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Reply by Mr. Hole
607
LETTERS TO THE EDITOR
in the prostatic lobes without general anesthesia (a 20 ml. physiological saline solution containing antibiotics and 20 ml. lidocaine hydrochloride-2.0 ml. 1 per cent lidocaine is injected using a long, fine needle) has the advantages of the direct presence of high active antibiotic concentration at the site of the infection, no limitation of concentration in prostatic fluid of high alkaline pH and no possible inactivation of the antibiotic by metabolism in the body. The discomfort experienced by the patients during direct injection into the prostate is minimal. Our data have revealed that antibiotics enter the prostatic fluid in therapeutic levels after direct injection into the prostate and are curative in 66 to 90 per cent of the cases. We, therefore, recommend this method as treatment of choice in cases of chronic bacterial prostatitis and believe that this therapeutic approach should be considered in a reappraisal of treatment. Respectfully, Luc Baert Mgr Dehaernelaan, 56 8500 Kortrijk (Belgium)
H. and Pyck, J.: Chronic bacterial prostatitis. A new therapeutic approach: local antibiotics. Ann. Urol., 10: 99, 1976. Baert, L.: Bacterial prostatitis treated by local antibiotics. Letter to the Editor. Urology, 8: 644, 1976. L.: Bacterial prostatitis and its present treatment. Ann. H: 275, 1977. Baert, · Direct antibiotic injection clears most prostatitis. Family Practice News, 7: 57, 1977. Plomb, T. A., Baert, L. and Maes, R. A.: Treatment of recurrent chronic bacterial prostatitis by local injection of thiamphenicol, into the prostate and the thiamphenicol concentrations in serum and prostatic fluid. Submitted for publication. Meares, E. M., Jr. and Stamey, T. A.: The diagnosis and management of bacterial prostatitis. Brit. J. Urol., 44: 175, 1972.
1. Baert, L., Soep,
2. 3. 4. 5.
6.
by Authors. Periodically, reports are received about the effiinjection into the prostate in the treatment of prostatitis. the references referred to by Doctor Baert provide a good description of the technique for localization of lower tract infections there are no actual data presented about the results of cultures before and after treatment. Thus, I believe that this technique should be evaluated by the same stringent criteria used to evaluate the response of prostatic infection to treatment with oral or systemically injected antibiotics. We would be most enthused over any agent that gives a 66 to 90 per cent cure rate in the treatment of chronic bacterial prostatitis. However, without more detailed case reports documenting the bacterial counts before, during and after therapy it is impossible to assess of any treatment. It is well recognized that the vast majority of patients presenting to the urologist with symptoms of prostatitis will have these symptoms not on the basis of a bacterial infection. In this regard, the lack of controls in the references cited raises the questions as to whether a placebo injection would have had a significant effect. RE: THE RESULTS OF PROSTATECTOMY: A SYMPTOMATIC AND URODYNAMIC ANALYSIS OF 152 PATIENTS
P.H. Abrams, D. J. Farrar, R. T. Turner- Warwick, C. G. Whiteside and R. C. L. Feneley J. Urol., 121: 640-642, 1979 To the Editor. The authors of this article claim that "The objective results of operation have been improved from 72 to 88 per cent by the inclusion of urodynamic studies in the preoperative assessment of patients". Some errors cast doubt on this and other conclusions. Only 152 patients were followed postoperatively (Results, paragraph 1), yet table 3 on over-all results indicates 157 patients. In table 2 the combined total of Bristol and London patients is 192, yet only 190 patients are mentioned in the Results (paragraph 1). In Results (paragraph 1) it is stated that only 152 (of 190) patients were followed postoperatively because only those with preoperative unstable bladders in the London series were investigated fully. Table 2 shows 92 London patients, of whom 71 per cent are stated to be unstable preoperatively, that is 65 patients. With the 100 Bristol patients this should have been 165 patients (not 152 or 157). The figure of 88 per cent is mentioned only in the Abstract and in Results (paragraph 2-patients who said they were much improved).
This is clearly not an objective but a subjective result. However, it is compared to a series (reported by the first author 1 ) in which 87 cent of the patients undergoing prostatectomy "considered tnE:mi;ei,1es cured or much improved". Admittedly, the symptom scores of some of these patients suggested that they might be deluding themselves, but like must be compared with like, and the present article merely shows that full urodynamic studies have improved the (subjective) success rate of prostatectomy from 87 to 88 per cent. In the final sentence the authors claim that "Without urodynamic studies death may occur in patients who are unobstructed but have symptoms caused by unrecognized bladder hypersensitivity or instability". However, the work shows that even with urodynamic assessment such deaths might still occur. The article purports to show that the use of urodynamic assessment reduces the risk of no improvement after prostatectomy from 28 to 12 per cent. The operative mortality rate for prostatectomy performed in the United Kingdom is around 1 per cent. The risk of death in the operative period for any patient not likely to benefit from prostatectomy is, therefore, apparently reduced from 0.28 to 0.12 per cent. That risk is only removed if urodynamics can demonstrate all those patients who would not benefit from operation and this it certainly cannot do. Respectfully, Roger Hole Department of Urology North Ormesby Hospital Middlesbrough, Cleveland, TS3 6HJ England 1. Abrams, P. H.: Prostatism and prostatectomy: the value of urine
flow rate measurement in the preoperative assessment for operation. J. Urol., H7: 70, 1977.
