Intermittent Testicular Torsion: An Underdiagnosed Entity?

Intermittent Testicular Torsion: An Underdiagnosed Entity?

386 LETTERS TO THE EDITOR is 2 cm. compared to 4 cm. or longer. Again, I believed that my abilities to obtain good cosmetic results were benefited b...

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386

LETTERS TO THE EDITOR

is 2 cm. compared to 4 cm. or longer. Again, I believed that my abilities to obtain good cosmetic results were benefited by swinging the flap in this manner. The breadth of the pedicle to the flap is essentially the length of the flap. As described by Doctor De Sy the breadth of the pedicle used for his flap appears to be the same as the width of the flap itself. I have used the procedure in 10 patients and have received 2 letters from urological associates who have applied the procedure with good results. I certainly do not question the good results reported by Doctor De Sy. It is the application of his procedure in my hands with which I was unhappy. Doctor De Sy indicates that he is able to perform the procedure without diversion. He seems to attribute this ability on the basis of the donor site of the flap. This is a concept with which I am not familiar. In my recollection the need for diversion is determined by disruption of the integrity of the urethra and not by the donor site of the tissue transfer to the urethra. I believe that the disruption of the urethra in both procedures is identical. If Doctor De Sy is doing the procedure without diversion then it would appear that perhaps I am being overly conservative by performing diversion in my patients. Nonetheless, I continue to use a suprapubic catheter if the procedure is performed with coexisting more proximal stricture disease or I use a splint. The bottom line, however, is that both Doctor De Sy and I report good results. It appears that we have arrived at a fortunate place in fossa reconstruction in that there are at least 2 procedures that provide good functional and cosmetic results. RE: PAPAVERINE-INDUCED PRIAPISM: 2 CASE REPORTS

D. S. Halsted, J. W. Weigel, M. J. Noble and W. K. Mebust J. Urol., 136: 109-110, 1986

To the Editor. lntracavernous injection of various vasoactive drugs is a new and promising method to investigate and treat erectile failure, even though the diagnostic meaning, nevertheless, is questioned.' However, the efficiency of intracavernous injection is counteracted by an unquestionable morbidity rate. 1 - 3 The risks for immediate complications are genuine. General complications include arterial hypotension subsequent to the vasodilator effects of the injected drugs, and local complications include fibrosis and mainly priapism. Since 1984, our experience as well as a review of the literature and a personal investigation close to French-speaking urologists revealed the reality of this type of iatrogenic priapism, with 213 cases, although our investigation was incomplete and this method still was new and not widely diffused. The occurrence of injection-induced priapism sometimes is unpredictable. No relationship has been established to date between priapism and type or dosage of the drug injected, or even the date of injection.2 However, patients with neurological and psychogenic impotence seem to constitute a higher risk group for prolonged erection and priapism. The injection of small doses of vasoactive drugs can minimize this effect.' This type of pharmacological priapism also is difficult to treat. Decompressive cavernous puncture may be sufficient. Intracavernous injection of vasoconstrictive drugs often (mainly for priapism of the nonischemic type) but not always is effective. It may even be dangerous because of the risks of severe arterial hypertension and of cavernous necrosis.' Finally, the long-term effects of this method still remain unknown but cavernous fibrosis has begun to be reported in patients treated by auto-injection.2 Such problems should be remembered and we agree with the authors that intracavernous injection must be restricted to physicians who are familiar with the management of impotence and priapism until the precise indications for and risks of this promising but still experimental method are clarified. Respectfully, P. Bondi[ and J. L. Nguyen Qui 282 Bd Foch Salon de Provence 13300 France 1. Bondi!, P., Doremieux, J. and Nguyen Qui, J. L.: Les injections intracaverneuses de drogues vasoactives: contribution a l'etude de leur valeur dans l'impuissance erectile. J. d'Urol., 93: 361, 1987. 2. Bondi!, P. and Rigot, J. M.: Complications du traitement de l'impuissance par injection intracaverneuse de drogues vaso-actives. Contracept.-Fertil.-Sexual., 14: 349, 1986.

3. Virag, R.: About pharmacologically induced prolonged erection. Letter to the Editor. Lancet, 2: 519, 1985.

Reply by Authors. Doctors Bondi! and Nguyen Qui accurately note the difficulty of predicting response to intracavernous papaverine, especially in nonvasculogenic impotence. However, this form of therapy can no longer be considered experimental and, when indicated, it should be offered to the patient. Finally, intracavernous papaverine therapy, along with other medical and surgical treatment options, should be restricted to urologists whose training and experience allow timely and efficacious treatment of possible complications. MERLE'S CO-DENOMINATION FOR THE TECHNIQUES OF PENILE PLICATION FOR THE CORRECTION OF PEYRONIE'S DISEASE: A WELL DESERVED HOMAGE

