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Preoperative Assessment of Penile Curvature by Artificial Erection
1238
LETTERS TO THE EDITOR
cough and/or dyspnea without wheezing. Cough can lead to other problems, such as incontinence in our patient. An underlying anatomical problem in our patient that may have been unmasked by the enalapril-induced cough still may require evaluation. With the current explosion in use of angiotensin-converting enzyme inhibitors and the associated cough seen predominantly in women our case represents a problem of which primary care physicians and urologists must be aware when confronted with the incontinent female patient. Respectfully, James E. Casanova General Internal Medicine, Box 132 Medical College of Wisconsin 8700 West Wisconsin Avenue Milwaukee, Wisconsin 53226 1. McNally, E. M.: Cough due to captopril. West. J. Med., 146: 226, 1986. 2. Kaufman, J., Casanova, J., Riendl, P. and Schlueter, D. P.: Bronchial hyperreactivity and cough due to angiotensin-converting enzyme inhibitors. Chest, 95: 544, 1989. 3. Bucknall, C., Neilly, J., Carter, R., Stevenson, R. D. and Semple, P. F.: Bronchial hyperreactivity in patients who cough after receiving angiotensin converting enzyme inhibitors. Brit. Med. J., 296: 86, 1988.
PREOPERATIVE ASSESSMENT OF PENILE CURVATURE BY ARTIFICIAL ERECTION
To the Editor. Congenital or acquired penile curvature can be treated effectively by the Nesbit operation or similar procedures and an artificial erection performed during the operation permits achievement of a good aesthetic result. However, preoperative assessment of the penile curvature in the consulting room is problematic owing to the difficulty in examining the erect penis. Commonly, urologists ask the patient to obtain an instant photograph of the erect penis. However, this method is rather cumbersome for the patient and can considerably delay operative therapy. In 4 of our patients with congenital penile curvature that impeded intercourse we induced an artificial erection in the office by an intracavernous injection of 50 mg. papaverine or 20 µg. prostaglandin EL After the penis was examined and photographed the erection was stopped with an intracavernous injection of 0.2 mg. phenylephrine. No hypertensive effect was observed with this drug. Pharmacological artificial erection is a simple, rapid and effective method to evaluate penile curvature and determine the need for an operation. The systematic use of phenylephrine at the end of the examination avoids prolonged erection. Respectfully, A. Dittrich and M. Vandendris
Department of Urology Brugmann University Hospital 1020 Brussels, Belgium
RE: ARTERIOVENOUS MALFORMATION OF THE SPERMATIC CORD
P. M. Bumpers, Jr., W. C. Hulbert, Jr. and J. F. Jimenez J. Urol., 141: 103-104, 1989 To the Editor. The authors describe a 7-year-old boy with cystic fibrosis as having a normal left spermatic cord and a mass, which turned out to be an arteriovenous malformation attached to the right spermatic cord. The right vas, epididymis and testicle were excised, and they were found to be normal on pathological examination. I wish to reiterate to urologists the association of cystic fibrosis with congenital bilateral absence of the vasa deferentia, which has been found in every male child with this disorder. Pediatricians should know that cystic fibrosis in the male child can be ruled out if the vasa are palpable. Taussig and associates documented fertility in only 2% of 117 cases in a survey of 105 cystic fibrosis centers, and noted that normal fertility occurs in 2 to 3% of men with this disease.' The 2 fertile men with cystic fibrosis reported on by Taussig and associates, together with another such patient reported on by Feigelson and associates,' were unusual in that they had a variant form of cystic fibrosis in which the pulmonary symptoms developed relatively late
(after age 10 years) and in all 3 cases the diagnosis was made after age 19 years. These cases imply different genetic types of cystic fibrosis or variable gene penetrance with consequent differences in the time and completeness of involvement of various organs. It is most unlikely that the 7-year-old child described by Doctor Bumpers and associates has cystic fibrosis. This child should be reexamined and the diagnosis, with its poor long-term prognosis, should be reconsidered. Respectfully, Richard D. Amelar New York University School of Medicine 550 First Avenue New York, New York 10016 1. Taussig, L. M., Lobeck, C. C., di Sant'Agnese, P.A., Ackerman, D. R. and Kattwinkel, J.: Fertility in males with cystic fibrosis. New . Engl. J. Med., 287: 586, 1972. 2. Feigelson, J., Pecau, Y. and Shwachman, H.: A propos d'une paternite chez un malade atteint de mucoviscidose: etudes des fonctions genitales et de la filiation. Arch. Fr. Ped., 26: 937, 1969.
Reply by Authors. Doctor Amelar's comments were appreciated and prompted a reinvestigation of the patient and his sister. The children had been diagnosed as having cystic fibrosis on the basis of at least 2 marginally positive sweat chloride determinations each, as well as the presence of typical chronic obstructive pulmonary disease. Re-evaluation now shows test results in the normal range, and further investigation is planned. The future use of gene probes for more direct diagnosis in these children will be of great help.
