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Re: Epididymitis from Enterobius Vermicularis: Case Report by G. Kollias, M. Kyriakopoulos and G. Tiniahos J. Urol, 147: 1114-1116, 1992
487
LETTERS TO THE EDITOR which may also prevent attachment and withdrawal of the distal tip of the stent. Finally, such manipulation may result in poor visibility and this would make subsequent ureteroscopy difficult. Respectfully, Chandra Shekhar Biyani RG Stone Clinic D/49, Pamposh Enclave G. K. - I, New Delhi - 1 1 0 048 1. Mardis, H. K.: Evaluation of p olymeric materials for endourologic devices. Emerging importance of hydrogels. Sem. Intervent. Rad., 4: 36, 1987. Reply by Authors. Doctor Biyani raises several points concerning our technique for retrieval of a proximally migrated ureteral stent. We have used this technique successfully in more than 20 cases and have had 3 failures. In 1 failure there was a tendency for the stent to be displaced proximally by advancing the balloon dilator over the guide wire. In this instance we merely proceeded to the next logical step, which is ureteroscopy. We have not noted a significant tendency for a new balloon that is well coapted onto the shaft to displace stents proximally. However, this is a potential problem that is salvageable with ureteroscopy. All 3 failures were managed with the ureteroscope and we did not note an increase in difficulty because of poor visibility. All of the stents that we removed with the balloon technique have been silicone based, in which the proximal coil has uncurled easily. Theoret ically, polyurethane stents would be more difficult to retrieve in this fashion because of the increased durometer. For the same reason, however, polyurethane stents are less likely to migrate up into the ureter because of the decreased tendency for the distal coil to unfurl and migrate proximally. We expect that in patients with a large, capacious ureter, for example during pregnancy, the balloon technique would be less effective and ureteroscopic removal is indicated. However, we have found that our technique is effective, safe and rapid, and can be performed without the need for general anesthesia in the majority of patients.
RE: DISTRIBUTION OF RETROPERITONEAL METASTASES AFTER CHEMOTHERAPY IN PATIENTS WITH NONSEMINOMATOUS GERM CELL TUMORS D. P. Wood, Jr., H. W. Herr, G. Heller, V. Vlamis, P. C. Sogani, R. J. Motzer, W. R. Fair and G. J. Bosl J. Ural., 148: 1812-1816, 1992 To the Editor. The extent of surgical resection in patients with metastasized testicular germ cell tumors who undergo retroperitoneal lymphadenectomy after chemotherapy is still unclear. The authors suggest that excision of the residual tumor with limiting the dissection to the templates of the modified retroperitoneal lymphadenectomy might be appropriate for a select group of patients. To identify patients suitable for this approach, they use frozen section examination during the operation. Their arguments for decreasing the extent of surgery are the high complication rate of post-chemotherapy dissections of up to 26% as well as the loss of ejaculation in the case of bilateral dissections. Before embarking on this new strategy, 4 additional thoughts should be considered. 1) The complication rate cited by the authors and used as an argument for the modified approach is derived from patients undergoing surgery between 1965 and 1980, all of whom had undergone extended suprahilar dissections.' As stated by Doctor Richie in his Editorial Comment, the morbidity has substantially decreased since that time and suprahilar dissections also no longer belong to the routine retroperitoneal lymphadenectomy today. 2) The surgical boundaries upon which the analysis of the authors is based are not identical with the templates commonly understood as the boundaries of the modified retroperitoneal lymphadenectomy.2 If in the case of a left tumor the interaortocaval region and the entire preaortic space are resected, then the term modified retroperitoneal lymphadenectomy is clearly mislead ing. Moreover, if the dissection extends thus far then the goal of avoiding the "disruption of sympathetic nerves" will necessarily be missed because the sympathetic hypogastric plexus lies exactly in this area. If one's goal is to preserve the nerves one should consider truly nerve sparing techniques,3 possibly aided by electrostimulation for the identification of relevant nerves.• 3) Frozen section examination un doubtedly has its merits. However, in the setting of post-chemotherapy
