- Email: [email protected]
Re: A New Use of Ureteroscopy by M. A. Bazeed J. Urol., 150: 922-923, 1993
0022-5347/94/1524-1213$03.00/0 VoL 152, 1213-1216, October 1994 Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1994 by AMERICAN
UROLOGICAL AsSOCIATION, INC.
Letters to the Editor RE: A NEW USE OF URETEROSCOPY
M. A. Bazeed J. Urol., 150: 922-923, 1993
To the Editor. Two apparently good techniques to manage a nondeflating Foley catheter balloon were described. In both techniques the metal stylet of the ureteral catheter was used to puncture the balloon via the working channel of the ureteroscope or cystoscope. The latter method has been reported previously.! We used this technique and found it impossible to puncture the balloon with the metal stylet since it slides over the balloon. The reason was believed to be the flimsy nature of the stylet and inability to stabilize the balloon. Therefore, the balloon was punctured suprapubically with a 20 gauge spinal needle under cystoscopic guidance. The puncture was possible because of the stiffer nature of the spinal needle. In 2 subsequent cases we conceived a technique to puncture the balloon endoscopically after stabilizing it. The urethral catheter is cut at the meatus and a 21F Sachse urethrotome sheath is introduced, passing the catheter into the bladder. While the urethrotome sheath is kept in the bladder, the working element is changed to a cold-cup biopsy forceps with a zero degree lens. The catheter is held by the cups of the biopsy forceps near the balloon and a sedation-analgesia injection needle is introduced through the working channel of the urethrotome sheath to puncture the balloon. An alternative to this needle is a ureteral catheter with a metal stylet protruding through the proximal end, stabilized by artery forceps at the distal end. The protruding end of metal stylet is used to puncture the balloon through the urethrotome sheath. The catheter is grasped at 1 end with the biopsy forceps and withdrawn. We believe that endoscopic puncture should have a role if ultrasound guidance is either not available or fails. An improvising mind is essential to manage the problem because a purpose-built instrument is not yet available. Respectfully, Mahesh Goel and R. P. S. Bhadauria Department of Urology SGPGIMS Lucknow 226001 (U.P.) INDIA 1. Subrahmanyam, K., Sridar, P., Venugopal, K. and Suryaprakesh, B.: Endoscopic removal of non-deflating Foley balloon catheter. Brit. J. Urol., 70: 454, 1992.
substantially higher than in earlier reports. We have evidence to suggest that earlier reports may be overly optimistic due to relatively short followup. In fact, if we compare the largest reported series with followup comparable to that in our study, the Southwest Oncology Group comparison of Conn aught BCG with doxorubicin,2 illustrated in the figure, the interval to recurrence curve is identical to that of our combined BCG treated patients. Therefore, the overall long-term
100 Q) Q)
90
r:...
80
s...
70
S ;::j
50
s... 0
E-< ...,J
I=l
60 .••
"1
...
40
Q) C)
30
s... Q)
20
P-.
10
o· .
o· ...
0
0-0
Vitamin Study SWOG 8216
o~~~~~~~~~~~~~~~~~~~~~
o
5
10
15
20
25
30
35
40
45
50
55
60
Months From Registration Long-term effects of BCG immunotherapy incidence of tumor recurrence in our study does not differ from the expected. However, one might have expected the group receiving recommended daily allowance vitamins to have had a long-term incidence of recurrence equal to that previously reported. The fact that they had a higher than expected estimated 5-year recurrence (91 %) may relate to the study design, which prohibited the consumption of additional vitamins. Of adults in the United States 40% or more currently consume supplemental vitamins. 3 This common consumption of vitamins may partly explain the overall better protection from tumor recurrence observed in other studies. Respectfully, Donald L. Lamm Department of Urology West Virginia University Morgantown, West Virginia 26506
Reply by Author. I am grateful to Doctors Goel and Bhadauria for their interest in my article. I agree that endoscopic puncturing should have a role if ultrasound guidance is either not available or fails. To avoid the difficulty of using a ureteral catheter metal stylet, I used a strong stylet after sharpening the end. Later, I found that introducing the ureteroscope forceps through the working channel of the panendoscope catches and punctures the balloon easily. I appreciate the 2 techniques described by Doctors Goel and Bhadauria to puncture the balloon. After my study was published, I encountered a case of a nondeflatable Foley catheter in a female patient. I pulled the Foley catheter with the left hand to stabilize the balloon at the internal urethral meatus. With the right hand, I introduced a spinal needle through the urethral lumen on the outer surface of the catheter to puncture the balloon. This technique was simple.