RE: POSTOPERATIVE RADIOTHERAPY OF THE PROSTATE FOR PATIENTS UNDERGOING RADICAL PROSTATECTOMY WITH POSITIVE MARGINS, SEMINAL VESICLE INVOLVEMENT AND/OR PENETRATION THROUGH THE CAPSULE
D. F. Paulson, J. W. Moul, J.E. Robertson and P. J. Walther J. Urol., 143: 1178-1182, 1990 To the Editor. In response to this manuscript we wish to make several points. Theoretical basis for postoperative radiotherapy. Evidence exists in a number of tumor systems, including carcinoma of the breast, soft tissue sarcoma and carcinoma of the head and neck region, that incomplete tumor resection as manifested by histopathologically positive margins leads to a high frequency of local failure if no further therapy is given. Postoperative radiotherapy can substantially decrease the local failure rate in these circumstances. We believe it unlikely that the principles for urological cancer in general or prostate cancer specifically are different. Literature data. Our 1987 study' listed 4 other studies 2 - 5 purporting to show a benefit from postoperative radiotherapy for patients with pathological stage C prostate cancer after radical prostatectomy. Subsequently, 3 other studies also have appeared suggesting benefits from adjuvant postoperative radiotherapy in pathological stage C disease. 6- 8 All of these studies are admittedly retrospective and suffer from inclusion of patients often receiving therapies other than radiation, and comprising heterogeneous groups difficult to compare with other institutions. Nevertheless, a pattern of benefit seems to be apparent, which is much in keeping with what would be expected from the theoretical considerations mentioned previously. Differing views of the Duke data. Doctor Paulson and associates have called to our attention some errors in analysis in our original report. In particular, 3 patients were included in the surgery only group who had undergone cystoprostatectomy primarily for bladder cancer, with prostate cancer being an incidental finding in the surgical specimen. However, since 2 of these 3 patients were long-term survivors their exclusion would have resulted in a lesser survival in the surgery only group and tended to make the differences reported even greater than they were otherwise. We did include patients with cystoprostatectomy whose primary diagnosis was prostate cancer and we believe this inclusion is proper. Most of the differences between our analysis and the current analysis by the authors, however, are related to different criteria for failure and different methods to subdivide the patients for analysis. In particular, the current manuscript did not accept local recurrence unless this had
LETTERS TO THE EDITOR
cough and/or dyspnea without wheezing. Cough can lead to other problems, such as incontinence in our patient. An underlying anatomical problem in our patient that may have been unmasked by the enalapril-induced cough still may require evaluation. With the current explosion in use of angiotensin-converting enzyme inhibitors and the associated cough seen predominantly in women our case represents a problem of which primary care physicians and urologists must be aware when confronted with the incontinent female patient. Respectfully, James E. Casanova General Internal Medicine, Box 132 Medical College of Wisconsin 8700 West Wisconsin Avenue Milwaukee, Wisconsin 53226 1. McNally, E. M.: Cough due to captopril. West. J. Med., 146: 226, 1986. 2. Kaufman, J., Casanova, J., Riendl, P. and Schlueter, D. P.: Bronchial hyperreactivity and cough due to angiotensin-converting enzyme inhibitors. Chest, 95: 544, 1989. 3. Bucknall, C., Neilly, J., Carter, R., Stevenson, R. D. and Semple, P. F.: Bronchial hyperreactivity in patients who cough after receiving angiotensin converting enzyme inhibitors. Brit. Med. J., 296: 86, 1988.
