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Re: Laparoscopic Ureteroneocystostomy
0022-5347/95/1544-1483$03.00/0 JOURNAL OF U R O l a G Y AMERICAN
Copfight 0 1995 by
Vol. 154.1463-1484, October 1995 Printed in U S A
UROLOCICAL ASSOCIATION, INC.
Letters to the Editor RE: LWAROSCOPIC ITRETERONEOCYSTOSTOMY P. K. Reddy and R. M. Evans
resulted in significant spermatogenic a r r e e t . g However, Goldstein neglected to etate that testicular atrophy din every case. The authors themselves mncluded that ”testicular volume is well mrrelated with testicular function.” This point is critical since not only J . Urol., 1 5 2 2057-2059, 1994 was atrophy not observed in any of our patienta but the testis To the Editor. To our knowledge the first reported ureteral reim- demonstrated significant ‘catch-up growth.” If, as these authors plantations performed laparoscopically were, in fact, our initial 2 conclude, testicular volume is correlated with function, then the a s in May 1993.’ While we have always advocated “pushing the hypothesis regarding testicular artery ligation is incorrect. envelope” in laparoscopic surgery, we are concerned that a 4.5-hour Finally, the concerns about performing vasectomy following a procedure in a 74-year-old man, while it may have heen technically Palomo procedure are entirely speculative. The Palomo procedure feasible, may be stretching the limits of propriety. There is no men- has been performed for many years. Indeed, many urologists curtion of the medical or cardiac condition of the patient. In addition, rently perform %advertent” Palomo procedures because identificathere is no mention of a postoperative voiding cystourethmgram to tion of the testicular artery with standard surgical techniques is indicate if reflux was prevented. exceedingly diEcult. To my knowledge, testicular atrophy following vasedomy in men who have undergone varimlectmny is not a Respectfully, Richard M. Ehrlich. Gerhard F u h and Alex Gershmun frequent complication. It may be that mictoeurgicalv a r i m l e ligation will pmve to be the standard technique but conclusions should 100 UCLA MedicalPlaza be based upon fads and not speculation. Presently, Goldstein clearly Suite 690 overstates the role for mieroseopic varicoceledomy. LQSAngeles, California 90024-6970 1. Ehrlich, R. M., Gershman, A. and Fuchs, G.: Laparoscopic vesi-
coureteroplasty in children: initial caae reports. Urology, 43: 255,1994.
Reply by Authors. We believe that Ehrlich et al are incorrect in their assumptions. They claim that they performed the first ureteral reimplantations in May 1993, when in fact they only report extravesical correction of vesicoureteral reflux, which they performed laparoscopically.This procedure is difFerent from the ureteral reimplantation (ureteroneocystostomy)that we performed on May 4, 1993 and reported in the Journal. Also, 4.6 hours to perform a laparoscopic ureteral reimplantation (to our knowledge the first of its kind) in an obese adult is by no means stretching the limits of propriety. The patient was discharged home 48 hours postoperatively with minimal morbidity and early convalescence, which could not have been achieved with an open ureteral reimplantation. Moreover, with currently available laparoscopic suturing equipment the surgical time can be further decreased significantly.We also wonder in why Ehrlich et al do not apply the aame standard to their -8, which 3 hours and 15 minutes were necessary to perform extraveaical reflux correction only without reimplantation in a child. Finally, the article clearly stated that a ureterovesical anastomosis with reflux was performed in our patient. It would be meaningless to perform a voiding cystourethrogram to determine if we prevented reflux.We did report that an excretory urogram 1 year postoperatively showed a good functioning kidney.
ReSpectfullY. Evan J. &rss Diviswn of Pediatric Urdogv William Beaumont Hospital 3601 West Thirteen Mile Road Royal Oak. Michigan 48073-6769 1. Ivanissevitch, 0.:Left v a r i m l e due to reflux; e rience with 4,470 operative cases in forty-twoyears. J. Int. %U. Surg., 34: 742,1960. 2. Kass, E. J. and Marml, B.: Results of varimcele surgery in adolescents: a comparison of techniques. J. Urol., 148: 694, 1992. 3. Hsu, T. H., Huang, J. K, Ho, D. M.!Liu, R. S., Chen, M. T.and Chang, L. S.: Role of the spermatx arte m spermatogenesis and sex hormone synthesis. Arch. A n d . 31, : 191,1993.