1. Lamm, D. L., Riggs, D. R., Shriver, J. S., vanGilder, P. F., Rach, J. F. and DeHaven, J. I.: Megadose vitamins in bladder cancer: a double-blind clinical trial. J. Urol., 151: 21, 1994. 2. Lamm, D. L., Blumenstein, B. A., Crawford, E. D., Montie, J. E., Scardino, P., Grossman, H. B., Stanisic, T. H., Smith, J. A., Jr., Sullivan, J., Sarosdy, M. F., Crissman, J. D. and Coltman, C. A.: A randomized trial of intravesical doxorubicin and immunotherapy with bacillus Calmette-Guerin for transitionalcell carcinoma of the bladder. New Engl. J. Med., 325: 1205, 1991. 3. Kaplan, J. P., Annest, J. L., Loyde, P. M. and Rubin, G. L.: Nutrient intake and supplementation in the United States (NHANEA II). Amer. J. Public Health, 76: 287, 1986.
M. J. Droller
RE: RETURN OF ERECTIONS AND URINARY CONTINENCE FOLLOWING NERVE SPARING RADICAL RETROPUBIC PROSTATECTOMY
J. Urol., 151: 47-48, 1994
W. J. Catalona and J. W. Basler
To the Editor. In Doctor Droller's comments regarding our article on megadose vitamins in bladder cancer! he expressed the opinion, as did we, that the estimated incidence of tumor recurrence at 5 years in bacillus Calmette-Guerin (BCG) treated patients was
J. Urol., 150: 905-907, 1993
RE: EDITORIAL: BLADDER CANCER
To the Editor. With regard to the data concerning the return of erectile function presented in this article, there are 2 issues that
1213
THE JOURNAL OF UROLOGY
Copyright © 1994 by AMERICAN
UROLOGICAL AsSOCIATION, INC.
Letters to the Editor RE: A NEW USE OF URETEROSCOPY
M. A. Bazeed J. Urol., 150: 922-923, 1993
To the Editor. Two apparently good techniques to manage a nondeflating Foley catheter balloon were described. In both techniques the metal stylet of the ureteral catheter was used to puncture the balloon via the working channel of the ureteroscope or cystoscope. The latter method has been reported previously.! We used this technique and found it impossible to puncture the balloon with the metal stylet since it slides over the balloon. The reason was believed to be the flimsy nature of the stylet and inability to stabilize the balloon. Therefore, the balloon was punctured suprapubically with a 20 gauge spinal needle under cystoscopic guidance. The puncture was possible because of the stiffer nature of the spinal needle. In 2 subsequent cases we conceived a technique to puncture the balloon endoscopically after stabilizing it. The urethral catheter is cut at the meatus and a 21F Sachse urethrotome sheath is introduced, passing the catheter into the bladder. While the urethrotome sheath is kept in the bladder, the working element is changed to a cold-cup biopsy forceps with a zero degree lens. The catheter is held by the cups of the biopsy forceps near the balloon and a sedation-analgesia injection needle is introduced through the working channel of the urethrotome sheath to puncture the balloon. An alternative to this needle is a ureteral catheter with a metal stylet protruding through the proximal end, stabilized by artery forceps at the distal end. The protruding end of metal stylet is used to puncture the balloon through the urethrotome sheath. The catheter is grasped at 1 end with the biopsy forceps and withdrawn. We believe that endoscopic puncture should have a role if ultrasound guidance is either not available or fails. An improvising mind is essential to manage the problem because a purpose-built instrument is not yet available. Respectfully, Mahesh Goel and R. P. S. Bhadauria Department of Urology SGPGIMS Lucknow 226001 (U.P.) INDIA 1. Subrahmanyam, K., Sridar, P., Venugopal, K. and Suryaprakesh, B.: Endoscopic removal of non-deflating Foley balloon catheter. Brit. J. Urol., 70: 454, 1992.
