LETTERS TO THE EDITOR
AIR AND CARBON DIOXIDE CYSTOMETRY
I would highly endorse the modified procedure by either technique.
To the Editor: We share Dr. Merrill’s sentiments (Letter to the Editor, UROLOGY, vol. 4, page 495) in recommending that air cystometry be discontinued in favor of carbon dioxide (C02) cystometry. We have manufactured and marketed a compact, inexpensive CO2 adaptor for use with our air cystometer since November, 1973 - well before any report of air embolism. When Dr. Keitzer * notified us of the fatality, we informed our customers by letter of this incident and have subsequently sent them a second letter. We have discontinued manufacturing the Mode1 I500 Air Cystometer and have replaced it with the Mode1 1550 CO2 Cystometer. G. R. Atwood, President LT Instruments, Inc. Houston, Texas 77036 *Keitzer, W. A.: Personal communication,
April 3, 1974.
A MODIFICATION OF HRYNTSHAK TECHNIQUE To the Editor: I was very interested in the article, “Suprapubic Prostatectomy: Modified Hryntshak Technique,” by Roy Witherington, M.D., and W. C. Shelor, Jr., M.D., in the November issue (vol. 4, page 550) of UROLOGY. This was the same method successfully employed by Dr. C. D. Creevy in 1959, during my residency at the University of Minnesota Hospitals. However, in 1961, while I was an instructor at Downstate Medical Center, in Brooklyn, New York, Dr. Andrew McGowan and Dr. Frank Hamm developed another simplification of the Hryntshak technique which was reported at the New York Section, AUA, Essay Contest in 1962. Since then I have used this method with great success and satisfaction. In this modification, the plain sutures are placed longitudinally from posterior to anterior vesical neck, closing the neck transversely. The sutures can be placed much more rapidly and with greater ease; there is less tension so that 3-O plain catgut can be used. It is not necessary to tie the sutures around the catheter making the ties easier. The bladder is still closed primarily.
288
Hryntshak
Gerald Litzky, M.D. 191 Engle Street Englewood, New Jersey 07631
GRADING SYSTEM URETERALREFLUX
FOR
To the Editor: The editorial on “A Plea for Grading Vesicoureteric Reflux” by Arnold H. Colodny, M.D., and Robert L. Lebowitz, M.D., in the September issue (vol. 4, page 357) of UROLOGY was very timely. However, it should be pointed out that a system for grading vesicoureteric reflux associated with a longterm prognostic’ evaluation was first published by a group from Christchurch, New Zealand, in 1970.’ They treated a large group of infants with documented ureteral reflux for many years with only conservative, nonsurgical therapy. All these children were evaluated with intravenous pyelograms and voiding cystourethrograms. Reflux in all cystograms was graded into three categories: slight reflux being equivalent to grade 1 mentioned by Colodny and Lebowitz; moderate reflux equivalent to grades 2A and 2B; and gross reflux equivalent to grades 3 and 4. They noted that grade 3 or gross reflux was associated with a high incidence of initial renal damage. They also found that those patients with grades 3 and 4 reflux had a high incidence of progressive renal scarring. Furthermore, in a two-to-nine-year follow-up of 58 children with moderate reflux (grades 2A and 2B) treated without surgical intervention, scarring of the renal parenchyma developed in only 1 chi1d.2 These data strongly suggest that patients with less than gross reflux are at little risk in terms of further renal scarring developing. Considering this fact, I think it would behoove many urologists, as Dr. Colodny and Dr. Lebowitz suggested, to document the degree of reflux that they are correcting or treating. Certainly, the group from Christchurch would make it appear that many patients with reflux in the United States are being treated surgically when the degree of reflux would probably cease spontaneously or would cause no significant progressive renal damage. To inflict any significant complications by a surgical procedure in this group
UROLOGY I FEBRUARY 1975 i VOLUME V, NUMBER 2
of patients with moderate reflux would seem to be meddlesome. On the other hand, the fact that scarring did develop in I out of 58 children with moderate reflux points out the need for continuing medical follow-up with this group. Anyone who is interested in this subject should read the article by Rolleston, Shannon, and Utley,’ as it is, I think, an important contribution in this somewhat controversial field. C. D. Vermillion, The Billings Billings, Montana
M.D. Clinic 59103
References 1. ROLI,ES?.ON. G. L., SHANNON, F. T., ~~~UTLEY, W. L.: Relationship of infantile vesicoureteric reflux to renal damage, Br. Med. J. 1: 406 (1970). 2. SHANNON, F. T.: Personal communication, 1973.
