Pubic rami resection for urologic cancer

Never before has so little information been of so much potential practical value in the domain of human sexuality, for if these observations can be re-confirmed the impact will be explosive. The result will perforce one day lead to a reassessment of many of our concepts in the areas of education in human sexuality, sex therapy, and forensic medicine. Vincent J. Longo, M.D., AASECT* Chief of Urology Lawrence-Memorial Hospital New London, Connecticut *AASECT = -4merican and Therapists.

Association

of Sex Educators,

Counselors

Bibliography Addiego F, et al: Female ejaculation: a case study, J, Sex Res. 17: 13 (1981). Belzer E: Orgasmic expulsions of women: a review and heuristic inquiry, ibid. 17: 1 (1981). Campbell M: Urology, vol. II, Philadelphia, W. B. Saunders co., 1954, p. 1579. Freud S: Three Essays on the Theory of Sexuality, Complete Psychological Works of Sigmund Freud, Hawaii, Hogarth Press, 1955. Grafenberg E: The role of urethra in female orgasm, Int. J. Sex. 3: 145 (1959). Masters W, and Johnson V: Human Sexual Response, Boston. Little Brown & Co., 1966, p. 322. Perry J, and Whipple B: Pelvic muscle strength of female ejaculators: evidence in support of a new theory of orgasm, J. Sex Res. 17: 22 (1981). -IDEM: The Varieties of Female Orgasm and Female Ejaculation, SIECUS Report. May-July 1981, pp. 15-16.

PERINEAL

IJRETHROSTOMY

To the Editor: The technique of perineal urethrostomy described by Dr. Paul J. Marsidi, Dr. Wen I. Lin, and Dr. Henry A. Wise in the December issue (vol. 18, pages 610-11, 1981) of UROLOGY has been used almost exclusively at our center for more than fifteen years. It was independently developed at the University of Alberta by Dr. J. 0. Metcalf, former professor of urology. He has presented this technique several times at meetings across North America and most recently at the combined British and Canadian Urological Associations meeting held in Montreal in June, 1981. As the authors point out, this is a quick, simple, and effective method; its only drawiback is the need for some trained assistance. We have performed this technique in several thousand patients without difficulty and several points are worth emphasizing. Although plerineal urethrostomy may decrease the incidence of postoperative urethral stric-

UROLOGY

/

JULY

19‘32

/

VOLUME

XX,

NUMBER

1

tures, the major advantages are the ability to routinely utilize a 28-F sheath and the distinct improvement in mobility of the resectoscope. These factors allow resection of even large glands (greater than 50 Gm.) with relative ease. We have not found it necessary to rotate the sheath during insertion, as the authors illustrate. We also have abandoned suture repair of the urethrostomy following the operation since more than 95 per cent of these heal spontaneously within three days with only a small dressing. The remainder heal with an additional one to two days of catheter drainage. This technique is useful and is recommended for transurethral resection of the prostate. D. Ft. Mador, M.D. M. S. McPhee, M.D. Department of Surgery Cross Cancer Institute 11560 University Avenue Edmonton, Alberta T6G 122

PUBIC RAM1 RESECTION UROLOGIC CANCER

FOR

To the Editor: Regarding the article, “Exenterative Surgery for Posterior Urethral Cancer,” by Dr. R. Bruce Bracken, published in the March issue (vol. 19, page 248, 1982) of UROLOGY: We agree that the primary cause of failure in patients with invasive posterior urethral carcinoma is local recurrence. For this reason a wider surgical margin is necessary and achievable by resection of the pubic rami en bloc with the anterior perineum, urogenital diaphragm, genitalia, pelvic organs, and lymph nodes. Apparently, the first description of pubic rami resection for urologic cancer (which included two cases of urethral carcinoma) was reported by MacKenzie and Whitmore in 1968. * They described single-stage en bloc exenterative surgery including all four pubic rami with ileal conduit urinary diversion in 8 cases. Because of possible sacroiliac subluxation, which occurred in 1 case, the bony resection was modified to include just the inferior pubic rami in a ninth case. Since this initial report, an additional 11 patients with a diagnosis of invasive posterior urethral carcinoma (Stage C) have undergone preoperative irradiation therapy followed by single-stage surgical excision of the inferior pubic *MacKenzie, .4. R., and Whitmore, pubic rami for urologic cancer, J. Urol.

W. F., Jr.: Resection 100: 546 (1968).

of

109

rami, anterior perineum, urogenital diaphragm, and genitalia en bloc with the pelvic organs and lymph nodes with diverting ileal conduit at Memorial Hospital. A report on that latter ex-perience is in preparation. Frederick A. Klein, M.D. Willet F. Whitmore, Jr., M.D. Memorial Sloan-Kettering Cancer Center New York, New York 10021 A SIMPLER METHOD BLADDER IRRIGATION

FOR CONTINUOUS

To the Editor: I read with much interest the article by P. M. Livne et al., “Simple Method of Continuous Bladder Irrigation for Prevention of Postprostatectomy Complications,” published in the March (vol. 19, pages 314-315, 1982) of UROLOGY. I endorse their use of a twocatheter system for bladder irrigation; I always have thought that the continuous irrigation catheters commercially available have the disadvantage of a decreased outflow lumen. However, I wish to propose an even simpler method which has had good success, and with widei application. Livne et al. advocate the use of a whistletip catheter. In insuring against postprostatectomy complications, I think it is imperative to use a catheter which can supply traction. Accordingly, I use a 24-F, 30-cc balloon Foley catheter. My inflow is provided through the peripheral central venous pressure (CVP) line supplied with a 14- or 16-gauge needle. The needle permits oblique insertion into the catheter lumen opposite the balloon inflow valve (Fig. 1). The CVP line is then passed so that it exits from the eye. The stylet is then removed. and the metal wire is severed from the plastic cap, The CVP line is then cut, leaving enough

FIGURE catheter through

110

1.

Needle of CVP obliquely stylet allows easy advancement catheter lumen.

inserted; of line

FIGURE 2. Complete continuous irrigation system, note amount of CVP line exiting .from catheter eyra. and plastic guard as good aid .for proper tethering to thigh.

through the eye so that it can be bent back to allow smooth passage into the bladder. The plastic cap is retained to use as a sterile barrier when the inflow line is not in use. Irrigation is supplied through a simple intravenous line. The plastic guard which is provided for the protection of the CVP line as it passes through the cutting end of the insertion needle allows for good tethering to the leg (Fig. 2). When no longer necessary, the CVP line can be withdrawn easily: from the catheter, the oblique angle of entry preventing any- leakage of fluid. This simple system can be used in any situation requiring continuous bladder irrigation, does not require side by side catheters. and does not need suture materials or tape on the catheter. David Jay Caro, M.D. 100 NE Randolph Peoria, Illinois 61604 ELECTROCAUTERY

CIRCUMCISION

To the Editor: I was dismayed to note A. Barry Belman’s article, “Electrocautery Circumcision,” published in the November issue (vol. 18, pages 506-507, 1981) of UROLOGY, and especially the absence of editorial caveat. I cannot give the citations, but I know that there has been at least one disastrous complication of circumcision by cautery, resulting in substantial penile loss for the patient, and monetary gain for his lawyer. As I recall, this also involved the use of a Gomco clamp, which is not part of Dr. Belman’s technique. The facility of the procedure is not sufficiently enhanced, in my opinion, to counterbalance the real added risks of cautery in this application. G. B. Perlstein, M.D. Champaign, Illinois 61820

UROLOGY / JULY1932 / VOLUMEXX,NUMBERl