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Re: Elevated Bone Marrow Acid Phosphatase: The Problem of False Positives, by Srianee M. Dias and Roy N. Barnett, J. Urol., 117: 749–751, 1977
1074
LETTERS TO THE EDITOR
Reply by authors. We presented this case not because of the surgical management but because of the unique type of trauma. The management described was neither ideal nor the only solution. Of course, an emergency nephrostomy followed by a delayed restoration of the ureter is a possibility but we personally believe that autotransplantation would have been the ideal management and we regret that we did not do it.
PEYRONIE'S DISEASE AND PENILE IMPLANTATION
To the Editor. Raz and associates described a technique to treat advanced Peyronie's disease by incision of the plaque (or plaques) and insertion of a Small-Carrion prosthesis.' This approach has been successful in their hands. I propose that the technique can be simplified. There appear to be 2 disadvantages in their method: 1) much dissection must, of necessity, be slow and time-consuming and, unavoidably, does injure some neurovascular bundles however carefully it is done, and 2) the minor or major impairment of these nerves and vessels will interfere with the erectile potentialities to some degree, thus altering and diminishing full erection superimposed upon the inserted prosthesis. For these reasons I suggest that there is no need for any attention to any or all of the areas of Peyronie's plaque formation. The prosthetic devices, themselves, are sufficient to overcome the tendency to penile curvature on erection; nor ultimately is there any pain with this expedient of non-incision or removal of the plaque. Illustrative case. S. B., a 54-year-old college dean, was first seen in June 1976. He had had Peyronie's disease for 3 years and had had a multitude of therapies. His problem was that of a totally disabling erectile curvature downward and to the left and he had been unable to perform sexually during all of this time. He was distraught emotionally and his marital life was in total disharmony. Examination showed a line of hard and rigid material along the dorsum of the penis somewhat to the left of the midline, virtually from the glands to the base. Smaller thickened areas were palpable as discrete bundles along the left lateral border of the penis. An operation was done via a semicircular skin incision; no attempt at interference with the Peyronie's plaque was made. A SmallCarrion prosthesis was inserted into each corpus cavernosum through a 1.5 cm. longitudinal incision made in each investing cover of the corpus. These incisions were approximately at mid-length of the penile shaft and were closed with absorbable sutures, as were all additional layers including the skin. No postoperative difficulties were encountered. The patient was asked not to engage in sexual activity for 1 month. Subsequently, the patient reported that coitus was eminently satisfactory, that there was no pain or curvature and that he had a natural erection, which enhanced the rigidity of the penis. Comment. I believe that this case is indicative of the thesis that there is no need for interference with the Peyronie's plaque when penile prostheses are inserted to restore normal male sexual function. I must also mention that I differ too from the approach of Small and associates, in that I do not insert any prosthesis via the perinea! route (except in an associated post-prostatectomy repair for incontinence) for impotence whatever the cause. 2 It is my own belief that there is a great possibility of postoperative infection (warranted or not) if one uses the perinea! route. I have inserted the prostheses via the penile incisions and have had uniform success without the fear of invading through a potentially contaminated and/or infected area. This procedure also has eliminated the need for an extensive antibiotic coverage, which is customarily essential in the perinea! placement of the foreign bodies. Respectfully, Philip R. Roen New York Medical College St. Clare's Hospital New York, New York 1. Raz, S., deKernion, J. B. and Kaufman, J. J.: J. Urol., 117: 598, 1977. 2. Small, M. P., Carrion, H. M. and Gordon, J. A.: Urology, 5: 479, 1975.
RE: ELEVATED BONE MARROW ACID PHOSPHATASE: THE PROBLEM OF FALSE POSITIVES
Srianee M. Dias and Roy N. Barnett J. Urol., 117: 749-751, 1977
To the Editor. These authors add to the present controversy in the role of bone marrow acid phosphatase assay in staging prostatic cancer. There are several aspects of the study that deserve comment. First, determination of the enzyme in marrow from cadavers is of questionable value since postmortem changes may give spurious results. This fact is seen clearly in the tables, showing that all cadavers had values above the normal range. Also, the substrate pnitrophenyl phosphate is of known low specificity' and, thus, the enzymatic activity may well not be of prostatic origin. Finally, the technique and timing of the sampling are of paramount importance: strong and negative pressure on the syringe promotes hemolysis and release ofnon-prostatic acid phosphatase, and recent manipulation of the gland increases the levels of the prostatic fraction of the enzyme. We believe that the role of bone marrow acid phosphatase in the staging of patients with early carcinoma of the prostate has not been defined. Only by comparative evaluation of the various colorimetric and newly developed specific immunological methods, other staging procedures (radiological, histological) and sufficient folIowup of large populations can the value of the bone marrow acid phosphatase assay be placed in proper perspective. We agree with the authors that bone marrow acid phosphatase levels should not be the sole basis for management decisions in carcinoma of the prostate. However, let us give the bone marrow acid phosphatase assay a fair trial before sentencing it! Respectfully, A. W. Bruce, A. Morales and A. F. Clark Queen's University Kingston, Ontario, Canada 1. Li, C. Y., Chuda, R. A., Lam, W. K. W. and Yam, L. T.: Acid phosphatases in human plasma. J. Lab. Clin. Med., 82: 446, 1973.