substantially higher than in earlier reports. We have evidence to suggest that earlier reports may be overly optimistic due to relatively short followup. In fact, if we compare the largest reported series with followup comparable to that in our study, the Southwest Oncology Group comparison of Conn aught BCG with doxorubicin,2 illustrated in the figure, the interval to recurrence curve is identical to that of our combined BCG treated patients. Therefore, the overall long-term
100 Q) Q)
90
r:...
80
s...
70
S ;::j
50
s... 0
E-< ...,J
I=l
60 .••
"1
...
40
Q) C)
30
s... Q)
20
P-.
10
o· .
o· ...
0
0-0
Vitamin Study SWOG 8216
o~~~~~~~~~~~~~~~~~~~~~
o
5
10
15
20
25
30
35
40
45
50
55
60
Months From Registration Long-term effects of BCG immunotherapy incidence of tumor recurrence in our study does not differ from the expected. However, one might have expected the group receiving recommended daily allowance vitamins to have had a long-term incidence of recurrence equal to that previously reported. The fact that they had a higher than expected estimated 5-year recurrence (91 %) may relate to the study design, which prohibited the consumption of additional vitamins. Of adults in the United States 40% or more currently consume supplemental vitamins. 3 This common consumption of vitamins may partly explain the overall better protection from tumor recurrence observed in other studies. Respectfully, Donald L. Lamm Department of Urology West Virginia University Morgantown, West Virginia 26506
Reply by Author. I am grateful to Doctors Goel and Bhadauria for their interest in my article. I agree that endoscopic puncturing should have a role if ultrasound guidance is either not available or fails. To avoid the difficulty of using a ureteral catheter metal stylet, I used a strong stylet after sharpening the end. Later, I found that introducing the ureteroscope forceps through the working channel of the panendoscope catches and punctures the balloon easily. I appreciate the 2 techniques described by Doctors Goel and Bhadauria to puncture the balloon. After my study was published, I encountered a case of a nondeflatable Foley catheter in a female patient. I pulled the Foley catheter with the left hand to stabilize the balloon at the internal urethral meatus. With the right hand, I introduced a spinal needle through the urethral lumen on the outer surface of the catheter to puncture the balloon. This technique was simple.
1. Lamm, D. L., Riggs, D. R., Shriver, J. S., vanGilder, P. F., Rach, J. F. and DeHaven, J. I.: Megadose vitamins in bladder cancer: a double-blind clinical trial. J. Urol., 151: 21, 1994. 2. Lamm, D. L., Blumenstein, B. A., Crawford, E. D., Montie, J. E., Scardino, P., Grossman, H. B., Stanisic, T. H., Smith, J. A., Jr., Sullivan, J., Sarosdy, M. F., Crissman, J. D. and Coltman, C. A.: A randomized trial of intravesical doxorubicin and immunotherapy with bacillus Calmette-Guerin for transitionalcell carcinoma of the bladder. New Engl. J. Med., 325: 1205, 1991. 3. Kaplan, J. P., Annest, J. L., Loyde, P. M. and Rubin, G. L.: Nutrient intake and supplementation in the United States (NHANEA II). Amer. J. Public Health, 76: 287, 1986.
M. J. Droller
RE: RETURN OF ERECTIONS AND URINARY CONTINENCE FOLLOWING NERVE SPARING RADICAL RETROPUBIC PROSTATECTOMY
J. Urol., 151: 47-48, 1994
W. J. Catalona and J. W. Basler
To the Editor. In Doctor Droller's comments regarding our article on megadose vitamins in bladder cancer! he expressed the opinion, as did we, that the estimated incidence of tumor recurrence at 5 years in bacillus Calmette-Guerin (BCG) treated patients was
J. Urol., 150: 905-907, 1993
RE: EDITORIAL: BLADDER CANCER
To the Editor. With regard to the data concerning the return of erectile function presented in this article, there are 2 issues that
1213