- Email: [email protected]
Note by Editor
316
LETTERS TO THE EDITOR
Reply by Author. I read this letter with interest but believe that Doctor Wishahi misses the point in children, a group to which our study was directed. Indeed, excising a distal ureteral obstruction may correct hydronephrosis but in the small pediatric bladder some form of tapering is mandatory to achieve the desired ratio of 5:1 tunnel length to ureteral width to obviate reflux. He also should note that, as stated in our article, tapering was not done with any ureter when a 5:1 ratio could be achieved without a plication procedure. Moreover, 31 of 74 ureters studied were not obstructed at all but only had reflux, which was corrected by the folding technique. Doctor Wishahi does not tell us how many of his 60 patients have postoperative reflux, which in adults may not portend as badly as in children. In any event, I am heartened that, at the least, the folding procedure used in his 20 patients in Egypt was reproducible and successful even at such a distance. SELF-ADHESIVE WRAP
To the Editor. A principal problem associated with the wear of condom catheters is leakage of urine along the penile shaft between the skin and the catheter. This leakage often leads to a decrease in adherence of adhesives and loosening or loss of the catheter. We have adopted a technique in selected patients to prevent this occurrence. The patient is instructed to place the condom catheter in the usual manner. A short (8 to 10 inches) segment of elastic, self-adhesive wrap* then is applied proximal to the glans penis along the proximal portion of the condom catheter. Although snug, overly tight application is avoided. It is suggested that the condom catheter be left unchanged for no longer than 12 to 18 hours. This self-adhesive wrap has been used by our service as a postoperative penile dressing for a number of years. Recently, we have used it as an inexpensive adjunct to prolong the usefulness of condom catheters and to improve the patient's sense of security. Although the wrap has the appearance of tape, it has no adhesive and adheres to itself through friction created by its rugated texture. We have encountered no complications from this adjunct and patients have found that it almost completely eliminates the embarrassing accidents of sudden condom dislodgement. Respectfully, Ian M. Thompson Urology Service Brooke Army Medical Center Fort Sam Houston, Texas 78234 * Caban, Medical Products Division/3M, St. Paul, Minnesota.
the penis of young, potent men, anatomical studies of the cadaver penis or microscopical investigations. The authors' interpretations of their findings differ somewhat from mine. The emissary veins of the corpora cavernosa emerge normally only ventrally, in the distal end of the corpora. The emissary veins shown in figure 3 of this study are pathological (increased drainage). In addition, the presence of circumflex veins at the base of the penis indicates venous insufficiency of the corpora cavernosa. Finally, the presence of deep penile veins, which normally are insignificant, demonstrates venous insufficiency of the corpora; the enlargement of these abnormal veins parallels the degree of insufficiency. The authors state that "According to Fitzpatrick and associates, 9 and Velcek and Evansu the cavernous bodies always drain via the venae profundae penis". I believe that they drain in the presence of venous insufficiency. I have described venous insufficiency in patients with chordee. 3 Opacification of the glans during cavernosography occurs not only through retrograde flow via the deep dorsal vein but mainly through direct ventral communications between the corpora cavernosa and corpus spongiosum urethrae. This phenomenon occurs only in patients with venous insufficiency of the corpora cavernosa and, therefore, it is not physiological. There are no direct physiological or pathological shunts between the corpora and glans. There are only iatrogenic shunts after the treatment of priapism with the method of Winter. During a recent meeting a complete afternoon was dedicated to the discussion of the 'leakage factor' of the corpus cavernosum. 4 This lesion, which is caused mainly by wear and tear of the albuginea of the corpora, is in my opinion, after more than 1,500 operations for organic impotence, the most frequent cause of erectile dysfunction in aged men. Respectfully, Th. Tudoriu Clinic Medicia 5483 Bad Neuenahr West Germany 1. Hasche-Khinder, R., Bourmer, H., Tudoriu, Th. and Falge, P.: Impotentia coeun9.i - Aktueller Stand der chirurgischen Behandlung. Deutsches Arzteblatt, 75, 37: 2037-2044, 1978. 2. Tudoriu, Th.: Impotenz. Eine Verschlei/3erscheinung. Med. Tribune, 27.02: 84, 1981. 3. Tudoriu, Th. and Bourmer, H.: The hemodynamics of erection at the level of the penis and its local deterioration. J. Ural., 129: 741, 1983. 4. Third International Meeting on Corpus Cavernosum Revascularization. Copenhagen, August 1982. (Drs. J. Ebbehoj and G. Wagner). Note by Editor. This Letter to the Editor was submitted to the authors of the article for reply. In response, they have submitted another manuscript for our consideration. That manuscript currently is under review.
