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RE: FEMALE STRESS URINARY INCONTINENCE CLINICAL GUIDELINES PANEL SUMMARY REPORT ON SURGICAL MANAGEMENT OF FEMALE STRESS URINARY INCONTINENCE
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LETTERS TO THE EDITOR outcomes in stress urinary incontinence surgery rather than as guidelines for clinical practice. This time is exciting in the field of urinary incontinence and pelvic floor reconstruction. New nonsurgical methods and innovative surgical techniques are being developed at a rapid pace. Laparoscopy, bone anchoring techniques, periurethral bulking agents and new types of sling materials have all been introduced in recent years. It will be interesting to see which of these new techniques will be effective and durable in the long term when they are subjected to the rigors of peer review analysis. With this consideration in mind, the guidelines panel wisely concluded the report with recommendations for future clinical trials and research. An objective classification system should be used to stratify patients with urinary incontinence, similar to the TNM criteria for urological malignancies. The use of this type of system would provide an objective framework for patient characterization and classification as well as allow comparison between different treatment modalities. Only in this way can the various treatment strategies for stress urinary incontinence be objectively evaluated with regard to specific outcome parameters.* It is hoped that in the future, when a second meta-analysis is performed on the surgical treatment of stress urinary incontinence, some of the limitations seen in this review will no longer be present, and the data will permit more objective determination of the best surgical treatment for stress urinary incontinence in the female patient. Respectfully, Eric S. Rovner, David A. Ginsberg and Shlomo Raz Department of Urology UCLA School of Medicine 924 Westwood Blvd., Suite 520 Los Angeles, California 90024 1. Haab, F., Zimmern, P. E. and Leach, G. E.: Female stress urinary incontinence due to intrinsic sphincteric deficiency: recognition and management. J. Urol., 1 5 6 3, 1996. 2. Raz, S. and Erickson, D. R.: SEAF'I QMN incontinence classification system. Neurourol. Urodynam., 11: 187, 1992.
Reply by Authors. The members of the American Urological Association Female Stress Urinary Incontinence Clinical Guidelines Panel agree with the assessment of Rovner et a1 of the deficienciesin the literature. The panel recognized the weaknesses in the literature and clearly documented all of these in the main panel report, which is more comprehensivethan the Journal of Urology article. Given the deficiencies in the literature, the panel also relied on expert opinion as noted in the methodology section of the article. Notwithstanding the deficiencies in the peer review literature, we were gratified to see that the same literature did support panel conclusions. The panel is unanimous in the support of this document. Interested readers are encouraged to examine this main report, which is available from the American Urological Association.
RE: MODIFIED NESBIT PROCEDURE FOR THE TREATMENT OF PEYRONIES DISEASE: A COMPARATIVE OUTCOME ANALYSIS
M . R. Licht and R. W. Lewis J. Urol., 1 5 8 460-463, 1997 To the Editor. The authors compare a modified Nesbit technique to synthetic patch grafting. They refer to the scarcity of reports using synthetic patch material with small numbers of men in each study. We refer the authors to our study in 1995, which included 16 men treated with plaque incision and grafting with polytetrafluoroethylene material who were followed for a mean of 47 months.' With preoperative evaluation confirming adequate erectile rigidity, all of these men maintained normal postoperative sexual activity without complications and with no loss of length. Thus, we agree with the authors that plaque incision and synthetic grafting should be considered an alternative reconstructive approach. Respectfully, Gary E. Leach Tower Urology Institute for Continence Cedars-Sinai Medical Center Los Angeles, California 90048 1. Ganabathi, K., Dmochowski, R., Zimmern, P. E. and Leach G. E? Pe nie's disease: surgical treatment based on penille ng&ty. YUroI., 153: 662, 1995.
Reply by Authors. We compared a modified Nesbit technique to the Nesbit procedure and to complete plaque excision with patching of the defect in the tunica using polyester mesh r einforced silicone sheeting. We do not endorse the use of the latter Firocedure due to the high complication rate we encountered. The 2 r eports cited in our article also describe complete plaque excision and Flatching using similar synthetic material and they represent small S,tudies with few patients.1.2 Leach describes the results with plaque incision and polytetrafluoroethylenepatching. This different p m Clure may indeed have some merit as an alternative surgical a p Iroach.
Standard Synthetic
1. Lowe, D. H., Mo, P. C., Parsons, C. L. and Schmidt, J. D.: Sur 'cal treatment of Peyronie disease with D a m n graft. Uroggy, 1 9 609, 1982. 2. Schiffman, Z. J., Gursel, E. 0. and Laor, E.: Use of Dacron patch graft in Peyronie disease. Urology, 25: 38, 1985.
