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Urological Services


Ablation of Renal Masses
The American Urological Association believes that various new ablative technologies (e.g., cryotherapy, radio-frequency, microwave, etc.) are appropriate methods of treatment for renal masses in properly selected patients. Moreover, urologists trained in these open, laparoscopic or percutaneous technologies are capable of providing these services in a safe and effective manner."

Board of Directors, October 2006


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LHRH Analog Therapy
The American Urological Association, Inc.® (AUA) recognizes that LHRH analog therapy for prostate cancer provides a biochemical castration without performing a bilateral orchiectomy. Furthermore, there may be be psychological benefit regarding body image in not removing the testicles. LHRH analog therapy may be indicated in a number of situations including, but not limited to the following: as an adjunct to planned curative radiation therapy, as an adjunct for some patients prior to radical prostatectomy, a rising PSA after radiation therapy, a rising PSA after radical prostatectomy, a rising PSA after cryotherapy, metastatic prostate cancer (with or without symptoms), for local symptoms from prostate cancer (obstruction, bleeding, pain) and patients who are too ill to undergo more aggressive forms of therapy.

A rising PSA in a patient who has been on LHRH analog therapy does not eliminate the benefit of the drug.

Board of Directors, June 2000
Board of Directors, February 2005 (Revised)


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Circumcision
The American Urological Association, Inc.® (AUA) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. Neonatal circumcision is generally a rapid and safe procedure when performed by an experienced operator. There are immediate risks to circumcision such as bleeding, infection and penile injury, as well as complications recognized later that may include buried penis, meatal stenosis, skin bridges, chordee and poor cosmetic appearance. Some of these complications may require surgical correction. Nevertheless, when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low. The minor complications are reported to be three percent.

Properly performed neonatal circumcision prevents phimosis, paraphimosis and balanoposthitis, and is associated with a decreased incidence of cancer of the penis among U.S. males. In addition, there is a connection between the foreskin and urinary tract infections in the neonate. For the first three to six months of life, the incidence of urinary tract infections is at least ten times higher in uncircumcised than circumcised boys. Evidence associating circumcision with reduced incidence of sexually transmitted diseases is conflicting. Circumcision may be required in a small number of uncircumcized boys when phimosis, paraphimosis or recurrent balanoposthitis occur and may be requested for ethnic and cultural reasons after the newborn period. Circumcision in these children usually requires general anesthesia.

When circumcision is being discussed with parents and informed consent obtained, medical benefits and risks, and ethnic, cultural, religious and individual preferences should be considered. The risks and disadvantages of circumcision are encountered early whereas the advantages and benefits may be prospective.

Board of Directors, May 1989
Board of Directors, October 1996 (Revised)
Board of Directors, February 1998 (Revised)
Board of Directors, February 2003 (Revised)


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Early Detection of Prostate Cancer

"Both prostate specific antigen (PSA) and digital rectal examination (DRE) should be offered annually, beginning at age 50 years, to men who have a life expectancy of at least 10 years. Men at high risk (those with a family history of prostate cancer or African American men) should consider beginning testing at an earlier age. Information should be provided to patients about benefits and limitations of testing. Men who desire to learn more about benefits and limitations of testing for early detection and treatment of prostate cancer should be counseled regarding the availability of resources to aid them in their decision-making.

NCI Physician and Patient Data Query:
http://www.cancer.gov/cancertopics/pdq/screening/prostate/patient

American Cancer Society:
http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp?sitearea=PED

US Preventive Services Task Force:
http://www.ahrq.gov/clinic/uspstf/uspsprca.htm

Further evaluation of a man undergoing prostate cancer screening with digital rectal examination and PSA should incorporate other known risk factors including family history of prostate cancer, age, ethnicity/race, and whether the individual has had a prior negative prostate biopsy. The risk of cancer if biopsy is performed, the health and life expectancy of the man, and his personal preferences should be incorporated in the decision to perform further evaluation, generally with a prostate biopsy.

Board of Directors, January 1992
Board of Directors, May 1992 (Reaffirmed)
Board of Directors, August 1993 (Revised)
Board of Directors, January 1994 (Revised)
Board of Directors, January 1995 (Revised)
Board of Directors, September 1997 (Revised)
Board of Directors, March 2001 (Revised)
Board of Directors, May 2006 (Revised)


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Penile Augmentation Surgery
The American Urological Association, Inc.® (AUA) considers subcutaneous fat injection for increasing penile girth to be a procedure which has not been shown to be safe or efficacious.

The AUA also considers the division of the suspensory ligament of the penis for increasing penile length in adults to be a procedure which has not been shown to be safe or efficacious.

Board of Directors, January 1994
Board of Directors, January 1995 (Reaffirmed)
Board of Directors, September 1995 (Revised)
Board of Directors, January 2001 (Reaffirmed)
Board of Directors, February 2006 (Reaffirmed)


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Diagnostic Evaluation of Impotence
The American Urological Association, Inc.® (AUA) endorses the position statement of the Society for the Study of Impotence regarding the diagnostic evaluation of impotence as follows:

"Diagnostic studies used to identify the pathophysiology of impotence should be individualized for each patient.