RE: DYNAMIC CAVERNOSOGRAPHY: VENOUS OUTFLOW STUDIES OF CAVERNOUS BODIES
H. Porst, J. E. Altwein, D. Bach and W. Thon
RE: FAILURE OF THE JONAS PROSTHESIS
J. Ural., 134: 276-279, 1985
E. A. Tawil and J. G. Gregory
To the Editor. I was pleased to read this article on venous drainage of the corpora cavernosa. It is important that the studies were done in vivo with cavernosography and artificial erection to allow for more precise details, since the exact anatomical position of venous drainage of the penis and the need for a blockage mechanism to induce an erection are moot, according to these investigators. The authors report some interesting findings. They indicate that the flow rates to induce an artificial erection show considerable individual differences: the flow rates range from 55 to 160 ml. per minute to obtain and from 12 to 90 ml. per minute to maintain an erection. They found that "in 2 patients with erectile dysfunction penile rigidity was not achieved despite the high flow rates (more than 180 ml. per minute) and, thus, venous insufficiency was diagnosed". I agree with the statement that recent studies have shown more erectile disorders than expected to be attributable to an excessive outflow of venous blood. 1- 3 I described the leakage factor in 1975 but not in the English literature. Because none of my articles is cited in the present work I wish to discuss some of the authors' statements. The authors studied 15 patients between 14 and 72 years old. Ten patients had organic diseases and 5 had erectile dysfunction. Unfortunately neither the age nor the clinical aspect of the penis is cited for these 15 patients. The authors do not include a parallel comparison of
J. Ural., 135: 702-703, 1986
To the Editor. I read this article with interest. Of the total 27 patients 7 had fractured wires confirmed operatively. The Mayo Clinic group presented a larger series in July 1984 with only 2 patients with wire fractures. Numerous other surgeons have reported their experience with the Jonas prosthesis, which has had a higher percentage of success than any of the other prostheses used to date. Our experience with almost 70 implantations has dictated removal of 1 prosthesis owing to extrusion and infection, which in our opinion was a technical error. However, we are aware of no fractured wires to date. Patients with a Jonas implant tend to be lost to followup because they do not particularly have problems after the pain in the immediate postoperative period. In summary, with the high fracture rate in this article I question whether there is a difference in the authors' surgical technique for implantation of the device compared to most of the surgeons in the United States as well as in the world. Construction of the Jonas prosthesis has changed since July 1984. Each individual wire now is coated with polytetrafluoroethylene (Teflon) to prevent this rare but bothersome problem. I do have high hopes that the new self-contained inflatable devices as well as the new Omniphase prosthesis will have
LETTERS TO THE EDITOR
Reply by Author. I read this letter with interest but believe that Doctor Wishahi misses the point in children, a group to which our study was directed. Indeed, excising a distal ureteral obstruction may correct hydronephrosis but in the small pediatric bladder some form of tapering is mandatory to achieve the desired ratio of 5:1 tunnel length to ureteral width to obviate reflux. He also should note that, as stated in our article, tapering was not done with any ureter when a 5:1 ratio could be achieved without a plication procedure. Moreover, 31 of 74 ureters studied were not obstructed at all but only had reflux, which was corrected by the folding technique. Doctor Wishahi does not tell us how many of his 60 patients have postoperative reflux, which in adults may not portend as badly as in children. In any event, I am heartened that, at the least, the folding procedure used in his 20 patients in Egypt was reproducible and successful even at such a distance. SELF-ADHESIVE WRAP
To the Editor. A principal problem associated with the wear of condom catheters is leakage of urine along the penile shaft between the skin and the catheter. This leakage often leads to a decrease in adherence of adhesives and loosening or loss of the catheter. We have adopted a technique in selected patients to prevent this occurrence. The patient is instructed to place the condom catheter in the usual manner. A short (8 to 10 inches) segment of elastic, self-adhesive wrap* then is applied proximal to the glans penis along the proximal portion of the condom catheter. Although snug, overly tight application is avoided. It is suggested that the condom catheter be left unchanged for no longer than 12 to 18 hours. This self-adhesive wrap has been used by our service as a postoperative penile dressing for a number of years. Recently, we have used it as an inexpensive adjunct to prolong the usefulness of condom catheters and to improve the patient's sense of security. Although the wrap has the appearance of tape, it has no adhesive and adheres to itself through friction created by its rugated texture. We have encountered no complications from this adjunct and patients have found that it almost completely eliminates the embarrassing accidents of sudden condom dislodgement. Respectfully, Ian M. Thompson Urology Service Brooke Army Medical Center Fort Sam Houston, Texas 78234 * Caban, Medical Products Division/3M, St. Paul, Minnesota.
