doppler

ultrasonography (CDUS). Although a relatively rare condition,

arteriovenous fistulae or malformations (AVMs) are an impor-

tant cause of benign haematuria that need to be identified. With

a reported incidence of 0.04%, these abnormalities are often

not detected in the early stages of the investigation [3].

Angiography is the accepted ‘gold standard’ for diagnosing

AVMs but this invasive procedure is not without its complica-

tions. From a review of published studies CDUS has been shown

to be effective in both the diagnosis and subsequent monitoring

of AVMs. Takebayashi et al. [4] compared the use of CDUS

with angiography in 46 patients who presented with haemat-

uria. Six patients were found on angiograms to have AVMs

of varying locations, sizes and degrees of shunting. CDUS

detected all six patients with no false-positive results [4].

Recently, a 51-year-old woman presented to our department

with a 10-year history of recurrent episodic haematuria.

Previous investigations had excluded a malignant cause but

a diagnosis had not been reached. CDUS showed a large

congenital AVM in the lower pole of the right kidney (Fig. 1).

In our experience CDUS is a good investigation in those

patients with persistent or repeated episodes of bleeding.

We would therefore recommend a further revision of the

algorithm by including CDUS before proceeding to helical CT or

angiography.

G.M. Brown, MRCS, Clinical Research Fellow

P.N. Matthews, Consultant Urologist

Department of Urology, University Hospital of Wales,

Heath Park, Cardiff, UK

1 Rowbotham C, Anson K. Benign lateralizing haematuria: the

impact of upper tract endoscopy. BJU Int 2001; 88: 841–9

2 McMurty J, Clayman R, Preminger G. Endourologic diagnosis

and treatment of essential hematuria. J Endourol 1987;

1: 145–51

3 Cho K, Stanley J. Non-neoplastic congenital and required

renal arteriovenous malformations and fistulas. Radiology

1978; 129: 333–43

4 Takebayashi S, Aida N, Matsui K. Arteriovenous malforma-

tions of the kidneys: Diagnosis and follow-up with color

doppler sonography in six patients. Am J Roentgenol 1991;

157: 991–5

Reply

The suggested modification of our algorithm for managing

patients with benign lateralizing haematuria (BLH) to include

CDUS before proceeding to helical CT or angiography merits

careful consideration. CDUS is safer, less expensive and less

time-consuming than helical CT or angiography, especially

if it is used at the same time as traditional grey-scale US,

and vascular malformations such as small to medium-sized

congenital AVMs may be detected. For these reasons, Brown

and Matthews proposed its routine use in the investigation of

patients with BLH before helical CT or angiography, although

they do not specify if it should be before or after endoscopy.

If its use were confined to patients with persistent or

recurrent bleeding after endoscopy it may well reduce the

requirement for helical CT in those patients with a positive scan.

However, these patients are uncommon and we consider that

the additional cost of routine CDUS after endoscopy can only be

justified if a negative result allows angiography to be safely

omitted. However, there is insufficient published evidence to be

reassured by a negative Doppler scan. Takebayashi et al. [1]

reported the use of CDUS in the diagnosis of congenital renal

AVMs in a group of patients presenting with haematuria. We

do not consider that this small study alone justifies the omission

of angiography if the CDUS is negative. Although the value of

CDUS in the diagnosis of iatrogenic AVMs in transplant kidneys

is well documented, this experience cannot be transferred to

congenital AVMs in native kidneys for two reasons; first

because of the different characteristics of these two types of

AVM, and second because of the difficulty in clearly insonating

the more deeply situated native kidneys, as it is subject to

respiratory excursion [1,2].

Routine CDUS and grey-scale US before endoscopy would

be cost-competitive only if both endoscopy and helical CT are

Fig. 1. CDUS clearly showing the appearance of an AVM; white

arrow, feeding artery; yellow arrow, AVM; green arrow, draining

renal vein.

BJU International (2002), 90, 140–144

# 2002 BJU International140

avoided in patients with a positive scan. However, helical CT

and angiography would still be necessary in patients with

persistent or recurrent bleeding and a negative CDUS, for

the reasons cited above. Furthermore, because most congenital

AVMs are located in the lamina propria immediately below

the transitional epithelium of the collecting system, it is possible

that smaller AVMs are being treated endoscopically [2].