Reply by Authors. We are grateful to Mr. Hole for pointing out the indefensible lapses in arithmetic and inadequate emphasis on objectiv-ity and subjectivity. We should have stated, "The objective and subjective results of operation ... ". If we might clarify the numerical problems-192 patients were in-vestigated: 100 from Bristol and 92 from London. Of the 65 unstable London patients 13 were not investigated fully postoperatively and, therefore, should have been excluded from the results. However, 5 of these patients who had normal postoperative flow studies were included erroneously in the first group in table 3. We should be unhappy if these valid arithmetic criticisms deflected the readers from the main point of the article, which is the improvement in objective results. In the earlier series 14 per cent of the patients had unimproved postoperative flow rates compared to only 6.5 per cent in the recent series. Since prostatic symptoms are notoriously fluctuant and unreliable we would not place so much emphasis on the symptoms score improvement from 80 to 88 per cent. Mr. Hole rightly points out that even with urodynamic selection of patients deaths will occur. According to the bibliography available to us the mortality rate for prostatectomy is between l and 3 per cent. Our figures suggest that approximately 8 per cent of the non-urodynamically selected prostatic operations are unnecessary. Assuming that the United Kingdom's mortality rate is 1 per cent and 26,000 prostatectomies are done annually this represents 2,080 unnecessary operations and 21 unnecessary deaths in Britain alone' We hold the view that a urologist without urodynamic facilities is like a gastroenterologist without a gastroscope. Reply by Mr. Hole. The authors' figure of "21 unnecessary deaths" is actually the predicted number of deaths of patients who may have had an unnecessary operation. Critics of urologists who do not use urodynamic assessment routinely should note that even if everyone of the 26,000 patients had been assessed by preoperative urodynamic studies, only 12 of the 21 would have been predicted (and so operation and death might have been avoided). RE: PELVIC LYMPHADENECTOMY FOR STAGING PROSTATIC CARCINOMA: IS IT ALWAYS NECESSARY 9
Faud S. Freiha, David A. Pistenma and Malcolm A. Bagshaw J. Urol., 122: 176-177, 1979
To the Editor. Freiha and associates attempted to identify patients with prostatic carcinoma who are at least risk or at greatest risk for the
LETTERS TO THE EDITOR
in the prostatic lobes without general anesthesia (a 20 ml. physiological saline solution containing antibiotics and 20 ml. lidocaine hydrochloride-2.0 ml. 1 per cent lidocaine is injected using a long, fine needle) has the advantages of the direct presence of high active antibiotic concentration at the site of the infection, no limitation of concentration in prostatic fluid of high alkaline pH and no possible inactivation of the antibiotic by metabolism in the body. The discomfort experienced by the patients during direct injection into the prostate is minimal. Our data have revealed that antibiotics enter the prostatic fluid in therapeutic levels after direct injection into the prostate and are curative in 66 to 90 per cent of the cases. We, therefore, recommend this method as treatment of choice in cases of chronic bacterial prostatitis and believe that this therapeutic approach should be considered in a reappraisal of treatment. Respectfully, Luc Baert Mgr Dehaernelaan, 56 8500 Kortrijk (Belgium)
H. and Pyck, J.: Chronic bacterial prostatitis. A new therapeutic approach: local antibiotics. Ann. Urol., 10: 99, 1976. Baert, L.: Bacterial prostatitis treated by local antibiotics. Letter to the Editor. Urology, 8: 644, 1976. L.: Bacterial prostatitis and its present treatment. Ann. H: 275, 1977. Baert, · Direct antibiotic injection clears most prostatitis. Family Practice News, 7: 57, 1977. Plomb, T. A., Baert, L. and Maes, R. A.: Treatment of recurrent chronic bacterial prostatitis by local injection of thiamphenicol, into the prostate and the thiamphenicol concentrations in serum and prostatic fluid. Submitted for publication. Meares, E. M., Jr. and Stamey, T. A.: The diagnosis and management of bacterial prostatitis. Brit. J. Urol., 44: 175, 1972.
1. Baert, L., Soep,
2. 3. 4. 5.
