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RE: FUNCTIONAL LOWER URINARY TRACT VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
0022-5347/00/1642-046010 Vol. 164,460-462,August 2000 Printed in U.S.A.
THEJOURNAL OF UROLOGY@ Copyright 0 2000 by AMERICAN UROL~CICAL ASSOCUTION, INC.@
Letters to the Editor RE: INCORPORATION OF PATIENT PREFERENCES IN THE TREATMENT OF UPPER URINARY TRACT CALCULI: A DECISION ANALYTICAL VIEW
RE: FUNCTIONAL LOWER URINARY TRACT VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
R. L. Kuo, P. Aslan, P. H. Abrahamse, D. B. Matchar and G. M. Preminger
D. J. Parekh, W.B. Gilbert and J. A. Smith, Jr.
J Urol, 163: 56-59, 2000
J Urol, 162 1913-1919, 1999 To the Editor. The authors emphasize the importance of incorporating patient preferences when selecting treatment for urinary calculi. An approach using a utility measure, such as standard gamble, which constitutes a form of quality of life assessment measure can be followed in clinical practice. However, we would like to indicate a few aspects of this article that raise factual and methodological controversies. The scenarios in this study are overtly simplistic and to some extent unrepresentative of routine clinical practice. In the following clinical scenarios the statements are neither uniformly applicable nor completely factual:’ 1)mild pain with lithotripsy-“there will be no long-term effects” and 2) long-term medication-“you will have to take 2 tablets twice a day“ and “apart from mild nausea you will be in perfect health.” We recognize that there is often a need to use straightforward scenarios in research involving patient decision analysis. However, descriptions of the pain used in this study are based on physician assumptions, and are too simple and rigidly linked to the treatment options without adequate explanation about the efficacy of each treatment option. These scenarios do not perform adequate assessment of all the domains of general health. The diversity of the study pop,ulation with respect to age, previous stone experience, stone treatment and the oversimplicity of the scenarios may have created bias in the selection and acceptability of treatment options. It has been established that probabilities used in the standard gamble approach may be difficult to understand for some of the respondents.2 An alternate approach to understanding patient preferences is the prospective assessment of the quality of life using a generic health measure, such as the EuroQol health index.3 We have used this approach to compare the health related quality of life of patients, while evaluating the impact of 2 alternative modalities, namely the Double-J* stent and nephrostomy tube, for the treatment of upper urinary tract obstruction.4 The use of an instrument, such as EuroQol, has an additional advantage as a utility measure. Using the time trade-off technique, information gathered with such a measure can also be used to perform a cost analysis (Quality Adjusted Life Years), thus, incorporating quality of life and economic evaluations. Incorporating these views along with the concepts presented by Kuo et a1 can add another dimension to the application of this subject in routine clinical settings. Respectfully, H. B. Joshi, A. Stainthorpe and F. X. Keeley, Jr. Department of Urology, and Research and Development Unit Southmead Hospital Bristol, BS 10 5NB United Kingdom 1. Lingeman, J., Woods, J. and Toth, P. e t al: The role of lithotripsy and its side effects. J Urol, part 2, 141: 793, 1989 2. Feeny, D., Labelle, R. and Torrance, G.: Integrating economic evaluations and quality of life assessments. In: Quality of Life Assessments in Clinical Trials. Edited by B. Spilker. New York Raven Press, Ltd., 1990 3. The EuroQol Group: EuroQol-a new facility for the measurement of health-related quality of life. Health Policy, 16:pp. 199-208, 1990 4. Joshi, H. B., Adams, S.,Obadeyi, P. N. e t al: Nephrostomy or JJ stent: what do patients feel? A health related quality of life study. J Endourol, suppl., 13:A37, 1999
*Medical Engineering Corp., New York, New York.
