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RE: LAPAROSCOPIC DONOR NEPHRECTOMY: THE UNIVERSITY OF MARYLAND 6-YEAR EXPERIENCE
1199
LETTERS TO THE EDITOR Our study shows that daytime urinary incontinence is associated with inadequate toilet training skills. For this reason evaluation and treatment of patients with DUI must be accompanied by toilet training reeducation, in which all aspects of toilet training are considered. Respectfully, Gokhan Baysoy, Tugba Aydogmus, Demet Akin and Ayten P. Uyan Department of Pediatrics Izzet Baysal Medical School Izzet Baysal University 14280, Bolu Turkey 1. Bakker, E., Van Gool, J. D., Van Sprundel, M., Van Der Auwera, C. and Wyndaele, J. J.: Results of a questionnaire evaluating the effects of different methods of toilet training on achieving bladder control. BJU Int, 90: 456, 2002 2. Stadtler, A. C., Gorski, P. A. and Brazelton, T. B.: Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. Pediatrics, 103: 1359, 1999
Reply by Authors. We think that most cases of DUI in children occur functionally and are caused mainly by inappropriate voiding habits and maturational delay. Inappropriate toilet habits include postponement of urge, straining, incorrect voiding posture and constipation. We completely agree that “inappropriate toilet training methods . . . and timing are associated with urinary symptoms,” if the inappropriate toilet habits are genuinely attributable to initial inappropriate toilet training methods. However, it is interesting that the prevalence of DUI in children and the annual rate of spontaneous disappearance of DUI are almost the same worldwide, despite differences in toilet training methods, age at toilet training, cultural determinants and race. In addition, our data demonstrated that the prevalence of increased daytime frequency and average daytime frequency decrease gradually with age in both sexes. Our results suggest that the voiding mechanism continues to mature even after entrance into primary school. For these reasons we think that maturational aspects have an important role in the pathogenic mechanisms underlying DUI in children. DOI: 10.1097/01.ju.0000134351.64311.2e
RE: LAPAROSCOPIC DONOR NEPHRECTOMY: THE UNIVERSITY OF MARYLAND 6-YEAR EXPERIENCE S. C. Jacobs, E. Cho, C. Foster, P. Liao
AND
S. T. Bartlett
J Urol, 171: 47–51, 2004 To the Editor. The authors of this important article have been pioneers in popularizing laparoscopic live donor nephrectomy. The literature is replete with articles rationalizing the laparoscopic approach as superior to open nephrectomy in decreasing donor morbidity. I have performed live donor nephrectomies for more than 30 years using an extraperitoneal flank approach exclusively. In a previous letter to the editor I questioned the high complication rate of transperitoneal live donor nephrectomies reported by the Cleveland Clinic group.1 A total complication rate of 30.4% with 3.5% major complications and 2.3% incidental splenectomy seemed rather high.2 In 1981 we reported our experience with live donor nephrectomies using a standard extraperitoneal flank approach.3 There were no major and only 14.4% minor complications. The Cleveland Clinic group changed their approach in 1983 to flank extraperitoneal with rib resection and reported a 12.2% complication rate. The majority of these events were pneumothorax related to rib resection.4 Jacobs et al have reported their experience with a large number of cases followed for up to 6 years. A major intraoperative complication rate of 6.8% and 17.1% major postoperative complications reported with the laparoscopic approach are similar to if not worse than open transperitoneal live donor nephrectomies. Is this outcome justifiable in a healthy volunteer donor for the sake of shorter hospitalization, decreased use of pain medications and somewhat earlier return to work? The complications of major vascular injuries, spleen, liver and bowel lacerations, pancreatitis
and intestinal obstruction requiring laparotomy are peculiar to this laparoscopic transperitoneal approach. I have not observed any of these complications in more than 300 cases done via the open extraperitoneal flank method. The risks of laparoscopic donor nephrectomy should have been emphasized in a stronger tone with mention in the title in bold print. The strong desire to chase every new fad has made this operation routine throughout the country. Others have raised similar concerns regarding all living donors, and have reported 5 donor deaths after laparoscopic nephrectomy.5 The need for a national donor registry is urgent and just as important as the data kept by the United Network for Organ Sharing. We need to know the combined experience of complications and long-term outcome in live organ donors rather than short-term reports from a single institution. All new techniques should be developed, investigated and improved at a few centers of excellence to be made worthy of widespread use. Respectfully, Mohammad Amin Veterans Affairs Medical Center 800 Zorn Ave. Louisville, Kentucky 40206 1. Amin, M.: Re: Transperitoneal live donor nephrectomy (letter to the editor). J Urol, 126: 280, 1981 2. Ruiz, R., Novick, A. C., Braun, W. E., Montague, D. K. and Stewart, B. H.: Transperitoneal live donor nephrectomy. J Urol, 123: 819, 1980 3. DeMarco, T., Amin, M. and Harty, J. I.: Live donor nephrectomy: factors influencing morbidity. J Urol, 127: 1082, 1982 4. Streen, S. B., Novick, A. C., Steinmuller, D. R. and Graneto, D.: Flank donor nephrectomy: efficiency in the donor and recipient. J Urol, 141: 1099, 1989 5. Vastag, B.: Living-donor transplants reexamined: experts cite growing concerns about safety of donors. JAMA, 290: 181, 2003
