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RE: 13-YEAR EXPERIENCE WITH PERCUTANEOUS MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA
925
LETTERS TO THE EDITOR RE: 13-YEAR EXPERIENCE WITH PERCUTANEOUS MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA P. E. Clark, S. B. Streem and M. A. Geisinger J. Urol., 161: 772–776, 1999 To the Editor. We agree with the conclusions of the authors that percutaneous management of upper tract transitional cell carcinoma is technically feasible and associated with preservation of renal function. As stated in the editorial comment it is important that the treatment should be tailored to the patient and tumor. The results obtained are similar to those published in other and our series (unpublished data). We had a 26.1% ipsilateral recurrence rate and a 4.3% cancer specific death rate after percutaneous treatment of 23 patients at a mean followup of 60 months. A difference between the study of the authors and ours is that the indication was elective in 10 of our patients (43.5%) and absolute in the remainder (solitary kidney, bilateral disease or high surgical risk). A second difference is that our mean time to recurrence was 22.3 months (range 8 to 53) versus 11 months (range 2.4 to 33.2) in the series of the author. Finally, the pathological grade was different, since 65.2% of our patients had grade 2 and 13% had grade 3 disease. Although there may be some differences in the results possibly due to patient selection, we do not agree with the 3 initial endoscopic procedures that all of the patients underwent in this series. The authors performed the therapeutic percutaneous procedure, second look 3 to 5 days later and then third look after bacillus CalmetteGuerin (BCG) treatment at 3 months after the initial resection as did Jarrett et al.1 Do they really consider it necessary to repeat this procedure so many times? There was no comment on the advantages of or rationale for it. The 12 renal units did not have disease recurrence, which means 24 apparently unnecessary endoscopic procedures were performed, and in those with recurrence we do not know how many were diagnosed at the second or third look. It is obvious that if there is early recurrence or persistence of disease then endoscopy should be done. A short time to recurrence in the series of Clark et al (11 months, range 2.4 to 33.2) and the series of Elliott et al (7.3 months, range 1.5 to 27)2 may justify this approach. However, based on our experience (22.3 months, range 8 to 53) and that of Patel et al (44.6 months, range 8 to 60)3 with a longer elapsed time between initial treatment and recurrence, we do not believe that early revision is necessary provided initial treatment was successful and intracavitary BCG was administered. Respectfully, J. Palou, F. Milla´n, J. Salvador and J. Vicente Department of Urology Fundacio´ Puigvert Universitat Auto`noma de Barcelona Cartagena, 340 08025, Barcelona, Spain 1. Jarrett, T. W., Sweetser, P. M., Weiss, G. H., et al.: Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience. J Urol, 154: 1629, 1995 2. Elliott, D. S., Blute, M. L., Patterson, D. E., et al: Long-term follow-up of endoscopically treated upper urinary tract transitional cell carcinoma. Urology, 47: 819, 1996 3. Patel, A., Soonawalla, P., Shepherd, S. F., et al.: Long-term outcome after percutaneous treatment of transitional cell carcinoma of the renal pelvis. J Urol, 155: 868, 1996
Reply by Authors. We still believe that second look nephroscopy 2 to 3 days following the initial percutaneous tumor extirpation is worthwhile as it allows complete visualization of the pyelocaliceal system through what is by then a mature tract. In those patients receiving 6 weekly instillations of BCG we also like to perform third look nephroscopy 2 to 3 weeks following completion of BCG instillation as the nephrostomy tube has been indwelling anyway, and it seems reasonable to take advantage of that. However, as Palou et al suggest residual or recurrent tumor has been diagnosed only rarely at that time and, ultimately, such close surveillance may not prove necessary, especially in patients with no multifocal disease or carcinoma in situ.
