Editorial Comment: In this excellent review from a group that has treated more than 500patients with balanitis xerotica obliterans a treatment protocol that includes circumcision, ifnot already done, and topical steroids for milder cases is suggested. In the United States mostmen with balanitis xerotica obliterans (87%) have been circumcised and the steroid preparationwould be the first line therapy for many. I have been impressed with the beneficial clinicalresponse to the steroid clobetasol 0.05% ointment. I believe it is important to use the ointmentinstead of the cream because of its longer skin contact time.

In patients with extensive glandular involvement the authors report that removal of the glanssurface with re-epithelialization is successful, and on occasion skin grafting to the glans isnecessary. Urethral involvement begins at the meatus and progresses proximally. Topical ste-roids usually arrest the process but do not cure the proximal urethral stenosis or sclerosis. Insome cases the entire anterior urethra becomes involved and requires reconstruction. In thisreport squamous cell carcinoma of the penis was linked with balanitis xerotica obliterans in2.3% of cases, suggesting an association. Although balanitis xerotica obliterans is uncommon,urologists will be required to treat this problem, and these authors provide excellent guidelinesfor its diagnosis and management.

Jack W. McAninch, M.D.

A Simple Model to Help Distinguish Necrotizing Fasciitis From Nonnecrotizing Soft TissueInfection

D. B. WALL, S. R. KLEIN, S. BLACK AND C. DE VIRGILIO, Department of Surgery, Harbor-UCLA Medical Center,Torrance, California

J Am Coll Surg, 191: 227–231, 2000

Background: Necrotizing fasciitis (NF) has been associated with certain “hard” clinical signs (hypoten-sion, crepitance, skin necrosis, bullae, and gas on x-ray), but these may not always be present. Using resultsof a previous study, we developed a simple model to serve as an adjunctive tool in diagnosing NF (admissionWBC . 15.4 3 109/L or serum sodium [Na] , 135 mmol/L) and determined its ability to distinguish betweenpatients with NF and nonnecrotizing soft tissue infection (non-NF).

Study Design: A retrospective review was conducted of consecutive NF (n 5 31) and non-NF patients (n 5328) treated at a single institution during an 11-month period. Comparison of admission vital signs,physical examination findings, radiology results, and number of patients meeting model criteria wasperformed.

Results: Ninety percent of NF patients and 24% of non-NF patients met model criteria (p , 0.0001). Themodel had a sensitivity of 90%, a specificity of 76%, a positive predictive value of 26%, and a negativepredictive value of 99% for diagnosing NF. Nineteen (61%) NF patients had no “hard” signs of NF; the modelcorrectly classified 18 (95%) of these patients.

Conclusions: Admission WBC greater than 15.4 3 109/L and serum Na less than 135 mmol/L are usefulparameters that may help to distinguish NF from non-NF infection, particularly when classic “hard” signsof NF are absent.

Editorial Comment: The male external genitalia are a common site of necrotizing fasciitis,which usually originates from perirectal abscess or infection, folliculitis or skin ulcerations andperiurethral abscess. The authors retrospectively reviewed and compared cases with necrotiz-ing fasciitis and nonnecrotizing fasciitis to provide adjunctive findings to support the “hard”clinical signs of the necrotizing gangrenous process. A white blood count greater than 15.4 3109/l. and serum sodium less than 135 mmol./l. at presentation were statistically significant inthe group diagnosed with necrotizing fasciitis. These findings supported the typical clinicalsigns and indicated the systemic effect of the infection.

I have found that ultrasound is also a valuable adjunctive tool to diagnose this severe infec-tious process as it detects sensitively even small quantities of gas produced by infectiousbacteria in the subcutaneous tissue. Detection of gas by ultrasound often precedes detection onphysical examination (crepitation) or plain x-ray and allows prompt initiation of therapy.

Jack W. McAninch, M.D.

BOOK REVIEWS

Atlas of Laparoscopic Retroperitoneal Surgery

J. T. BISHOFF AND L. R. KAVOUSSI, Philadelphia: W. B. Saunders Co., 260 pages, 2000

Laparoscopy has become the approach of choice for surgical extirpation of the kidney for benign disease.The experience of the last 10 years with laparoscopic urology has broadened the application of this

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minimally invasive approach to a variety of surgical procedures for disease in the retroperitoneal space.Numerous textbooks pertaining to laparoscopic urological surgery have been published in the decade sinceClayman introduced the concept of the laparoscopic nephrectomy.