retroperitoneal lymphadenectomy it is a highly difficult task for the surgical pathologist. Usually, in these specimens there are wide areas of necrosis and fibrosis, and viable tumor cells might be hidden in small areas and be disclosed only after thorough immunohistological exami nation. The rate of false-negative frozen section examinations of 10% as stated in the article corresponds to the general experience in our department but it should also be noted that due to small sample size the 95% confidence limits in the study range up to 23% . Thus, it appears that frozen section technique is an instrument that should be used with great caution, especially in the post-chemotherapy setting. 4) The principal aim of the authors was to decrease morbidity while doing post-chemotherapy retroperitoneal lymphadenectomy. No one would dispute the benefits of this attitude. However, it is worth remem bering that the authors operate on an unselected group of patients (that is all patients after chemotherapy) and then select a sub group of patients during the operation for whom a reduced surgical procedure is believed appropriate. If the authors find that a modified dissection is safe in patients with no apparent residual tumor the question may be asked whether it is meaningful to perform retroperitoneal lymphade nectomy without selection in all patients. It might also be asked if a subgroup of patients could have been spared the operation by transfer ring the process of selecting patients from intraoperatively to the time before the operation. This might indeed be the most preferable way to decrea;,e surgical morbidity. Respectfully, Klaus-P. Dieckmann Urologische Klinik Universitatsklinikum Steglitz Hindenburgdamm 30 D-1 000 Berlin 45 Federal Republic of Germany 1. Donohue, J. P. and Rowland, R. G.: Complications of retroperito neal lymph node dissection. J. Urol. , 125: 338, 1981. 2. Richie, J. P.: Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J. Urol., 1 4 4 : 1160, 1990. 3. Donohue, J. P., Foster, R. S., Rowland, R. G., Bihrle, R., Jones, J. and Geier, G.: Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation. J. Urol., 144: 287, 1990. 4. Dieckmann, K.-P., Huland, H. and Gross, A. J.: A test for the identification of relevant sympathetic nerve fibers during nerve sparing retroperitoneal lymphadenectomy. J. Urol., 1 48: 1450, 1992. Reply by Authors. Although the complication rate has decreased during the years, a post-chemotherapy retroperitoneal lymphadenec tomy remains a formidable procedure in the best of hands, and any effort to limit the extent of surgery and potential morbidity should be explored. Perhaps a limited rather than a modified retroperitoneal lymphadenectomy is a more appropriate term, since we propose that dissection below the origin of the inferior mesenteric artery is unnec essary in the case of a negative frozen section of a mass removed from the primary landing site. The caution regarding relying on frozen section examination is well taken and requires further study by a dedicated pathologist examining tissue from a prospective study. We agree that better preoperative selection to avoid an operation is the ultimate goal and certainly would decrease morbidity. Our study was done precisely because our prior studies of such patients failed to identify reliably a subset who could be spared retroperitoneal lymph adenectomy. Finally, our observations need confirmation in a prospec tive, unbiased trial. Such study is currently underway at our institution.
RE: EPIDIDYMITIS FROM ENTEROBIUS VERMICULARIS: CASE REPORT G. Kollias, M. Kyriakopoulos and G. Tiniakos J. Urol., 147: 1114-11 16, 1992 To the Editor. The authors reported a case of epididymitis due to 1 or several male pinworms. As far as I could ascertain there has been no similar report in the literature describing disease related to male pinworms. 1 Unfortunately, the authors did not provide any details on the diagnosis except for the diameter of the parasite (250 to 350 µ.) on transverse section. However, these diameters are too large for male Enterobius vermicularis, which is actually 0.1 to 0.2 mm. in greatest diameter. 2
488
LETTERS TO THE EDITOR
Another doubtful or incorrect point in their case report is the diagnosis of enterobiasis. They state that "the diagnosis depends upon finding adult worms in the stool on the perianal skin." I believe that we should also take their comment that "the patient reported that he was voiding pinworms in the urine" with a grain of salt. For these reasons it may be advisable to obtain the views of an authority (such as Prof. P. C. Beaver of Tulane University) on the histopathological sections. Respectfully,
Gulendame Saygi Cumhuriyet University Faculty of Medicine Department of Microbiology 58140 Sivas, Turkey
1. Vural, S., Tahsinoglu, M. and Girisken, G.: Granuloma in the pouch of Douglas caused by Enterobius vermicularis. Ann. Trop. Med. Parasit., 60: 125, 1966. 2. Beaver, P. C., Jung, R. C. and Cupp, E. W.: Clinical Parasitology, 9th ed. Philadelphia: Lea & Febiger, 1984.