Reply by authors. We do not believe that we have sentenced the bone marrow acid phosphatase assay without a fair trial. Under the conditions of our experiment, which were essentially those currently in use by those who recommend the test, there are an inordinate number of false positives, including 8 of 18 living patients.
BALLOON OCCLUSION OF THE RENAL ARTERY
To the Editor. Balloon occlusion of the renal artery represents a distinct urologic surgical procedure to control effectively renal blood flow. A 21-year-old woman required urologic investigation because of a large and rapidly growing abdominal mass on the right side. The diagnostic studies included a venacavogram, flush aortogram and selective renal arteriogram. A 7F end-hole double-lumen catheter was positioned just distal to the origin of the right renal artery via a right groin Seldinger approach and the balloon was inflated with 0.6 cc fluid. A thoracoabdominal incision was used. Instead of encountering a tense, bulging mass covered with vascular collaterals ready to burst into a thousand bonfires, the hypernephroma-bearing kidney, weighing more than 2 pounds, presented itself as a soft virtually bloodless organ, which yielded readily to radical nephrectomy. Balloon arterial occlusion is not necessary for most renal neoplasms but it certainly and safely facilitates the dissection of large renal tumors. This same technique of balloon occlusion of the renal artery was used in a 15-year-old boy who sustained a major right renal injury, the result of a motorcycle accident. The drip infusion pyelogramnephrotomogram, the sonogram, the selective renal arteriogram and, of course, the clinical findings disclosed a shattered kidney with a rapidly expanding flank mass and rapidly dropping hemoglobin and hematocrit, which obviously warranted urgent nephrectomy. Preoperative intra-arterial balloon occlusion quickly stemmed the tide,
LETTERS TO THE EDITOR
Reply by authors. We presented this case not because of the surgical management but because of the unique type of trauma. The management described was neither ideal nor the only solution. Of course, an emergency nephrostomy followed by a delayed restoration of the ureter is a possibility but we personally believe that autotransplantation would have been the ideal management and we regret that we did not do it.
PEYRONIE'S DISEASE AND PENILE IMPLANTATION
To the Editor. Raz and associates described a technique to treat advanced Peyronie's disease by incision of the plaque (or plaques) and insertion of a Small-Carrion prosthesis.' This approach has been successful in their hands. I propose that the technique can be simplified. There appear to be 2 disadvantages in their method: 1) much dissection must, of necessity, be slow and time-consuming and, unavoidably, does injure some neurovascular bundles however carefully it is done, and 2) the minor or major impairment of these nerves and vessels will interfere with the erectile potentialities to some degree, thus altering and diminishing full erection superimposed upon the inserted prosthesis. For these reasons I suggest that there is no need for any attention to any or all of the areas of Peyronie's plaque formation. The prosthetic devices, themselves, are sufficient to overcome the tendency to penile curvature on erection; nor ultimately is there any pain with this expedient of non-incision or removal of the plaque. Illustrative case. S. B., a 54-year-old college dean, was first seen in June 1976. He had had Peyronie's disease for 3 years and had had a multitude of therapies. His problem was that of a totally disabling erectile curvature downward and to the left and he had been unable to perform sexually during all of this time. He was distraught emotionally and his marital life was in total disharmony. Examination showed a line of hard and rigid material along the dorsum of the penis somewhat to the left of the midline, virtually from the glands to the base. Smaller thickened areas were palpable as discrete bundles along the left lateral border of the penis. An operation was done via a semicircular skin incision; no attempt at interference with the Peyronie's plaque was made. A SmallCarrion prosthesis was inserted into each corpus cavernosum through a 1.5 cm. longitudinal incision made in each investing cover of the corpus. These incisions were approximately at mid-length of the penile shaft and were closed with absorbable sutures, as were all additional layers including the skin. No postoperative difficulties were encountered. The patient was asked not to engage in sexual activity for 1 month. Subsequently, the patient reported that coitus was eminently satisfactory, that there was no pain or curvature and that he had a natural erection, which enhanced the rigidity of the penis. Comment. I believe that this case is indicative of the thesis that there is no need for interference with the Peyronie's plaque when penile prostheses are inserted to restore normal male sexual function. I must also mention that I differ too from the approach of Small and associates, in that I do not insert any prosthesis via the perinea! route (except in an associated post-prostatectomy repair for incontinence) for impotence whatever the cause. 2 It is my own belief that there is a great possibility of postoperative infection (warranted or not) if one uses the perinea! route. I have inserted the prostheses via the penile incisions and have had uniform success without the fear of invading through a potentially contaminated and/or infected area. This procedure also has eliminated the need for an extensive antibiotic coverage, which is customarily essential in the perinea! placement of the foreign bodies. Respectfully, Philip R. Roen New York Medical College St. Clare's Hospital New York, New York 1. Raz, S., deKernion, J. B. and Kaufman, J. J.: J. Urol., 117: 598, 1977. 2. Small, M. P., Carrion, H. M. and Gordon, J. A.: Urology, 5: 479, 1975.