RE: ORTHOTOPIC URINARY DIVERSION WITH PRESERVATION OF ERECTILE AND EJACULATORY FUNCTION IN MEN REQUIRING RADICAL CYSTECTOMY FOR NONUROTHELIAL MALIGNANCY: A NEW TECHNIQUE A. Spitz, J. P. Stein, G. Lieskovsky and D. G. Skinner J. Urol., 161: 1761–1764, 1999 To the Editor. The authors describe a technique to remove the bladder with the adjacent prostatic portion, calling the excision radical cystectomy. The procedure may be oncologically adequate for controlling nonurothelial tumors, prompting Spitz et al to call it radical cystectomy. However, their use of that term needs to be acknowledged as distinct from radical cystoprostatectomy. We fear that changing the term in this way might lead to confusion since radical cystectomy is often used loosely for radical cystoprostatectomy. Therefore, we suggest that this procedure be named supramontanal cystoprostatectomy for whatever the underlying indication may be. We doubt that there is any oncological benefit in removing this portion of the prostate rather than limiting the distal extent of excision to only the bladder neck. In these cases the prostate does not carry any inherent risk of disease recurrence as does transitional cell carcinoma. These patients are not known to be at high risk for prostate cancer. In any case the procedure does not include the important peripheral zone of the prostate where adenocarcinoma commonly develops. Nerve sparing cystoprostatectomy that maintains sexual potency has been described previously by Schlegel and Walsh.1 Preservation of ejaculation is a novel concept that Spitz et al describe in the context of cystectomy. However, they failed to explain how their technique could preserve antegrade ejaculation despite removal of the bladder neck. In other words, the technique was described but not its functional mechanism. It is well known that retrograde ejaculation is common after bladder neck or internal sphincter damage after transurethral resection of the prostate or bilateral sympathetic denervation. In the last 10 years there have been revolutionary developments in the understanding of the finer details of the mechanism of erection and ejaculation. There is some published evidence that might explain how antegrade ejaculation could be preserved. Early reports on this issue may well have been the basis on which the authors based their new concept. It is known that the urethral segment proximal to the verumontanum has an important role in antegrade ejaculation. Recker and Tsholl in an intraoperative study of 11 human subjects demonstrated with urethroscopy and ultrasonography that electrical stimulation of lumbar nerves leads to prostatic urethral closure starting from the bladder neck up to the colliculus seminalis.2 This closure precedes deposition of ejaculate into the urethra. Hoepffner et al were able to preserve antegrade ejaculation in 32 of 36 patients with benign prostatic hyperplasia (BPH) undergoing bladder neck incision by preserving a supramontanal ring of urethral muscle.3 Of their patients 8 underwent simultaneous median lobe resection while sparing the cervical muscular ring. They reasoned that contraction of this muscular portion during orgasm prevented retrograde ejaculation. Similar success was observed with resection of the prostate and bladder neck by Ronzoni and De Vecchis in 36 of 45 patients with BPH by conserving prostatic tissue from 1 cm. of the proximal verumontanum.4 Spitz et al failed to present this important information. Respectfully, Ramesh I. Gulla, Bhalchandra D. Kashyapi and Jagdeesh N. Kulkarni Tata Memorial Hospital Parel, Mumbai 400 012 India 1. Schlegel, P. N. and Walsh, P. C.: Neuroanatomical approach to radical cystoprostatectomy with preservation of sexual function. J Urol, 138: 1402, 1987 2. Recker, F. and Tsholl, R.: Monitoring of emission as direct intraoperative control for nerve sparing retroperitoneal lymphadenectomy. J Urol, 150: 1360, 1993 3. Hoepffner, J. L., Fontaine, E., Benfadel, S. et al: A modified cervicoprostatic incision in hypertrophic adenoma in young subjects desiring to preserve ejaculation. Prog Urol, 4: 371, 1994 4. Ronzoni, G. and De Vecchis, M.: Preservation of antegrade ejaculation after transurethral resection of both prostate and bladder neck. Br J Urol, 81: 830, 1998
LETTERS TO THE EDITOR RE: 13-YEAR EXPERIENCE WITH PERCUTANEOUS MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA P. E. Clark, S. B. Streem and M. A. Geisinger J. Urol., 161: 772–776, 1999 To the Editor. We agree with the conclusions of the authors that percutaneous management of upper tract transitional cell carcinoma is technically feasible and associated with preservation of renal function. As stated in the editorial comment it is important that the treatment should be tailored to the patient and tumor. The results obtained are similar to those published in other and our series (unpublished data). We had a 26.1% ipsilateral recurrence rate and a 4.3% cancer specific death rate after percutaneous treatment of 23 patients at a mean followup of 60 months. A difference between the study of the authors and ours is that the indication was elective in 10 of our patients (43.5%) and absolute in the remainder (solitary kidney, bilateral disease or high surgical risk). A second difference is that our mean time to recurrence was 22.3 months (range 8 to 53) versus 11 months (range 2.4 to 33.2) in the series of the author. Finally, the pathological grade was different, since 65.2% of our patients had grade 2 and 13% had grade 3 disease. Although there may be some differences in the results possibly due to patient selection, we do not agree with the 3 initial endoscopic procedures that all of the patients underwent in this series. The authors performed the therapeutic percutaneous procedure, second look 3 to 5 days later and then third look after bacillus CalmetteGuerin (BCG) treatment at 3 months after the initial resection as did Jarrett et al.1 Do they really consider it necessary to repeat this procedure so many times? There was no comment on the advantages of or rationale for it. The 12 renal units did not have disease recurrence, which means 24 apparently unnecessary endoscopic procedures were performed, and in those with recurrence we do not know how many were diagnosed at the second or third look. It is obvious that if there is early recurrence or persistence of disease then endoscopy should be done. A short time to recurrence in the series of Clark et al (11 months, range 2.4 to 33.2) and the series of Elliott et al (7.3 months, range 1.5 to 27)2 may justify this approach. However, based on our experience (22.3 months, range 8 to 53) and that of Patel et al (44.6 months, range 8 to 60)3 with a longer elapsed time between initial treatment and recurrence, we do not believe that early revision is necessary provided initial treatment was successful and intracavitary BCG was administered. Respectfully, J. Palou, F. Milla´n, J. Salvador and J. Vicente Department of Urology Fundacio´ Puigvert Universitat Auto`noma de Barcelona Cartagena, 340 08025, Barcelona, Spain 1. Jarrett, T. W., Sweetser, P. M., Weiss, G. H., et al.: Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience. J Urol, 154: 1629, 1995 2. Elliott, D. S., Blute, M. L., Patterson, D. E., et al: Long-term follow-up of endoscopically treated upper urinary tract transitional cell carcinoma. Urology, 47: 819, 1996 3. Patel, A., Soonawalla, P., Shepherd, S. F., et al.: Long-term outcome after percutaneous treatment of transitional cell carcinoma of the renal pelvis. J Urol, 155: 868, 1996
Reply by Authors. We still believe that second look nephroscopy 2 to 3 days following the initial percutaneous tumor extirpation is worthwhile as it allows complete visualization of the pyelocaliceal system through what is by then a mature tract. In those patients receiving 6 weekly instillations of BCG we also like to perform third look nephroscopy 2 to 3 weeks following completion of BCG instillation as the nephrostomy tube has been indwelling anyway, and it seems reasonable to take advantage of that. However, as Palou et al suggest residual or recurrent tumor has been diagnosed only rarely at that time and, ultimately, such close surveillance may not prove necessary, especially in patients with no multifocal disease or carcinoma in situ.
