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Controlled vacuum chamber fordocumenting penile erectile deformity
LETTERS TO THE EDITOR DIAGNOSIS OF RENAL ONCOCYTOMA To the Editor: We have read with interest the recent ease report of a granular renal cell carcinoma by B. Lazzaro and colleagues, in their article, Renal Cell Carcinoma vs Renal Oncocytoma, published in the January issue (vol. 37, page 52, 1991) of UROLOGY.In their article the authors state that a diagnosis of renal oncocytoma should not be made without electron microscopic confirmation. We do not support this recommendation since in our opinion the majority of these tumors may be diagnosed using light microscopy. In our view the indiscriminate use of electron microscopy is a costly waste of resources. Renal oncocytomas are not rare tumors, with approximately 750 new cases diagnosed annually in the United States. 2 The tumor has a characteristic angiographic pattern 3 and a typical macroscopic appearance. 4 Microscopically oncocytomas are composed only of cells with bland nuclear features and bright eosinophilic granular cytoplasm. The cellular arrangement is also significant since most of these tumors have cell nests arranged in an organoid pattern within a myxoid stroma. In addition, diagnosis depends on the absence of mitotic figures, clear cells, and areas of necrosis. 5 Infiltration of the renal capsule has been described and the presence of this should not be considered an excluding factor. 8 Utilizing these criteria, a diagnosis of renal oncocytoma may be made with confidence after a liberal sampiing of the specimen. In the case reported by Lazzaro and colleagues, the diagnosis of oncocytoma was doubtful even after examination of the initial sections. The angiographic pattern was unhelpful while the photograph of the gross specimen appears to show central necrosis rather than fibrosis. The tumor had an extensive papillary pattern histologically, and there was a notable degree of nuclear pleomorphism. The discovery of clear cells in subsequent sections confirmed the diagnosis of renal eell carcinoma. We believe that the place for electron microscopy in the diagnosis of renal oncoeytoma is in those cases where fine-needle aspiration (FNA) cytology has been undertaken. Lazzaro et al. state that diagnosis of this tumor by needle or aspiration biopsy can be at most tentative, We would disagree with this and have recently demonstrated that such a technique is of value in those patients with bilateral tumors or with impaired renal function. 7 In such cases, where angiography is suggestive of oncocytoma, FNA should be undertaken. The presence of cells indicative of renal cell carcinoma would necessitate treatment of the tumor by radical nephreetomy. If the cytology is suggestive of oneoeytoma, then eonfirmation may be obtained from electron microscopic examination of a centrifuge preparation from the residual aspirate. This would allow a nephron-sparing
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partial nephrectomy to be undertaken with confirmation of the diagnosis by intra-operative frozen sections and subsequent paraffin sections. We believe the judicious use of this technique is of considerable importance in those cases where radical nephrectomy is undesirable. Brett Delahunt, MB., ChB., FRCPA Raj K. Gupta, M.D., FIAC John N. Nacey, M.D., FRACS From the Departments of Pathology and Surgery Wellington School of Medicine, University of Otago Wellington, New Zealand Referenees 1. LieberMM: Renaloneoeytoma,in JavadpourN (Ed): Caneer of the Kidney,New York,Thieme-Stratton,chap 13, 19847 p 139. 2. QuinnMJ, HartmanDS, and FriedmanAC: Renaloncoeytoma, new observations, Radiology153:49 (1984). 3. MostofiFK, SesterhennIA, and Davis CJ: Benigntumorsof the kidney,EORTCGenitourinaryGroup Monograph5: Progress and Controversiesin OneologicalUrologyII, New York,Alan R. Liss, Ine, 1988, p 329. 4. LawrenceWT, and BajallanNMS: The importanceof recognizingrenal oncoeytoma,Br J Urol 57:625 (1985). 5. DelahuntB, NaeeyJN, HammettGD, and Frater WJ: Nucleolar organizingregionsin renal cell carcinoma, renal oneoey, toma and renal adenoma, Anal Cell Pathol 1:185 (1989). 6. Gupta RK, Delahunt B, and WakefieldStJ: Preoperative diagnosis of bilateral renal oneoeytomaby needle aspirationcytology, Acta Cytol, in press, (1991).