RE: LATE LOCAL COMPLICATIONS AFTER DEFINITIVE RADIOTHERAPY FOR PROSTATIC ADENOCARCINOMA J. G. Moreno and T. E. Ahlering
with local recurrences are usually excluded from the determination of complication rates by statistical methods. One patient who required colostomy was subsequently found to have nonHodgkin's lymphoma, not radiotherapy, as the etiology of the bowel obstruction. Many patients with complications were treated more than 10 years ago by radiotherapy techniques that lacked contemporary methods, such as computerized tomography treatment planning, 4-field box technique and custom blocking.' While we believe it is necessary for radiation oncologists to analyze treatment complications in an effort to improve outcome for their patients, the study by Doctors Moreno and Ahlering has several signif icant problems that preclude its possible usefulness. In an editorial in the March 1992 issue of the Journal of Urology, Doctor Shipley ex presses the judgment that the true prevalence of local complications after prostate cancer irradiation is closer to 1 1 % than 70%. 2 We agree and would like to add that an appropriate analysis of treatment-related complications should be based upon comprehensive reviews from single institutions or protocol groups free of selection bias. Respectfully, Richard D. Pezner and James A. Lipsett Division of Radiation Oncology City of Hope National Medical Center Duarte, California 91010
1. Soffen, E. M., Hanks, G. E., Hwang, C. C. and Chu, J. C.: Conformal static field therapy for low volume low grade prostate cancer with rigid immobilization. Int. J. Rad. Oncol. Biol. Phys. , 20: 141, 1991. 2. Shipley, W. U.: Radiation therapy. J. Urol., part 2, 147: 929, 1992.
J. Urol., 14 7 : 926-928, 1992 To the Editor. The authors stated "that patients with recurrent prostate cancer after definitive radiotherapy will experience a 70% risk of late local complications . . . . " As radiation oncologists who have practiced at City of Hope National Medical Center for more than a dozen years, we were particularly interested in this rather surprising conclusion. The authors provided a list of the 33 analyzed radiation therapy patients for our review. We would like to make several obser vations concerning the limitations of their analysis. Analysis was limited to patients for whom a death certificate was available. We note that, with few exceptions, institutional policy has been to place copies of death certificates in medical records only for patients who died while hospitalized at City of Hope National Medical Center. The 33 analyzed patients are, thus, highly selected. During the same 10-year period more than 200 patients with prostate cancer of various stages were evaluated with or without receiving treatment at City of Hope National Medical Center and they subsequently died. Of the 33 evaluated patients 15 underwent radiotherapy elsewhere before referral to City of Hope National Medical Center. Patients are referred to tertiary cancer hospitals following treatment because they have new medical problems. This is a built-in bias of studies that include selected patients referred following treatment. While most patients treated elsewhere were referred for management of distant metastases or a new primary malignancy, 3 had local-regional tumor recurrence at referral. One patient was referred for surgery to alleviate bladder outlet obstruction following radical prostatectomy and post operative radiation therapy. Of the 33 patients 6 had local-regional recurrences following defini tive radiotherapy. These patients should be analyzed separately. To merge patients requiring surgery for recurrences would be analogous to evaluating the results of radical prostatectomy by combining patients having complications with those having local recurrences. Patients
Reply by Authors. The commentary on our article by Doctors Pezner and Lipsett deserves some clarification. Our experience with managing late local problems after definitive radiotherapy treated at or referred to the City of Hope National Medical Center prompted this study. Patients were selected for analysis if they received definitive radiother apy and then died with or of metastatic disease while being cared for at the City of Hope National Medical Center. Patients with localized inactive disease that comprised the other 200 cases were not the focus of our analysis. Patients having received post-radical prostatectomy radiotherapy were not part of the review as incorrectly stated. Early in the design of the study we were cognizant of the inherent limitations of a retrospective analysis, which include some of the selection biases cited by Doctors Pezner and Lipsett. Therefore, we compared the radiotherapy group to a cohort of patients who primarily received hormonal deprivation and subsequently died at the City of Hope National Medical Center with or of metastatic disease. This group was influenced by the same selection factors and, in essence, the main difference between these 2 cohorts is that 1 received definitive radio therapy early in the disease process. We found that 30% of the hor monal and 70% of the radiotherapy patients experienced local prob lems. It is also important to note that our study used death as the end point, and that most local problems occurred in the last 15 months of life. Previous reports have been limited to 5 or 10 years of followup, which as our report suggests would miss when most complications occur. We concluded that these data question reports claiming that patients who die with advanced prostate cancer almost always enjoy good local palliation. For the clinician the usefulness of this study is that it suggests that hormonal therapy alone is a viable option in the management of locally advanced prostate cancer. Furthermore, we hope that this study will stimulate and support research directed at analyzing the long-term local morbidity rate associated with definitive radiother apy.
