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Female cystourethritis
EDITORIALS
CADAVER
TRANSPLANTATION
Although renal transplantation is the therapy of choice for end-stage renal failure, it is denied most patients because of an inadequate supply of cadaver kidneys. Furthermore, too many of those kidneys that are transplanted are lost due to immunologic rejection. The graft survival rate is ideal only in HL-A identical siblings. The inadequate supply of cadaver kidneys has not permitted the potential value of HL-A matching in this donor-recipient combination to be realized. Although ALG, which is the most potent immunosuppressive in animals, has not proved to be as beneficial in man. Some of the reasons have to do with the difficulties in its preparation as well as the proper dosage scheduled in man when used in combination with other agents. Hence, cadaver gratis over the last several years have reached a plateau of between 50 and 60 per cent one-year survival rate, which is reasonable but less than ideal. The report by Guttmann et al., “New Developments in Immunosuppression and the Rehabilitation of Patients Following Cadaveric Renal Transplantation,” on page 102, in which they use pulse doses of methylprednisolone with and without cyclophosphamide, showing an 83 per cent one-year graft survival rate and excellent rehabilitation in a series of 38 patients receiving cadaver kidneys is a significant contribution. These results parallel those reljorted by Kountz and Cohn in 1969,’ obtained by using pulse doses of methylprednisolone in combination with actinomycin D in a series of related transplants. Thus, in the ideal risk patient, irrespective of HL-A matching, these authors have shown a significant improvement in graft survival. Since an inadequate supply of cadaver kidneys precludes obtaining a significant number of phenotypically HL-A identical cadaver transplants and problems still remain with the standard preparation of ALG, the use of the authors’ techniques provides an empirical method of improving results of cadaver transplants. Their technique has the advantage of immediate application. The separate value of cyclophosphamide cannot be judged
IIROLOGY
/ FEBRUARY
1973
/ VOLUME
I,NUMBER
2
from this study. Nevertheless, pulse doses of methylprednisolone has been shown by Turcotte et ~1.~and this report to be less toxic, having less side effects than oral doses of prednisone in similar dosage. Samuel L. Kountz, M.D. References 1. KOUNTZ, S. L., and COHN, R.: Initial treatment of renal allograftswith large intrarenal doses of immunosuppressive drugs, Lancet 1: 338 (1969). 2. TURCOTTE, J., et al.: Rejection crises in human renal transplant recipients: Control with high-dose methylprednisolone therapy, Arch. Surg. 105: 230 (1972).
FEMALE
CYSTOURETHRITIS
Elliot Leiter’s article on female cystourethritis appearing in this issue of UROLOGY is a timely addition to the relatively sparse literature on the actual day-to-day management of this common and perplexing problem. Because it is a condition which is not fatal, many of us assume a laissez-faire attitude in its management; however, to the myriads of patients who comprise “the female urologic cripple,” the condition seriously curtails their activities. In our experience this group of 10 per cent of Dr. Leiter’s patients represent about 30 per cent of the total patients that we see. Although axiomatic, it requires stressing that we are now talking about that group of women with resistant urethritis, well-defined by Dr. Leiter, in whom the other known entities have been excluded by appropriate tests, and the urine is free of pyuria and sterile by culture. In the present state of knowledge, infection in the distal urethra probably is initiated by initial colonization of introital bacteria, as stated by Dr. Leiter. An exhaustive review of the genital mycoplasmas by McCormack et cd.’ should be read for its overall background content. Rieser’s well-conceived concept of eliminating the suburethral gland reservoir, successfully
