Bingkun Li, M.D., Ph.D. Hulin Li, M.D. Department of Urology Zhujiang Hospital Southern Medical University Guangzhou, People’s Republic of China
References 1. Fitzgerald DJ, O’Malley K. Plasma drug levels as an aid to medical treatment. Ir Med Jf. 1984;77:23-26. 2. Li H, Xu K, Li B, et al. Percutaneous nephrolithotomy under local infiltration anesthesia: a single-center experience of 2000 Chinese cases. Urology. 2013;82:1020-1025.
Re: Bo et al.: Evaluation of Bladder Clots Using a Nonsurgical Treatment (Urology 2014;83:498-499) We congratulate the authors for describing a new method of clot removal using pancreatic enzymes as intravesical irrigation and/or infusion. Clot removal can sometimes be a really frustrating exercise. While using Ellik evacuator in the setting of clot retention, we have seen many bladder ruptures, especially if the procedure is done by trainee resident. Instead of “sucking out,” the surgeon “pushes” saline inside the bladder suddenly to fragment and suck out clots. To avoid this problem and also to remove really tenacious and large clots, we described the method of “suction” to remove these clots.1 Subsequently, we also developed a “suction bridge” to make the procedure simpler and more safe and effective (in collaboration with Karl Storz, Germany). In the article “Evaluation of bladder clots using a nonsurgical treatment” the word “Evaluation” should have been “Evacuation”. It would have been more enlightening had the authors also described the clot burden and the duration of clot retention. This is important, as it would be futile to delay definitive evacuation. For example, will the method described by the authors work if the clot bulk is significant? Also, how much time does it take to lyse clots by chymotripsin? Apul Goel, M.S., M.Ch., D.N.B., M.N.A.M.S. Siddharth Singh, M.S. Department of Urology King George Medical University Lucknow, India
Reference 1. Goel A, Sengottayan VK, Dwevedi AK. Mechanical suction: an effective and safe method to remove large and tenacious clots from the urinary bladder. Urology. 2011;77:494-496.
UROLOGY 83 (5), 2014
Re: Kozacioglu et al.: Anatomy of the Dorsal Nerve of the Penis, Clinical Implications (Urology 2014;83:121-125) We read with great interest the published article “Anatomy of the dorsal nerve of the penis, clinical implications” by Kozacioglu et al.1 The authors meticulously reported the anatomic variations of dorsal nerve of penis (DNP). We as anatomists take this opportunity to discuss few facts related to the study. In the methods section, the authors describe that they noted the farthest lateral points of insertion. One remains perplexed how a nerve can be described to have any insertion under normal anatomic description. Usually, it is a muscle which is inserted not a nerve. While referring to the branches of the DNP, it is very difficult to confirm a structure as a nerve under naked eye examination. Histology study with special stain for nerve is necessary to differentiate it from any thin band of fascia. It was not mentioned in the study whether the measurements were taken in a double-blinded manner, as vernier caliper measurements by a single observer may always account for any error. DNP usually accompanies the dorsal penile artery (DPA) between the layers of the suspensory ligament to the dorsum of the penis.2 The authors describe “the main trunk to be located in the midline of the dorsum penis on both sides of DPA”, which is very interesting. Does that mean that anomalous branching pattern of the DNP should also be accompanied with anomalous or normal DPA? It was also not mentioned whether DNP or any branch of the perineal nerve innervated the frenulum of the penis. This is important because an earlier study described the progressive increase of latencies from the shaft to the frenulum, which outlined the path of penile dorsal nerve branches through the glans, and this was thought to be important for neuroanatomic dissections.3 The present study has many important clinical implications. In humans, it is not only the glans penis, which may be a primary source of sensory information to the central nervous system, but also the receptors present in glans penis.4 Another important aspect to discuss is the penile peripheral neuropathy in which the fibers innervating the glans penis are most susceptible and the axonal degeneration, which proceeds from distal to proximal direction.5 Could we speculate that abnormal branching in the glans penis could play an important role in penile peripheral neuropathy? Overall, this is an interesting article, and we thank the authors and editor for publishing it. Farihah Haji Suhaimi, M.D., Ph.D. Norzana Abd Ghafar, M.D., Ph.D. Srijit Das, M.D., M.B.B.S., M.S. Department of Anatomy Universiti Kebangsaan Malaysia Kuala Lumpur, Malaysia
1207
References 1. Fitzgerald DJ, O’Malley K. Plasma drug levels as an aid to medical treatment. Ir Med Jf. 1984;77:23-26. 2. Li H, Xu K, Li B, et al. Percutaneous nephrolithotomy under local infiltration anesthesia: a single-center experience of 2000 Chinese cases. Urology. 2013;82:1020-1025.