LETTERS TO THE EDITOR which may also prevent attachment and withdrawal of the distal tip of the stent. Finally, such manipulation may result in poor visibility and this would make subsequent ureteroscopy difficult. Respectfully, Chandra Shekhar Biyani RG Stone Clinic D/49, Pamposh Enclave G. K. - I, New Delhi - 1 1 0 048 1. Mardis, H. K.: Evaluation of p olymeric materials for endourologic devices. Emerging importance of hydrogels. Sem. Intervent. Rad., 4: 36, 1987. Reply by Authors. Doctor Biyani raises several points concerning our technique for retrieval of a proximally migrated ureteral stent. We have used this technique successfully in more than 20 cases and have had 3 failures. In 1 failure there was a tendency for the stent to be displaced proximally by advancing the balloon dilator over the guide wire. In this instance we merely proceeded to the next logical step, which is ureteroscopy. We have not noted a significant tendency for a new balloon that is well coapted onto the shaft to displace stents proximally. However, this is a potential problem that is salvageable with ureteroscopy. All 3 failures were managed with the ureteroscope and we did not note an increase in difficulty because of poor visibility. All of the stents that we removed with the balloon technique have been silicone based, in which the proximal coil has uncurled easily. Theoret ically, polyurethane stents would be more difficult to retrieve in this fashion because of the increased durometer. For the same reason, however, polyurethane stents are less likely to migrate up into the ureter because of the decreased tendency for the distal coil to unfurl and migrate proximally. We expect that in patients with a large, capacious ureter, for example during pregnancy, the balloon technique would be less effective and ureteroscopic removal is indicated. However, we have found that our technique is effective, safe and rapid, and can be performed without the need for general anesthesia in the majority of patients.
RE: DISTRIBUTION OF RETROPERITONEAL METASTASES AFTER CHEMOTHERAPY IN PATIENTS WITH NONSEMINOMATOUS GERM CELL TUMORS D. P. Wood, Jr., H. W. Herr, G. Heller, V. Vlamis, P. C. Sogani, R. J. Motzer, W. R. Fair and G. J. Bosl J. Ural., 148: 1812-1816, 1992 To the Editor. The extent of surgical resection in patients with metastasized testicular germ cell tumors who undergo retroperitoneal lymphadenectomy after chemotherapy is still unclear. The authors suggest that excision of the residual tumor with limiting the dissection to the templates of the modified retroperitoneal lymphadenectomy might be appropriate for a select group of patients. To identify patients suitable for this approach, they use frozen section examination during the operation. Their arguments for decreasing the extent of surgery are the high complication rate of post-chemotherapy dissections of up to 26% as well as the loss of ejaculation in the case of bilateral dissections. Before embarking on this new strategy, 4 additional thoughts should be considered. 1) The complication rate cited by the authors and used as an argument for the modified approach is derived from patients undergoing surgery between 1965 and 1980, all of whom had undergone extended suprahilar dissections.' As stated by Doctor Richie in his Editorial Comment, the morbidity has substantially decreased since that time and suprahilar dissections also no longer belong to the routine retroperitoneal lymphadenectomy today. 2) The surgical boundaries upon which the analysis of the authors is based are not identical with the templates commonly understood as the boundaries of the modified retroperitoneal lymphadenectomy.2 If in the case of a left tumor the interaortocaval region and the entire preaortic space are resected, then the term modified retroperitoneal lymphadenectomy is clearly mislead ing. Moreover, if the dissection extends thus far then the goal of avoiding the "disruption of sympathetic nerves" will necessarily be missed because the sympathetic hypogastric plexus lies exactly in this area. If one's goal is to preserve the nerves one should consider truly nerve sparing techniques,3 possibly aided by electrostimulation for the identification of relevant nerves.• 3) Frozen section examination un doubtedly has its merits. However, in the setting of post-chemotherapy
