LETTERS TO THE EDITOR
CYSTIC FIBROSIS DEFERENS
AND
ABSENCE
OF
VAS
To the Editor: Dr. R. Amelar and Dr. L. Dubin in their letter to the editor (UROLOGY, vol. 4, page 495), suggested that cystic fibrosis can be ruled out in the male child if the vasa are papable. Infertility and abnormalitiesofthemesonephricderivativesarecommon in patients with cystic fibrosis, but it is not a uniform with cystic finding. Taussiget al. l reported on2patients fibrosis who had proved fertility. Abnormalities of the vas could be documented in pathologic studies,2 but the vas was found to be present in some patients who died of cystic fibrosis. In many patients, absence could not be ruled out on physical examination. In healthy, young children the vas is not easily palpable; even when it is, the degree ofcertainty in its identification is less than in the post-pubertal male. Cystic fibrosis is a disease with protean manifestations, and it would be a mistake to rule out cystic fibrosis just because the vas can be palpated or to have victims of cystic fibrosis labeled as infertile. George D. Kornitzer, Robert A. Newton, 2000 Washington Newton, Massachusetts
M.D. M.D. Street 02162
References 1. TAUSSIG, L. M., et al. : Fertility in males with cystic fibrosis, New Engl. J. Med. 287: 586 (1972). 2. HOLSCLAW,D. S. ,.PERLMUTTER,A. D. ,JOCKIN, H., and SCHACHMAN,H.: Genital abnormalities in male patients with cystic fibrosis, J. Urol. 106: 568 (1971).
CONGENITAL
ABSENCE
OF VASA
To the Editor: In their letter to the editor in the October issue of UROLOGY (vol. 4, page 495), Dr. R. Amelar and Dr. L. Dubin make several valid statements concerning congenital absence of the vasa. We, however, must take exception to their statements concerning this problem in patients with cystic fibrosis. Although it is generally true that most male patients with cystic fi brosis are infertile due to congenital atresia or absence of the vasal structures, this finding is not invariable. Taussig et al. l reported 2 well-studied pa-
158
tie& with cystic fibrosis who had normal semen analysis, and at this writing both have fathered children (2). A third patient with normal semen analysis also is known to US.* In addition there are many instances of presumed but undocumented paternity in these patients. Cystic fibrosis centers estimate male fertility at2 to 3 per cent; although low, this figure warrants semen analysis before assuming sterility. In view of this, we fee1 that the diagnosis of cystic fibrosis should be considered when the vasa are absent, but it is incorrect to exclude the diagnosis on the basis of palpable vasa. Sally S. Roth, Robert A. Roth, 4902 Brookeway Bethesda, Maryland
M.D. M.D. Drive 20016
References 1. Taussig, L. M., et al.: Fertility in males with cystic fibrosis, New Engl. J. Med. 287: 586 (1972). 2. DISANT’AGNESE,P. A.: Personalcommunication, 1974.
RESERPINE
AND
PROSTATIC
CANCER
To the Editor: In our article, “Does Reserpine Increase Cancer of the Prostate? A Prolactin and Exacerbate Case Control Study,” published in the November issue of UROLOGY (vol. 4, page 525), we noted that in our series there were fewer cancer deaths in patients reserpine treated than in the control group and observed that “one might conclude that there is some suggestion that reserpine protects one against death from cancer of the prostate. This, however, is probably not the case, the findings being explained by the increased competing risk of death due to cardiovascular disease in the reserpine treated group.” The purpose of this letter is to point out an alternative explanation for these findings which came to the attention of one of us (C.B.). In a review on the mechanisms of spread of cancer, Dr. Warren Cole’ summarized the work of Buinauskas, Brown, and Cole2 on the inhibiting and enhancing effects of various chemical agents on rats’ resistance to inoculated Walker 256 tumor cells. Briefly, rats were injected subcutaneously with a standard dose of SUSpended Walker 256 tumor cells and then anesthetized and subjected to a forty-five-minute celiotomy to see if
UROLOGY
/
JANUARY 1975
/
VOLUME V, NUMBER 1