Diagnosis of these lesions by CDUS before endoscopy should

therefore lead to a decision between treatment by embolization

or whether endoscopic management should be considered.

Overall we agree with Brown and Matthews that CDUS

warrants a place in the algorithm for the management of

BLH and should be used instead of grey-scale US when available.

However, we feel that angiography is still indicated in the

presence of a negative CDUS and persistent or recurrent

bleeding after endoscopy.

C. Rowbotham, MA, MSc, FRCS

K.M. Anson

1 Takebayashi S, Aida N, Matsui K. Arteriovenous mal-

formations of the kidneys: diagnosis and follow-up with

color doppler sonography in six patients. Am J Roentgenol

1991; 157: 991–5

2 Crotty KL, Orihuela E, Warren MM. Recent advances in

the diagnosis and treatment of renal arteriovenous

malformations and fistulas. J Urol 1993; 150: 1355–9

Can diet affect prostate cancer?

Sir,

We read with great interest this review [1] which covers

what has become a vast topic and is of increasing importance

to the practising urologist. However, it is disappointing that

lycopene, the carotenoid that gives tomatoes their red colour,

was entirely overlooked. The possible importance of dietary

lycopene became well known after publication of analysed data

from the Health Professional Follow-Up study [2]. This showed

that of all the dietary factors investigated, including several

carotenoids and vitamin E, only high levels of dietary lycopene

were associated with a decrease in the risk of developing

prostate cancer. From this, experimental work using immortal

prostate cancer cell lines has repeatedly confirmed a remarkable

inhibition of cell proliferation and increased rates of cell

apoptosis in the presence of physiological concentrations of

lycopene [3]. Furthermore, early clinical trials of short term

lycopene supplementation, either in the form of an oleoresin or

in tomato pasta sauce, in patients before radical prostatectomy

has led to significant decreases in PSA level, together with

evidence of down-regulation of cancerous cell activity [4,5].

These results, together with a host of related experimental

data, including recent work by the present authors showing at

least a 50% reduction in cell invasion capacity by the PC3 cell

line in the presence of lycopene (unpublished) and a case report

describing a large decrease in PSA level in a man with hormone-

resistant prostate cancer after starting supplemental lycopene

[6], would all suggest a potentially important role for lycopene

not only in the development but also in the progression of

prostate cancer. Given the strength and range of this evidence it

is not surprising that there is an increasing amount of interest in

the role that dietary lycopene may play in prostate cancer [7].

Indeed, there are numerous websites and articles in the press

expounding its virtues. If urologists are to be fully armed in

the face of increasingly health-conscious and knowledgeable

patients it is important that urologists should have some

understanding of this interesting carotenoid – the patients

already do!

N.J. Barber, G. Zhu and G.H. Muir

Department of Urology, King’s College Hospital, London, UK

1 Meyer J-P, Gillatt DA. Can diet affect prostate cancer? BJU Int

2002; 89: 250–4

2 Giovannucci E, Ascherio A, Rimm EB, Stampfer MJ,

Colditz GA, Willett WC. Intake of carotenoids and retinol

in relation to risk of prostate cancer. J Natl Cancer Inst 1995;

87: 1767–76

3 Kotake-Nara E, Kushiro M, Zhang H, Sugawara T,

Miyashita K, Nagao A. Carotenoids affect proliferation of

human prostate cancer cells. J Nutrition 2001; 131: 3303–6

4 Kucuk O, Sarkar FH, Sakr W et al. Phase II randomized

clinical trial of lycopene supplementation before radical

prostatectomy. Cancer Epidemiol Biomarkers Prev 2001;

10: 861–8

5 Chen L, Stacewicz-Sapuntzakis M, Duncan C et al.

Oxidative DNA damage in prostate cancer patients consum-

ing tomato sauce-based entrees as a whole-food intervention.

J Natl Cancer Inst 2001; 93: 1872–9

6 Matlaga BR, Hall MC, Stindt D, Torti FM. Response

of hormone refractory prostate cancer to lycopene. J Urol

2001;166: 613

7 Barber NJ, Barber J. Lycopene and prostate cancer.

Prostate Cancer Prostatic Dis 2002; 5: 1–7

Sir,

I read this article [1] with interest. Fat is described as

the foremost dietary component contributing to the aetiology of

prostate cancer. The role of essential fatty acids as a cause

of prostate cancer has been described in some detail and

some proposals made about the mechanism of carcinogenesis.

