Vol. 121, May Printed in U.S.A.
0022-5347 /79/1215-0689 $02.00/0 THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Letters to the Editor 1. Heffernan, J.C., Lightwood, R. G. and Snell, M. E.: Horseshoe
DIABETES INSIPIDUS AND HYDRONEPHROSIS To the Editor. After having read the interesting Review Article on this subject' we thought that we should describe our 2 patients who were treated recently. The first patient was a 14-year-old girl with a complex of symptoms, including juvenile diabetes mellitus without peripheral neuropathy, diabetes insipidus, optic atrophy, hearing loss, dilatation of the upper urinary tract and a bladder without infravesical obstruction (probably Wolfram's syndrome).2 Many theories and explanations have been indicated for the etiology of Wolfram's syndrome. It is not yet clear whether dilatation of the upper urinary tract and bladder is the result of the diabetes insipidus or whether it is part of the syndrome. Urinary retention and urinary tract dilatation in our patient were managed by intermittent catheterization and oral administration of bethanechol bromide. A year after treatment residual urine was reduced to nil and dilatation was no longer present. The second patient was a man with diabetes insipidus and significant dilatation of the upper urinary tract and bladder. There was a large volume of residual urine. Bladder neck stenosis was found on a voiding cystogram, cystourethroscopy and urethral profile and this was confirmed on pathological examination. Transurethral resection of the bladder neck restored normal voiding and the upper urinary tract dilatation gradually returned to normal. Because of these cases we emphasize that dilatation of the upper urinary tract and bladder in patients with diabetes insipidus should not always be considered a necessary result of the diabetes. The dilatation could be part of a syndrome or the result of bladder neck obstruction. Our cases reveal the need for a physical examination as well as radiological and endoscopic studies for these patients. In this way an accurate diagnosis can be made, proper treatment will be administered and the renal damage will be avoided. Respectfully, C. Dimopoulos, M. Likourinas and M. Melekos Department of Urology University of Athens Hospital "Vassilevs Pavlas" Goudi, Athens, Greece 1. Shapiro, S. R., Woerner, S., Adelman, R. and Palmer, J. M.:
Diabetes insipidus and hydronephrosis. J. Urol., 119: 715, 1978. 2. Dimopoulos, C., Likourinas, M. and Dakou-Voutetakis, K.: Juvenile diabetes mellitus, diabetes insipidus, hearing loss, optic atrophy, dilatation of upper urinary tract and urinary bladder and other abnormalities. Presented at European Urology Congress, Monte Carlo, 1978.
kidney with retrocaval ureter: second reported case. J. Urol., 120: 358, 1978. 2. Eidelman, A., Yuval, E., Simon, D. and Sibi, Y.: Retrocaval ureter. Eur. Urol., 4; 279, 1978. RE: EXTRACTION OF URETERAL CALCULI FROM PATIENTS WITH ILEAL LOOPS: A NEW TECHNIQUE A. D. Smith, P.H. Lange, D. B. Reinke and R. P. Miller J. Urol., 120: 623-625, 1978 To the Editor. These authors have stated "In patients with an ileal conduit obstructing small calculi in the di;tal third of the ureter cannot be removed with a stone basket using standard procedures". In 1974 we described retrograde ureteral catheteriza-· tion and stone basket manipulation in a patient with an ileal conduit in whom we used a standard panendoscope. 1 The panendoscope was passed through a 24F Foley catheter with a 30 cc balloon, which provided for occlusion of the stoma of the conduit with subsequent distension of the conduit. We have continued to use this technique for observation and cannulation of the ureteral orifices. We would recommend that this procedure be used before percutaneous nephrostomy.
Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 1. Redman, J. F., Meacham, K. R., Rountree, G. A. and Bissada, N. K.: Endoscopy of ilea] conduit with ureteral instrumentation. Urology, 3: 565, 1974. Reply by Authors. We regret having overlooked the article by Redman and associates. We have made numerous attempts to catheterize ureteroileostomies without success. Nevertheless, in an uncomplicated case the approach described by these authors should be tried first. However, in the extremely ill patient percutaneous nephrostomy allows immediate decompression of the kidney and stabilization of the patient. We believe that subsequent antegrade manipulation past the calculus may be safer because there is less chance of a false pass. In addition, the operator using fluoroscopy has precise control of the stone basket and it is easy to place a silicone rubber ureteral splint postoperatively. IDIOPATHIC RETROPERITONEAL FIBROSIS
HORSESHOE KIDNEY WITH RETROCAVAL URETER To the Editor. It seems logical that in the presence of a persistent subcardinal infrarenal vena cava with a concurrent horseshoe kidney the isthmus of the latter would be located retrocavally too, because of the same anomalous development. A horseshoe kidney and retrocaval ureter are not necessarily the main causes of urinary tract obstruction in these cases, either separately or jointly. As depicted in the case of Heffernan and associates the contralateral (left) renal moiety was affected much more severely than the right side, which drained into the retrocaval ureter. 1 Similarly, in one of our recent cases (presumably making this the "third reported case") right hydronephrosis was caused by pelvioureteral stenosis and not by the associated horseshoe kidney, retrocaval ureter, retrocaval interrenal isthmus or coincidental aberrant renal vessels (case 3 in our article). 2
To the Editor. I enjoyed reading the report by Willscher and associates on the possible association of the HLA-B27 antigen with idiopathic retroperitoneal fibrosis and its potential usefulness as an immunologic marker in this disease. 1 I had a 46-year-old black male patient with surgically proved idiopathic retroperitoneal fibrosis who underwent histocompatibility antigen testing. He was tested for HLA-Al, A2, A3, A9, B7, BS, B12 and B27, and was positive only for Al and B7. The significance of these particular positive antigens in my patient is unclear; he did not respond to oral prednisone before right ureterolysis and omentopexy with eventual placement of a polyethylene ureteral stent. 2 Despite this failure to confirm the suspected association, I, too, believe that tissue typing should be continued in this condition to possibly obtmn much valuable information.
Respectfully, Avraham Eide/man of Urology Hospital
Respectfully, John H. Norton, III Adult and Pediatric Urology 2006 Dwight Way, Suite 204 Berkeley, California 94704 1. Willscher, !\ILK., Novicki, D.
of HLA-B27 antigen with 120: 631, 1978.
589
rP"r.rr,-cw-r11r.m1PB
W. F.: Association fibrosis. J. U rol.,
0022-5347 /79/1215-0689 $02.00/0 THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Letters to the Editor 1. Heffernan, J.C., Lightwood, R. G. and Snell, M. E.: Horseshoe
DIABETES INSIPIDUS AND HYDRONEPHROSIS To the Editor. After having read the interesting Review Article on this subject' we thought that we should describe our 2 patients who were treated recently. The first patient was a 14-year-old girl with a complex of symptoms, including juvenile diabetes mellitus without peripheral neuropathy, diabetes insipidus, optic atrophy, hearing loss, dilatation of the upper urinary tract and a bladder without infravesical obstruction (probably Wolfram's syndrome).2 Many theories and explanations have been indicated for the etiology of Wolfram's syndrome. It is not yet clear whether dilatation of the upper urinary tract and bladder is the result of the diabetes insipidus or whether it is part of the syndrome. Urinary retention and urinary tract dilatation in our patient were managed by intermittent catheterization and oral administration of bethanechol bromide. A year after treatment residual urine was reduced to nil and dilatation was no longer present. The second patient was a man with diabetes insipidus and significant dilatation of the upper urinary tract and bladder. There was a large volume of residual urine. Bladder neck stenosis was found on a voiding cystogram, cystourethroscopy and urethral profile and this was confirmed on pathological examination. Transurethral resection of the bladder neck restored normal voiding and the upper urinary tract dilatation gradually returned to normal. Because of these cases we emphasize that dilatation of the upper urinary tract and bladder in patients with diabetes insipidus should not always be considered a necessary result of the diabetes. The dilatation could be part of a syndrome or the result of bladder neck obstruction. Our cases reveal the need for a physical examination as well as radiological and endoscopic studies for these patients. In this way an accurate diagnosis can be made, proper treatment will be administered and the renal damage will be avoided. Respectfully, C. Dimopoulos, M. Likourinas and M. Melekos Department of Urology University of Athens Hospital "Vassilevs Pavlas" Goudi, Athens, Greece 1. Shapiro, S. R., Woerner, S., Adelman, R. and Palmer, J. M.:
Diabetes insipidus and hydronephrosis. J. Urol., 119: 715, 1978. 2. Dimopoulos, C., Likourinas, M. and Dakou-Voutetakis, K.: Juvenile diabetes mellitus, diabetes insipidus, hearing loss, optic atrophy, dilatation of upper urinary tract and urinary bladder and other abnormalities. Presented at European Urology Congress, Monte Carlo, 1978.