RE: ORTHOTOPIC URINARY DIVERSION WITH PRESERVATION OF ERECTILE AND EJACULATORY FUNCTION IN MEN REQUIRING RADICAL CYSTECTOMY FOR NONUROTHELIAL MALIGNANCY: A NEW TECHNIQUE A. Spitz, J. P. Stein, G. Lieskovsky and D. G. Skinner J. Urol., 161: 1761–1764, 1999 To the Editor. The authors describe a technique to remove the bladder with the adjacent prostatic portion, calling the excision radical cystectomy. The procedure may be oncologically adequate for controlling nonurothelial tumors, prompting Spitz et al to call it radical cystectomy. However, their use of that term needs to be acknowledged as distinct from radical cystoprostatectomy. We fear that changing the term in this way might lead to confusion since radical cystectomy is often used loosely for radical cystoprostatectomy. Therefore, we suggest that this procedure be named supramontanal cystoprostatectomy for whatever the underlying indication may be. We doubt that there is any oncological benefit in removing this portion of the prostate rather than limiting the distal extent of excision to only the bladder neck. In these cases the prostate does not carry any inherent risk of disease recurrence as does transitional cell carcinoma. These patients are not known to be at high risk for prostate cancer. In any case the procedure does not include the important peripheral zone of the prostate where adenocarcinoma commonly develops. Nerve sparing cystoprostatectomy that maintains sexual potency has been described previously by Schlegel and Walsh.1 Preservation of ejaculation is a novel concept that Spitz et al describe in the context of cystectomy. However, they failed to explain how their technique could preserve antegrade ejaculation despite removal of the bladder neck. In other words, the technique was described but not its functional mechanism. It is well known that retrograde ejaculation is common after bladder neck or internal sphincter damage after transurethral resection of the prostate or bilateral sympathetic denervation. In the last 10 years there have been revolutionary developments in the understanding of the finer details of the mechanism of erection and ejaculation. There is some published evidence that might explain how antegrade ejaculation could be preserved. Early reports on this issue may well have been the basis on which the authors based their new concept. It is known that the urethral segment proximal to the verumontanum has an important role in antegrade ejaculation. Recker and Tsholl in an intraoperative study of 11 human subjects demonstrated with urethroscopy and ultrasonography that electrical stimulation of lumbar nerves leads to prostatic urethral closure starting from the bladder neck up to the colliculus seminalis.2 This closure precedes deposition of ejaculate into the urethra. Hoepffner et al were able to preserve antegrade ejaculation in 32 of 36 patients with benign prostatic hyperplasia (BPH) undergoing bladder neck incision by preserving a supramontanal ring of urethral muscle.3 Of their patients 8 underwent simultaneous median lobe resection while sparing the cervical muscular ring. They reasoned that contraction of this muscular portion during orgasm prevented retrograde ejaculation. Similar success was observed with resection of the prostate and bladder neck by Ronzoni and De Vecchis in 36 of 45 patients with BPH by conserving prostatic tissue from 1 cm. of the proximal verumontanum.4 Spitz et al failed to present this important information. Respectfully, Ramesh I. Gulla, Bhalchandra D. Kashyapi and Jagdeesh N. Kulkarni Tata Memorial Hospital Parel, Mumbai 400 012 India 1. Schlegel, P. N. and Walsh, P. C.: Neuroanatomical approach to radical cystoprostatectomy with preservation of sexual function. J Urol, 138: 1402, 1987 2. Recker, F. and Tsholl, R.: Monitoring of emission as direct intraoperative control for nerve sparing retroperitoneal lymphadenectomy. J Urol, 150: 1360, 1993 3. Hoepffner, J. L., Fontaine, E., Benfadel, S. et al: A modified cervicoprostatic incision in hypertrophic adenoma in young subjects desiring to preserve ejaculation. Prog Urol, 4: 371, 1994 4. Ronzoni, G. and De Vecchis, M.: Preservation of antegrade ejaculation after transurethral resection of both prostate and bladder neck. Br J Urol, 81: 830, 1998