TORSION OF INTRA-ABDOMINAL SEMINOMA OF TESTIS To the Editor: It is interesting to note that one more case of torsion of intra-abdominal seminoma of testis is reported by Dr. Douglas Dahl in his article on “Torsion of Intra-Abdominal Seminoma of Testis” (UROLOGY, vol. 4, page 590). Please note that after a case described by Garber and Kauffer in 1967,’ three more cases have been added to the literature. The twenty-fourth case of torsion of intra-abdominal testis with tumor (seminoma) was reported by me in 1969.* This case was noteworthy, since this patient was the oldest in the series (fifty-two years of age). Although a differential diagnosis of intra-abdominal torsion of the left testis was entertained, it was not strongly considered because the patient insisted that his left testicle had been removed at the time of his inguinal hemiorrhaphy at age twenty-nine. Dr. Dahl’s case thus becomes the twenty-fifth to be reported in the literature. I would like to reemphasize that the diagnosis of intra-abdominal torsion of the testis should be strongly considered if a male patient has abdominal pains and a nonpalpable gonad. Unless there is documented histopathologic evidence that the specimen removed is testis, mere history of orchiectomy for an undescended testicle should not hinder one from making a presumptive diagnosis of torsion of intra-abdominal testis in such circumstances. It is recognized that when a testis remains intra-abdominal torsion and tumor are distinct hazards. Mustan D. Jhaveri, M.D. 129 N.E. IO2nd Street Portland, Oregon 97220
UROLOGY
I FEBRUARY 1975 / VOLUME V, NUMBER Z
References 1. GARBER, H. E., and KAUFFER, 6. I.: Torsion of an intra-abdominal testicular seminoma. J. Ural. 98: 684 (1967). 2. JHAVERI, M. D., JACOBSON. MM.E.. and RORINSON. F. W.: Testis, tumor and torsion; torsion of intra-ahdominal testis with tumor, J. Kansas W Sot. 70: 451 (1969).
BEHAVIORAL AND PENILE
TECHNIQUE ERECTION
To the Editor: We read with interest the article “Injection Technique to Induce Penile Erection,” by R. F. Gittes, M.D., and A. P. McLaughlin, III, M.D., in the October issue (vol. 4, page 473) of UROLOGY. The authors are certainly to be commended for their simple technique to induce penile erection when careful observation is needed to correct a penile deformity. We wish, however, lo call the attention of the readers to recent advances in the field of psychology which offer another simple technique to achieve penile erection in the office. Rubin and his colleagues’*’ have shown that it is possible to achieve voluntary control over the occurrence of penile erection by exposing the subjects to erotically stimulating motion pictures with or without a description of the behavioral content of the erotic stimulus film. The subjects are later able to achieve erection voluntarily in the absence of the erotic stimuli. To monitor changes in penile circumference, these authors employed a mercury strain gauge which is fitted around the penis.3 We were also able to condition penile erection in response to sexually arousing auditory stimuli in a young male homosexual by providing him feedback of changes in penile erection as measured by changes in penile temperature sensed by a thermistor attached to the skin of the patient.4 If a patient is trained, through behavioral techniques, to control the penile erection response voluntarily, he will then be able to achieve erection in the physician’s office when needed. Victor A. Colotla, Ph.D. Department of Psychology, Toronto Western Hospital, Toronto, Canada M5T 2S8 Benjamin Dominguez, M. SC. Faculty of Psychology, National University of Mexico, Mexico City, Mexico.
References 1. LAWS, D. R., and RUBIN, H. B.: Instruction control of an autonomic sexual response. J. Appl. Behav. Anal. 3: 93 (1969).