To the Editor. In a recent review based on the literature concerning Peyronie's disease it was noted that the suggested techniques of surgecy were relatively new. 1 Among these procedures are those involving plication of the tunica albuginea with or without its excision, which is a simplified technique that provides good results.'·' However, in 1899 Merle first performed contralateral plication of the penile curvature to minimize the bend caused by Peyronie's disease.' Therefore, we find it only fair to pay homage to this author, who during the last century proposed this original surgical technique, which can be considered modern although historical, for the treatment of Peyronie's disease. We believe that Merle should be considered the father of the technique of plication of the penile axis. Respectfully, Helio Begliomini and Claudio Francisco Atilio Gorga Urological Service Hospital do Servidor Publico do Estado de Sao Paulo Sao Paulo, Brazil 1. Begliomini, H. and Gorga, C. F. A.: Doen~a de Peyronie. Uma

revisiio objectiva. In press. 2. Borrelli, M., Bruschini, H., Prado, M. J., Alaor de Figueiredo, J., Lucon, A. M. and Menezes de Goes, G.: Surgical correction of Peyronie's disease using Nesbit's technique-an excellent way to reconstruct erectile potency. World J. Urol., 1: 257, 1983. 3. Nesbit, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation. J. Urol., 93: 230, 1965. 4. Merle, M. M.: Contribution a l'etude de l'induration des corps caverneux. These, Toulouse, 1899, 320. Cited by Jolidon, C., Zephir, D. and Ybert, G.: Considerations historiques sur la maladie de La Peyronie ... Peu de choses ont change! J. d'Urol., 90: 365, 1984. INTERMITTENT TESTICULAR TORSION: AN UNDERDIAGNOSED ENTITY?

To the Editor. While reviewing my experience with acute scrotal lesions during a 3-year period I was impressed by the high incidence of intermittent or nonacute testicular torsion. During this interval I encountered 8 patients with this condition, all of whom had been referred electively for the evaluation of testicular pain. Patient age ranged from 13 to 28 years. The symptoms had been present for up to 3 years and the patients had had 1 to several prior acute episodes. The acute symptoms ranged from severe and debilitating to mild and shortlived. The episodes usually resolved spontaneously (1 patient described vividly having to manipulate the testicle to relieve the pain). Two patients had been treated elsewhere for epididymitis. Two patients had significant testicular atrophy and 6 had either a transverse lie or a hypermobile testicle. All 8 patients had a bell clapper deformity at operation. Bilateral orchiopexy relieved the symptoms. During the same period I treated 19 cases of acute testicular torsion, for a ratio of intermittent to acute torsion of 1:2.4. Therefore, intermittent testicular torsion would appear to be more common than generally is appreciated. Although the finding of a transverse lie of the testicle or a hypermobile testicle is helpful, a history of recurrent testicular pain associated with or without physical activity and that

387

LETTERS TO TH~E EDITOR resolved spontaneously is sufficient evidence to warrant exploration, which is the only safe and certain method to establish the diagnosis.

Total Gleason Score

Respectfully, Jonathan S. Vordermark, II Urology Service Department of Surgery Letterman Army Medical Center Presidio of San Francisco, California 94129-6700

2 3 4

RE: TESTICULAR TORSION IN A 62-YEAR-OLD MAN

5 6 7

H. J. Alfert and D. A. Canning

9

8

J. Ural., 138: 149-150, 1987 To the Editor. I agree with the authors that the age distribution in patients with testicular torsion has a biphasic pattern with peaks in the first year of life (when mainly extravaginal torsion occurs) and early adolescence (when exclusively intravaginal torsion is encountered).1 I also agree that torsion of the testis in adults more than 21 years old is not so uncommon. In our previous study 22.7 per cent of the patients with this acute scrotal condition were older than 21 years and of them 20 per cent were more than 30 years old, including a 62year-old patient.' However, I would not claim that this is the second oldest reported patient with this condition, since others have reported patients 69 and even up to 78 years old. 3 - 5 Nevertheless, I agree completely with the recommendation that torsion of the testis should be considered in patients of all ages with an acute scrotum. Respectfully, Michael D. Melekos Department of Urology University of Patras School of Medicine Rio - Patras, Greece 1. Melekos, M. D., Asbach, H. W. and Markou, S. A.: Etiology of acute

2. 3. 4. 5.

scrotum in children with special regard to age distribution. J. Urol., 139: 1023, 1988. Melekos, M., Patsalas, J., Christoforidis, P., Melekos, J. andAsbach, H. W.: Torsion of the testis in the adult. Hellenic Armed Forces Med. Rev., 18: 107, 1984. O'Conor, V. J.: Torsion of the spermatic cord and torsion of the hydatid testis. Med. Clin. N. Amer., 43: 1731, 1959. Allan, W. R. and Brown, R. B.: Torsion of the testis: a review of 58 cases. Brit. Med. J., l: 1396, 1966. Skoglund, R. W., McRoberts, J. W. and Ragde, H.: Torsion of the spermatic cord: a review of the literature and an analysis of 70 new cases. J. Urol., 104: 604, 1970.