6.
by Authors. Periodically, reports are received about the effiinjection into the prostate in the treatment of prostatitis. the references referred to by Doctor Baert provide a good description of the technique for localization of lower tract infections there are no actual data presented about the results of cultures before and after treatment. Thus, I believe that this technique should be evaluated by the same stringent criteria used to evaluate the response of prostatic infection to treatment with oral or systemically injected antibiotics. We would be most enthused over any agent that gives a 66 to 90 per cent cure rate in the treatment of chronic bacterial prostatitis. However, without more detailed case reports documenting the bacterial counts before, during and after therapy it is impossible to assess of any treatment. It is well recognized that the vast majority of patients presenting to the urologist with symptoms of prostatitis will have these symptoms not on the basis of a bacterial infection. In this regard, the lack of controls in the references cited raises the questions as to whether a placebo injection would have had a significant effect. RE: THE RESULTS OF PROSTATECTOMY: A SYMPTOMATIC AND URODYNAMIC ANALYSIS OF 152 PATIENTS
P.H. Abrams, D. J. Farrar, R. T. Turner- Warwick, C. G. Whiteside and R. C. L. Feneley J. Urol., 121: 640-642, 1979 To the Editor. The authors of this article claim that "The objective results of operation have been improved from 72 to 88 per cent by the inclusion of urodynamic studies in the preoperative assessment of patients". Some errors cast doubt on this and other conclusions. Only 152 patients were followed postoperatively (Results, paragraph 1), yet table 3 on over-all results indicates 157 patients. In table 2 the combined total of Bristol and London patients is 192, yet only 190 patients are mentioned in the Results (paragraph 1). In Results (paragraph 1) it is stated that only 152 (of 190) patients were followed postoperatively because only those with preoperative unstable bladders in the London series were investigated fully. Table 2 shows 92 London patients, of whom 71 per cent are stated to be unstable preoperatively, that is 65 patients. With the 100 Bristol patients this should have been 165 patients (not 152 or 157). The figure of 88 per cent is mentioned only in the Abstract and in Results (paragraph 2-patients who said they were much improved).
This is clearly not an objective but a subjective result. However, it is compared to a series (reported by the first author 1 ) in which 87 cent of the patients undergoing prostatectomy "considered tnE:mi;ei,1es cured or much improved". Admittedly, the symptom scores of some of these patients suggested that they might be deluding themselves, but like must be compared with like, and the present article merely shows that full urodynamic studies have improved the (subjective) success rate of prostatectomy from 87 to 88 per cent. In the final sentence the authors claim that "Without urodynamic studies death may occur in patients who are unobstructed but have symptoms caused by unrecognized bladder hypersensitivity or instability". However, the work shows that even with urodynamic assessment such deaths might still occur. The article purports to show that the use of urodynamic assessment reduces the risk of no improvement after prostatectomy from 28 to 12 per cent. The operative mortality rate for prostatectomy performed in the United Kingdom is around 1 per cent. The risk of death in the operative period for any patient not likely to benefit from prostatectomy is, therefore, apparently reduced from 0.28 to 0.12 per cent. That risk is only removed if urodynamics can demonstrate all those patients who would not benefit from operation and this it certainly cannot do. Respectfully, Roger Hole Department of Urology North Ormesby Hospital Middlesbrough, Cleveland, TS3 6HJ England 1. Abrams, P. H.: Prostatism and prostatectomy: the value of urine
flow rate measurement in the preoperative assessment for operation. J. Urol., H7: 70, 1977.
Reply by Authors. We are grateful to Mr. Hole for pointing out the indefensible lapses in arithmetic and inadequate emphasis on objectiv-ity and subjectivity. We should have stated, "The objective and subjective results of operation ... ". If we might clarify the numerical problems-192 patients were in-vestigated: 100 from Bristol and 92 from London. Of the 65 unstable London patients 13 were not investigated fully postoperatively and, therefore, should have been excluded from the results. However, 5 of these patients who had normal postoperative flow studies were included erroneously in the first group in table 3. We should be unhappy if these valid arithmetic criticisms deflected the readers from the main point of the article, which is the improvement in objective results. In the earlier series 14 per cent of the patients had unimproved postoperative flow rates compared to only 6.5 per cent in the recent series. Since prostatic symptoms are notoriously fluctuant and unreliable we would not place so much emphasis on the symptoms score improvement from 80 to 88 per cent. Mr. Hole rightly points out that even with urodynamic selection of patients deaths will occur. According to the bibliography available to us the mortality rate for prostatectomy is between l and 3 per cent. Our figures suggest that approximately 8 per cent of the non-urodynamically selected prostatic operations are unnecessary. Assuming that the United Kingdom's mortality rate is 1 per cent and 26,000 prostatectomies are done annually this represents 2,080 unnecessary operations and 21 unnecessary deaths in Britain alone' We hold the view that a urologist without urodynamic facilities is like a gastroenterologist without a gastroscope. Reply by Mr. Hole. The authors' figure of "21 unnecessary deaths" is actually the predicted number of deaths of patients who may have had an unnecessary operation. Critics of urologists who do not use urodynamic assessment routinely should note that even if everyone of the 26,000 patients had been assessed by preoperative urodynamic studies, only 12 of the 21 would have been predicted (and so operation and death might have been avoided). RE: PELVIC LYMPHADENECTOMY FOR STAGING PROSTATIC CARCINOMA: IS IT ALWAYS NECESSARY 9
Faud S. Freiha, David A. Pistenma and Malcolm A. Bagshaw J. Urol., 122: 176-177, 1979
To the Editor. Freiha and associates attempted to identify patients with prostatic carcinoma who are at least risk or at greatest risk for the