retroperitoneal lymphadenectomy it is a highly difficult task for the surgical pathologist. Usually, in these specimens there are wide areas of necrosis and fibrosis, and viable tumor cells might be hidden in small areas and be disclosed only after thorough immunohistological exami nation. The rate of false-negative frozen section examinations of 10% as stated in the article corresponds to the general experience in our department but it should also be noted that due to small sample size the 95% confidence limits in the study range up to 23% . Thus, it appears that frozen section technique is an instrument that should be used with great caution, especially in the post-chemotherapy setting. 4) The principal aim of the authors was to decrease morbidity while doing post-chemotherapy retroperitoneal lymphadenectomy. No one would dispute the benefits of this attitude. However, it is worth remem bering that the authors operate on an unselected group of patients (that is all patients after chemotherapy) and then select a sub group of patients during the operation for whom a reduced surgical procedure is believed appropriate. If the authors find that a modified dissection is safe in patients with no apparent residual tumor the question may be asked whether it is meaningful to perform retroperitoneal lymphade nectomy without selection in all patients. It might also be asked if a subgroup of patients could have been spared the operation by transfer ring the process of selecting patients from intraoperatively to the time before the operation. This might indeed be the most preferable way to decrea;,e surgical morbidity. Respectfully, Klaus-P. Dieckmann Urologische Klinik Universitatsklinikum Steglitz Hindenburgdamm 30 D-1 000 Berlin 45 Federal Republic of Germany 1. Donohue, J. P. and Rowland, R. G.: Complications of retroperito neal lymph node dissection. J. Urol. , 125: 338, 1981. 2. Richie, J. P.: Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J. Urol., 1 4 4 : 1160, 1990. 3. Donohue, J. P., Foster, R. S., Rowland, R. G., Bihrle, R., Jones, J. and Geier, G.: Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation. J. Urol., 144: 287, 1990. 4. Dieckmann, K.-P., Huland, H. and Gross, A. J.: A test for the identification of relevant sympathetic nerve fibers during nerve sparing retroperitoneal lymphadenectomy. J. Urol., 1 48: 1450, 1992. Reply by Authors. Although the complication rate has decreased during the years, a post-chemotherapy retroperitoneal lymphadenec tomy remains a formidable procedure in the best of hands, and any effort to limit the extent of surgery and potential morbidity should be explored. Perhaps a limited rather than a modified retroperitoneal lymphadenectomy is a more appropriate term, since we propose that dissection below the origin of the inferior mesenteric artery is unnec essary in the case of a negative frozen section of a mass removed from the primary landing site. The caution regarding relying on frozen section examination is well taken and requires further study by a dedicated pathologist examining tissue from a prospective study. We agree that better preoperative selection to avoid an operation is the ultimate goal and certainly would decrease morbidity. Our study was done precisely because our prior studies of such patients failed to identify reliably a subset who could be spared retroperitoneal lymph adenectomy. Finally, our observations need confirmation in a prospec tive, unbiased trial. Such study is currently underway at our institution.
RE: EPIDIDYMITIS FROM ENTEROBIUS VERMICULARIS: CASE REPORT G. Kollias, M. Kyriakopoulos and G. Tiniakos J. Urol., 147: 1114-11 16, 1992 To the Editor. The authors reported a case of epididymitis due to 1 or several male pinworms. As far as I could ascertain there has been no similar report in the literature describing disease related to male pinworms. 1 Unfortunately, the authors did not provide any details on the diagnosis except for the diameter of the parasite (250 to 350 µ.) on transverse section. However, these diameters are too large for male Enterobius vermicularis, which is actually 0.1 to 0.2 mm. in greatest diameter. 2
488
LETTERS TO THE EDITOR
Another doubtful or incorrect point in their case report is the diagnosis of enterobiasis. They state that "the diagnosis depends upon finding adult worms in the stool on the perianal skin." I believe that we should also take their comment that "the patient reported that he was voiding pinworms in the urine" with a grain of salt. For these reasons it may be advisable to obtain the views of an authority (such as Prof. P. C. Beaver of Tulane University) on the histopathological sections. Respectfully,
Gulendame Saygi Cumhuriyet University Faculty of Medicine Department of Microbiology 58140 Sivas, Turkey
1. Vural, S., Tahsinoglu, M. and Girisken, G.: Granuloma in the pouch of Douglas caused by Enterobius vermicularis. Ann. Trop. Med. Parasit., 60: 125, 1966. 2. Beaver, P. C., Jung, R. C. and Cupp, E. W.: Clinical Parasitology, 9th ed. Philadelphia: Lea & Febiger, 1984.