To the Editor. Recent articles about neobladder, such as this one, concentrate on quality of life issues and tend to ignore the fundamental issues of cancer biology. In a public sector series we found 60% of the patients whose bladder remained in situ despite muscle invasive bladder cancer and whose bladder had been staged radiologically to be without distant metastases at 10 years and longer without contemporary chemotherapeutic treatment.’ Therefore it seems that 50 of 100 patients in the series of Parekh e t a1 could have obtained cancer specific survival comparable to published cystectomy series with dated public sector, in situ treatment characteristic of the 1970s and 1980s. In addition, 26 of their cases were not muscle invasive and were eligible for a sophisticated, contemporary bladder sparing procedure.2 It is admirable that 71% of their patients were completely dry at night. However, 25% and probably 50% of their patients could have had the same quality of life and similar cancer specific survival without cystectomy. With the Medicare fee schedule for cystectomy as low as it is, this news is good for private practitioners without residents. Respectfully, Anthony H. Horan Department of Surgery Veterans Affairs Medical Center Fresno, California 93704 1. Horan, A. H. and Kaplan, A,: Mean time to death in muscle invasive bladder cancer with and without cystectomy: a longterm, retrospective, public sector study. Read a t the annual meeting of the Western section of the American Urological Association, Monterey, California, September 26, 1999 2. Cookson. M. S.. Herr. H. W.. Zhane. Z.. et al: The treated natural history of high risk superficial-bladder cancer: 15-year outcome. J Urol, 168 63, 1997
Reply by Authors. One could only hope that recommendations for or against surgery for invasive bladder cancer, whether in the public sector or elsewhere, are made independent of Medicare fee schedules. Furthermore, the implication that patients with muscle invasive bladder cancer should be offered no therapy is hardly an example of a sophisticated understanding of the fundamental issues of cancer biology.
RE: MONOCLONAL ANTIBODY CONFIRMATION OF A PRIMARY LEIOMYOMA OF THE TESTIS
C. M. Gonzalez, T. A. Victor, E. Bourtsos and M. D. Blum
J Urol, 161: 1908: 1999
To the Editor. The authors suggest that a positive immunohistochemical reaction with monoclonal antibodies to actin (clone 1A4 and HHF35) is proof of smooth muscle origin and, in this case, confirmation of a diagnosis of leiomyoma. They conclude that these antibodies are reliable markers of various smooth muscle actin isoforms but actin may also be demonstrated in a variety of nonsmooth muscle cell types, including myoepithelial cells and myofibroblastic cells.’ We recently excised a soR tissue mass from the anterior pelvis of a 38-year-old woman. Histologically, the tumor was composed of bizarre spindle cells arranged in untidy fasciculi, exhibiting nuclear pleomorphism, a low mitotic rate and an infiltrate of chronic inflammatory cells (fig. 1). Immunohistochemical staining was positive in 460
THEJOURNAL OF UROLOGY@ Copyright 0 2000 by AMERICAN UROL~CICAL ASSOCUTION, INC.@
Letters to the Editor RE: INCORPORATION OF PATIENT PREFERENCES IN THE TREATMENT OF UPPER URINARY TRACT CALCULI: A DECISION ANALYTICAL VIEW
RE: FUNCTIONAL LOWER URINARY TRACT VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
R. L. Kuo, P. Aslan, P. H. Abrahamse, D. B. Matchar and G. M. Preminger
D. J. Parekh, W.B. Gilbert and J. A. Smith, Jr.
J Urol, 163: 56-59, 2000
J Urol, 162 1913-1919, 1999 To the Editor. The authors emphasize the importance of incorporating patient preferences when selecting treatment for urinary calculi. An approach using a utility measure, such as standard gamble, which constitutes a form of quality of life assessment measure can be followed in clinical practice. However, we would like to indicate a few aspects of this article that raise factual and methodological controversies. The scenarios in this study are overtly simplistic and to some extent unrepresentative of routine clinical practice. In the following clinical scenarios the statements are neither uniformly applicable nor completely factual:’ 1)mild pain with lithotripsy-“there will be no long-term effects” and 2) long-term medication-“you will have to take 2 tablets twice a day“ and “apart from mild nausea you will be in perfect health.” We recognize that there is often a need to use straightforward scenarios in research involving patient decision analysis. However, descriptions of the pain used in this study are based on physician assumptions, and are too simple and rigidly linked to the treatment options without adequate explanation about the efficacy of each treatment option. These scenarios do not perform adequate assessment of all the domains of general health. The diversity of the study pop,ulation with respect to age, previous stone experience, stone treatment and the oversimplicity of the scenarios may have created bias in the selection