Reply by Author. The contention that T h e Palomo procedure achieves a sigm&antly higher surgical success rate when compared to artery sparing techniques” is based on the 1992 article by Kaee and Marcol (reference 2 in Letter) in which 4% power loupe magnification was used for the artery sparing techniques. Our own expe riencel and that of other@ have shown that the higher magnification (10 to 32X) provided by the operating mieroseope is neceesar~~ for preservation of the artery without preservation of the @arterial venous plexus, which as the data of Kass and Marc01so clearly show is respmsible for recurrence. Much larger series of mieroeurgical inguinal or subinguinal operations have resulted in recurrence ratea equal to or less than that achieved by Kaes and Marc01 wingthe Palomo mass ligation technique.1.2 The morbidity resulting from testicular artery ligation is probably underreported in adults. The author evaluated 5 men for amosperRE: EDITORIAL: ADOLESCENT VARICOCELE mia or severe oligospermia,which developed subsequent to bilateral M. Goldstein nouartery sparing variaxelectomy. In adults hticular volume is a crude measure of seminiferous tubular function, as notad by the J. U r ~ l .153: , 484-485.1995 testis biopsies of men with normal testis volumes that reveal matuTo the Editor. This editorial deserves a response. First Of d,the ration arrest or the Sertoli-cell-onlysyndrome. The points made by Kass are well taken. However, I remind him reference cited in our article to support the conelusion that ?he that my comments were clearly labeled ‘Editorial” which according Palomo procedure achieves a significantly higher surgical suwss rate when compared to artery sparing techniques” is not the 1960 to the dietionary meam =an article in a newspaper, magazine and 80 article by Ivanissevitch,1but our 1992 article in the Journal.2TOdate forth explicitly stating opinions.” we have performed approximately 100 Palomo operations and have 1. Goldstein,M., Gilbert, B. R., Dicker, A P., Dwosh, J. and Gneaa~, noted only 1persistent varicmele. There has been no single incident C.:Microsurgicalinguinal VaricoQleCtomywith delivery of the Of kSticular atroohv. testis: an artery and lymphatic sparing technique. J. Urol., Secondly, the & o t h e s i s that testicular artery ligation is a s k 148: 1808, 1992. with substantial morbidity in the animal model and human cal varieoce2. Marmar, J. L. and Kim, Y.:Subin lectomy: a technical criti ue a n K 2 s % O E & s of semen adults may be overstating the fads. IU the primary reference cited by & pregnancy data. J. 8rol., 168: 1127,1994. h h t e i n the authors reported that testicular artery ligation in dogs 1483
Copfight 0 1995 by
Vol. 154.1463-1484, October 1995 Printed in U S A
UROLOCICAL ASSOCIATION, INC.
Letters to the Editor RE: LWAROSCOPIC ITRETERONEOCYSTOSTOMY P. K. Reddy and R. M. Evans
resulted in significant spermatogenic a r r e e t . g However, Goldstein neglected to etate that testicular atrophy din every case. The authors themselves mncluded that ”testicular volume is well mrrelated with testicular function.” This point is critical since not only J . Urol., 1 5 2 2057-2059, 1994 was atrophy not observed in any of our patienta but the testis To the Editor. To our knowledge the first reported ureteral reim- demonstrated significant ‘catch-up growth.” If, as these authors plantations performed laparoscopically were, in fact, our initial 2 conclude, testicular volume is correlated with function, then the a s in May 1993.’ While we have always advocated “pushing the hypothesis regarding testicular artery ligation is incorrect. envelope” in laparoscopic surgery, we are concerned that a 4.5-hour Finally, the concerns about performing vasectomy following a procedure in a 74-year-old man, while it may have heen technically Palomo procedure are entirely speculative. The Palomo procedure feasible, may be stretching the limits of propriety. There is no men- has been performed for many years. Indeed, many urologists curtion of the medical or cardiac condition of the patient. In addition, rently perform %advertent” Palomo procedures because identificathere is no mention of a postoperative voiding cystourethmgram to tion of the testicular artery with standard surgical techniques is indicate if reflux was prevented. exceedingly diEcult. To my knowledge, testicular atrophy following vasedomy in men who have undergone varimlectmny is not a Respectfully, Richard M. Ehrlich. Gerhard F u h and Alex Gershmun frequent complication. It may be that mictoeurgicalv a r i m l e ligation will pmve to be the standard technique but conclusions should 100 UCLA MedicalPlaza be based upon fads and not speculation. Presently, Goldstein clearly Suite 690 overstates the role for mieroseopic varicoceledomy. LQSAngeles, California 90024-6970 1. Ehrlich, R. M., Gershman, A. and Fuchs, G.: Laparoscopic vesi-
coureteroplasty in children: initial caae reports. Urology, 43: 255,1994.
