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Posterior approach to renoureteral surgery
LETTERS
TO THE EDITOR
POSTERIOR APPROACH TO RENOURETEBAL SURGERY TO the Editor: I enjoyed the article on “Misconceptions About Posterior Approach for Renoureteral Surgery,” by Hector Bensimon et al. published in the May issue (vol. 19, pages 462-466, 1982) of UROLOGY. However, I am sure you have realized by now that Figure 5 shows the vessels to be posterior to the renal pelvis. Robert J. Murchison, M.D. 1650 West Magnolia Fort Worth, Texas 76104
REPLY OF DR. BENSIMON To the Editor: It is appropriate that you publish Dr. Murchinson’s comment about Figure 5 of my article, “Misconceptions About the Posterior Approach for Renoureteral Surgery.” This will afford me the opportunity to stress an important point. When using the sponge stick to displace the kidney upward (laterally), the kidney also rotates anteriorly. This brings the stretched main renal vessels superficially as shown in Figure 5. The anterior-superior dip of the branches of the main renal artery, toward the normal anterior position, is not shown in this picture. Hector Bensimon, M.D. Veterans Administration Medical Center Washington, D.C. 20422
CLASSIFICATION VAS DEFERENS
OF ECTOPIA
OF
To the Editor: We read, with interest, the article, “Ectopic Vas Deferens Communicatiing with Lower Ureter,” by F. Ayyat, M. D. Palmer, and J. 0. Tingley, published in the April issue (vol. 19, pages 423-426, 1982), of UROLOGY. In 1979, we reported on 2 patients with vas ectopia and reviewed the literature. * Since that time, one of us (M.D. G.) has seen one more case, totaling 12 cases and 14 ectopic vas communications. In addition, we have: (1) classified ectopia of the vas deferens into ureteral (vasoureteric) and bladder (vasovesical) insertions, (2) developed an embryologic theory (based on Stephens’ concepts of ureterotrigonal development), and (3) made a point to distinguish vas ectopia from ureteral ectopia. In our series (which includes the four children in the aforementioned authors’ group), we found a high incidence of imperforate anus (59%), vesicoureteral reflux (57%), and ectopia lateralis
350
(43%), as well as upper tract anomalies and malformations (69%). Exactly one third of the patients presented with acute epididymitis or scrotal abscesses. Vesicoureteric ectopia (64%) was found more commonly than vasovesical ectopia (36%). Thus, we support the concept of a high degree of suspicion, as well as a thorough urologic workup in newborn males with anal rectal malformations and scrotal inflammatory processes. We believe, however, that the embryologic explanation is somewhat more complex than the authors’ theory of “failure of process of absorption of the common duct into the urogenital sinus.” Our embryologic theory of the bipotential proximal vas precursor segment of the wolfBan duct is applicable to all ectopic vas-anomalous unions described for both single and duplex systems. M. David Gibbons, M.D. Texas Children’s Hospital Baylor College of Medicine Houston, Texas John W. Duckett, Jr., M.D. Children’s Hospital of Philadelphia University of Pennsylvania Philadelphia, Pennsylvania *Gibbons MD, Duck&t JW, and Cromie WJ: Clmification of
ectopicvasdeferens, J Ural 120: 597 (1978).
ALPHA-FETOPROTEIN AND HCG ASSAYS IN TESTICULAR CANCER To the Editor: I have read with interest the article on The Transient Rise in Tumor Markers After Initial Adjuvant Chemotherapy for Testicular Cancer by Dr. D. J. Wolf and Dr. J. J. Williams, published in the July issue (vol. 20, pages 50-52, 1982) of UROLOGY. These authors have reported on a patient with Stage IIB embryonal carcinoma undergoing orchiectomy and retroperitoneal lymphadenectomy. The serum levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) were within normal limits prior to adjuvant chemotherapy. However, serum HCG had risen slightly after initial chemotherapy. We have observed this phenomenon of a false positive serum level of HCG in patients receiving initial chemotherapy due to slight elevation of serum LH secondary to a transient hypogonadism. This cross reactivity of HCG and LH is explained on the basis of the&subunit of HCG sharing the first II0 amino acids with thep-subunit ofLH, therefore giving a slight elevation of HCG when serum LH is elevated.