RE: LEECH THERAPY FOR MASSIVE SCROTAL HEMATOMA FOLLOWING PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY C. Goessl, K. Steffen-Wilke and K. Miller
J. Urol., 158: 545, 1997 To the Editor. The medicinal leech, Hirudo medicinalis, has been used for literally thousands of years as a therapeutic agent. Since the 1980s when French microsurgeons began using leeches to assist with artery only digital replantation in which no vein repairs were p s s i ble, there has been a resurgence of interest in the use of leeches, particularly in the fields of reconstructive and microvascular surgery. The saliva of the leech contains an astonishing array of biologically active agents, including the anticoagulant hirudin, local anesthetics and vasodilators. The efficacy of the leech is believed to be due t~ its ability to salvage tissue suffering from venous congestion. The leech bite produces a small bleeding wound that serves as an alternative source of venous outflow, which allows the leech to maintain nutritive capillary perfusion to compromised tissue. Clinicians have since reported on many different uses of the leech, ranging from well defined cases of replanted digits, avulsion injuries or free flaps suffering from venous congestion to the management of postoperative swelling and this case described by the authors. The primary action of the leech bite is not to evacuate a hematoma or other subcutaneous fluid collection. The bite produces a freshly bleeding site that reduces the tissue swelling that is produced by transudation of fluid secondary to venous outflow impairment. The authors describe applying 70 leeches in a 12-day period and yet maintain that there was no significant decrease in blood hemoglobin. The leech consumes an average of 5 ml. of blood during biting but a wound typically oozes up to 50 ml. of blood for up to 48 hours due to the anticoagulant effect of hirudin. If used properly, 70 leeches may therefore create a loss of blood of up to 3,500 ml., which is a significant subacute blood loss even during a 12-day period. Finally, although the authors state that no infection developed,they neglect to mention whether the patient was maintained on prophylactic antibiotics. Aeromonas hydrophila is a normal inhabitant of the leech gut, which has an active role in the breakdown of imbibed heme. Aeromonas hydrophila is a known pathogen in man, and leech related infections are being reported with increasing frequency, ranging from simple cellulitis to the formation of abscess collections and wound myonecrosis.' Repeated application of leeches to a closed space containing blood, particularly when there was an apparent persistent resistance to feeding as judged by the minimal decrease in hemoglobin, may have placed the patient at risk for the development of an infected hematoma. The authors are to be congratulated for conceiving a creative solution to a difficult problem. However, the potential hazards of leech therapy should be emphasized and balanced against the clinical benefit obtained. Respectfully, Allan J. Pantuck Robert Wood Johnson Medical School New Brunswick, New Jersey 08903-0019 1. Lineaweaver, W. C., Hill, M. K, Buncke, G. M., Follansbee, S., Buncke, H. J., Wong, R. K., Manders, E. K, Grotting, J. C., Anthon , J and Mathes, S. J.: Aeromonas hydrophilia infections foGowing use of medicinal leeches m replantation and flan sureerv.Ann. Plast. S m . - ,29: 238,1992.
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LETTERS TO THE EDITOR outcomes in stress urinary incontinence surgery rather than as guidelines for clinical practice. This time is exciting in the field of urinary incontinence and pelvic floor reconstruction. New nonsurgical methods and innovative surgical techniques are being developed at a rapid pace. Laparoscopy, bone anchoring techniques, periurethral bulking agents and new types of sling materials have all been introduced in recent years. It will be interesting to see which of these new techniques will be effective and durable in the long term when they are subjected to the rigors of peer review analysis. With this consideration in mind, the guidelines panel wisely concluded the report with recommendations for future clinical trials and research. An objective classification system should be used to stratify patients with urinary incontinence, similar to the TNM criteria for urological malignancies. The use of this type of system would provide an objective framework for patient characterization and classification as well as allow comparison between different treatment modalities. Only in this way can the various treatment strategies for stress urinary incontinence be objectively evaluated with regard to specific outcome parameters.* It is hoped that in the future, when a second meta-analysis is performed on the surgical treatment of stress urinary incontinence, some of the limitations seen in this review will no longer be present, and the data will permit more objective determination of the best surgical treatment for stress urinary incontinence in the female patient. Respectfully, Eric S. Rovner, David A. Ginsberg and Shlomo Raz Department of Urology UCLA School of Medicine 924 Westwood Blvd., Suite 520 Los Angeles, California 90024 1. Haab, F., Zimmern, P. E. and Leach, G. E.: Female stress urinary incontinence due to intrinsic sphincteric deficiency: recognition and management. J. Urol., 1 5 6 3, 1996. 2. Raz, S. and Erickson, D. R.: SEAF'I QMN incontinence classification system. Neurourol. Urodynam., 11: 187, 1992.
Reply by Authors. The members of the American Urological Association Female Stress Urinary Incontinence Clinical Guidelines Panel agree with the assessment of Rovner et a1 of the deficienciesin the literature. The panel recognized the weaknesses in the literature and clearly documented all of these in the main panel report, which is more comprehensivethan the Journal of Urology article. Given the deficiencies in the literature, the panel also relied on expert opinion as noted in the methodology section of the article. Notwithstanding the deficiencies in the peer review literature, we were gratified to see that the same literature did support panel conclusions. The panel is unanimous in the support of this document. Interested readers are encouraged to examine this main report, which is available from the American Urological Association.