the penis of young, potent men, anatomical studies of the cadaver penis or microscopical investigations. The authors' interpretations of their findings differ somewhat from mine. The emissary veins of the corpora cavernosa emerge normally only ventrally, in the distal end of the corpora. The emissary veins shown in figure 3 of this study are pathological (increased drainage). In addition, the presence of circumflex veins at the base of the penis indicates venous insufficiency of the corpora cavernosa. Finally, the presence of deep penile veins, which normally are insignificant, demonstrates venous insufficiency of the corpora; the enlargement of these abnormal veins parallels the degree of insufficiency. The authors state that "According to Fitzpatrick and associates, 9 and Velcek and Evansu the cavernous bodies always drain via the venae profundae penis". I believe that they drain in the presence of venous insufficiency. I have described venous insufficiency in patients with chordee. 3 Opacification of the glans during cavernosography occurs not only through retrograde flow via the deep dorsal vein but mainly through direct ventral communications between the corpora cavernosa and corpus spongiosum urethrae. This phenomenon occurs only in patients with venous insufficiency of the corpora cavernosa and, therefore, it is not physiological. There are no direct physiological or pathological shunts between the corpora and glans. There are only iatrogenic shunts after the treatment of priapism with the method of Winter. During a recent meeting a complete afternoon was dedicated to the discussion of the 'leakage factor' of the corpus cavernosum. 4 This lesion, which is caused mainly by wear and tear of the albuginea of the corpora, is in my opinion, after more than 1,500 operations for organic impotence, the most frequent cause of erectile dysfunction in aged men. Respectfully, Th. Tudoriu Clinic Medicia 5483 Bad Neuenahr West Germany 1. Hasche-Khinder, R., Bourmer, H., Tudoriu, Th. and Falge, P.: Impotentia coeun9.i - Aktueller Stand der chirurgischen Behandlung. Deutsches Arzteblatt, 75, 37: 2037-2044, 1978. 2. Tudoriu, Th.: Impotenz. Eine Verschlei/3erscheinung. Med. Tribune, 27.02: 84, 1981. 3. Tudoriu, Th. and Bourmer, H.: The hemodynamics of erection at the level of the penis and its local deterioration. J. Ural., 129: 741, 1983. 4. Third International Meeting on Corpus Cavernosum Revascularization. Copenhagen, August 1982. (Drs. J. Ebbehoj and G. Wagner). Note by Editor. This Letter to the Editor was submitted to the authors of the article for reply. In response, they have submitted another manuscript for our consideration. That manuscript currently is under review.
RE: DYNAMIC CAVERNOSOGRAPHY: VENOUS OUTFLOW STUDIES OF CAVERNOUS BODIES
H. Porst, J. E. Altwein, D. Bach and W. Thon
RE: FAILURE OF THE JONAS PROSTHESIS
J. Ural., 134: 276-279, 1985
E. A. Tawil and J. G. Gregory
To the Editor. I was pleased to read this article on venous drainage of the corpora cavernosa. It is important that the studies were done in vivo with cavernosography and artificial erection to allow for more precise details, since the exact anatomical position of venous drainage of the penis and the need for a blockage mechanism to induce an erection are moot, according to these investigators. The authors report some interesting findings. They indicate that the flow rates to induce an artificial erection show considerable individual differences: the flow rates range from 55 to 160 ml. per minute to obtain and from 12 to 90 ml. per minute to maintain an erection. They found that "in 2 patients with erectile dysfunction penile rigidity was not achieved despite the high flow rates (more than 180 ml. per minute) and, thus, venous insufficiency was diagnosed". I agree with the statement that recent studies have shown more erectile disorders than expected to be attributable to an excessive outflow of venous blood. 1- 3 I described the leakage factor in 1975 but not in the English literature. Because none of my articles is cited in the present work I wish to discuss some of the authors' statements. The authors studied 15 patients between 14 and 72 years old. Ten patients had organic diseases and 5 had erectile dysfunction. Unfortunately neither the age nor the clinical aspect of the penis is cited for these 15 patients. The authors do not include a parallel comparison of
J. Ural., 135: 702-703, 1986
To the Editor. I read this article with interest. Of the total 27 patients 7 had fractured wires confirmed operatively. The Mayo Clinic group presented a larger series in July 1984 with only 2 patients with wire fractures. Numerous other surgeons have reported their experience with the Jonas prosthesis, which has had a higher percentage of success than any of the other prostheses used to date. Our experience with almost 70 implantations has dictated removal of 1 prosthesis owing to extrusion and infection, which in our opinion was a technical error. However, we are aware of no fractured wires to date. Patients with a Jonas implant tend to be lost to followup because they do not particularly have problems after the pain in the immediate postoperative period. In summary, with the high fracture rate in this article I question whether there is a difference in the authors' surgical technique for implantation of the device compared to most of the surgeons in the United States as well as in the world. Construction of the Jonas prosthesis has changed since July 1984. Each individual wire now is coated with polytetrafluoroethylene (Teflon) to prevent this rare but bothersome problem. I do have high hopes that the new self-contained inflatable devices as well as the new Omniphase prosthesis will have