and acceptability of treatment options. It has been established that probabilities used in the standard gamble approach may be difficult to understand for some of the respondents.2 An alternate approach to understanding patient preferences is the prospective assessment of the quality of life using a generic health measure, such as the EuroQol health index.3 We have used this approach to compare the health related quality of life of patients, while evaluating the impact of 2 alternative modalities, namely the Double-J* stent and nephrostomy tube, for the treatment of upper urinary tract obstruction.4 The use of an instrument, such as EuroQol, has an additional advantage as a utility measure. Using the time trade-off technique, information gathered with such a measure can also be used to perform a cost analysis (Quality Adjusted Life Years), thus, incorporating quality of life and economic evaluations. Incorporating these views along with the concepts presented by Kuo et a1 can add another dimension to the application of this subject in routine clinical settings. Respectfully, H. B. Joshi, A. Stainthorpe and F. X. Keeley, Jr. Department of Urology, and Research and Development Unit Southmead Hospital Bristol, BS 10 5NB United Kingdom 1. Lingeman, J., Woods, J. and Toth, P. e t al: The role of lithotripsy and its side effects. J Urol, part 2, 141: 793, 1989 2. Feeny, D., Labelle, R. and Torrance, G.: Integrating economic evaluations and quality of life assessments. In: Quality of Life Assessments in Clinical Trials. Edited by B. Spilker. New York Raven Press, Ltd., 1990 3. The EuroQol Group: EuroQol-a new facility for the measurement of health-related quality of life. Health Policy, 16:pp. 199-208, 1990 4. Joshi, H. B., Adams, S.,Obadeyi, P. N. e t al: Nephrostomy or JJ stent: what do patients feel? A health related quality of life study. J Endourol, suppl., 13:A37, 1999
*Medical Engineering Corp., New York, New York.
To the Editor. Recent articles about neobladder, such as this one, concentrate on quality of life issues and tend to ignore the fundamental issues of cancer biology. In a public sector series we found 60% of the patients whose bladder remained in situ despite muscle invasive bladder cancer and whose bladder had been staged radiologically to be without distant metastases at 10 years and longer without contemporary chemotherapeutic treatment.’ Therefore it seems that 50 of 100 patients in the series of Parekh e t a1 could have obtained cancer specific survival comparable to published cystectomy series with dated public sector, in situ treatment characteristic of the 1970s and 1980s. In addition, 26 of their cases were not muscle invasive and were eligible for a sophisticated, contemporary bladder sparing procedure.2 It is admirable that 71% of their patients were completely dry at night. However, 25% and probably 50% of their patients could have had the same quality of life and similar cancer specific survival without cystectomy. With the Medicare fee schedule for cystectomy as low as it is, this news is good for private practitioners without residents. Respectfully, Anthony H. Horan Department of Surgery Veterans Affairs Medical Center Fresno, California 93704 1. Horan, A. H. and Kaplan, A,: Mean time to death in muscle invasive bladder cancer with and without cystectomy: a longterm, retrospective, public sector study. Read a t the annual meeting of the Western section of the American Urological Association, Monterey, California, September 26, 1999 2. Cookson. M. S.. Herr. H. W.. Zhane. Z.. et al: The treated natural history of high risk superficial-bladder cancer: 15-year outcome. J Urol, 168 63, 1997
Reply by Authors. One could only hope that recommendations for or against surgery for invasive bladder cancer, whether in the public sector or elsewhere, are made independent of Medicare fee schedules. Furthermore, the implication that patients with muscle invasive bladder cancer should be offered no therapy is hardly an example of a sophisticated understanding of the fundamental issues of cancer biology.
RE: MONOCLONAL ANTIBODY CONFIRMATION OF A PRIMARY LEIOMYOMA OF THE TESTIS
C. M. Gonzalez, T. A. Victor, E. Bourtsos and M. D. Blum
J Urol, 161: 1908: 1999
To the Editor. The authors suggest that a positive immunohistochemical reaction with monoclonal antibodies to actin (clone 1A4 and HHF35) is proof of smooth muscle origin and, in this case, confirmation of a diagnosis of leiomyoma. They conclude that these antibodies are reliable markers of various smooth muscle actin isoforms but actin may also be demonstrated in a variety of nonsmooth muscle cell types, including myoepithelial cells and myofibroblastic cells.’ We recently excised a soR tissue mass from the anterior pelvis of a 38-year-old woman. Histologically, the tumor was composed of bizarre spindle cells arranged in untidy fasciculi, exhibiting nuclear pleomorphism, a low mitotic rate and an infiltrate of chronic inflammatory cells (fig. 1). Immunohistochemical staining was positive in 460