A generic or standard list of diagnostic tests for all patients is not an appropriate practice.

Studies used for the diagnostic evaluation of impotence should be limited in general to the tests which are needed to identify the treatment options available to each patient, taking into account each patient's unique clinical status and treatment preferences.

For the patient who wishes to identify the cause or causes of his erectile dysfunction as organic and/or psychogenic, nocturnal penile tumescence and rigidity (NPTR) monitoring, vascular and other testing may be indicated and useful, but the patient must be provided information permitting an informed decision to seek testing which is not essential to the selection of treatment options.

NPTR monitoring and extensive vascular testing are not indicated for the diagnostic evaluation of every impotent patient.

Ethical medical practice requires that diagnostic, therapeutic and other decisions must be made solely for the benefit of the patient and must be made without regard for the benefit of the health care provider." (Sexual Medicine Society of North America, January 17, 1997)

Board of Directors, April 1997


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Routine Histologic Confirmation Unnecessary in Performing Vasectomy
The American Urological Association, Inc.® (AUA) recommends that physicians in practice and that residency training programs no longer require histologic confirmation of the vas deferens as a measurement of vasectomy success. The finding of azoospermia after a bilateral vasectomy is the standard for success. The persistence of sperm in the semen after a bilateral vasectomy is a surgical failure regardless of a pathologic confirmation that two segments of the vas were removed.

The lack of clinical value makes the routine histologic evaluation of surgical specimens obtained by a surgeon experienced in performing vasectomies clinically unnecessary. The surgeon should decide whether a histologic evaluation is warranted.

The surgeon should document in the patient's record comprehensive preoperative counseling, careful patient selection, meticulous surgical technique and whether azoospermia was achieved in the postoperative semen.

Board of Directors, February 1998
Board of Directors, February 2003 (Reaffirmed)


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Vasectomy and Prostate Cancer
The American Urological Association Inc.® (AUA) is aware of the recent controversy surrounding prostate cancer risk following vasectomy. However, the association feels that vasectomy is a safe method of surgical sterilization and men need not worry about an increased risk of developing prostate cancer after the procedure. Clinicians should be confident in advising their patients about the benefits and risks of surgical sterilization.

Two papers in the Journal of the American Medical Association (JAMA) in 1993 raised the possibility that vasectomy resulted in the increased incidence of prostate cancer. The AUA immediately formed a committee composed of Drs. John Grayhack, Patrick Walsh, Donald Coffey, Bert Peterson and Stuart Howards. This committee reviewed all the available data, and then formulated a position paper for the AUA, which stated that evidence was not convincing and that it was unlikely there was a relationship between vasectomy and prostate cancer. This opinion was based on the fact that the relationship was extremely weak although statistically significant in that there was no biologic rationale. The committee did recommend that clinicians advise patients who requested a vasectomy of the fact that some investigators felt there might be a relationship between vasectomy and prostate cancer. Soon after the AUA position paper, the National Institutes of Health (NIH) convened a conference involving Dr. Howards and many epidemiologists. The consensus statement of the NIH conference was that there was no convincing evidence of a relationship been vasectomy and prostate cancer and the NIH did not even recommend informing patients of the previous publications.

Since that time a large number of papers have been published which include more patients at risk for many more patient years than did the first two manuscripts. None of these papers have documented a relationship between vasectomy and prostate cancer. In 1998 Bernal-Delgado and Associates reviewed 14 existing papers on this subject including five cohort and nine case-control studies. Relative risk shown in these studies ranged between .44 and 6.75. The overall relative risk was not significant. They concluded that there was no casual relationship between vasectomy and prostate cancer. They also concluded that individuals who had undergone vasectomy are not at higher risk for developing prostate cancer. These authors did a population-based control study of 923 new cases of prostate cancer from the New Zealand Cancer Registry. They found there was no association between prostate cancer and vasectomy.

A June 2002 JAMA article provided reassuring data that indicated no correlation between prostate cancer risk and vasectomy. More than 1,000 men with prostate cancer and 1,800 men without the disease were contacted in a large retrospective study in New Zealand. Men were asked about various health data, including a history of having undergone a vasectomy; 9 percent of cancer patients and 10 percent of controls had undergone the procedure. The relative risk of prostate cancer was not increased in patients who had undergone vasectomy in the past.

In summary, papers published over the last nine years have conclusively documented that there is no increased risk of prostate cancer after vasectomy. Therefore, it is no longer imperative to inform patients of a possible risk and it is very safe to use vasectomy as a form of male sterilization.

  1. Fertility and Sterility, 1998: Vol. 70, Page 191-200)
  2. Cox et al, JAMA 287, page 3110-3115, 2002

Board of Directors, November 2002


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