CONTROLLED VACUUM CHAMBER FOR DOCUMENTING PENILE ERECTILE DEFORMITY To the Editor: Re: "Controlled Vacuum Chamber for Standardized Photographic Documentation of Penile Erectile Deformity," by Martin K. Gelbard, published in the Oct. issue (vol. 36, pages 367-369, 1990) of tmOLOCY. I would like to congratulate the author for his article and the special vacuum chamber he used for producing an erection-like state for documenting penile curvatures. During the last three years, we used the "negative i pressure-induced erection" for assessing either congenital or acquired penile curvature in patients w h o could not document the curvature for technical r e a sons or because of unsustained erections. The examination was performed using the commerciallY available negative-pressure devices impotent pa, tients use. Except for the Pos-T-Vac system, all the marketed devices lack a vaeuum gauge and the limit of the negative pressure applied is empirical, based on the pain the patient feels. When using the Post~TVac device we also observed that a satisfactory erection could be achieved by 5-7 inHg negative pressure. The results of this technique were published a
UROLOGY / JUNE1991 / VOLUMEXXXVII, NUMBER6
year ago. 1 In none of the patients was the severity of the deformity an obstacle in assessing the deviation angle. Even curvatures of 46-65 degrees were examined without difficulty using the standard cylinders. Although the limited space in the vacuum cylinder caused some patients to report pain, the moment the penis was removed from the cylinder with the constricting band at the base, the penis snapped back to its angulated form and the pain subsided. Since the examination of the deviation was performed after the cylinder was removed from the penis, fogging of the inner walls of the cylinder did not cause a problem. We developed the idea further and used it in infants with penile deformities, including cases with chordee, z We also used a miniature device we developed for screening newborn males for penile deformities and finding the incidence rate of congenital penile curvatures. Our preliminary findings were presented during the Ninth International Symposium of Operative Andrology2 We conclude that the assessment of penile deformities using the "negative pressure-induced erection" is reliable and easy to perform in every age patient and avoids the need to use invasive methods like intracorporeal saline or vasoactive drug injections.
FIGURE 1.
Lead sheet.
Daniel Yachia, M.D. Head, Department of Urology Hillel Yaffe Medical Center Hadera, Israel References 1. YachiaD: Negativepressure-inducederection for the assessrent of impotent patients with Peyronie's disease, Br J Urol 66: 106 (1990). 2. YachiaD: Early assessmentof penile curvaturesin infants, J Urol 145:103 (1991). 3. YachiaD: Beyar M, and Descalu S: Incidenceof penile curvatures, presented at the 9th International Symposiumof Operative Andrology,Berlin, Germany, March 15-17, 1990.
HYPOSPADIAS RETRACTOR
To the Editor: The article, "Hypospadias Retractor," by B. Woodworth and L. R. King, published in the January issue (vol. 35, page 63, 1990) of UROLOGYis interesting, and we agree with them regarding the necessity for adequate stabilization of the penis during dissection and suture placement. The use of a holder as they recommend is very helpful, but it would be easier to use a simple steri-
UROLOGY / JUNE 199I / VOLUMEXXXVII, NUMBER6
FIGURE 2.
Lead sheet in place during hypospadias
repair. lized lead sheet (Fig. 1) with peripheral incisions as we* described in 1980. The traction suture is placed through the glans penis or through the prepuce and anchored to the periphery of the lead sheet through the appropriate incision (Fig. 2). B. Dore, M.D. J. Aubert, M.D. 86000 Poitiers, France *Aubert J, and Dore B: Use of lead sheet in hypospadiasrepair, J d'Urol (Paris) 86:483 (1980).
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partial nephrectomy to be undertaken with confirmation of the diagnosis by intra-operative frozen sections and subsequent paraffin sections. We believe the judicious use of this technique is of considerable importance in those cases where radical nephrectomy is undesirable. Brett Delahunt, MB., ChB., FRCPA Raj K. Gupta, M.D., FIAC John N. Nacey, M.D., FRACS From the Departments of Pathology and Surgery Wellington School of Medicine, University of Otago Wellington, New Zealand Referenees 1. LieberMM: Renaloneoeytoma,in JavadpourN (Ed): Caneer of the Kidney,New York,Thieme-Stratton,chap 13, 19847 p 139. 2. QuinnMJ, HartmanDS, and FriedmanAC: Renaloncoeytoma, new observations, Radiology153:49 (1984). 3. MostofiFK, SesterhennIA, and Davis CJ: Benigntumorsof the kidney,EORTCGenitourinaryGroup Monograph5: Progress and Controversiesin OneologicalUrologyII, New York,Alan R. Liss, Ine, 1988, p 329. 4. LawrenceWT, and BajallanNMS: The importanceof recognizingrenal oncoeytoma,Br J Urol 57:625 (1985). 5. DelahuntB, NaeeyJN, HammettGD, and Frater WJ: Nucleolar organizingregionsin renal cell carcinoma, renal oneoey, toma and renal adenoma, Anal Cell Pathol 1:185 (1989). 6. Gupta RK, Delahunt B, and WakefieldStJ: Preoperative diagnosis of bilateral renal oneoeytomaby needle aspirationcytology, Acta Cytol, in press, (1991).