kidney with retrocaval ureter: second reported case. J. Urol., 120: 358, 1978. 2. Eidelman, A., Yuval, E., Simon, D. and Sibi, Y.: Retrocaval ureter. Eur. Urol., 4; 279, 1978. RE: EXTRACTION OF URETERAL CALCULI FROM PATIENTS WITH ILEAL LOOPS: A NEW TECHNIQUE A. D. Smith, P.H. Lange, D. B. Reinke and R. P. Miller J. Urol., 120: 623-625, 1978 To the Editor. These authors have stated "In patients with an ileal conduit obstructing small calculi in the di;tal third of the ureter cannot be removed with a stone basket using standard procedures". In 1974 we described retrograde ureteral catheteriza-· tion and stone basket manipulation in a patient with an ileal conduit in whom we used a standard panendoscope. 1 The panendoscope was passed through a 24F Foley catheter with a 30 cc balloon, which provided for occlusion of the stoma of the conduit with subsequent distension of the conduit. We have continued to use this technique for observation and cannulation of the ureteral orifices. We would recommend that this procedure be used before percutaneous nephrostomy.
Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 1. Redman, J. F., Meacham, K. R., Rountree, G. A. and Bissada, N. K.: Endoscopy of ilea] conduit with ureteral instrumentation. Urology, 3: 565, 1974. Reply by Authors. We regret having overlooked the article by Redman and associates. We have made numerous attempts to catheterize ureteroileostomies without success. Nevertheless, in an uncomplicated case the approach described by these authors should be tried first. However, in the extremely ill patient percutaneous nephrostomy allows immediate decompression of the kidney and stabilization of the patient. We believe that subsequent antegrade manipulation past the calculus may be safer because there is less chance of a false pass. In addition, the operator using fluoroscopy has precise control of the stone basket and it is easy to place a silicone rubber ureteral splint postoperatively. IDIOPATHIC RETROPERITONEAL FIBROSIS
HORSESHOE KIDNEY WITH RETROCAVAL URETER To the Editor. It seems logical that in the presence of a persistent subcardinal infrarenal vena cava with a concurrent horseshoe kidney the isthmus of the latter would be located retrocavally too, because of the same anomalous development. A horseshoe kidney and retrocaval ureter are not necessarily the main causes of urinary tract obstruction in these cases, either separately or jointly. As depicted in the case of Heffernan and associates the contralateral (left) renal moiety was affected much more severely than the right side, which drained into the retrocaval ureter. 1 Similarly, in one of our recent cases (presumably making this the "third reported case") right hydronephrosis was caused by pelvioureteral stenosis and not by the associated horseshoe kidney, retrocaval ureter, retrocaval interrenal isthmus or coincidental aberrant renal vessels (case 3 in our article). 2
To the Editor. I enjoyed reading the report by Willscher and associates on the possible association of the HLA-B27 antigen with idiopathic retroperitoneal fibrosis and its potential usefulness as an immunologic marker in this disease. 1 I had a 46-year-old black male patient with surgically proved idiopathic retroperitoneal fibrosis who underwent histocompatibility antigen testing. He was tested for HLA-Al, A2, A3, A9, B7, BS, B12 and B27, and was positive only for Al and B7. The significance of these particular positive antigens in my patient is unclear; he did not respond to oral prednisone before right ureterolysis and omentopexy with eventual placement of a polyethylene ureteral stent. 2 Despite this failure to confirm the suspected association, I, too, believe that tissue typing should be continued in this condition to possibly obtmn much valuable information.
Respectfully, Avraham Eide/man of Urology Hospital
Respectfully, John H. Norton, III Adult and Pediatric Urology 2006 Dwight Way, Suite 204 Berkeley, California 94704 1. Willscher, !\ILK., Novicki, D.
of HLA-B27 antigen with 120: 631, 1978.
589
rP"r.rr,-cw-r11r.m1PB
W. F.: Association fibrosis. J. U rol.,
