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Thomas Otto, Ph.D.Holger Gerullis, M.D.

Department of Urology, Lukas Hospital, Neuss, Germany

Ingo Theuerkauf, M.D.Department of Pathology, Lukas Hospital, Neuss, Germany

eferences. White MA, De Haan AP, Stephens DD, et al. Comparative analysis

of surgical margins between radical retropubic prostatectomy andRALP: are patients sacrificed during initiation of robotics program?Urology. 2009;73:567-71.

. Bill-Axelson A, Holmberg L, Filen F, et al. Radical prostatectomyversus watchful waiting in localized prostate cancer: the Scandina-vian prostate cancer group-4 randomized trial. J Natl Cancer Inst.2008;100:1144-1154.

. Wieder JA, Solaway MS. Incidence, etiology, location, prevention,and treatment of positive surgical margins after radical prostatec-tomy for prostate cancer. J Urol. 1988;160:299-315.

. Lawrentschuk N, Evans A, Srigley J, et al. Surgical margin status forradical prostatectomy in pathological T2 disease: a population-basedstudy. J Urol. 2009;181:168-169.

. Stöckle M, Siemer S. Robot-assisted (da Vinci) laparoscopy: thebeginning of a new era in operative urology? Urologe A.2008;47:409-413.

eply by the Authors

O THE EDITOR:

e appreciate the comments on our recent publication.he goal of the study was to determine whether surgicalargin status would be compromised for the urologist

hanging from open radical retropubic prostatectomyRP) to robotic-assisted laparoscopic prostatectomyRALP), specifically during the learning curve. The dataoncerning the surgeon’s initial outcomes with RALP areften omitted as there appears to be an acceptance thatnferior results occur during the learning curve. Wehought it important to report this information, withegards to margin status so as to help counsel futureatients and urologists considering adopting this technol-gy. In addition, we wanted to know how this comparedo an equally matched cohort of recently performed RPs.

We agree with the comment that RP vs watchfulaiting has a limited effect on cancer-related death andevelopment of distant metastases. It was not our aim toiscuss the merits of overall treatment, yet we believehat a reduction of 5.4% and 7.3% with regard to cancer-elated death and development of distant metastases islinically significant.1

We acknowledge that the positive margin status of ourP cohort is high (36%), but this still falls within theublished range.2 We agree that factors such as individualurgeon and pathologic processing may explain differ-nces, but this should not have been the case in our studys all surgeries were performed by a single surgeon at the

ame institution. p

76

We agree that introduction of the RALP is notost-effective; this has been succinctly examined byotan et al.3 Our intent was not to suggest the supe-iority of one technique over the other. RALP is a highlyarketed procedure that is not likely to disappear, and if

ommunity urologists want to continue prostatectomies,hey will have to adapt or watch their caseload decline.

The last point in the editor’s comments addresses theroblem in comparing new techniques with the acceptedtandard. We agree that the gold standard should consistf a randomized prospective study; unfortunately, theopularity and demand of the RALP will likely precludehis from happening, at least in the United States.

Michael A. White, D.O.Alexander P. De Haan, D.O.

Michigan State University College of Osteopathic MedicineUrologic ConsortiumWyoming, Michigan

Thomas J. Maatman, D.O.Michigan Urological Clinic

Grand RapidsMichigan

eferences. Bill-Axelson A, Holmberg L, Filén F, et al. Radical prostatectomy

versus watchful waiting in localized prostate cancer: the Scandina-vian prostate cancer group-4 randomized trial. J Natl Cancer Inst.2008;100:1144-1154.

. Chang SS, Cookson MS. Impact of positive surgical margins afterradical prostatectomy. Urology. 2006;68:249-252.

. Lotan Y, Cadeddu JA, Gettman MT. The new economics of radicalprostatectomy: cost comparison of open, laparoscopic and robotassisted techniques. J Urol. 2004;172:1431-1435.

e: Wang et al.: Diagnosisnd Surgical Treatment of Nutcrackeryndrome: A Single-Center Experience.Urology 2009;73:871-876)

O THE EDITOR:

rthostatic proteinuria, a condition characterized by in-reased protein excretion in the upright position butormal protein excretion in the supine position, affects%-5% of adolescents.1 In most subjects with orthostaticroteinuria, imaging studies have disclosed entrapment ofhe left renal vein in the fork between the abdominalorta and the proximal superior mesenteric artery close tots origin.2,3 It has been therefore postulated that partialbstruction to the flow in the left renal vein in thepright position alters glomerular microcirculation, thuseading to increased protein filtration.

The authors of an article recently published in this jour-al report, among others, on a 14-year-old girl with postural

roteinuria and entrapment of the left renal vein docu-

UROLOGY 74 (2), 2009