this procedure would increase the number of “takes,” simulating the effect of anesthesia and surgery on cancer patients. Under these conditions there was an average of 48.6 per cent “takes” in control animals versus 75. Spercent in those who underwent celiotomy. Following this experiment a number of drugs were tested for their ability to reduce the increased number of “takes” in rats undergoing celiotomy. Among these drugs were histamine, antihistamine compounds, dextran, and reserpine. With the exception of reserpine, all drugs tried following celiotomy produced an increase instead ofa decrease in the percentage of“takes” over those with celiotomy alone. In 57 animals subjected to celiotomy and reserpine, “takes” occurred in 34(59.6percent)comparedwith44(75.9percent)in58 animals having celiotomy alone. In their discussion, Buinauskas et al. ’ suggest that this may be explained by the fact that 5-hydroxytryptamine was shown to increase the number of “takes,” this substance rather than histamine being more important in the rat in this regard. The results with reserpine might be explained because reserpine is a known antagonist to 5-hydroxytryptamine. Of course, the usual caution is necessary in relating the results of animal experimentation to clinical cancer in man, but this work may be important in suggesting a possible mechanism for the effect ofreserpine in cancer patients. At the very least it suggests an alternative explanation to the findings of our study and provides us with a testable hypothesis. Recent evidence has appeared suggesting that use of reserpine for treating hypertension in women may lead to an increased risk of breast cancer developing. 3-5 It would be strange, indeed, if a substance which increases the risk of one cancer developing can be shown to lessen the severity of another. David P. Byar, M.D. National Cancer Institute Bethesda, Maryland
Veterans
Clyde E. Blackard, M.D. Administration Hospital Minneapolis, Minnesota
References 1. COLE, W. H.: The mechanisms of spread of cancer, Surg. Gynec. Obstet. 137: 853 (1973). 2. BUINAUSKAS,P., BROWN, E. R., and COLE,W. H.: Inhibitingandenhancingeffectofvariouschemicalagentson rats’ resistance to inoculated Walker 256 tumor cells, J. Surg. Reg. 5: 538 (1965). 3. Boston Collaborative Drug Surveillance Program: Resperpine and breast cancer, Lancet 2: 669 (1974). 4. ARMSTRONG,B., STEVENS, N., and DOLL, R.: Retrospective study of the association between use of rauwolfia derivatives and breast cancer in English women. ibid. 2: 672 (1974). 5. HEINONEN, 0. P., SHAPIRO, S., TUOMINEN, L., and
TURUNEN, M. I.: Reserpine use in relation to breast cancer, ibid. 2: 675 (1974).
UROLOGY
/ JANUARY 1975
/ VOLUME V. NUMBER1
IMMOBILIZATION IN OFFICE
OF
VAS
VASECTOMY
To the Editor: I read with interest the timely article “Immobilization of the Vas in Office Vasectomy,” by James A. Roberts, M.D., in the Surgeon’s Workshop section of UROLOGY (vol. 4, page 475). Rather than utilizing a modified towel clip for vas immobilization I have routinely employed a simple Allis clamp. After isolation of the vas by finger palpation, the classic linear incision is obtained under local anesthesia, and the vas is then easily grasped with the Allis clamp. Over 200 vasectomies have been accomplished during the past three years via this technique with good results. Ronald S, Rosenthal, ;M. 1). 1245 Highland Avenue Abington, Pennsylvania 19001
CRYOSURGERY CARCINOMA
FOR
PROSTATIC
To the Editor:We have read, quite obviously, with much interest the attempt by Dr. Jones’ in his review article, “Cryosurgery for Prostatic Carcinoma,” to present salient studies of the application of cryotherapy and its immunopotential as a therapeutic modality in the treatment of prostatic malignant disease. We believe in light of Dr. Jones’ kind but yet frankly distressful reference to some of our studies, apparently due to the quite reasonable difficulties encountered by all of us in attempting to bridge the gap between basic science and clinical investigation, that it is important and particularly relevant to the readers of UROLOGY to clarify a few points. I. Studies of serum proteins ofpatients with benign prostatic hypertrophy (BPH) and prostaticcancer were carried out on specimens obtained prior to2s3not following (cryo)surgery, as would appear to be indicated by Hoch-Ligeti et al. 4 in their study of serum protein patterns following surgery. In this regard, we are aware that alterations of serum proteins occur following surgery, whether they be due to anesthetic agents, stress, trauma, or the operative procedure per se. In fact, although not appropriate to go into specific detail here, we should mention that in contrast to the general alteration of serum proteins following surgical trauma characterized by a transient decrease of albumin and an increase of the alpha 1 and 2 globulin fractions, 4,5our postcryosurgical observations revealed a distinct decrease in the alpha 2 globulin fraction, which appeared to correlate with the clinical response of the patient. 6*7 Furthermore, while the frequency of an elevated level of alpha 2 globulin in patients with BPH and