RE: MODIFIED NESBIT PROCEDURE FOR THE TREATMENT OF PEYRONIES DISEASE: A COMPARATIVE OUTCOME ANALYSIS
M . R. Licht and R. W. Lewis J. Urol., 1 5 8 460-463, 1997 To the Editor. The authors compare a modified Nesbit technique to synthetic patch grafting. They refer to the scarcity of reports using synthetic patch material with small numbers of men in each study. We refer the authors to our study in 1995, which included 16 men treated with plaque incision and grafting with polytetrafluoroethylene material who were followed for a mean of 47 months.' With preoperative evaluation confirming adequate erectile rigidity, all of these men maintained normal postoperative sexual activity without complications and with no loss of length. Thus, we agree with the authors that plaque incision and synthetic grafting should be considered an alternative reconstructive approach. Respectfully, Gary E. Leach Tower Urology Institute for Continence Cedars-Sinai Medical Center Los Angeles, California 90048 1. Ganabathi, K., Dmochowski, R., Zimmern, P. E. and Leach G. E? Pe nie's disease: surgical treatment based on penille ng&ty. YUroI., 153: 662, 1995.
Reply by Authors. We compared a modified Nesbit technique to the Nesbit procedure and to complete plaque excision with patching of the defect in the tunica using polyester mesh r einforced silicone sheeting. We do not endorse the use of the latter Firocedure due to the high complication rate we encountered. The 2 r eports cited in our article also describe complete plaque excision and Flatching using similar synthetic material and they represent small S,tudies with few patients.1.2 Leach describes the results with plaque incision and polytetrafluoroethylenepatching. This different p m Clure may indeed have some merit as an alternative surgical a p Iroach.
Standard Synthetic
1. Lowe, D. H., Mo, P. C., Parsons, C. L. and Schmidt, J. D.: Sur 'cal treatment of Peyronie disease with D a m n graft. Uroggy, 1 9 609, 1982. 2. Schiffman, Z. J., Gursel, E. 0. and Laor, E.: Use of Dacron patch graft in Peyronie disease. Urology, 25: 38, 1985.
RE: LEECH THERAPY FOR MASSIVE SCROTAL HEMATOMA FOLLOWING PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY C. Goessl, K. Steffen-Wilke and K. Miller
J. Urol., 158: 545, 1997 To the Editor. The medicinal leech, Hirudo medicinalis, has been used for literally thousands of years as a therapeutic agent. Since the 1980s when French microsurgeons began using leeches to assist with artery only digital replantation in which no vein repairs were p s s i ble, there has been a resurgence of interest in the use of leeches, particularly in the fields of reconstructive and microvascular surgery. The saliva of the leech contains an astonishing array of biologically active agents, including the anticoagulant hirudin, local anesthetics and vasodilators. The efficacy of the leech is believed to be due t~ its ability to salvage tissue suffering from venous congestion. The leech bite produces a small bleeding wound that serves as an alternative source of venous outflow, which allows the leech to maintain nutritive capillary perfusion to compromised tissue. Clinicians have since reported on many different uses of the leech, ranging from well defined cases of replanted digits, avulsion injuries or free flaps suffering from venous congestion to the management of postoperative swelling and this case described by the authors. The primary action of the leech bite is not to evacuate a hematoma or other subcutaneous fluid collection. The bite produces a freshly bleeding site that reduces the tissue swelling that is produced by transudation of fluid secondary to venous outflow impairment. The authors describe applying 70 leeches in a 12-day period and yet maintain that there was no significant decrease in blood hemoglobin. The leech consumes an average of 5 ml. of blood during biting but a wound typically oozes up to 50 ml. of blood for up to 48 hours due to the anticoagulant effect of hirudin. If used properly, 70 leeches may therefore create a loss of blood of up to 3,500 ml., which is a significant subacute blood loss even during a 12-day period. Finally, although the authors state that no infection developed,they neglect to mention whether the patient was maintained on prophylactic antibiotics. Aeromonas hydrophila is a normal inhabitant of the leech gut, which has an active role in the breakdown of imbibed heme. Aeromonas hydrophila is a known pathogen in man, and leech related infections are being reported with increasing frequency, ranging from simple cellulitis to the formation of abscess collections and wound myonecrosis.' Repeated application of leeches to a closed space containing blood, particularly when there was an apparent persistent resistance to feeding as judged by the minimal decrease in hemoglobin, may have placed the patient at risk for the development of an infected hematoma. The authors are to be congratulated for conceiving a creative solution to a difficult problem. However, the potential hazards of leech therapy should be emphasized and balanced against the clinical benefit obtained. Respectfully, Allan J. Pantuck Robert Wood Johnson Medical School New Brunswick, New Jersey 08903-0019 1. Lineaweaver, W. C., Hill, M. K, Buncke, G. M., Follansbee, S., Buncke, H. J., Wong, R. K., Manders, E. K, Grotting, J. C., Anthon , J and Mathes, S. J.: Aeromonas hydrophilia infections foGowing use of medicinal leeches m replantation and flan sureerv.Ann. Plast. S m . - ,29: 238,1992.
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