However, the role of saturated fat and animal meat was

not discussed. There has been some research to determine the

role of saturated fat and the method of cooking in the aetiology

of prostate cancer. Cooking animal fat and meat at high

temperature produces polycyclic aromatic hydrocarbons

(PAH), e.g. benzo[a]pyrene and heterocyclic amines (HCA),

e.g. 2-amino-1-methyl-6-phenyl imidazopyridine, 2-amino-3-

methyl imidazo quinoline, by pyrolysis of fat [2]. These hydro-

carbons and heterocyclic amines are mutagenic in animal and

human studies [3]. The PAH and HCA need to be biologically

activated by the prostate before they form a DNA adduct. This

involves N-hydroxylation by cytochrome p450 enzymes and

these N-hydroxy derivatives are further o-esterified, catalysed by

N-acetyl transferases (NATs)/sulpho-transferases to form reac-

tive nitrenium ion derivatives. These covalently bind with DNA

CORRESPONDENCE 141

# 2002 BJU International 90, 140–144

to form adducts. Studies have confirmed that the prostate

necessarily expresses these key xenobiotic metabolising

enzymes, i.e. cytochrome p450 1A2, 1A1 and 181 [4]. Wang

et al. [5] identified the overexpression of NAT1 enzymes in

human prostate tissue by PCR. Muir et al. [4] confirmed that

these fat-derived PAH and HCA form DNA adducts in human

prostate tissue by analysis after 32P-labelling. Further research

is being undertaken to identify the correlation between diet,

method of cooking and prevalence of DNA adducts induced

by PAH and HCA among the general population and subjects

with prostate cancer. Hence the role of fat in prostate

cancer is more complex than suggested and simple addition

or deletion of a particular type of fat/fatty acid may not alone

be a sufficient preventive strategy. Lifestyle issues like mode

of cooking need to be addressed when considering dietary

manipulation.

V. Kumar, MBBS, MS, FRCSEd, Research Registrar

Institute of Cancer Research, Sutton, Surrey, UK

1 Meyer J-P, Gillatt DA. Can diet affect prostate cancer? BJU Int

2002; 89: 250–4

2 Knize MG, Salmon CP, Pais P, Felton JS. Food heating

and the formation of heterocyclic aromatic amine and

polycyclic aromatic hydrocarbon mutagens/carcinogens.

Adv Exp Med Biol 1999; 459: 179–93

3 El-Bayoumy K. Environmental carcinogens that may be

involved in human breast cancer etiology. Chem Res Toxicol

1992; 5: 585–90

4 Muir GH, Williams GH, Martin FL, Hewer A,

Grover PL, Philips DH. Metabolic activation of carcinogens

and expression of various cytochromes P450 in human

prostate tissue. Carcinogenesis 2000; 21: 1683–9

5 Wang CV, Debiec-Rychter M, Schut HA, Morse P,

Jones RF. N-acetyltransferase expression and DNA

binding of N-hydroxyheterocyclic amines in human prostate

epithelium. Carcinogenesis 1999; 20: 1591–5

Reply

We are grateful for the interest in our paper expressed by

Barber et al., and their comments on lycopene. There is at

present great interest in evaluating the link between diet and

prostate cancer, and Barber et al. correctly identify lycopene as

one of the dietary components being considered as having a

key role in a possible dietary aetiology. Carotenoids are a

widely distributed group of naturally occurring pigments,

usually red, orange or yellow, with lycopene being one type

of carotenoid. Unfortunately, given the vastness of the subject

of a potential dietary cause for prostate cancer, we did not

specifically mention the potential role of lycopene. We also only

briefly mentioned another important dietary component, the

trace element selenium. This is presently the subject of a

North American double-blind randomized study (the ‘selenium

vitamin E chemoprevention trial’, SELECT), the initial results of

which are expected in 2012 and are eagerly awaited.