173
applied by Dr. Leiter, is a valid one in our experience, and this search should be incorporated in the treatment regimen. But in our group, this etiologic factor was noted in only a small number of women and unless the glands are visibly infected per se, their distal eradication (the nether ramifications into the bladder neck area cannot be destroyed) did little to relieve the chronic “urologic cripple.” But where found and rendered curative, it is most gratifying, and Rieser and Leiter are to be commended for their contributions. We have found Richardson’s’ external urethroplasty for distal stenosis to be of value where that unyielding tissue can be distinctly demonstrated, otherwise we do not perform the procedure. Again the number of cases in which we see this is small compared to Richardson’s large group, In addition to the bougie calibration, I find that my small pinkie (which calibrates to 34 French at the distal phalanx) is of great aid because it is a live calibration technique. This Nagamatsu pinkie technique is also helpful in determining the presence of actual bladder contracture in the female in which transurethral resection is indicated. Using this added criterion, the cases in this category are far between and contrary to that seen by some observers. By the same token, we have not been impelled to employ internal urethrotomy as applied with success by McLean and Emmett.” Electrofulguration of the granular lesions in the urethra as advocated by Folsom4 as far back as 1931 and by Spence5 has been the most gratifying in the stubborn cases in our experience. Where cystoscopy reveals only a diffuse chronic congestion of the urethra, topical applications of phenol in glycerine solution are useful. This can be used in concentrated solutions of as high as 60 per cent without creating a cicatrix. Caution: do not use silver nitrate. Topical applications of gentian violet solution are helpful especially when urethroscopy reveals the chronic lesions to be concentrated just inside the meatal introit. George
3.
4. 5.
174
M.D.
References The genital mycoplasmas, New England J. Med. 288: 79 (1973). RICHARDSON, F. H.: External urethroplasty in women: technique and clinical evaluation, J. Urol. 101: 719 (1969). MCLEAN, P., and EMMETT, J. L.: Internal urethrotomy in women for recurrent infection and chronic urethritis, ibid. 101: 724 (1969). FOLSOM, A. I.: The female urethra; a clinical and pathologic study, J.A.M.A. 97: 1345 (1931). SPENCE, H. M.: Granular urethritis in women, J. Urol. 43: 199 (1940).
1. MCCORMACK,
2.
R. Nagamatsu,
W.
M., et al.:
MAX LEONARD
ROSENHEIM,
F.R.C.P.
The editors of UROLOGY take note of the death of Max Leonard Rosenheim, emeritus professor of medicine at University College Hospital, London, on December 2, 1972, at the age of sixty-four. In the 1930s while still a student, Lord Rosenheim discovered the value of mandelic acid as a urinary antiseptic. A keen clinician, he appears to have maintained an interest in the kidney throughout his professional life. That his contribution has had far reaching effects on urology cannot be gainsaid. Most commonly used as methenamine mandelate, countless patients have benefited by its therapeutic action. Supplemented by oral ammonium chloride, methionine, ascorbic acid, or Na Hz SO4 urine can be kept below pH 5.5 to 6 to control or even eradicate many infective organisms. The following quote from the extensive obituary published in The Lancet, December 9, 1972, page 1,264, will suffice to give some idea of the high esteem for this remarkable man: The sense of grief and loss at the death of Max Rosenheim is one that will be shared by scores, perhaps by hundreds, of people all round the world, His contribution to research, to academic life, to teaching, and to medicine as a whole was immense, but greatest of all was his contribution of himself as a human being. Adrian Zorgniotti,
M.D.
