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Androgen receptors in TCC
LETTERS URETHRAL
TO THE EDITOR DIVERTICULUM
IN FEMALES
To the Editor: This letter is in response to comments made by Dr. Gary E. Leach (UROLOGY 29:350, March, 1987) and Dr. Alan Wein (UROLOGY 29:463, April, 1987) regarding the article, “Role of Urodynamics in the Management of Urethral Diverticulum in Females,” which was published in the October issue (vol. 28, pages 342-346,1986), of UROLOGY. The fact that two letters have been written about this article suggests to me the need for clarification and hopefully, this response will accomplish this. 1. Urethral profilometry was never intended to be the sole or determining criteria as to whether a urethropexy should be done jointly with the urethral diverticulectomy. A complete preoperative urodynamic examination, including dynamic cystography under stress was done on every patient and the standard anatomic changes of stress urinary incontinence were sought. If these were found, the patient was considered to be at risk for incontinence developing and was, therefore, already considered for a combined urethropexy-diverticulectomy. The intraoperative profilometry was used as an additional test for determining the need for urethropexy, as well as for monitoring the urethropexy. 2. Profilometry studies were done after the induction of anesthesia and repeated after the diverticulectomy, the comparison was between pre- and post-diverticulectomy measurements under the same anesthetic, obviating any artifactual changes introduced by the anesthetic. We have studied the effect of anesthesia on profilometry measurements in 80 female patients. What has precluded publishing this work is the fact that our patients are given multiple agents during anesthesia. However, in general what we have seen is that anesthesia lowers closure pressure and elongates the urethra. 3. Regarding the risk of infection, it is our practice to treat all patients undergoing urethral diverticulectomy with digital evacuation and antibiotics for a period of one week prior to the surgical procedure. Additional precautions consist of povidoneiodine douches the night before surgery and antibiotic coverage is given preoperatively, during, and after surgery as well. Infection has not proved to be a factor in 23 diverticulectomies or 45 Stamey urethropexies which we have done, neither procedure being considered “truly sterile.” Regarding the comment about doing the urethropexy before the diverticulectomy, in my view, this would not likely eliminate the risk of infection but just make the surgical procedure more difficult. 4. All urethral profilometry studies are done with an empty bladder, and detrusor contractions in this
674
setting under anesthesia have not proved to be a problem. 5. The purpose of the urethral profilometry measurements is not to compare normal females to stress-incontinent females (we are aware of the fact that this has not proved fruitful), but simply to compare the pre- and postoperative profilometry measurements in the same patient undergoing diverticulectomy. The patient acts as her own control. 6. I disagree that incontinence after diverticulectomy is due solely to urethrovaginal fistula. I have seen both conditions (fistula and stress incontinence) after diverticulectomy in about equal numbers. In my opinion, profilometry measurements as an adjunct to urodynamic tests has helped us to determine which patients undergoing urethral diverticulectomy will also need urethropexy. Roberto E. Reid, M.D. Albert Einstein College of Medicine Bronx, New York 10461
ANDROGEN
RECEPTORS
IN TCC
To the Editor: With reference to “Sex Hormone Receptors in Localized and Advanced Transitional Cell Carcinoma of Urinary Tract in Humans,” by R. E X. Noronha and B. R. Rao in the November issue (vol. 28, pages 401-403, 1986) of UROLOGY, I would like to add our experience.’ After the published work of Laor et a1.,2 we set up a trial to measure androgen receptor content of various TCC tissues in Glasgow, Scotland. We used a saturation analysis method using mibolerone as ligand. Ten patients had T, tumor, 1 had T, tumor, and 5 had T, tumor. Twelve specimens were taken by TUR, and open resection was used in 4 patients. Significant androgen receptors could not be detected in either the soluble or the nuclear fraction of any of the 13 bladder tumors and 3 ureteric tumors. Although method of specimen collection (involvement of electroresection), storage and technical problems of receptor assays may be the cause of these conflicting results, our data suggest that human TCC appears unlikely to be hormone-dependent. Ziya Kirkali, M.D. Ankara 06660, Turkey References 1. Kirkali Z, Cowan S, and Leake RE: Androgen receptors in transitional cell carcinoma, Urol Res 14: 160 (1986). 2. Laor E, et al: Androgen receptors in bladder tumors, Urology 25: 161 (1985).
