1332 RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION

been described in essentially all parts of the world except sub-Saharan Africa, where life expectancy
is still shorter. This finding illustrates the burgeoning geriatric population that will need urological
care today and in the future.

Tomas Griebling, M.D., M.P.H.

Suggested Reading

Elzayat EA, Al-Mandil MS, Khalaf I et al: Holmium laser ablation of the prostate versus photoselective vaporization of prostate 60 cc or less: short-term results
of a prospective randomized trial. J Urol 2009; 182: 133.
Reich O, Gratzke C, Bachmann A et al: Urology Section of the Bavarian Working Group for Quality Assurance: Morbidity, mortality and early outcome of
transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol 2008; 180: 246.
Elshal AM, Elmansy HM, Elhilali MM: Can we predict the outcome of 532 nm laser photoselective vaporization of the prostate? Time to event analysis. J Urol
2012; 188: 1746.

Renal Transplantation and Renovascular Hypertension

Re: Debilitating Lower Urinary Tract Symptoms in the Post-Renal Transplant

Population Can Be Predicted Pretransplantation

M. Dion, O. Cristea, S. Langford, P. P. Luke and A. Sener

Department of Surgery, Division of Urology, Western University, London, Ontario, Canada

Transplantation 2013; 95: 589e594.

Abstract available at http://jurology.com/

Editorial Comment: This article addresses issues that may be experienced by the general urology
community outside the confines of academic medical centers with transplant programs. The authors
provide data that support the ability to predict moderate to severe post-transplant lower urinary tract
symptoms on the basis of pre-transplant findings, namely the Quality of Life Questionnaire subscale
and daily urine output less than 250 cc. These data may be helpful in planning for the transplant and
identifying at urological risk individuals.

David A. Goldfarb, M.D.

Benign Prostatic Hyperplasia

Re: Association between Physical Activity, Lower Urinary Tract Symptoms (LUTS)
and Prostate Volume

J. H. Fowke, S. Phillips, T. Koyama, S. Byerly, R. Concepcion, S. S. Motley and P. E. Clark

Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
BJU Int 2013; 111: 122e128.

Abstract available at http://jurology.com/

Editorial Comment: Obesity affects many aspects of overall health. Urological dysfunction, in
particular related to voiding and sexual health, is a prominent issue. Historically urological teaching
was that obese men have smaller prostates. More recent epidemiological research suggests that men
 BENIGN PROSTATIC HYPERPLASIA 1333

with central obesity tend to have larger prostates and concomitant LUTS. Are there factors that
temper these associations?
The authors present an interesting cross-sectional analysis in which they report that leisure time
and home time physical activity (PA) is inversely associated with the severity of LUTS. It is note-
worthy that the benefit of PA was seen in storage and not in voiding symptoms. This finding was
independent of prostate volume. The results are not surprising. Other studies have demonstrated
that overactive bladder symptoms are correlated with obesity in men and women. It is not surprising
that these symptoms are independent of the prostate and are ameliorated by PA. Moreover, one
would suspect that voiding symptoms are more prostate related and less influenced by the degree of
PA. As the authors note, it is possible that men can be more physically active because they have fewer
storage symptoms, ie it is easier to ride a bicycle when you have less urgency. Nevertheless, the
message is that we should encourage patients to maintain a commitment to physical activity. It may
help their urological function.

Steven A. Kaplan, M.D.

Re: Testosterone Replacement Therapy and Prostate Health

A. S. Polackwich, K. A. Ostrowski and J. C. Hedges

Department of Urology, Oregon Health and Science University, Portland, Oregon

Curr Urol Rep 2012; 13: 441e446.

Abstract available at http://jurology.com/

Editorial Comment: One of the basic tenets of urological lore was never to give testosterone to a
man with an enlarged prostate, much less one with prostate cancer. The rationale was that
increasing the testosterone led to prostate growth and worsening voiding dysfunction. Clearly the
science has evolved and been better elucidated, and urologists have become much more comfortable
managing men with late onset hypogonadism. The authors perform a thorough review of the rela-
tionship between prostate growth and androgens, prostate specific antigen and hormone supple-
mentation, and the effects on lower urinary tract symptoms (LUTS). There are a number of important
take home points that can be gleaned, including 1) testosterone replacement therapy (TRT) has little,
if any, negative effect on prostate growth, 2) similarly prostate specific antigen does not precipitously
increase and seems to stabilize, and 3) TRT does not adversely affect LUTS and in some cases may
ameliorate the severity of symptoms. It appears that the estrogen-to-testosterone ratio is a much
more important factor than testosterone alone and that this relationship heralds the magnitude of
inflammation and potential prostate growth. Given the epidemic of obesity and the consequent effects
on hormone metabolism and pelvic health, urologists need to be well versed in TRT in an effort to
improve LUTS, sexual function and libido in this cohort of men.

Steven A. Kaplan, M.D.

1334 RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION

Transplantation/Vascular Surgery

Urological Survey

Renal Transplantation and Renovascular Hypertension

Re: Quantification of the Early Risk of Death in Elderly Kidney

Transplant Recipients

J. S. Gill, E. Schaeffner, S. Chadban, J. Dong, C. Rose, O. Johnston and J. Gill

Division of Nephrology, University of British Columbia, Vancouver, Canada, and Tufts-New England Medical Center, Boston, Massachusetts

Am J Transplant 2013; 13: 427e432.

Abstract available at http://jurology.com/

Editorial Comment: This is an interesting analysis that addresses the survival advantage of
patients undergoing transplantation compared to wait-listed patients. The authors stratify cases
based on cardiovascular comorbidity and rate them as low, intermediate or high. Living donor
transplantation gave an immediate survival advantage for low and intermediate risk candidates.
The longest time to equal survival was in high risk candidates receiving an expanded criteria
donor kidney, and was 521 days. That means that living donation rapidly gives an immediate
survival advantage in many candidates and that the break-even point for the highest risk
combination was less than 1.5 years. This is good news for appropriately selected older candidates
and should encourage the use of living donors in this population.

David A. Goldfarb, M.D.

Re: Renal Transplantation after Ex Vivo Normothermic Perfusion: The First

Clinical Study
S. A. Hosgood
Department of Infection, Immunity and Inflammation, Transplant Group, Leicester General Hospital, University of Leicester, Leicester, United Kingdom
Am J Transplant 2013; 13: 1246e1252.

Abstract available at http://jurology.com/

Editorial Comment: Hypothermic pulsatile perfusion has become an important method for
preservation of nonstandard criteria donor kidneys. This method has beneficial effects in assessing
kidneys for use and is associated with decreased rates of delayed graft function. Nonetheless, injury
still develops in hypothermically stored organs at reperfusion. Preliminary animal experiments
suggest that a brief period of exposure to normothermic oxygenated perfusion ex vivo just before
transplantation may afford organ rehabilitation and lead to improved early function. Importantly
interventions to improve kidney function can be delivered at metabolic temperatures that are not
achievable at low temperatures. The authors showed a marked reduction in delayed graft function
compared to standard cold storage. The apparatus was simple to construct and used a red blood cell
based perfusate. If such experience can be replicated, normothermic oxygenated perfusion could
become an important technique for organ rehabilitation and storage for deceased donor programs.

David A. Goldfarb, M.D.