DIFFUSE PROLIFERATIVE LUPUS NEPHRITIS* Evaluation
of Therapy
Disseminated diffuse proliferative lupus nephritis (DPLN) is usually treated with corticosteroid and/or immunosuppressive drugs, despite the lack of data documenting the efficacy of such therapy. There is need for long-term, controlled evaluation of cytotoxic drugs in diffuse proliferative lupus nephritis as there is in inflammatory diseases in general. l-3 Skinner and Schwartz2 “urge a moratorium on case reports” of drug treatment of systemic lupus erythematosus (SLE) and decry “further publication of poorly designed therapeutic trials, which can only worsen an already bleak situation.” They emphasize the important *From the Departments University lyn, New
of Pediatrics and Medicine, State of New York, Downstate Medical Center, Brook-
York,
UROLOGY
/
FEBRUAHY
1973
/
VOLUhlE
I, NUhlBEH 2
CADAVER
TRANSPLANTATION
Although renal transplantation is the therapy of choice for end-stage renal failure, it is denied most patients because of an inadequate supply of cadaver kidneys. Furthermore, too many of those kidneys that are transplanted are lost due to immunologic rejection. The graft survival rate is ideal only in HL-A identical siblings. The inadequate supply of cadaver kidneys has not permitted the potential value of HL-A matching in this donor-recipient combination to be realized. Although ALG, which is the most potent immunosuppressive in animals, has not proved to be as beneficial in man. Some of the reasons have to do with the difficulties in its preparation as well as the proper dosage scheduled in man when used in combination with other agents. Hence, cadaver gratis over the last several years have reached a plateau of between 50 and 60 per cent one-year survival rate, which is reasonable but less than ideal. The report by Guttmann et al., “New Developments in Immunosuppression and the Rehabilitation of Patients Following Cadaveric Renal Transplantation,” on page 102, in which they use pulse doses of methylprednisolone with and without cyclophosphamide, showing an 83 per cent one-year graft survival rate and excellent rehabilitation in a series of 38 patients receiving cadaver kidneys is a significant contribution. These results parallel those reljorted by Kountz and Cohn in 1969,’ obtained by using pulse doses of methylprednisolone in combination with actinomycin D in a series of related transplants. Thus, in the ideal risk patient, irrespective of HL-A matching, these authors have shown a significant improvement in graft survival. Since an inadequate supply of cadaver kidneys precludes obtaining a significant number of phenotypically HL-A identical cadaver transplants and problems still remain with the standard preparation of ALG, the use of the authors’ techniques provides an empirical method of improving results of cadaver transplants. Their technique has the advantage of immediate application. The separate value of cyclophosphamide cannot be judged
IIROLOGY
/ FEBRUARY
1973
/ VOLUME
I,NUMBER
2
from this study. Nevertheless, pulse doses of methylprednisolone has been shown by Turcotte et ~1.~and this report to be less toxic, having less side effects than oral doses of prednisone in similar dosage. Samuel L. Kountz, M.D. References 1. KOUNTZ, S. L., and COHN, R.: Initial treatment of renal allograftswith large intrarenal doses of immunosuppressive drugs, Lancet 1: 338 (1969). 2. TURCOTTE, J., et al.: Rejection crises in human renal transplant recipients: Control with high-dose methylprednisolone therapy, Arch. Surg. 105: 230 (1972).
FEMALE
CYSTOURETHRITIS
Elliot Leiter’s article on female cystourethritis appearing in this issue of UROLOGY is a timely addition to the relatively sparse literature on the actual day-to-day management of this common and perplexing problem. Because it is a condition which is not fatal, many of us assume a laissez-faire attitude in its management; however, to the myriads of patients who comprise “the female urologic cripple,” the condition seriously curtails their activities. In our experience this group of 10 per cent of Dr. Leiter’s patients represent about 30 per cent of the total patients that we see. Although axiomatic, it requires stressing that we are now talking about that group of women with resistant urethritis, well-defined by Dr. Leiter, in whom the other known entities have been excluded by appropriate tests, and the urine is free of pyuria and sterile by culture. In the present state of knowledge, infection in the distal urethra probably is initiated by initial colonization of introital bacteria, as stated by Dr. Leiter. An exhaustive review of the genital mycoplasmas by McCormack et cd.’ should be read for its overall background content. Rieser’s well-conceived concept of eliminating the suburethral gland reservoir, successfully
173
applied by Dr. Leiter, is a valid one in our experience, and this search should be incorporated in the treatment regimen. But in our group, this etiologic factor was noted in only a small number of women and unless the glands are visibly infected per se, their distal eradication (the nether ramifications into the bladder neck area cannot be destroyed) did little to relieve the chronic “urologic cripple.” But where found and rendered curative, it is most gratifying, and Rieser and Leiter are to be commended for their contributions. We have found Richardson’s’ external urethroplasty for distal stenosis to be of value where that unyielding tissue can be distinctly demonstrated, otherwise we do not perform the procedure. Again the number of cases in which we see this is small compared to Richardson’s large group, In addition to the bougie calibration, I find that my small pinkie (which calibrates to 34 French at the distal phalanx) is of great aid because it is a live calibration technique. This Nagamatsu pinkie technique is also helpful in determining the presence of actual bladder contracture in the female in which transurethral resection is indicated. Using this added criterion, the cases in this category are far between and contrary to that seen by some observers. By the same token, we have not been impelled to employ internal urethrotomy as applied with success by McLean and Emmett.” Electrofulguration of the granular lesions in the urethra as advocated by Folsom4 as far back as 1931 and by Spence5 has been the most gratifying in the stubborn cases in our experience. Where cystoscopy reveals only a diffuse chronic congestion of the urethra, topical applications of phenol in glycerine solution are useful. This can be used in concentrated solutions of as high as 60 per cent without creating a cicatrix. Caution: do not use silver nitrate. Topical applications of gentian violet solution are helpful especially when urethroscopy reveals the chronic lesions to be concentrated just inside the meatal introit. George
3.
