ureter. Laugh if you will, but this may work. I learned of this approach from Dr. Charles Rowe, of High Point, North Carolina, who says that this concept did not originate with him. Nephroureterectomy 1. If you do not remove the ureteral orifice, you have not done a nephroureterectomy, you have done a nephrectomy and partial ureterectomy. No matter what you have been told, you cannot do the operation without opening the bladder and dissecting the distal ureter and its orifice as you would in a reimplantation of the ureter for reflux. So when you dissect the ureter down to the area of the bladder, this is a good place to stop, and continue the dissection through the bladder working upward. 2. If your patient is a thin woman with somewhat mobile kidneys, consider doing the entire operation through a single paramedian incision to avoid cutting any muscle.
Prostatosis It makes little sense to try and differentiate between prostatitis and prostatosis. They might as well be considered manifestations of the same disease. All males have abnormal prostatic secretions at some time or other, with inspissation and blockage of various ducts. Bacteria probably become normal flora. Because they cannot be cultured does not mean they do not exist. Ductal obstruction in the face of saprophytic organisms, such as occurs in acne, a similar pathologic condition, results in pathology, and this in prostatitis. When the ducts open, the inflammation resolves, for a time anyway. Alcohol can precipitate symptoms. Is this because the blood-prostatic tissue “barrier” has a high lipid content, resulting in concentration of alcohol in prostatic secretions? Looking for leucocytes in “expressed secretions” seems to be a huitless diagnostic exercise, since false negative and false positive results occur. If you are uncertain as to whether a patient has prostatitis or not, a therapeutic trial of doxycycline is a practical way of finding out. (Doxycycline has high lipid solubility and is concentrated in the gland.) To learn more about prostatitis, it is interesting to reflect on the best way to produce it: on recovering from a minor viral illness, avoid sexual intercourse, while imbibing 2 beers a day for a few days. Try it. Nonspecific It exist, simply clear gland, come
1.
cure
654
John Somerville,
BENIGN PROSTATIC IN XX MAN
Urethritis
of Prostate
Gland
In the past, there has been only one way to a patient with carcinoma of the prostate gland,
H. Lifland, 242 E. Main New Jersey
M.D. Street 08876
HYPERPLASIA
To the Editor:
is likely that nonspecific urethritis does not or is rare, as a discrete entity, but rather it is a manifestation of prostatitis in which the morning discharge comes from the prostate or horn the urethral mucosa which has beinflamed from a primary prostatitis. Carcinoma
and that is with surgical extirpation. At the present time, radiotherapy has been touted as a reasonable approach. It has never been proved, however, that a single patient has been cured of this disease by radiation. The burden of proof falls on the advocates of this treatment. 2. If you have performed a radical prostatectomy and subsequently find that there is a positive iliac lymph node, do not radiate the nodes. The morbidity of radiotherapy in these circumstances is prohibitive. Another lesson learned the hard way. 3. After performing a radical prostatectomy, be on the lookout for various manifestations of excessive autonomic nerve stimulation. When the bladder neck and trigone are pulled down to meet the urogenital diaphragm, the autonomic nerve fibers that richly invest this area are most likely stretched. Reflex anuria can result. Persistent vomiting, on a neumgenic basis, also may result. Although symptoms usually resolve spontaneously, autonomic blocking agents may be considered to shorten the duration of the problem.
We found the article, Benign Prostatic Hyperplasia in XX Man, by M. J. Marinello, M. S., et al. published in the June issue (vol. 13, page 640) of UROLOGY, noteworthy. We also think that the most interesting point to which emphasis must be given is the male appearance of the patients with 46 XX genotype so that the presence of an abnormal chromosomal pattern is usually unsuspected. For this reason, we believe that the true incidence of the disorder must be higher than that generally reported, since many individuals seek medical advice not for some deviation from the normal sex characteristics but only when they face an infertility problem. Two such patients have been seen in the male infertility clinic of our department over the last two years.* Both were young and had awospermia. The first patient claimed normal sexual activity. In both, plasma testosterone and LH levels were within normal limits but the FSH level was slightly elevated. Since the plasma testosterone, LH, and FSH levels were different in the case mentioned by to accept that Marine110 et al., it seems reasonable the endocrinologic findings show some variation in patients with 46 XX genotype. Unfortunately since both of our patients denied a testicular biopsy, we were not able to examine the
UROLOGY
/ DECEMBER1979
/ VOLUMEXIV,
NUMBER6
testicular histology. These cases show the importance of cytogenetic studies in patients with severe oligospermia or azoospermia. C. Dimopoulos, V. Jannopoulos, N. Goulandris, University of Athens,
*Dimopoulos 2 observations.