PREOPERATIVE ASSESSMENT OF PENILE CURVATURE BY ARTIFICIAL ERECTION
To the Editor. Congenital or acquired penile curvature can be treated effectively by the Nesbit operation or similar procedures and an artificial erection performed during the operation permits achievement of a good aesthetic result. However, preoperative assessment of the penile curvature in the consulting room is problematic owing to the difficulty in examining the erect penis. Commonly, urologists ask the patient to obtain an instant photograph of the erect penis. However, this method is rather cumbersome for the patient and can considerably delay operative therapy. In 4 of our patients with congenital penile curvature that impeded intercourse we induced an artificial erection in the office by an intracavernous injection of 50 mg. papaverine or 20 µg. prostaglandin EL After the penis was examined and photographed the erection was stopped with an intracavernous injection of 0.2 mg. phenylephrine. No hypertensive effect was observed with this drug. Pharmacological artificial erection is a simple, rapid and effective method to evaluate penile curvature and determine the need for an operation. The systematic use of phenylephrine at the end of the examination avoids prolonged erection. Respectfully, A. Dittrich and M. Vandendris
Department of Urology Brugmann University Hospital 1020 Brussels, Belgium
RE: ARTERIOVENOUS MALFORMATION OF THE SPERMATIC CORD
P. M. Bumpers, Jr., W. C. Hulbert, Jr. and J. F. Jimenez J. Urol., 141: 103-104, 1989 To the Editor. The authors describe a 7-year-old boy with cystic fibrosis as having a normal left spermatic cord and a mass, which turned out to be an arteriovenous malformation attached to the right spermatic cord. The right vas, epididymis and testicle were excised, and they were found to be normal on pathological examination. I wish to reiterate to urologists the association of cystic fibrosis with congenital bilateral absence of the vasa deferentia, which has been found in every male child with this disorder. Pediatricians should know that cystic fibrosis in the male child can be ruled out if the vasa are palpable. Taussig and associates documented fertility in only 2% of 117 cases in a survey of 105 cystic fibrosis centers, and noted that normal fertility occurs in 2 to 3% of men with this disease.' The 2 fertile men with cystic fibrosis reported on by Taussig and associates, together with another such patient reported on by Feigelson and associates,' were unusual in that they had a variant form of cystic fibrosis in which the pulmonary symptoms developed relatively late
(after age 10 years) and in all 3 cases the diagnosis was made after age 19 years. These cases imply different genetic types of cystic fibrosis or variable gene penetrance with consequent differences in the time and completeness of involvement of various organs. It is most unlikely that the 7-year-old child described by Doctor Bumpers and associates has cystic fibrosis. This child should be reexamined and the diagnosis, with its poor long-term prognosis, should be reconsidered. Respectfully, Richard D. Amelar New York University School of Medicine 550 First Avenue New York, New York 10016 1. Taussig, L. M., Lobeck, C. C., di Sant'Agnese, P.A., Ackerman, D. R. and Kattwinkel, J.: Fertility in males with cystic fibrosis. New . Engl. J. Med., 287: 586, 1972. 2. Feigelson, J., Pecau, Y. and Shwachman, H.: A propos d'une paternite chez un malade atteint de mucoviscidose: etudes des fonctions genitales et de la filiation. Arch. Fr. Ped., 26: 937, 1969.
Reply by Authors. Doctor Amelar's comments were appreciated and prompted a reinvestigation of the patient and his sister. The children had been diagnosed as having cystic fibrosis on the basis of at least 2 marginally positive sweat chloride determinations each, as well as the presence of typical chronic obstructive pulmonary disease. Re-evaluation now shows test results in the normal range, and further investigation is planned. The future use of gene probes for more direct diagnosis in these children will be of great help.
RE: POSTOPERATIVE RADIOTHERAPY OF THE PROSTATE FOR PATIENTS UNDERGOING RADICAL PROSTATECTOMY WITH POSITIVE MARGINS, SEMINAL VESICLE INVOLVEMENT AND/OR PENETRATION THROUGH THE CAPSULE
D. F. Paulson, J. W. Moul, J.E. Robertson and P. J. Walther J. Urol., 143: 1178-1182, 1990 To the Editor. In response to this manuscript we wish to make several points. Theoretical basis for postoperative radiotherapy. Evidence exists in a number of tumor systems, including carcinoma of the breast, soft tissue sarcoma and carcinoma of the head and neck region, that incomplete tumor resection as manifested by histopathologically positive margins leads to a high frequency of local failure if no further therapy is given. Postoperative radiotherapy can substantially decrease the local failure rate in these circumstances. We believe it unlikely that the principles for urological cancer in general or prostate cancer specifically are different. Literature data. Our 1987 study' listed 4 other studies 2 - 5 purporting to show a benefit from postoperative radiotherapy for patients with pathological stage C prostate cancer after radical prostatectomy. Subsequently, 3 other studies also have appeared suggesting benefits from adjuvant postoperative radiotherapy in pathological stage C disease. 6- 8 All of these studies are admittedly retrospective and suffer from inclusion of patients often receiving therapies other than radiation, and comprising heterogeneous groups difficult to compare with other institutions. Nevertheless, a pattern of benefit seems to be apparent, which is much in keeping with what would be expected from the theoretical considerations mentioned previously. Differing views of the Duke data. Doctor Paulson and associates have called to our attention some errors in analysis in our original report. In particular, 3 patients were included in the surgery only group who had undergone cystoprostatectomy primarily for bladder cancer, with prostate cancer being an incidental finding in the surgical specimen. However, since 2 of these 3 patients were long-term survivors their exclusion would have resulted in a lesser survival in the surgery only group and tended to make the differences reported even greater than they were otherwise. We did include patients with cystoprostatectomy whose primary diagnosis was prostate cancer and we believe this inclusion is proper. Most of the differences between our analysis and the current analysis by the authors, however, are related to different criteria for failure and different methods to subdivide the patients for analysis. In particular, the current manuscript did not accept local recurrence unless this had