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. Kozacioglu Z, Kiray A, Ergur I, et al. Anatomy of the dorsal nerve of the penis, clinical implications. Urology. 2014;83:121-125. 2. Williams PL. Gray’s Anatomy—The Anatomical Basis of Medicine and Surgery. 38th ed. Edinburgh: Churchill Livingstone; 1995:1288. 3. Yang CC, Bradley WE. Innervation of the human glans penis. J Urol. 1999;161:97-102. 4. Halata Z, Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res. 1986;371:205-230. 5. Kimura J. Anatomy and Physiology of the Peripheral Nerve. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. 2nd ed. Philadelphia: F. A. Davis Co; 1989:55-77.
Reply by the Authors DEAR EDITOR,
We read the letter about our study on penile dorsal nerves and thank you for giving us the opportunity to answer some issues: We believe that what is meant with the word “insertion” about the nerves going into the glans penis is quite understandable, but formally the readers are correct, the word “entry” might have been a better one. In the text, it is said that we have used the Carl Zeiss Stereoscopic Dissection Microscope. So the dissections were not done under naked eye, and the epineurium around the fibers were seen and verified by all 3 anatomists participating in the study just similar to the use of the
1208
vernier caliper. In the materials and methods section, we did find it necessary to mention about it. What is meant by the “main trunks were placed on the midline of the dorsum penis on both sides of the dorsal penile artery (DPA)” is that the trunks were placed as a bunch of nerve fibers, not just 1 trunk, along both sides of the DPA on both sides. Also, the phrase was used to describe the main trunks being in close relation with each other on the lateral aspects of the DPA, which is located on the midline, on the mid dorsum of the penis and to distinguish them from the branches going laterally. We are not talking about an anomalous dorsal nerve of penis or an anomalous DPA. We could not identify any branches innervating the frenulum, which does not mean that they are not there. We did not work inside the glans penises, so we cannot make a comment about the pathways inside it. We thank the readers about their important comments about our study and those on the penile peripheral neuropathy. Zafer Kozacioglu, M.D. Urology Clinic Bozyaka Training and Research Hospital Izmir, Turkey Amac Kiray, M.D. Gulsah Zeybek, Ph.D. Department of Anatomy Dokuz Eylul University Izmir, Turkey
UROLOGY 83 (5), 2014
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. Kozacioglu Z, Kiray A, Ergur I, et al. Anatomy of the dorsal nerve of the penis, clinical implications. Urology. 2014;83:121-125. 2. Williams PL. Gray’s Anatomy—The Anatomical Basis of Medicine and Surgery. 38th ed. Edinburgh: Churchill Livingstone; 1995:1288. 3. Yang CC, Bradley WE. Innervation of the human glans penis. J Urol. 1999;161:97-102. 4. Halata Z, Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res. 1986;371:205-230. 5. Kimura J. Anatomy and Physiology of the Peripheral Nerve. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. 2nd ed. Philadelphia: F. A. Davis Co; 1989:55-77.
Reply by the Authors DEAR EDITOR,
We read the letter about our study on penile dorsal nerves and thank you for giving us the opportunity to answer some issues: We believe that what is meant with the word “insertion” about the nerves going into the glans penis is quite understandable, but formally the readers are correct, the word “entry” might have been a better one. In the text, it is said that we have used the Carl Zeiss Stereoscopic Dissection Microscope. So the dissections were not done under naked eye, and the epineurium around the fibers were seen and verified by all 3 anatomists participating in the study just similar to the use of the
1208
vernier caliper. In the materials and methods section, we did find it necessary to mention about it. What is meant by the “main trunks were placed on the midline of the dorsum penis on both sides of the dorsal penile artery (DPA)” is that the trunks were placed as a bunch of nerve fibers, not just 1 trunk, along both sides of the DPA on both sides. Also, the phrase was used to describe the main trunks being in close relation with each other on the lateral aspects of the DPA, which is located on the midline, on the mid dorsum of the penis and to distinguish them from the branches going laterally. We are not talking about an anomalous dorsal nerve of penis or an anomalous DPA. We could not identify any branches innervating the frenulum, which does not mean that they are not there. We did not work inside the glans penises, so we cannot make a comment about the pathways inside it. We thank the readers about their important comments about our study and those on the penile peripheral neuropathy. Zafer Kozacioglu, M.D. Urology Clinic Bozyaka Training and Research Hospital Izmir, Turkey Amac Kiray, M.D. Gulsah Zeybek, Ph.D. Department of Anatomy Dokuz Eylul University Izmir, Turkey
UROLOGY 83 (5), 2014