J.-P. Meyer and D. Gillatt

Laparoscopy in urology: indicationsand training

Sir,

The authors are to be congratulated on this review [1], and

for a lucid description of the pitfalls pertaining to laparoscopy

in urology and difficulties that face the urological trainee or

established general urological surgeon in the UK who wishes to

train in laparoscopy. However, I was surprised to note that the

role of hand-assistance was not mentioned. Several studies [2,3]

confirmed that the advantages in easing training and our

experiences [4] supports these observations.

A. Rane

Department of Urology,

Surrey and Sussex Health Care Trust, Redhill, UK

1 McNeill SA, Tolley DA. Laparoscopy in urology: indications

and training. BJU Int 2002; 89: 169–73

2 Wolf JS, Moon T, Nakada SY. Hand-assisted laparoscopic

nephrectomy: comparison to standard laparoscopic nephrec-

tomy. J Urol 1988; 160: 22–7

3 Batler RA, Schoor RA, Gonzalez CM, Engel JD, Nadler RB.

Hand-assisted radical nephrectomy: the experience of the

inexperienced. J Endourol 2001; 15: 513–5

4 Rane A et al. Urological laparoscopy: is the learning curve

really less steep with hand-assisted laparoscopy. Eur Urol

2002; 41 (Suppl. 1): 28A102

Sir,

I read with interest this article [1]; the authors highlight

the importance of aptitude testing and ‘good spatial awareness’

for surgery, but especially for laparoscopic surgery. Spatial

awareness or visual-spatial ability is clearly a subject that

generates many misunderstandings. Several surgeons are

loosely applying this term as a method for selecting future

candidates. However, this is an over-simplification; visual-spa-

tial ability refers to the human visual system’s processing of

image properties so that three-dimensional information can be

extracted from the two-dimensional image that is projected

onto the retina. It has been suggested that there is a hierarchy of

visual-spatial ability: (i) edge and surface extraction; (ii) edge-

orientation encoding; (iii) whole object recognition; (iv) spatial

relations of object parts in two dimensions; and (v) images that

involve two-dimensional and three-dimensional whole-object

spatial rotations and translations [2,3].

That there is a link between visual-spatial ability and

surgical skill is itself tenuous. Current research suggests

that all surgical tasks involve low-level visual processing, e.g.

object edge extraction, but the ability to visualize an end product

before initiating a procedure is likely to involve higher level

visual-spatial processing. A recent study used visual-spatial

ability ranging from low- to high-level visual processing, and

assessed competency in a spatially complex surgical procedure.

They found that trainees with a high score did significantly

better in the procedure than those with lower scores. However,

the latter group achieved a comparable level of competency

with practice and feedback [4].

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The conflicting results that emerge from research in

visual-spatial ability reflect the complexity of the subject.

There are many visual-spatial tests available and to date

there has been little justification for the use of a particular

test; many studies have not used objective measures of surgical

skill, and many researchers have failed to use a homogeneous

group of trainees, i.e. trainees perform too many and varied

surgical tasks to establish any relationship with visual-spatial

ability. Thus we are a long way from using any visual-spatial

test for selection or aptitude testing. In the first instance, each

speciality needs to determine specific tasks with measurable

constructs, and then establish visual-spatial tests that parallel

these measurements.

Jyoti Shah

1 McNeill SA, Tolley DA. Laparoscopy in urology: indications

and training. BJU Int 2002; 89: 169–73

2 Keney TL. Crossroads in the Mind of Man. Stanford: Stanford

University Press, 1928

3 Lohman DF. Spatial ability: a review and re-analysis

of correlational literature. Stanford University: Aptitude

Research Project, Report No. 8, 1979

4 Wanzel KR, Hamstra SJ, Anastakis DJ et al. Effect of

visual-spatial ability on learning of spatially complex surgical

skills. Lancet 2002; 359: 230–1

Reply

We thank Rane and Shah for their interest in our article. We

are familiar with the technique of hand-assisted laparoscopy,

having introduced it into our practice some years ago [1,2].