Re: Bo et al.: Evaluation of Bladder Clots Using a Nonsurgical Treatment (Urology 2014;83:498-499) We congratulate the authors for describing a new method of clot removal using pancreatic enzymes as intravesical irrigation and/or infusion. Clot removal can sometimes be a really frustrating exercise. While using Ellik evacuator in the setting of clot retention, we have seen many bladder ruptures, especially if the procedure is done by trainee resident. Instead of “sucking out,” the surgeon “pushes” saline inside the bladder suddenly to fragment and suck out clots. To avoid this problem and also to remove really tenacious and large clots, we described the method of “suction” to remove these clots.1 Subsequently, we also developed a “suction bridge” to make the procedure simpler and more safe and effective (in collaboration with Karl Storz, Germany). In the article “Evaluation of bladder clots using a nonsurgical treatment” the word “Evaluation” should have been “Evacuation”. It would have been more enlightening had the authors also described the clot burden and the duration of clot retention. This is important, as it would be futile to delay definitive evacuation. For example, will the method described by the authors work if the clot bulk is significant? Also, how much time does it take to lyse clots by chymotripsin? Apul Goel, M.S., M.Ch., D.N.B., M.N.A.M.S. Siddharth Singh, M.S. Department of Urology King George Medical University Lucknow, India
Reference 1. Goel A, Sengottayan VK, Dwevedi AK. Mechanical suction: an effective and safe method to remove large and tenacious clots from the urinary bladder. Urology. 2011;77:494-496.
UROLOGY 83 (5), 2014
Re: Kozacioglu et al.: Anatomy of the Dorsal Nerve of the Penis, Clinical Implications (Urology 2014;83:121-125) We read with great interest the published article “Anatomy of the dorsal nerve of the penis, clinical implications” by Kozacioglu et al.1 The authors meticulously reported the anatomic variations of dorsal nerve of penis (DNP). We as anatomists take this opportunity to discuss few facts related to the study. In the methods section, the authors describe that they noted the farthest lateral points of insertion. One remains perplexed how a nerve can be described to have any insertion under normal anatomic description. Usually, it is a muscle which is inserted not a nerve. While referring to the branches of the DNP, it is very difficult to confirm a structure as a nerve under naked eye examination. Histology study with special stain for nerve is necessary to differentiate it from any thin band of fascia. It was not mentioned in the study whether the measurements were taken in a double-blinded manner, as vernier caliper measurements by a single observer may always account for any error. DNP usually accompanies the dorsal penile artery (DPA) between the layers of the suspensory ligament to the dorsum of the penis.2 The authors describe “the main trunk to be located in the midline of the dorsum penis on both sides of DPA”, which is very interesting. Does that mean that anomalous branching pattern of the DNP should also be accompanied with anomalous or normal DPA? It was also not mentioned whether DNP or any branch of the perineal nerve innervated the frenulum of the penis. This is important because an earlier study described the progressive increase of latencies from the shaft to the frenulum, which outlined the path of penile dorsal nerve branches through the glans, and this was thought to be important for neuroanatomic dissections.3 The present study has many important clinical implications. In humans, it is not only the glans penis, which may be a primary source of sensory information to the central nervous system, but also the receptors present in glans penis.4 Another important aspect to discuss is the penile peripheral neuropathy in which the fibers innervating the glans penis are most susceptible and the axonal degeneration, which proceeds from distal to proximal direction.5 Could we speculate that abnormal branching in the glans penis could play an important role in penile peripheral neuropathy? Overall, this is an interesting article, and we thank the authors and editor for publishing it. Farihah Haji Suhaimi, M.D., Ph.D. Norzana Abd Ghafar, M.D., Ph.D. Srijit Das, M.D., M.B.B.S., M.S. Department of Anatomy Universiti Kebangsaan Malaysia Kuala Lumpur, Malaysia
1207