RE: LATE LOCAL COMPLICATIONS AFTER DEFINITIVE RADIOTHERAPY FOR PROSTATIC ADENOCARCINOMA J. G. Moreno and T. E. Ahlering
with local recurrences are usually excluded from the determination of complication rates by statistical methods. One patient who required colostomy was subsequently found to have nonHodgkin's lymphoma, not radiotherapy, as the etiology of the bowel obstruction. Many patients with complications were treated more than 10 years ago by radiotherapy techniques that lacked contemporary methods, such as computerized tomography treatment planning, 4-field box technique and custom blocking.' While we believe it is necessary for radiation oncologists to analyze treatment complications in an effort to improve outcome for their patients, the study by Doctors Moreno and Ahlering has several signif icant problems that preclude its possible usefulness. In an editorial in the March 1992 issue of the Journal of Urology, Doctor Shipley ex presses the judgment that the true prevalence of local complications after prostate cancer irradiation is closer to 1 1 % than 70%. 2 We agree and would like to add that an appropriate analysis of treatment-related complications should be based upon comprehensive reviews from single institutions or protocol groups free of selection bias. Respectfully, Richard D. Pezner and James A. Lipsett Division of Radiation Oncology City of Hope National Medical Center Duarte, California 91010
1. Soffen, E. M., Hanks, G. E., Hwang, C. C. and Chu, J. C.: Conformal static field therapy for low volume low grade prostate cancer with rigid immobilization. Int. J. Rad. Oncol. Biol. Phys. , 20: 141, 1991. 2. Shipley, W. U.: Radiation therapy. J. Urol., part 2, 147: 929, 1992.
J. Urol., 14 7 : 926-928, 1992 To the Editor. The authors stated "that patients with recurrent prostate cancer after definitive radiotherapy will experience a 70% risk of late local complications . . . . " As radiation oncologists who have practiced at City of Hope National Medical Center for more than a dozen years, we were particularly interested in this rather surprising conclusion. The authors provided a list of the 33 analyzed radiation therapy patients for our review. We would like to make several obser vations concerning the limitations of their analysis. Analysis was limited to patients for whom a death certificate was available. We note that, with few exceptions, institutional policy has been to place copies of death certificates in medical records only for patients who died while hospitalized at City of Hope National Medical Center. The 33 analyzed patients are, thus, highly selected. During the same 10-year period more than 200 patients with prostate cancer of various stages were evaluated with or without receiving treatment at City of Hope National Medical Center and they subsequently died. Of the 33 evaluated patients 15 underwent radiotherapy elsewhere before referral to City of Hope National Medical Center. Patients are referred to tertiary cancer hospitals following treatment because they have new medical problems. This is a built-in bias of studies that include selected patients referred following treatment. While most patients treated elsewhere were referred for management of distant metastases or a new primary malignancy, 3 had local-regional tumor recurrence at referral. One patient was referred for surgery to alleviate bladder outlet obstruction following radical prostatectomy and post operative radiation therapy. Of the 33 patients 6 had local-regional recurrences following defini tive radiotherapy. These patients should be analyzed separately. To merge patients requiring surgery for recurrences would be analogous to evaluating the results of radical prostatectomy by combining patients having complications with those having local recurrences. Patients
Reply by Authors. The commentary on our article by Doctors Pezner and Lipsett deserves some clarification. Our experience with managing late local problems after definitive radiotherapy treated at or referred to the City of Hope National Medical Center prompted this study. Patients were selected for analysis if they received definitive radiother apy and then died with or of metastatic disease while being cared for at the City of Hope National Medical Center. Patients with localized inactive disease that comprised the other 200 cases were not the focus of our analysis. Patients having received post-radical prostatectomy radiotherapy were not part of the review as incorrectly stated. Early in the design of the study we were cognizant of the inherent limitations of a retrospective analysis, which include some of the selection biases cited by Doctors Pezner and Lipsett. Therefore, we compared the radiotherapy group to a cohort of patients who primarily received hormonal deprivation and subsequently died at the City of Hope National Medical Center with or of metastatic disease. This group was influenced by the same selection factors and, in essence, the main difference between these 2 cohorts is that 1 received definitive radio therapy early in the disease process. We found that 30% of the hor monal and 70% of the radiotherapy patients experienced local prob lems. It is also important to note that our study used death as the end point, and that most local problems occurred in the last 15 months of life. Previous reports have been limited to 5 or 10 years of followup, which as our report suggests would miss when most complications occur. We concluded that these data question reports claiming that patients who die with advanced prostate cancer almost always enjoy good local palliation. For the clinician the usefulness of this study is that it suggests that hormonal therapy alone is a viable option in the management of locally advanced prostate cancer. Furthermore, we hope that this study will stimulate and support research directed at analyzing the long-term local morbidity rate associated with definitive radiother apy.