289
AIR AND CARBON DIOXIDE CYSTOMETRY
I would highly endorse the modified procedure by either technique.
To the Editor: We share Dr. Merrill’s sentiments (Letter to the Editor, UROLOGY, vol. 4, page 495) in recommending that air cystometry be discontinued in favor of carbon dioxide (C02) cystometry. We have manufactured and marketed a compact, inexpensive CO2 adaptor for use with our air cystometer since November, 1973 - well before any report of air embolism. When Dr. Keitzer * notified us of the fatality, we informed our customers by letter of this incident and have subsequently sent them a second letter. We have discontinued manufacturing the Mode1 I500 Air Cystometer and have replaced it with the Mode1 1550 CO2 Cystometer. G. R. Atwood, President LT Instruments, Inc. Houston, Texas 77036 *Keitzer, W. A.: Personal communication,
April 3, 1974.
A MODIFICATION OF HRYNTSHAK TECHNIQUE To the Editor: I was very interested in the article, “Suprapubic Prostatectomy: Modified Hryntshak Technique,” by Roy Witherington, M.D., and W. C. Shelor, Jr., M.D., in the November issue (vol. 4, page 550) of UROLOGY. This was the same method successfully employed by Dr. C. D. Creevy in 1959, during my residency at the University of Minnesota Hospitals. However, in 1961, while I was an instructor at Downstate Medical Center, in Brooklyn, New York, Dr. Andrew McGowan and Dr. Frank Hamm developed another simplification of the Hryntshak technique which was reported at the New York Section, AUA, Essay Contest in 1962. Since then I have used this method with great success and satisfaction. In this modification, the plain sutures are placed longitudinally from posterior to anterior vesical neck, closing the neck transversely. The sutures can be placed much more rapidly and with greater ease; there is less tension so that 3-O plain catgut can be used. It is not necessary to tie the sutures around the catheter making the ties easier. The bladder is still closed primarily.
288
Hryntshak
Gerald Litzky, M.D. 191 Engle Street Englewood, New Jersey 07631
GRADING SYSTEM URETERALREFLUX
FOR
To the Editor: The editorial on “A Plea for Grading Vesicoureteric Reflux” by Arnold H. Colodny, M.D., and Robert L. Lebowitz, M.D., in the September issue (vol. 4, page 357) of UROLOGY was very timely. However, it should be pointed out that a system for grading vesicoureteric reflux associated with a longterm prognostic’ evaluation was first published by a group from Christchurch, New Zealand, in 1970.’ They treated a large group of infants with documented ureteral reflux for many years with only conservative, nonsurgical therapy. All these children were evaluated with intravenous pyelograms and voiding cystourethrograms. Reflux in all cystograms was graded into three categories: slight reflux being equivalent to grade 1 mentioned by Colodny and Lebowitz; moderate reflux equivalent to grades 2A and 2B; and gross reflux equivalent to grades 3 and 4. They noted that grade 3 or gross reflux was associated with a high incidence of initial renal damage. They also found that those patients with grades 3 and 4 reflux had a high incidence of progressive renal scarring. Furthermore, in a two-to-nine-year follow-up of 58 children with moderate reflux (grades 2A and 2B) treated without surgical intervention, scarring of the renal parenchyma developed in only 1 chi1d.2 These data strongly suggest that patients with less than gross reflux are at little risk in terms of further renal scarring developing. Considering this fact, I think it would behoove many urologists, as Dr. Colodny and Dr. Lebowitz suggested, to document the degree of reflux that they are correcting or treating. Certainly, the group from Christchurch would make it appear that many patients with reflux in the United States are being treated surgically when the degree of reflux would probably cease spontaneously or would cause no significant progressive renal damage. To inflict any significant complications by a surgical procedure in this group
UROLOGY I FEBRUARY 1975 i VOLUME V, NUMBER 2
of patients with moderate reflux would seem to be meddlesome. On the other hand, the fact that scarring did develop in I out of 58 children with moderate reflux points out the need for continuing medical follow-up with this group. Anyone who is interested in this subject should read the article by Rolleston, Shannon, and Utley,’ as it is, I think, an important contribution in this somewhat controversial field. C. D. Vermillion, The Billings Billings, Montana
M.D. Clinic 59103
References 1. ROLI,ES?.ON. G. L., SHANNON, F. T., ~~~UTLEY, W. L.: Relationship of infantile vesicoureteric reflux to renal damage, Br. Med. J. 1: 406 (1970). 2. SHANNON, F. T.: Personal communication, 1973.