CONTROLLED VACUUM CHAMBER FOR DOCUMENTING PENILE ERECTILE DEFORMITY To the Editor: Re: "Controlled Vacuum Chamber for Standardized Photographic Documentation of Penile Erectile Deformity," by Martin K. Gelbard, published in the Oct. issue (vol. 36, pages 367-369, 1990) of tmOLOCY. I would like to congratulate the author for his article and the special vacuum chamber he used for producing an erection-like state for documenting penile curvatures. During the last three years, we used the "negative i pressure-induced erection" for assessing either congenital or acquired penile curvature in patients w h o could not document the curvature for technical r e a sons or because of unsustained erections. The examination was performed using the commerciallY available negative-pressure devices impotent pa, tients use. Except for the Pos-T-Vac system, all the marketed devices lack a vaeuum gauge and the limit of the negative pressure applied is empirical, based on the pain the patient feels. When using the Post~TVac device we also observed that a satisfactory erection could be achieved by 5-7 inHg negative pressure. The results of this technique were published a
UROLOGY / JUNE1991 / VOLUMEXXXVII, NUMBER6
year ago. 1 In none of the patients was the severity of the deformity an obstacle in assessing the deviation angle. Even curvatures of 46-65 degrees were examined without difficulty using the standard cylinders. Although the limited space in the vacuum cylinder caused some patients to report pain, the moment the penis was removed from the cylinder with the constricting band at the base, the penis snapped back to its angulated form and the pain subsided. Since the examination of the deviation was performed after the cylinder was removed from the penis, fogging of the inner walls of the cylinder did not cause a problem. We developed the idea further and used it in infants with penile deformities, including cases with chordee, z We also used a miniature device we developed for screening newborn males for penile deformities and finding the incidence rate of congenital penile curvatures. Our preliminary findings were presented during the Ninth International Symposium of Operative Andrology2 We conclude that the assessment of penile deformities using the "negative pressure-induced erection" is reliable and easy to perform in every age patient and avoids the need to use invasive methods like intracorporeal saline or vasoactive drug injections.
FIGURE 1.
Lead sheet.
Daniel Yachia, M.D. Head, Department of Urology Hillel Yaffe Medical Center Hadera, Israel References 1. YachiaD: Negativepressure-inducederection for the assessrent of impotent patients with Peyronie's disease, Br J Urol 66: 106 (1990). 2. YachiaD: Early assessmentof penile curvaturesin infants, J Urol 145:103 (1991). 3. YachiaD: Beyar M, and Descalu S: Incidenceof penile curvatures, presented at the 9th International Symposiumof Operative Andrology,Berlin, Germany, March 15-17, 1990.
HYPOSPADIAS RETRACTOR
To the Editor: The article, "Hypospadias Retractor," by B. Woodworth and L. R. King, published in the January issue (vol. 35, page 63, 1990) of UROLOGYis interesting, and we agree with them regarding the necessity for adequate stabilization of the penis during dissection and suture placement. The use of a holder as they recommend is very helpful, but it would be easier to use a simple steri-
UROLOGY / JUNE 199I / VOLUMEXXXVII, NUMBER6
FIGURE 2.
Lead sheet in place during hypospadias
repair. lized lead sheet (Fig. 1) with peripheral incisions as we* described in 1980. The traction suture is placed through the glans penis or through the prepuce and anchored to the periphery of the lead sheet through the appropriate incision (Fig. 2). B. Dore, M.D. J. Aubert, M.D. 86000 Poitiers, France *Aubert J, and Dore B: Use of lead sheet in hypospadiasrepair, J d'Urol (Paris) 86:483 (1980).
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