RE: ELEVATED BONE MARROW ACID PHOSPHATASE: THE PROBLEM OF FALSE POSITIVES
Srianee M. Dias and Roy N. Barnett J. Urol., 117: 749-751, 1977
To the Editor. These authors add to the present controversy in the role of bone marrow acid phosphatase assay in staging prostatic cancer. There are several aspects of the study that deserve comment. First, determination of the enzyme in marrow from cadavers is of questionable value since postmortem changes may give spurious results. This fact is seen clearly in the tables, showing that all cadavers had values above the normal range. Also, the substrate pnitrophenyl phosphate is of known low specificity' and, thus, the enzymatic activity may well not be of prostatic origin. Finally, the technique and timing of the sampling are of paramount importance: strong and negative pressure on the syringe promotes hemolysis and release ofnon-prostatic acid phosphatase, and recent manipulation of the gland increases the levels of the prostatic fraction of the enzyme. We believe that the role of bone marrow acid phosphatase in the staging of patients with early carcinoma of the prostate has not been defined. Only by comparative evaluation of the various colorimetric and newly developed specific immunological methods, other staging procedures (radiological, histological) and sufficient folIowup of large populations can the value of the bone marrow acid phosphatase assay be placed in proper perspective. We agree with the authors that bone marrow acid phosphatase levels should not be the sole basis for management decisions in carcinoma of the prostate. However, let us give the bone marrow acid phosphatase assay a fair trial before sentencing it! Respectfully, A. W. Bruce, A. Morales and A. F. Clark Queen's University Kingston, Ontario, Canada 1. Li, C. Y., Chuda, R. A., Lam, W. K. W. and Yam, L. T.: Acid phosphatases in human plasma. J. Lab. Clin. Med., 82: 446, 1973.
Reply by authors. We do not believe that we have sentenced the bone marrow acid phosphatase assay without a fair trial. Under the conditions of our experiment, which were essentially those currently in use by those who recommend the test, there are an inordinate number of false positives, including 8 of 18 living patients.
BALLOON OCCLUSION OF THE RENAL ARTERY
To the Editor. Balloon occlusion of the renal artery represents a distinct urologic surgical procedure to control effectively renal blood flow. A 21-year-old woman required urologic investigation because of a large and rapidly growing abdominal mass on the right side. The diagnostic studies included a venacavogram, flush aortogram and selective renal arteriogram. A 7F end-hole double-lumen catheter was positioned just distal to the origin of the right renal artery via a right groin Seldinger approach and the balloon was inflated with 0.6 cc fluid. A thoracoabdominal incision was used. Instead of encountering a tense, bulging mass covered with vascular collaterals ready to burst into a thousand bonfires, the hypernephroma-bearing kidney, weighing more than 2 pounds, presented itself as a soft virtually bloodless organ, which yielded readily to radical nephrectomy. Balloon arterial occlusion is not necessary for most renal neoplasms but it certainly and safely facilitates the dissection of large renal tumors. This same technique of balloon occlusion of the renal artery was used in a 15-year-old boy who sustained a major right renal injury, the result of a motorcycle accident. The drip infusion pyelogramnephrotomogram, the sonogram, the selective renal arteriogram and, of course, the clinical findings disclosed a shattered kidney with a rapidly expanding flank mass and rapidly dropping hemoglobin and hematocrit, which obviously warranted urgent nephrectomy. Preoperative intra-arterial balloon occlusion quickly stemmed the tide,