Reply by Authors. Amin has raised many important points. However, the reporting of complications in the distant past was incomplete. For example no flank wound complications were recorded after discharge from the hospital. This result is such an unreasonable expectation that one must doubt data from that era. Complication rates from laparoscopic surgery are probably similar to open surgery but they are different complications. In the same vein, I am aware of deaths occurring after laparoscopic and open nephrectomies. Protection of the donor must remain paramount. Studying the donor outcomes, including short and particularly long-term, may provide better donor education and protection but, of course, may ultimately decrease the number of live donor transplants. The plea by Amin for investigating and developing new techniques only at a few centers of excellence is commendable and understandable, and futilely contradicts the basic assumptions of a capitalist society. DOI: 10.1097/01.ju.0000134355.66217.6d
RE: MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF SEMINAL VESICLE CYSTS AND ASSOCIATED ANOMALIES J. O. Murphy, R. E. Power, M. Akhtar, W. C. Torreggiani, T. E. D. McDermott and J. A. Thornhill J Urol, 170: 2386, 2003 To the Editor. The publication by Murphy et al confirmed magnetic resonance imaging (MRI) as the definitive technology for the diagnosis of seminal vesicle cysts. We report another seminal vesicle condition where MRI was crucial in diagnosis—a case of unilateral seminal vesicle “obstruction/ectasia” with ipsilateral renal agenesis. A 33-year-old male with persistent left perineal and scrotal pain 5 years in duration had been empirically treated elsewhere for chronic abacterial prostatitis/left epididymitis. Scrotal ultrasound demonstrated a markedly enlarged left epididymal dilatation. Renal ultrasound and cystoscopy showed left renal/ureteral agenesis. Extensive
LETTERS TO THE EDITOR Our study shows that daytime urinary incontinence is associated with inadequate toilet training skills. For this reason evaluation and treatment of patients with DUI must be accompanied by toilet training reeducation, in which all aspects of toilet training are considered. Respectfully, Gokhan Baysoy, Tugba Aydogmus, Demet Akin and Ayten P. Uyan Department of Pediatrics Izzet Baysal Medical School Izzet Baysal University 14280, Bolu Turkey 1. Bakker, E., Van Gool, J. D., Van Sprundel, M., Van Der Auwera, C. and Wyndaele, J. J.: Results of a questionnaire evaluating the effects of different methods of toilet training on achieving bladder control. BJU Int, 90: 456, 2002 2. Stadtler, A. C., Gorski, P. A. and Brazelton, T. B.: Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. Pediatrics, 103: 1359, 1999
Reply by Authors. We think that most cases of DUI in children occur functionally and are caused mainly by inappropriate voiding habits and maturational delay. Inappropriate toilet habits include postponement of urge, straining, incorrect voiding posture and constipation. We completely agree that “inappropriate toilet training methods . . . and timing are associated with urinary symptoms,” if the inappropriate toilet habits are genuinely attributable to initial inappropriate toilet training methods. However, it is interesting that the prevalence of DUI in children and the annual rate of spontaneous disappearance of DUI are almost the same worldwide, despite differences in toilet training methods, age at toilet training, cultural determinants and race. In addition, our data demonstrated that the prevalence of increased daytime frequency and average daytime frequency decrease gradually with age in both sexes. Our results suggest that the voiding mechanism continues to mature even after entrance into primary school. For these reasons we think that maturational aspects have an important role in the pathogenic mechanisms underlying DUI in children. DOI: 10.1097/01.ju.0000134351.64311.2e
RE: LAPAROSCOPIC DONOR NEPHRECTOMY: THE UNIVERSITY OF MARYLAND 6-YEAR EXPERIENCE S. C. Jacobs, E. Cho, C. Foster, P. Liao
AND
S. T. Bartlett