UROLOGY
/ JUNE 1987
I VOLUME XXIX, NUMBER 6
TO THE EDITOR DIVERTICULUM
IN FEMALES
To the Editor: This letter is in response to comments made by Dr. Gary E. Leach (UROLOGY 29:350, March, 1987) and Dr. Alan Wein (UROLOGY 29:463, April, 1987) regarding the article, “Role of Urodynamics in the Management of Urethral Diverticulum in Females,” which was published in the October issue (vol. 28, pages 342-346,1986), of UROLOGY. The fact that two letters have been written about this article suggests to me the need for clarification and hopefully, this response will accomplish this. 1. Urethral profilometry was never intended to be the sole or determining criteria as to whether a urethropexy should be done jointly with the urethral diverticulectomy. A complete preoperative urodynamic examination, including dynamic cystography under stress was done on every patient and the standard anatomic changes of stress urinary incontinence were sought. If these were found, the patient was considered to be at risk for incontinence developing and was, therefore, already considered for a combined urethropexy-diverticulectomy. The intraoperative profilometry was used as an additional test for determining the need for urethropexy, as well as for monitoring the urethropexy. 2. Profilometry studies were done after the induction of anesthesia and repeated after the diverticulectomy, the comparison was between pre- and post-diverticulectomy measurements under the same anesthetic, obviating any artifactual changes introduced by the anesthetic. We have studied the effect of anesthesia on profilometry measurements in 80 female patients. What has precluded publishing this work is the fact that our patients are given multiple agents during anesthesia. However, in general what we have seen is that anesthesia lowers closure pressure and elongates the urethra. 3. Regarding the risk of infection, it is our practice to treat all patients undergoing urethral diverticulectomy with digital evacuation and antibiotics for a period of one week prior to the surgical procedure. Additional precautions consist of povidoneiodine douches the night before surgery and antibiotic coverage is given preoperatively, during, and after surgery as well. Infection has not proved to be a factor in 23 diverticulectomies or 45 Stamey urethropexies which we have done, neither procedure being considered “truly sterile.” Regarding the comment about doing the urethropexy before the diverticulectomy, in my view, this would not likely eliminate the risk of infection but just make the surgical procedure more difficult. 4. All urethral profilometry studies are done with an empty bladder, and detrusor contractions in this
674
setting under anesthesia have not proved to be a problem. 5. The purpose of the urethral profilometry measurements is not to compare normal females to stress-incontinent females (we are aware of the fact that this has not proved fruitful), but simply to compare the pre- and postoperative profilometry measurements in the same patient undergoing diverticulectomy. The patient acts as her own control. 6. I disagree that incontinence after diverticulectomy is due solely to urethrovaginal fistula. I have seen both conditions (fistula and stress incontinence) after diverticulectomy in about equal numbers. In my opinion, profilometry measurements as an adjunct to urodynamic tests has helped us to determine which patients undergoing urethral diverticulectomy will also need urethropexy. Roberto E. Reid, M.D. Albert Einstein College of Medicine Bronx, New York 10461
ANDROGEN
RECEPTORS
IN TCC
To the Editor: With reference to “Sex Hormone Receptors in Localized and Advanced Transitional Cell Carcinoma of Urinary Tract in Humans,” by R. E X. Noronha and B. R. Rao in the November issue (vol. 28, pages 401-403, 1986) of UROLOGY, I would like to add our experience.’ After the published work of Laor et a1.,2 we set up a trial to measure androgen receptor content of various TCC tissues in Glasgow, Scotland. We used a saturation analysis method using mibolerone as ligand. Ten patients had T, tumor, 1 had T, tumor, and 5 had T, tumor. Twelve specimens were taken by TUR, and open resection was used in 4 patients. Significant androgen receptors could not be detected in either the soluble or the nuclear fraction of any of the 13 bladder tumors and 3 ureteric tumors. Although method of specimen collection (involvement of electroresection), storage and technical problems of receptor assays may be the cause of these conflicting results, our data suggest that human TCC appears unlikely to be hormone-dependent. Ziya Kirkali, M.D. Ankara 06660, Turkey References 1. Kirkali Z, Cowan S, and Leake RE: Androgen receptors in transitional cell carcinoma, Urol Res 14: 160 (1986). 2. Laor E, et al: Androgen receptors in bladder tumors, Urology 25: 161 (1985).
UROLOGY
/ JUNE 1987
I VOLUME XXIX, NUMBER 6