Although it is argued that in many cases the incision used

for specimen extraction can initially be used for a hand-port,

we believe that use of an incision large enough to enable the

operator’s hand to be placed inside the abdomen rather defeats

the point of the laparoscopic approach. Whilst hand-assisted

laparoscopy may have a place in laparoscopic nephrectomy for

carcinoma, where the specimen is removed intact, the use of

this technique to accelerate learning can be no substitute for a

structured laparoscopic training programme, and it is our view

that those surgeons who undergo formal laparoscopic training

of the sort outlined in our article will find the use of hand

assistance unnecessary.

We thank Miss Shah for her detailed definition of spatial

awareness. There will be many who recognise that this term,

loosely applied by us, is perhaps an attempt to introduce some

objectivity into the differentiation between what experienced

surgeons will instantly recognise as the difference between the

naturally gifted surgeon and those of us who improve our skills

with experience.

D.A. Tolley and S.A. McNeill

1 Keeley FX Jr, Sharma NK, Tolley DA. Hand-assisted

laparoscopic nephrectomy. J Endourol 1997; 11

(Suppl. 1): S128

2 Keeley FX Jr, Sharma NK, Tolley DA. Hand-assisted

laparoscopic nephroureterectomy. BJU Int 1999; 83: 504–5

Laparoscopic lymph-node sampling in locallyadvanced prostate cancer

Sir,

I read this article [1] with interest and have a few comments.

In one conclusion the authors stated that laparoscopic pelvic

lymphadenectomy can be undertaken safely by a urologist

experienced in laparoscopic surgery. There are many studies

that previously confirmed the feasibility and safety of this

procedure, published earlier [2,3]; others studies have even

confirmed the safety of robotic surgery in this field [4]. The

other conclusion, that pelvic lymphadenectomy is justified

in selected cases of locally advanced prostate cancer, was

answered in the editorial comment by Professor Kirk. I think

that this article added no new role for laparoscopy or lymph

node biopsy in locally advanced prostate cancer, its only

strength being in one of the few British accounts in laparoscopic

urology which warrant publication because it reflects the local

experience. Please correct me if I am wrong and accept my

apologies.

W. Ali, Locum Specialist Registrar in Urology

Department of Urology, Guy’s Hospital, London, UK

1 Parkin J, Keely FX, Timoney AG. Laparoscopic lymph node

sampling in locally advanced prostate cancer. BJU Int 2002;

89: 14–8

2 Kerbl K, Clayman R, Petros JA et al. Staging pelvic

lymphadenectomy for prostate cancer. A comparison of

laparoscopic and open techniques. J Urol 1993; 150: 396–9

3 Kavoussi LR, Sosa E, Chandhoke P et al. Complications

of laparoscopic pelvic lymph node dissection. J Urol 1993;

149: 322

4 Guillonneau B, Oliver C, Martinez JB, Navarra S,

Vallancien G. Robotic assisted laparoscopic pelvic lymph

node dissection in humans. J Urol 2001; 165: 1078–81

Reply

Thank you for the opportunity to respond to Mr Ali’s criticism

of our paper. The last publication on the subject of laparoscopic

lymph node sampling in the BJU Int concluded that laparoscopic

lymph node sampling could be safely left to laparoscopic general

surgeons who had experience of the regional anatomy. Some

urological surgeons consider that the practice of urology should

be the preserve of the urologist; our article was written in

support of that view. Mr Ali seems to have missed one of the

main points of the article; by carrying out laparoscopic lymph

node sampling, 24% of patients in the series could be saved

needless radical local treatment, whether it be radiotherapy as

in this series or one of the experimental alternatives, e.g.

brachytherapy or cryotherapy. Previous reports described the

widespread use of laparoscopic lymph node sampling in patients

who were candidates for radical prostatectomy, a practice that

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has fallen from favour because of the low incidence of lymph

node metastases in that group of patients. Our indications are

strictly limited to patients with locally advanced disease. It is

true that until recently we have been one of the few British

centres to regularly undertake laparoscopic urology, but there

has recently been significantly increased interest in the

laparoscopic approach. The first two references Mr Ali cites

are both 9 years old and we felt that reporting our experiences

of laparoscopic lymph node sampling was timely. Finally,

Mr Ali quotes the experience of robotically assisted

lymph node sampling. While one of the senior authors

is a recognised advocate of the application of robotics in

surgery, even he realises that their widespread use remains

in the future.

A. Timoney, J. Parkin and F. Keeley

144 CORRESPONDENCE

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