J Urol, 171: 47–51, 2004 To the Editor. The authors of this important article have been pioneers in popularizing laparoscopic live donor nephrectomy. The literature is replete with articles rationalizing the laparoscopic approach as superior to open nephrectomy in decreasing donor morbidity. I have performed live donor nephrectomies for more than 30 years using an extraperitoneal flank approach exclusively. In a previous letter to the editor I questioned the high complication rate of transperitoneal live donor nephrectomies reported by the Cleveland Clinic group.1 A total complication rate of 30.4% with 3.5% major complications and 2.3% incidental splenectomy seemed rather high.2 In 1981 we reported our experience with live donor nephrectomies using a standard extraperitoneal flank approach.3 There were no major and only 14.4% minor complications. The Cleveland Clinic group changed their approach in 1983 to flank extraperitoneal with rib resection and reported a 12.2% complication rate. The majority of these events were pneumothorax related to rib resection.4 Jacobs et al have reported their experience with a large number of cases followed for up to 6 years. A major intraoperative complication rate of 6.8% and 17.1% major postoperative complications reported with the laparoscopic approach are similar to if not worse than open transperitoneal live donor nephrectomies. Is this outcome justifiable in a healthy volunteer donor for the sake of shorter hospitalization, decreased use of pain medications and somewhat earlier return to work? The complications of major vascular injuries, spleen, liver and bowel lacerations, pancreatitis
and intestinal obstruction requiring laparotomy are peculiar to this laparoscopic transperitoneal approach. I have not observed any of these complications in more than 300 cases done via the open extraperitoneal flank method. The risks of laparoscopic donor nephrectomy should have been emphasized in a stronger tone with mention in the title in bold print. The strong desire to chase every new fad has made this operation routine throughout the country. Others have raised similar concerns regarding all living donors, and have reported 5 donor deaths after laparoscopic nephrectomy.5 The need for a national donor registry is urgent and just as important as the data kept by the United Network for Organ Sharing. We need to know the combined experience of complications and long-term outcome in live organ donors rather than short-term reports from a single institution. All new techniques should be developed, investigated and improved at a few centers of excellence to be made worthy of widespread use. Respectfully, Mohammad Amin Veterans Affairs Medical Center 800 Zorn Ave. Louisville, Kentucky 40206 1. Amin, M.: Re: Transperitoneal live donor nephrectomy (letter to the editor). J Urol, 126: 280, 1981 2. Ruiz, R., Novick, A. C., Braun, W. E., Montague, D. K. and Stewart, B. H.: Transperitoneal live donor nephrectomy. J Urol, 123: 819, 1980 3. DeMarco, T., Amin, M. and Harty, J. I.: Live donor nephrectomy: factors influencing morbidity. J Urol, 127: 1082, 1982 4. Streen, S. B., Novick, A. C., Steinmuller, D. R. and Graneto, D.: Flank donor nephrectomy: efficiency in the donor and recipient. J Urol, 141: 1099, 1989 5. Vastag, B.: Living-donor transplants reexamined: experts cite growing concerns about safety of donors. JAMA, 290: 181, 2003
Reply by Authors. Amin has raised many important points. However, the reporting of complications in the distant past was incomplete. For example no flank wound complications were recorded after discharge from the hospital. This result is such an unreasonable expectation that one must doubt data from that era. Complication rates from laparoscopic surgery are probably similar to open surgery but they are different complications. In the same vein, I am aware of deaths occurring after laparoscopic and open nephrectomies. Protection of the donor must remain paramount. Studying the donor outcomes, including short and particularly long-term, may provide better donor education and protection but, of course, may ultimately decrease the number of live donor transplants. The plea by Amin for investigating and developing new techniques only at a few centers of excellence is commendable and understandable, and futilely contradicts the basic assumptions of a capitalist society. DOI: 10.1097/01.ju.0000134355.66217.6d
RE: MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF SEMINAL VESICLE CYSTS AND ASSOCIATED ANOMALIES J. O. Murphy, R. E. Power, M. Akhtar, W. C. Torreggiani, T. E. D. McDermott and J. A. Thornhill J Urol, 170: 2386, 2003 To the Editor. The publication by Murphy et al confirmed magnetic resonance imaging (MRI) as the definitive technology for the diagnosis of seminal vesicle cysts. We report another seminal vesicle condition where MRI was crucial in diagnosis—a case of unilateral seminal vesicle “obstruction/ectasia” with ipsilateral renal agenesis. A 33-year-old male with persistent left perineal and scrotal pain 5 years in duration had been empirically treated elsewhere for chronic abacterial prostatitis/left epididymitis. Scrotal ultrasound demonstrated a markedly enlarged left epididymal dilatation. Renal ultrasound and cystoscopy showed left renal/ureteral agenesis. Extensive