Editor's Choice
time is typically shorter than in pure laparoscopic partial nephrectomy, and usually shorter than the generally accepted limit of 30 min that has been associated with good preservation of postoperative renal function [5]. More recently, Wiener et al. [6] were able to establish that WIT ≤ 22 min prevented a statistically significant decline in renal function at 6–12 months. In light of this evidence, another technique of ‘early unclamping’ is being increasingly considered, especially in RPN, but several considerations, including increased blood loss and potential increased difficulty with the renorrhaphy, have limited its application [5]. The paper by Komninos et al. is supported by another study that analysed 95 consecutive RAPN cases, in which a variety of clamping techniques was used (artery and vein, artery alone and unclamp), showing that GFR and overall percentage decrease in GFR was similar for all three methods at a median follow-up of 6 months and suggesting that intermediate-term renal function outcome is irrespective of clamping technique [7]. Clearly there are limitations to the present study, including its non-randomized, retrospective nature and the low sample sizes of the off-clamp and selective artery groups and the authors have recognized this. The entire population also had a low body mass index and comorbidity status compared with many RAPN series. The off-clamp tumours were all relatively exophytic, significantly smaller than the other groups (1.7 vs 3.5 and 3.3 cm), and far less complex, with PADUA scores of 7 compared with 10 and 9. Despite this, the study has shown, with a respectable follow-up period, that although there is a significant initial deterioration in renal function with the main artery clamping technique at 3 months compared with the selective artery and off-clamp methods, there was no significant difference in renal deterioration between the three groups at 6 months and at 1 year. It is also interesting to see that, even though patients in the main artery clamping group had larger and more complex tumours, inevitably resulting in a greater resected volume of normal-functioning nephrons, renal function deterioration
was no different from the off-clamp group by 6 months. The authors have contributed to the evidence for main artery clamping in RPN, particularly in complex tumours in healthy younger patients with bilateral functioning renal units. Techniques to minimize warm ischaemia are likely to continue to have a role in higher risk and imperative indications for partial nephrectomy.
Conflict of Interest None declared. Buket N. Ertansel, Norbert Doeuk and Ben Challacombe Guy’s & St Thomas’s Hospital, London, UK
References 1
2
3 4
5
6
7
Komninos C, Shin TY, Tuliao P et al. Renal Function is the same regardless of clamp technique 6 months after Robot-assisted Partial Nephrectomy: analysis of Off-Clamp, Selective Arterial Clamp and Main Artery Clamp with minimum of 1 year follow-up. BJU Int 2014; doi: 10.1111/bju.12975. [Epub ahead of print] Thompson RH, Lane BR, Lohse CM et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 2010; 58: 340–5 Abreu AL, Gill IS, Desai MM. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU Int 2011; 108 (Pt 2): 948–54 George AK, Herati AS, Srinivasan AK et al. Perioperative outcomes of offclamp vs complete hilar control laparoscopic partial nephrectomy. BJU Int 2013; 111 (Pt B): E235–41 Cawley O, Roman A, Brown M, Challacombe B. Exploring the evidence for early unclamping during robot-assisted partial nephrectomy: is it worth the time and effort? BJU Int 2014; doi: 10.1111/bju.12836. [Epub ahead of print] Wiener S, Kiziloz H, Dorin RP, Finnegan K, Shichman SS, Meraney A. Predictors of postoperative decline in estimated glomerular filtration rate in patients undergoing robotic partialnephrectomy. J Endourol 2014; 28: 807–13 Krane LS, Mufarrij PW, Manny TB, Hemal AK. Comparison of clamping technique in robotic partial nephrectomy: does unclamped partial nephrectomy improve perioperative outcomes and renal func-tion? Can J Urol 2013; 20: 6662–7
When normal is not enough This is a useful reference on penile size, flaccid, stretched and erect [1]. It is interesting to note that the stretch length is quite a useful surrogate for erect length. Measuring stretch lengths obviously has inter-observer bias. This paper describes the standard technique for measuring from the pubic bone
852
© 2015 The Authors BJU International © 2015 BJU International
along the dorsum of the phallus to the tip, which is usually the external urinary meatus. Some men could well take solace in knowing that their penile length is within the normal range; however, men who complain of having a short penis are usually more complex. In our assessment, it can be useful
Editor's Choice
to measure flaccid stretch length and explain to the patient that his length is within range for his population, but being told ‘you are normal’ might not be enough. The feeling of inadequate length usually has emotional connotations that may not respond to reassurance. In my experience, these men have been told that they have a small penis in late childhood/ early puberty, or else have witnessed an adult penis before their own growth. This misconception then goes uncorrected for several years until they finally present. Locker room comparison does not help, as there is a parallax error in viewing one’s own penis from above as compared with the full frontal view of one’s peers.
medical/anatomical cause is not to be treated, I recommend psychosexual assessment and counselling.