TORSION OF INTRA-ABDOMINAL SEMINOMA OF TESTIS To the Editor: It is interesting to note that one more case of torsion of intra-abdominal seminoma of testis is reported by Dr. Douglas Dahl in his article on “Torsion of Intra-Abdominal Seminoma of Testis” (UROLOGY, vol. 4, page 590). Please note that after a case described by Garber and Kauffer in 1967,’ three more cases have been added to the literature. The twenty-fourth case of torsion of intra-abdominal testis with tumor (seminoma) was reported by me in 1969.* This case was noteworthy, since this patient was the oldest in the series (fifty-two years of age). Although a differential diagnosis of intra-abdominal torsion of the left testis was entertained, it was not strongly considered because the patient insisted that his left testicle had been removed at the time of his inguinal hemiorrhaphy at age twenty-nine. Dr. Dahl’s case thus becomes the twenty-fifth to be reported in the literature. I would like to reemphasize that the diagnosis of intra-abdominal torsion of the testis should be strongly considered if a male patient has abdominal pains and a nonpalpable gonad. Unless there is documented histopathologic evidence that the specimen removed is testis, mere history of orchiectomy for an undescended testicle should not hinder one from making a presumptive diagnosis of torsion of intra-abdominal testis in such circumstances. It is recognized that when a testis remains intra-abdominal torsion and tumor are distinct hazards. Mustan D. Jhaveri, M.D. 129 N.E. IO2nd Street Portland, Oregon 97220
UROLOGY
I FEBRUARY 1975 / VOLUME V, NUMBER Z
References 1. GARBER, H. E., and KAUFFER, 6. I.: Torsion of an intra-abdominal testicular seminoma. J. Ural. 98: 684 (1967). 2. JHAVERI, M. D., JACOBSON. MM.E.. and RORINSON. F. W.: Testis, tumor and torsion; torsion of intra-ahdominal testis with tumor, J. Kansas W Sot. 70: 451 (1969).
BEHAVIORAL AND PENILE
TECHNIQUE ERECTION
To the Editor: We read with interest the article “Injection Technique to Induce Penile Erection,” by R. F. Gittes, M.D., and A. P. McLaughlin, III, M.D., in the October issue (vol. 4, page 473) of UROLOGY. The authors are certainly to be commended for their simple technique to induce penile erection when careful observation is needed to correct a penile deformity. We wish, however, lo call the attention of the readers to recent advances in the field of psychology which offer another simple technique to achieve penile erection in the office. Rubin and his colleagues’*’ have shown that it is possible to achieve voluntary control over the occurrence of penile erection by exposing the subjects to erotically stimulating motion pictures with or without a description of the behavioral content of the erotic stimulus film. The subjects are later able to achieve erection voluntarily in the absence of the erotic stimuli. To monitor changes in penile circumference, these authors employed a mercury strain gauge which is fitted around the penis.3 We were also able to condition penile erection in response to sexually arousing auditory stimuli in a young male homosexual by providing him feedback of changes in penile erection as measured by changes in penile temperature sensed by a thermistor attached to the skin of the patient.4 If a patient is trained, through behavioral techniques, to control the penile erection response voluntarily, he will then be able to achieve erection in the physician’s office when needed. Victor A. Colotla, Ph.D. Department of Psychology, Toronto Western Hospital, Toronto, Canada M5T 2S8 Benjamin Dominguez, M. SC. Faculty of Psychology, National University of Mexico, Mexico City, Mexico.
References 1. LAWS, D. R., and RUBIN, H. B.: Instruction control of an autonomic sexual response. J. Appl. Behav. Anal. 3: 93 (1969).
289