4. 5.
174
M.D.
References The genital mycoplasmas, New England J. Med. 288: 79 (1973). RICHARDSON, F. H.: External urethroplasty in women: technique and clinical evaluation, J. Urol. 101: 719 (1969). MCLEAN, P., and EMMETT, J. L.: Internal urethrotomy in women for recurrent infection and chronic urethritis, ibid. 101: 724 (1969). FOLSOM, A. I.: The female urethra; a clinical and pathologic study, J.A.M.A. 97: 1345 (1931). SPENCE, H. M.: Granular urethritis in women, J. Urol. 43: 199 (1940).
1. MCCORMACK,
2.
R. Nagamatsu,
W.
M., et al.:
MAX LEONARD
ROSENHEIM,
F.R.C.P.
The editors of UROLOGY take note of the death of Max Leonard Rosenheim, emeritus professor of medicine at University College Hospital, London, on December 2, 1972, at the age of sixty-four. In the 1930s while still a student, Lord Rosenheim discovered the value of mandelic acid as a urinary antiseptic. A keen clinician, he appears to have maintained an interest in the kidney throughout his professional life. That his contribution has had far reaching effects on urology cannot be gainsaid. Most commonly used as methenamine mandelate, countless patients have benefited by its therapeutic action. Supplemented by oral ammonium chloride, methionine, ascorbic acid, or Na Hz SO4 urine can be kept below pH 5.5 to 6 to control or even eradicate many infective organisms. The following quote from the extensive obituary published in The Lancet, December 9, 1972, page 1,264, will suffice to give some idea of the high esteem for this remarkable man: The sense of grief and loss at the death of Max Rosenheim is one that will be shared by scores, perhaps by hundreds, of people all round the world, His contribution to research, to academic life, to teaching, and to medicine as a whole was immense, but greatest of all was his contribution of himself as a human being. Adrian Zorgniotti,
M.D.
DIFFUSE PROLIFERATIVE LUPUS NEPHRITIS* Evaluation
of Therapy
Disseminated diffuse proliferative lupus nephritis (DPLN) is usually treated with corticosteroid and/or immunosuppressive drugs, despite the lack of data documenting the efficacy of such therapy. There is need for long-term, controlled evaluation of cytotoxic drugs in diffuse proliferative lupus nephritis as there is in inflammatory diseases in general. l-3 Skinner and Schwartz2 “urge a moratorium on case reports” of drug treatment of systemic lupus erythematosus (SLE) and decry “further publication of poorly designed therapeutic trials, which can only worsen an already bleak situation.” They emphasize the important *From the Departments University lyn, New
of Pediatrics and Medicine, State of New York, Downstate Medical Center, Brook-
York,
UROLOGY
/
FEBRUAHY
1973
/
VOLUhlE
I, NUhlBEH 2