C, et al: Hommes Now. Presse Med.
steriles avec caryotypc 8: 1263 (1979).
appears to be related to perirenal extravasation of urine. These processes can be acute or chronic and are not necessarily associated with inflammation. The pleural effusion which occurs secondary to urinary tract obstruction appears to be a collection of urine in the pleural space, and, indeed, this has been documented in 2 patients as referenced in our article.
M.D. M.D. M.D. Greece
Morgantown,
46xx, *Salvatierra 0, Jr, Bucklew abscess: a report of 71 cases,
PLEURAL URETERAL
EFFUSION SECONDARY OBSTRUCTION
REPLY
FROM
DR.
/
DECEMBER
Harold A. Just, Massachusetts
i
VOLUME
Perinephric
To the Editor: In response to the letter of John F. Vallely, M.D., published in the June issue (vol. 13, page 705) of UROLOGY, I would like to emphasize that there are many physicians who prefer to use the semirigid (noninflatable) penile prostheses to inflatable ones. The pro and Contras for both methods have been discussed in recent publications, so I do not want to go into detail here. But from the point of expense, the cost of an inflatable prosthesis is much higher than a noninflatable one. This applies for each case. Although the extra-long urethro-cysto-resectoscope (UCR) is a very special endoscopic instrument, it is not very expensive. The extra-long UCR is purchased just once and can be used also for patients without prosthesis. In patients with a noninflatable penile prosthesis the only way to perform any diagnostic and/or therapuetic transurethral procedure without making a perineal urethrostomy is with this new extra-long urethro-cysto-resectoscope.
M.D. 02062
BELIS
1979
WB, and Morrow JW: J. Ural. 98: 296 (1967).
M. D. 26506
USE OF EXTRA LONG URETHRO-CYSTO-RESECTOSCOPE
To the Editor: Pleural effusions secondary to processes below the diaphragm are certainly not uncommon, and occur in up to I8 per cent of patients with perinephric abscesses.* The majority of these cases are inflammatory in nature. In contrast, the occurrence of a pleural effusion secondary to obstruction of the urinary tract is uncommon, and
UROLOGY
A. Belis, Virginia
TO
To the Editor: In the article, Pleural Effusion Secondary to Ureteral Obstruction (UROLOGY, vol. 14, page 27), Dr. J. A. Belis and Dr. D. Franklin Mylam accurately indicated that pleural effusion secondary to ureteral obstruction is rare. However, “sympathetic” pleural effusions secondary to processes below the diaphragm are not uncommon. Could the edema and inflammatory process in the kidney and perirenal tissue have caused a secondary effusion? Norwood.
John West
XIV,
NUMBER
A. Kelimi, M.D. Berlin, W. Germany
6
655
Prostatosis It makes little sense to try and differentiate between prostatitis and prostatosis. They might as well be considered manifestations of the same disease. All males have abnormal prostatic secretions at some time or other, with inspissation and blockage of various ducts. Bacteria probably become normal flora. Because they cannot be cultured does not mean they do not exist. Ductal obstruction in the face of saprophytic organisms, such as occurs in acne, a similar pathologic condition, results in pathology, and this in prostatitis. When the ducts open, the inflammation resolves, for a time anyway. Alcohol can precipitate symptoms. Is this because the blood-prostatic tissue “barrier” has a high lipid content, resulting in concentration of alcohol in prostatic secretions? Looking for leucocytes in “expressed secretions” seems to be a huitless diagnostic exercise, since false negative and false positive results occur. If you are uncertain as to whether a patient has prostatitis or not, a therapeutic trial of doxycycline is a practical way of finding out. (Doxycycline has high lipid solubility and is concentrated in the gland.) To learn more about prostatitis, it is interesting to reflect on the best way to produce it: on recovering from a minor viral illness, avoid sexual intercourse, while imbibing 2 beers a day for a few days. Try it. Nonspecific It exist, simply clear gland, come
1.
cure
654
John Somerville,
BENIGN PROSTATIC IN XX MAN
Urethritis
of Prostate
Gland
In the past, there has been only one way to a patient with carcinoma of the prostate gland,
H. Lifland, 242 E. Main New Jersey
M.D. Street 08876
HYPERPLASIA
To the Editor:
is likely that nonspecific urethritis does not or is rare, as a discrete entity, but rather it is a manifestation of prostatitis in which the morning discharge comes from the prostate or horn the urethral mucosa which has beinflamed from a primary prostatitis. Carcinoma
and that is with surgical extirpation. At the present time, radiotherapy has been touted as a reasonable approach. It has never been proved, however, that a single patient has been cured of this disease by radiation. The burden of proof falls on the advocates of this treatment. 2. If you have performed a radical prostatectomy and subsequently find that there is a positive iliac lymph node, do not radiate the nodes. The morbidity of radiotherapy in these circumstances is prohibitive. Another lesson learned the hard way. 3. After performing a radical prostatectomy, be on the lookout for various manifestations of excessive autonomic nerve stimulation. When the bladder neck and trigone are pulled down to meet the urogenital diaphragm, the autonomic nerve fibers that richly invest this area are most likely stretched. Reflex anuria can result. Persistent vomiting, on a neumgenic basis, also may result. Although symptoms usually resolve spontaneously, autonomic blocking agents may be considered to shorten the duration of the problem.