Reply by Authors. We are gratified that Doctor Melekos agrees with the major premise of our article, that is that testicular torsion is not uncommon in the older population. Our case was intended less as a urological oddity than as illustrative of that point. The criticism that our case did not represent the second oldest reported patient with torsion is noted. The studies cited by Doctor Melekos (references 3 and 5 in Letter) refer to the same 78-year-old patient, which still represents the oldest case in the literature. We had overlooked the study by Allan and Brown (reference 4 in Letter), who reported on a 69-yea:r-old man with surgically confirmed torsion. Thus, to be precise, our patient would be the third oldest with this condition. FORMULA TO ESTIMATE RISK OF PELVIC LYMPH NODE METASTASIS FROM THE TOTAL GLEASON SCORE FOR PROSTATE CANCER

To the Editor. It is well recognized that the Gleason histological pattern score of adenocarcinoma of the prostate has prognostic value. 1 The Gleason score also correlates with the incidence of pelvic node metastasis. 2 -• We devised a simple equation that will provide a close estimation of the risk of pelvic lymph node metastasis once the total Gleason score (2 to 10) is known. This equation is: (total Gleason score - 4) X 15 = per cent risk of pelvic lymph node metastasis. The risk of pelvic lymph node metastasis derived from this equation versus the observed incidence of pelvic lymph node metastasis for the different total Gleason scores is shown in the table. We believe that

10

Risk of Pelvic Lymph Node Metastasis Derived From Equation

Observed*

0 0 0 15 30 45 60 75 90

0 0 0 7-13 17-27 39-45 60-76 71-89 88-100

* Range of values derived from Bagshaw, M. A.: Int. J. Rad. Oneal. Biol. Phys., 12: 1721, 1986.

the equation is easy to use by clinicians who evaluate patients with prostatic carcinoma.

1.

2.

3. 4.

Respectfully, Shiao Woo, Irving Kaplan, Mack Roach and Malcolm Bagshaw Stanford University Medical Center 300 Pa,steur Drive Stanford, California 94305 Gleason, D. F.: Histologic grading and clinical staging of prostatic carcinoma. In: Urologic Pathology: The Prostate. Edited by M. Tannenbaum. Philadelphia: Lea & Febiger, part II, chapt. 9, pp. 171-198, 1977. Pistenma, D. A., Bagshaw, M.A. and Freiha, F. S.: Extended-field radiation therapy for prostatic adenocarcinoma: status report of a limited prospective trial. In: Cancer of the Genitourinary Tract. Edited by D. E. Johnson and M. L. Samuels. New York: Raven Press, pp. 229-247, 1979. Paulson, D. F. and Ura-Oncology Research Group: The impact of current staging procedures in assessing disease extent of prostatic adenocarcinoma. J. Urol., 121: 300, 1979. Kramer, S. A., Spahr, J., Brendler, C. B., Glenn, J. F. and Paulson, D. F.: Experience with Gleason's histopathologic grading in prostatic cancer. J. Urol., 124: 223, 1980.

RE: BENIGN PROSTATIC HYPERPLASIA AND UTERINE LEIOMYOMAS IN A FEMALE PSEUDOHERMAPHRODITE: A CASE REPORT

C. F. Heyns, P. D. Rimington, T. F. Kruger and V. G. Falck J. Ural., 137: 1245-1247, 1987

To the Editor. I read this article with interest. Unfortunately, I disagree with the diagnosis of the patient. The authors refer to their patient as a female pseudohermaphrodite with congenital adrenal hyperplasia. Based on the data presented by the authors, this patient most likely has true hermaphroditism, since the karyotype is 46XX, and the testosterone and serum cortisol levels are normal. The finding of testicular tissue in the presence of an ovary is the sine qua non diagnosis of true hermaphroditism. Therefore, their conclusion that adrenal androgens are sufficiently high enough to stimulate the prostate gland is not warranted. Respectfully, Jacob Rajfer Division of Urology Harbor/UCLA Medical Center 1000 West Carson Street Torrance, California 90509

Reply by Authors. The serum 17-hydroxyprogesterone level in our patient was almost 10 times higher than the upper limit of normal. There is no apparent reason why the serum level of this precursor should be so high if the patient were a true hermaphrodite. The finding of a normal serum cortisol does not exclude the possibility of congenital adrenal hyperplasia, since increased secretion of adrenocorticotropic hormone may induce complete compensation for the defect in the secretion of hydrocortisone. 1 Meticulous histological study of the gonads of our patient failed to reveal structures even remotely resembling seminiferous tubules. If one