When a man presents complaining of a short penis, a simple reassurance is unlikely to reverse years of conditioning. The patient could experience a dangerous sense of frustration should he feel dismissed as normal. Socalled ‘penile lengthening’ by partial division of the suspensory ligaments only has a 27% satisfaction rate among patients with penile dysmorphobic disorder [2]. Provided a
1
Conflict of interest None declared. Paul K. Hegarty Mater Misericordiae University Hospital & Mater Private, Cork & Dublin, Ireland E-mail: [email protected]
References
2
Veale D, Miles S, Bramley S, Muir G, Hodsoll J. Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men. BJU Int 2014. [Epub ahead of print]. Li CY, Kayes O, Kell PD, Christopher N, Minhas S, Ralph DJ. Penile suspensory ligament division for penile augmentation: indications and results. Eur Urol 2006; 49: 729–33
© 2015 The Authors BJU International © 2015 BJU International
853
Copyright of BJU International is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
time is typically shorter than in pure laparoscopic partial nephrectomy, and usually shorter than the generally accepted limit of 30 min that has been associated with good preservation of postoperative renal function [5]. More recently, Wiener et al. [6] were able to establish that WIT ≤ 22 min prevented a statistically significant decline in renal function at 6–12 months. In light of this evidence, another technique of ‘early unclamping’ is being increasingly considered, especially in RPN, but several considerations, including increased blood loss and potential increased difficulty with the renorrhaphy, have limited its application [5]. The paper by Komninos et al. is supported by another study that analysed 95 consecutive RAPN cases, in which a variety of clamping techniques was used (artery and vein, artery alone and unclamp), showing that GFR and overall percentage decrease in GFR was similar for all three methods at a median follow-up of 6 months and suggesting that intermediate-term renal function outcome is irrespective of clamping technique [7]. Clearly there are limitations to the present study, including its non-randomized, retrospective nature and the low sample sizes of the off-clamp and selective artery groups and the authors have recognized this. The entire population also had a low body mass index and comorbidity status compared with many RAPN series. The off-clamp tumours were all relatively exophytic, significantly smaller than the other groups (1.7 vs 3.5 and 3.3 cm), and far less complex, with PADUA scores of 7 compared with 10 and 9. Despite this, the study has shown, with a respectable follow-up period, that although there is a significant initial deterioration in renal function with the main artery clamping technique at 3 months compared with the selective artery and off-clamp methods, there was no significant difference in renal deterioration between the three groups at 6 months and at 1 year. It is also interesting to see that, even though patients in the main artery clamping group had larger and more complex tumours, inevitably resulting in a greater resected volume of normal-functioning nephrons, renal function deterioration
was no different from the off-clamp group by 6 months. The authors have contributed to the evidence for main artery clamping in RPN, particularly in complex tumours in healthy younger patients with bilateral functioning renal units. Techniques to minimize warm ischaemia are likely to continue to have a role in higher risk and imperative indications for partial nephrectomy.
Conflict of Interest None declared. Buket N. Ertansel, Norbert Doeuk and Ben Challacombe Guy’s & St Thomas’s Hospital, London, UK
References 1
2
3 4
5
6
7
Komninos C, Shin TY, Tuliao P et al. Renal Function is the same regardless of clamp technique 6 months after Robot-assisted Partial Nephrectomy: analysis of Off-Clamp, Selective Arterial Clamp and Main Artery Clamp with minimum of 1 year follow-up. BJU Int 2014; doi: 10.1111/bju.12975. [Epub ahead of print] Thompson RH, Lane BR, Lohse CM et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 2010; 58: 340–5 Abreu AL, Gill IS, Desai MM. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU Int 2011; 108 (Pt 2): 948–54 George AK, Herati AS, Srinivasan AK et al. Perioperative outcomes of offclamp vs complete hilar control laparoscopic partial nephrectomy. BJU Int 2013; 111 (Pt B): E235–41 Cawley O, Roman A, Brown M, Challacombe B. Exploring the evidence for early unclamping during robot-assisted partial nephrectomy: is it worth the time and effort? BJU Int 2014; doi: 10.1111/bju.12836. [Epub ahead of print] Wiener S, Kiziloz H, Dorin RP, Finnegan K, Shichman SS, Meraney A. Predictors of postoperative decline in estimated glomerular filtration rate in patients undergoing robotic partialnephrectomy. J Endourol 2014; 28: 807–13 Krane LS, Mufarrij PW, Manny TB, Hemal AK. Comparison of clamping technique in robotic partial nephrectomy: does unclamped partial nephrectomy improve perioperative outcomes and renal func-tion? Can J Urol 2013; 20: 6662–7
When normal is not enough This is a useful reference on penile size, flaccid, stretched and erect [1]. It is interesting to note that the stretch length is quite a useful surrogate for erect length. Measuring stretch lengths obviously has inter-observer bias. This paper describes the standard technique for measuring from the pubic bone
852
© 2015 The Authors BJU International © 2015 BJU International
along the dorsum of the phallus to the tip, which is usually the external urinary meatus. Some men could well take solace in knowing that their penile length is within the normal range; however, men who complain of having a short penis are usually more complex. In our assessment, it can be useful
Editor's Choice
to measure flaccid stretch length and explain to the patient that his length is within range for his population, but being told ‘you are normal’ might not be enough. The feeling of inadequate length usually has emotional connotations that may not respond to reassurance. In my experience, these men have been told that they have a small penis in late childhood/ early puberty, or else have witnessed an adult penis before their own growth. This misconception then goes uncorrected for several years until they finally present. Locker room comparison does not help, as there is a parallax error in viewing one’s own penis from above as compared with the full frontal view of one’s peers.
medical/anatomical cause is not to be treated, I recommend psychosexual assessment and counselling.
When a man presents complaining of a short penis, a simple reassurance is unlikely to reverse years of conditioning. The patient could experience a dangerous sense of frustration should he feel dismissed as normal. Socalled ‘penile lengthening’ by partial division of the suspensory ligaments only has a 27% satisfaction rate among patients with penile dysmorphobic disorder [2]. Provided a
1
Conflict of interest None declared. Paul K. Hegarty Mater Misericordiae University Hospital & Mater Private, Cork & Dublin, Ireland E-mail: [email protected]
References
2
Veale D, Miles S, Bramley S, Muir G, Hodsoll J. Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men. BJU Int 2014. [Epub ahead of print]. Li CY, Kayes O, Kell PD, Christopher N, Minhas S, Ralph DJ. Penile suspensory ligament division for penile augmentation: indications and results. Eur Urol 2006; 49: 729–33
© 2015 The Authors BJU International © 2015 BJU International
853
Copyright of BJU International is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