We found the article, Benign Prostatic Hyperplasia in XX Man, by M. J. Marinello, M. S., et al. published in the June issue (vol. 13, page 640) of UROLOGY, noteworthy. We also think that the most interesting point to which emphasis must be given is the male appearance of the patients with 46 XX genotype so that the presence of an abnormal chromosomal pattern is usually unsuspected. For this reason, we believe that the true incidence of the disorder must be higher than that generally reported, since many individuals seek medical advice not for some deviation from the normal sex characteristics but only when they face an infertility problem. Two such patients have been seen in the male infertility clinic of our department over the last two years.* Both were young and had awospermia. The first patient claimed normal sexual activity. In both, plasma testosterone and LH levels were within normal limits but the FSH level was slightly elevated. Since the plasma testosterone, LH, and FSH levels were different in the case mentioned by to accept that Marine110 et al., it seems reasonable the endocrinologic findings show some variation in patients with 46 XX genotype. Unfortunately since both of our patients denied a testicular biopsy, we were not able to examine the
UROLOGY
/ DECEMBER1979
/ VOLUMEXIV,
NUMBER6
testicular histology. These cases show the importance of cytogenetic studies in patients with severe oligospermia or azoospermia. C. Dimopoulos, V. Jannopoulos, N. Goulandris, University of Athens,
*Dimopoulos 2 observations.
C, et al: Hommes Now. Presse Med.
steriles avec caryotypc 8: 1263 (1979).
appears to be related to perirenal extravasation of urine. These processes can be acute or chronic and are not necessarily associated with inflammation. The pleural effusion which occurs secondary to urinary tract obstruction appears to be a collection of urine in the pleural space, and, indeed, this has been documented in 2 patients as referenced in our article.
M.D. M.D. M.D. Greece
Morgantown,
46xx, *Salvatierra 0, Jr, Bucklew abscess: a report of 71 cases,
PLEURAL URETERAL
EFFUSION SECONDARY OBSTRUCTION
REPLY
FROM
DR.
/
DECEMBER
Harold A. Just, Massachusetts
i
VOLUME
Perinephric
To the Editor: In response to the letter of John F. Vallely, M.D., published in the June issue (vol. 13, page 705) of UROLOGY, I would like to emphasize that there are many physicians who prefer to use the semirigid (noninflatable) penile prostheses to inflatable ones. The pro and Contras for both methods have been discussed in recent publications, so I do not want to go into detail here. But from the point of expense, the cost of an inflatable prosthesis is much higher than a noninflatable one. This applies for each case. Although the extra-long urethro-cysto-resectoscope (UCR) is a very special endoscopic instrument, it is not very expensive. The extra-long UCR is purchased just once and can be used also for patients without prosthesis. In patients with a noninflatable penile prosthesis the only way to perform any diagnostic and/or therapuetic transurethral procedure without making a perineal urethrostomy is with this new extra-long urethro-cysto-resectoscope.
M.D. 02062
BELIS
1979
WB, and Morrow JW: J. Ural. 98: 296 (1967).
M. D. 26506
USE OF EXTRA LONG URETHRO-CYSTO-RESECTOSCOPE
To the Editor: Pleural effusions secondary to processes below the diaphragm are certainly not uncommon, and occur in up to I8 per cent of patients with perinephric abscesses.* The majority of these cases are inflammatory in nature. In contrast, the occurrence of a pleural effusion secondary to obstruction of the urinary tract is uncommon, and
UROLOGY
A. Belis, Virginia
TO
To the Editor: In the article, Pleural Effusion Secondary to Ureteral Obstruction (UROLOGY, vol. 14, page 27), Dr. J. A. Belis and Dr. D. Franklin Mylam accurately indicated that pleural effusion secondary to ureteral obstruction is rare. However, “sympathetic” pleural effusions secondary to processes below the diaphragm are not uncommon. Could the edema and inflammatory process in the kidney and perirenal tissue have caused a secondary effusion? Norwood.
John West
XIV,
NUMBER
A. Kelimi, M.D. Berlin, W. Germany
6
655