UROLOGY
/
SEPTEMBER
1982
/
VOLUME
XX, NUMBER
3
TO THE EDITOR
POSTERIOR APPROACH TO RENOURETEBAL SURGERY TO the Editor: I enjoyed the article on “Misconceptions About Posterior Approach for Renoureteral Surgery,” by Hector Bensimon et al. published in the May issue (vol. 19, pages 462-466, 1982) of UROLOGY. However, I am sure you have realized by now that Figure 5 shows the vessels to be posterior to the renal pelvis. Robert J. Murchison, M.D. 1650 West Magnolia Fort Worth, Texas 76104
REPLY OF DR. BENSIMON To the Editor: It is appropriate that you publish Dr. Murchinson’s comment about Figure 5 of my article, “Misconceptions About the Posterior Approach for Renoureteral Surgery.” This will afford me the opportunity to stress an important point. When using the sponge stick to displace the kidney upward (laterally), the kidney also rotates anteriorly. This brings the stretched main renal vessels superficially as shown in Figure 5. The anterior-superior dip of the branches of the main renal artery, toward the normal anterior position, is not shown in this picture. Hector Bensimon, M.D. Veterans Administration Medical Center Washington, D.C. 20422
CLASSIFICATION VAS DEFERENS
OF ECTOPIA
OF
To the Editor: We read, with interest, the article, “Ectopic Vas Deferens Communicatiing with Lower Ureter,” by F. Ayyat, M. D. Palmer, and J. 0. Tingley, published in the April issue (vol. 19, pages 423-426, 1982), of UROLOGY. In 1979, we reported on 2 patients with vas ectopia and reviewed the literature. * Since that time, one of us (M.D. G.) has seen one more case, totaling 12 cases and 14 ectopic vas communications. In addition, we have: (1) classified ectopia of the vas deferens into ureteral (vasoureteric) and bladder (vasovesical) insertions, (2) developed an embryologic theory (based on Stephens’ concepts of ureterotrigonal development), and (3) made a point to distinguish vas ectopia from ureteral ectopia. In our series (which includes the four children in the aforementioned authors’ group), we found a high incidence of imperforate anus (59%), vesicoureteral reflux (57%), and ectopia lateralis
350
(43%), as well as upper tract anomalies and malformations (69%). Exactly one third of the patients presented with acute epididymitis or scrotal abscesses. Vesicoureteric ectopia (64%) was found more commonly than vasovesical ectopia (36%). Thus, we support the concept of a high degree of suspicion, as well as a thorough urologic workup in newborn males with anal rectal malformations and scrotal inflammatory processes. We believe, however, that the embryologic explanation is somewhat more complex than the authors’ theory of “failure of process of absorption of the common duct into the urogenital sinus.” Our embryologic theory of the bipotential proximal vas precursor segment of the wolfBan duct is applicable to all ectopic vas-anomalous unions described for both single and duplex systems. M. David Gibbons, M.D. Texas Children’s Hospital Baylor College of Medicine Houston, Texas John W. Duckett, Jr., M.D. Children’s Hospital of Philadelphia University of Pennsylvania Philadelphia, Pennsylvania *Gibbons MD, Duck&t JW, and Cromie WJ: Clmification of
ectopicvasdeferens, J Ural 120: 597 (1978).
ALPHA-FETOPROTEIN AND HCG ASSAYS IN TESTICULAR CANCER To the Editor: I have read with interest the article on The Transient Rise in Tumor Markers After Initial Adjuvant Chemotherapy for Testicular Cancer by Dr. D. J. Wolf and Dr. J. J. Williams, published in the July issue (vol. 20, pages 50-52, 1982) of UROLOGY. These authors have reported on a patient with Stage IIB embryonal carcinoma undergoing orchiectomy and retroperitoneal lymphadenectomy. The serum levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) were within normal limits prior to adjuvant chemotherapy. However, serum HCG had risen slightly after initial chemotherapy. We have observed this phenomenon of a false positive serum level of HCG in patients receiving initial chemotherapy due to slight elevation of serum LH secondary to a transient hypogonadism. This cross reactivity of HCG and LH is explained on the basis of the&subunit of HCG sharing the first II0 amino acids with thep-subunit ofLH, therefore giving a slight elevation of HCG when serum LH is elevated.
UROLOGY
/
SEPTEMBER
1982
/
VOLUME
XX, NUMBER
3