I 59
CYSTIC FIBROSIS DEFERENS
AND
ABSENCE
OF
VAS
To the Editor: Dr. R. Amelar and Dr. L. Dubin in their letter to the editor (UROLOGY, vol. 4, page 495), suggested that cystic fibrosis can be ruled out in the male child if the vasa are papable. Infertility and abnormalitiesofthemesonephricderivativesarecommon in patients with cystic fibrosis, but it is not a uniform with cystic finding. Taussiget al. l reported on2patients fibrosis who had proved fertility. Abnormalities of the vas could be documented in pathologic studies,2 but the vas was found to be present in some patients who died of cystic fibrosis. In many patients, absence could not be ruled out on physical examination. In healthy, young children the vas is not easily palpable; even when it is, the degree ofcertainty in its identification is less than in the post-pubertal male. Cystic fibrosis is a disease with protean manifestations, and it would be a mistake to rule out cystic fibrosis just because the vas can be palpated or to have victims of cystic fibrosis labeled as infertile. George D. Kornitzer, Robert A. Newton, 2000 Washington Newton, Massachusetts
M.D. M.D. Street 02162
References 1. TAUSSIG, L. M., et al. : Fertility in males with cystic fibrosis, New Engl. J. Med. 287: 586 (1972). 2. HOLSCLAW,D. S. ,.PERLMUTTER,A. D. ,JOCKIN, H., and SCHACHMAN,H.: Genital abnormalities in male patients with cystic fibrosis, J. Urol. 106: 568 (1971).
CONGENITAL
ABSENCE
OF VASA
To the Editor: In their letter to the editor in the October issue of UROLOGY (vol. 4, page 495), Dr. R. Amelar and Dr. L. Dubin make several valid statements concerning congenital absence of the vasa. We, however, must take exception to their statements concerning this problem in patients with cystic fibrosis. Although it is generally true that most male patients with cystic fi brosis are infertile due to congenital atresia or absence of the vasal structures, this finding is not invariable. Taussig et al. l reported 2 well-studied pa-
158
tie& with cystic fibrosis who had normal semen analysis, and at this writing both have fathered children (2). A third patient with normal semen analysis also is known to US.* In addition there are many instances of presumed but undocumented paternity in these patients. Cystic fibrosis centers estimate male fertility at2 to 3 per cent; although low, this figure warrants semen analysis before assuming sterility. In view of this, we fee1 that the diagnosis of cystic fibrosis should be considered when the vasa are absent, but it is incorrect to exclude the diagnosis on the basis of palpable vasa. Sally S. Roth, Robert A. Roth, 4902 Brookeway Bethesda, Maryland
M.D. M.D. Drive 20016
References 1. Taussig, L. M., et al.: Fertility in males with cystic fibrosis, New Engl. J. Med. 287: 586 (1972). 2. DISANT’AGNESE,P. A.: Personalcommunication, 1974.
RESERPINE
AND
PROSTATIC
CANCER
To the Editor: In our article, “Does Reserpine Increase Cancer of the Prostate? A Prolactin and Exacerbate Case Control Study,” published in the November issue of UROLOGY (vol. 4, page 525), we noted that in our series there were fewer cancer deaths in patients reserpine treated than in the control group and observed that “one might conclude that there is some suggestion that reserpine protects one against death from cancer of the prostate. This, however, is probably not the case, the findings being explained by the increased competing risk of death due to cardiovascular disease in the reserpine treated group.” The purpose of this letter is to point out an alternative explanation for these findings which came to the attention of one of us (C.B.). In a review on the mechanisms of spread of cancer, Dr. Warren Cole’ summarized the work of Buinauskas, Brown, and Cole2 on the inhibiting and enhancing effects of various chemical agents on rats’ resistance to inoculated Walker 256 tumor cells. Briefly, rats were injected subcutaneously with a standard dose of SUSpended Walker 256 tumor cells and then anesthetized and subjected to a forty-five-minute celiotomy to see if
UROLOGY
/
JANUARY 1975
/
VOLUME V, NUMBER 1