Reply by Authors. We believe that Ehrlich et al are incorrect in their assumptions. They claim that they performed the first ureteral reimplantations in May 1993, when in fact they only report extravesical correction of vesicoureteral reflux, which they performed laparoscopically.This procedure is difFerent from the ureteral reimplantation (ureteroneocystostomy)that we performed on May 4, 1993 and reported in the Journal. Also, 4.6 hours to perform a laparoscopic ureteral reimplantation (to our knowledge the first of its kind) in an obese adult is by no means stretching the limits of propriety. The patient was discharged home 48 hours postoperatively with minimal morbidity and early convalescence, which could not have been achieved with an open ureteral reimplantation. Moreover, with currently available laparoscopic suturing equipment the surgical time can be further decreased significantly.We also wonder in why Ehrlich et al do not apply the aame standard to their -8, which 3 hours and 15 minutes were necessary to perform extraveaical reflux correction only without reimplantation in a child. Finally, the article clearly stated that a ureterovesical anastomosis with reflux was performed in our patient. It would be meaningless to perform a voiding cystourethrogram to determine if we prevented reflux.We did report that an excretory urogram 1 year postoperatively showed a good functioning kidney.
ReSpectfullY. Evan J. &rss Diviswn of Pediatric Urdogv William Beaumont Hospital 3601 West Thirteen Mile Road Royal Oak. Michigan 48073-6769 1. Ivanissevitch, 0.:Left v a r i m l e due to reflux; e rience with 4,470 operative cases in forty-twoyears. J. Int. %U. Surg., 34: 742,1960. 2. Kass, E. J. and Marml, B.: Results of varimcele surgery in adolescents: a comparison of techniques. J. Urol., 148: 694, 1992. 3. Hsu, T. H., Huang, J. K, Ho, D. M.!Liu, R. S., Chen, M. T.and Chang, L. S.: Role of the spermatx arte m spermatogenesis and sex hormone synthesis. Arch. A n d . 31, : 191,1993.
Reply by Author. The contention that T h e Palomo procedure achieves a sigm&antly higher surgical success rate when compared to artery sparing techniques” is based on the 1992 article by Kaee and Marcol (reference 2 in Letter) in which 4% power loupe magnification was used for the artery sparing techniques. Our own expe riencel and that of other@ have shown that the higher magnification (10 to 32X) provided by the operating mieroseope is neceesar~~ for preservation of the artery without preservation of the @arterial venous plexus, which as the data of Kass and Marc01so clearly show is respmsible for recurrence. Much larger series of mieroeurgical inguinal or subinguinal operations have resulted in recurrence ratea equal to or less than that achieved by Kaes and Marc01 wingthe Palomo mass ligation technique.1.2 The morbidity resulting from testicular artery ligation is probably underreported in adults. The author evaluated 5 men for amosperRE: EDITORIAL: ADOLESCENT VARICOCELE mia or severe oligospermia,which developed subsequent to bilateral M. Goldstein nouartery sparing variaxelectomy. In adults hticular volume is a crude measure of seminiferous tubular function, as notad by the J. U r ~ l .153: , 484-485.1995 testis biopsies of men with normal testis volumes that reveal matuTo the Editor. This editorial deserves a response. First Of d,the ration arrest or the Sertoli-cell-onlysyndrome. The points made by Kass are well taken. However, I remind him reference cited in our article to support the conelusion that ?he that my comments were clearly labeled ‘Editorial” which according Palomo procedure achieves a significantly higher surgical suwss rate when compared to artery sparing techniques” is not the 1960 to the dietionary meam =an article in a newspaper, magazine and 80 article by Ivanissevitch,1but our 1992 article in the Journal.2TOdate forth explicitly stating opinions.” we have performed approximately 100 Palomo operations and have 1. Goldstein,M., Gilbert, B. R., Dicker, A P., Dwosh, J. and Gneaa~, noted only 1persistent varicmele. There has been no single incident C.:Microsurgicalinguinal VaricoQleCtomywith delivery of the Of kSticular atroohv. testis: an artery and lymphatic sparing technique. J. Urol., Secondly, the & o t h e s i s that testicular artery ligation is a s k 148: 1808, 1992. with substantial morbidity in the animal model and human cal varieoce2. Marmar, J. L. and Kim, Y.:Subin lectomy: a technical criti ue a n K 2 s % O E & s of semen adults may be overstating the fads. IU the primary reference cited by & pregnancy data. J. 8rol., 168: 1127,1994. h h t e i n the authors reported that testicular artery ligation in dogs 1483