In this textbook an updated and concise presentation of the wide array of laparoscopic procedures forretroperitoneal urological disease is presented. The authors are young endourologists who provide theperspective of their training and learning curve in these various procedures. The text is well organized andeasy to follow. Each chapter follows the same format and clearly presents the indications, preoperativepreparation and operative techniques for each procedure. Good descriptions of patient positioning, roompreparation and setup, and personnel positioning around the operative table are also included.

The text is complemented effectively by clear, well-done illustrations of room and patient setup, and eachmajor step of the techniques. The illustrations are positioned to coordinate with the text on the same page,which helps the novice laparoscopic surgeon to follow the described techniques. The text is presented as apicture book of laparoscopic urology and provides an excellent reference manual for various laparoscopicretroperitoneal procedures.

While the editors declare their intent to present contrasting descriptions of the techniques, their bias isevident throughout. All chapters endorse the use of the visual obturator for primary port access into theabdomen. While this approach may be beneficial for the novice laparoscopic surgeon, there are other accesstechniques and devices that reduce the risk of complications from primary port placement. In addition, thereis only a brief reference to the hand assist device, which recently acquired significant prominence inlaparoscopic urology, in the basic techniques section of the book. It seems important to include the use of thisdevice in the discussion of alternative techniques, particularly in the chapter on radical nephroureterec-tomy, when an open incision is used to extract the surgical specimen intact. For the novice laparoscopicurologist the use of hand assist device technology may be the stepping stone to offering minimally invasivesurgery to a wider population of patients. The absence of a concise description of these devices and the handassisted laparoscopic procedures may limit the usefulness of this book to urologists beginning retroperito-neal laparoscopy.

The final chapter on complications of laparoscopic surgery is well presented and provides detailed outlinesof techniques to minimize the risk of complications. In addition, it summarizes the appropriate investigationof cases with suspected complications and provides a thorough discussion of effective management optionsfor various intraoperative and postoperative complications. The wisdom of experience is the best teacher.This pictorial atlas provides an easy to follow “cookbook” for laparoscopic retroperitoneal surgery and wiseadvice for the surgeon commencing laparoscopic urology.

Elspeth M. McDougall, M.D.Department of Urologic SurgeryVanderbilt University School of MedicineNashville, Tennessee

Renal Cell Carcinoma: Molecular Biology, Immunology, and Clinical Management

R. M. BUKOWSKI AND A. C. NOVICK, Totowa: Humana Press, 425 pages, 2000

During the last 10 years, much has changed in our understanding and management of renal cellcarcinoma. Great strides have been made in staging, surgical techniques, understanding of the underlyingmolecular genetics, and enhanced understanding of prognostic factors and the immunobiology of solidtumors, which have led to an improved outlook for patients with renal cell carcinoma. This multiauthortextbook, which has been edited by 2 well-known kidney cancer experts, successfully provides a compre-hensive assessment of where things stand at the beginning of a new century and succeeds in filling in thegaps in our knowledge.

The text is divided into 3 sections. The first, introductory section provides an overview of renal cellcarcinoma basics, including chapters on epidemiology, pathology, molecular genetics, screening, staging andprognostic factors. There are 2 excellent chapters on the immunological response to renal cell carcinoma andmolecular mechanisms of immune dysfunction. The second section, which is the shortest, details themanagement of localized renal cell carcinoma. This section discusses radical surgery, nephron sparingsurgery, management of cases with vena caval thrombi, and has a nice, albeit already becoming outdated,review of laparoscopic and ablative surgery.

The third section, which comprises nearly half the book, is the strongest, and provides a broad andcomplete summary of the management of advanced and metastatic renal cell carcinoma. There are severalexcellent chapters on the role of nephrectomy and the surgical management of metastatic disease. Man-agement of pulmonary metastases is discussed by a thoracic surgeon, skeletal metastases by an orthopediconcologist, and central nervous system metastases by a neurosurgeon. These chapters offer a uniqueperspective and are a welcome addition to the text. Separate chapters deal with chemotherapy,interleukin-2, interferon and combination therapy. Finally, there are several chapters on emerging andmaturing technologies, including monoclonal antibodies, adoptive immunotherapy and anti-angiogenicagents.

The book covers common and uncommon topics in a detailed but concise manner. The editors havebrought together a diverse array of experts in the field. The chapters are generally well written, although

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