this procedure would increase the number of “takes,” simulating the effect of anesthesia and surgery on cancer patients. Under these conditions there was an average of 48.6 per cent “takes” in control animals versus 75. Spercent in those who underwent celiotomy. Following this experiment a number of drugs were tested for their ability to reduce the increased number of “takes” in rats undergoing celiotomy. Among these drugs were histamine, antihistamine compounds, dextran, and reserpine. With the exception of reserpine, all drugs tried following celiotomy produced an increase instead ofa decrease in the percentage of“takes” over those with celiotomy alone. In 57 animals subjected to celiotomy and reserpine, “takes” occurred in 34(59.6percent)comparedwith44(75.9percent)in58 animals having celiotomy alone. In their discussion, Buinauskas et al. ’ suggest that this may be explained by the fact that 5-hydroxytryptamine was shown to increase the number of “takes,” this substance rather than histamine being more important in the rat in this regard. The results with reserpine might be explained because reserpine is a known antagonist to 5-hydroxytryptamine. Of course, the usual caution is necessary in relating the results of animal experimentation to clinical cancer in man, but this work may be important in suggesting a possible mechanism for the effect ofreserpine in cancer patients. At the very least it suggests an alternative explanation to the findings of our study and provides us with a testable hypothesis. Recent evidence has appeared suggesting that use of reserpine for treating hypertension in women may lead to an increased risk of breast cancer developing. 3-5 It would be strange, indeed, if a substance which increases the risk of one cancer developing can be shown to lessen the severity of another. David P. Byar, M.D. National Cancer Institute Bethesda, Maryland
Veterans
Clyde E. Blackard, M.D. Administration Hospital Minneapolis, Minnesota
References 1. COLE, W. H.: The mechanisms of spread of cancer, Surg. Gynec. Obstet. 137: 853 (1973). 2. BUINAUSKAS,P., BROWN, E. R., and COLE,W. H.: Inhibitingandenhancingeffectofvariouschemicalagentson rats’ resistance to inoculated Walker 256 tumor cells, J. Surg. Reg. 5: 538 (1965). 3. Boston Collaborative Drug Surveillance Program: Resperpine and breast cancer, Lancet 2: 669 (1974). 4. ARMSTRONG,B., STEVENS, N., and DOLL, R.: Retrospective study of the association between use of rauwolfia derivatives and breast cancer in English women. ibid. 2: 672 (1974). 5. HEINONEN, 0. P., SHAPIRO, S., TUOMINEN, L., and
TURUNEN, M. I.: Reserpine use in relation to breast cancer, ibid. 2: 675 (1974).
UROLOGY
/ JANUARY 1975
/ VOLUME V. NUMBER1
IMMOBILIZATION IN OFFICE
OF
VAS
VASECTOMY
To the Editor: I read with interest the timely article “Immobilization of the Vas in Office Vasectomy,” by James A. Roberts, M.D., in the Surgeon’s Workshop section of UROLOGY (vol. 4, page 475). Rather than utilizing a modified towel clip for vas immobilization I have routinely employed a simple Allis clamp. After isolation of the vas by finger palpation, the classic linear incision is obtained under local anesthesia, and the vas is then easily grasped with the Allis clamp. Over 200 vasectomies have been accomplished during the past three years via this technique with good results. Ronald S, Rosenthal, ;M. 1). 1245 Highland Avenue Abington, Pennsylvania 19001
CRYOSURGERY CARCINOMA
FOR
PROSTATIC
To the Editor:We have read, quite obviously, with much interest the attempt by Dr. Jones’ in his review article, “Cryosurgery for Prostatic Carcinoma,” to present salient studies of the application of cryotherapy and its immunopotential as a therapeutic modality in the treatment of prostatic malignant disease. We believe in light of Dr. Jones’ kind but yet frankly distressful reference to some of our studies, apparently due to the quite reasonable difficulties encountered by all of us in attempting to bridge the gap between basic science and clinical investigation, that it is important and particularly relevant to the readers of UROLOGY to clarify a few points. I. Studies of serum proteins ofpatients with benign prostatic hypertrophy (BPH) and prostaticcancer were carried out on specimens obtained prior to2s3not following (cryo)surgery, as would appear to be indicated by Hoch-Ligeti et al. 4 in their study of serum protein patterns following surgery. In this regard, we are aware that alterations of serum proteins occur following surgery, whether they be due to anesthetic agents, stress, trauma, or the operative procedure per se. In fact, although not appropriate to go into specific detail here, we should mention that in contrast to the general alteration of serum proteins following surgical trauma characterized by a transient decrease of albumin and an increase of the alpha 1 and 2 globulin fractions, 4,5our postcryosurgical observations revealed a distinct decrease in the alpha 2 globulin fraction, which appeared to correlate with the clinical response of the patient. 6*7 Furthermore, while the frequency of an elevated level of alpha 2 globulin in patients with BPH and
I 59
