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Re: Osteoporosis as a complication of Orchiectomy in 2 Elderly Men with Prostatic Cancer
oo22-5347/96/1554-1395$03.0010
THE JOURNAL
Vol. 155. 13951396, April 1996 Printed in U.S.A.
OF UROLOGY h E H I r A N UROLOC~CALASSOCIATION,INC.
Copyright 0 1996 by
Letters to the Editor RE: BUCCAL MUCOSAL URETHRAL REPLACEMENT
prepuce, either outer leaf andor inner leaf, can be used as needed. I congratulate the authors on their results. Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 72205 1. Redman, J. F.: A technique for the correction of penoscrotal fusion. J. Urol., 1 3 3 432, 1985.
J . W. Duckett, D. Coplen, D. Ewalt and L. S. Baskin
J. Urol., 1 5 3 1660-1663, 1995 To the Editor. Humby not only suggested the use of buccal mucosa for urethral replacement but actually initiated its use.' In the course of a review of buccal mucosal urethroplasties performed during the last 5 years at various centers of pediatric urology, I located the notes of the first operation on record as well. On April 26, 1939 Humby performed urethroplasty with buccal (labial) mucosa in a child at the Hospital for Sick Children, Great Ormond Street, London. During the procedure a mucosal graft was harvested from the lower lip, tubularized over a catheter and anastomosed to the hypospadiac urethral meatus. The glans was then tunneled to accommodate the tube graft. The shaft was covered with ventral skin flaps and the prepuce was reconstructed. Cystostomy was performed while the graft was being prepared to provide for urinary diversion. Postoperatively, the skin cover broke down leading to dehiscence of the mucosal suture line, which had otherwise taken completely. This graft was re-tubularized successfully at a stage 2 procedure 14 months later, a delay obviously caused by war. The patient was followed for a few years with gratifying results. We thus document that the technique of buccal mucosa graft urethroplasty was established with this case. Humby can now be duly credited for a surgical innovation.'.* It is most likely that the knowledge of this technique was communicated through contacts, because other early pediatric applications have been m e n t i ~ n e d . ~ Respectfully, Seref Etker Kurukahveci Sok., 2 / 2 2 Daiyan-Kiziltoprak TR-81030 Istanbul, Turkey 1. Humby, G.: One-stage operation for hypospadias. Brit. J. Surg., 29: 84, 1941. 2. Wallace, A. F.: Three g r e a t r y s (Sir Astley Paston Cooper, Thomas Bryant, Thomas raham Humby). Brit. J. Plast. Surg., 41: 74, 1988. 3. El-Kasaby, A. W., Fath-Alla, M., Noweir, A. M., El-Halaby, M. R., Zakaria, W. and El-Beialy, M. H.: The use of buccal mucosa patch graft in the management of anterior urethral strictures. J. Urol., 149 276, 1993.
Reply by Authors. We appreciate the comments of Redman and agree that, whether or not the prepuce is resected or unfurled, the initial steps of our technique for correction of a buried penis are similar to those he described for correction of penoscrotal fusion. We stated this point in our article and had referred to his study (reference 1 in Letter). However, in contrast to penoscrotal fusion, we strongly recommend not to resect any parts of the prepuce in the buried penis because of the preexistent deficiency of penile shaft skin. The novel and crucial part of our technique lies not in dissecting the penile shaft skin and prepuce off the penile shaft but in relocating i t by the ventral-lateral or cross-over technique.
RE:OSTEOPOROSIS A S A COMPLICATION OF ORCHIECTOMY IN 2 ELDERLY MEN WITH PROSTATIC CANCER S.A. McCrath and T. Diamond
J. Urol., 154: 535-536, 1995 To the Editor. While I was delighted to see the correlation of 0sporosis and orchiectomy published nationally, I am surprised that the authors could not ". . .find a report linkmg androgen deprivation for prostatic cancer to osteoporosis in elderly men." In fact 3 reports exist.13 I found a 16%incidence of fractures or visible osteoporosis in the first 21 charts of patients on leuprolide that I surveyed.3 The authors are absolutely correct to emphasize the therapeutic effect of the diphosphonate, etidronate disodium. I have cured 2 compression fractures with it myself. A new drug, alendronate, should be even better at improving bone density. Not to be discounted also is a more direct effect on the tumor, since 2 diphosphonates prevented or delayed hind leg paralysis in the R3327-MATLyLurat model.4 Respectfully, Anthony H. Horan Department of Surgery 2615 East Clinton Fresno, California 93703 1. Goldray, D., Weisman, Y., Jaccard, N., Merdler, C., Chen, J. and Matzkin, H.: Decreased bone density in elderly men treated with the gonadotropin-releasing hormone agonist decapeptyl (D-Trp6-GnRH). J. Clin. Endocr. Metab., 7 6 288, 1993. 2. Clarke, N. W., McClure, J. and George, N. J.: The effects of orchidectomy on skeletal metabolism in metastatic prostate cancer. Scand. J. Urol. Nephrol., 21: 475, 1993. 3. Horan, A. H.: The incidence of Fracture ascribable to osteoporosis followingiatm enic hypogonadism for carrhoma of the prostate. Read at a n n u s meeting of Western Section of American Urological Association, Seattle, Washington,August 21-25, 1994. 4. Yu-Cheng,.S., Geldof, A. A., Newling, D. W. W. and Rao, B. R.: Progression delay of prostate tumor skeletal metastasis effects by bisphosphonates. J. Urol., 148: 1270, 1992.
Reply by Authors. We were pleased to read the account of Humby's case using buccal (labial) mucosa, which was not detailed in the 1941 report (reference 1 in Letter). One must remember that no antibiotics were available at the time, making a buccal graft a bold attempt. That it broke down is not a surprise. The cheek seems to be a more abundant donor site than the lip and i t can be closed primarily, which is another advantage. The importance of thinning the graft must be reemphasized. Humby missed a great contribution by not trying again. Buccal grafts are the best urethral replacement to date when the flaps are used up.
RE: THE SURGICAL CORRECTION OF BURIED PENIS: A NEW TECHNIQUE T . M. L. Boemers and T . P. V. M . De Jong
J. Urol., 154: 550452, 1995 To the Editor. I appreciated learning that the authors found my technique for correction of penoscrotal fusion to have satisfactory applications. However, I wish to correct a n apparent misinterpretation of my description. They stated, "In the Redman procedure, the Prepuce is resected but we used the unfurled prepuce as a substitute for the deficient shaft skin." In my description I stated, " h e p r e p tial layers were separated to provide a blanket of hairless skin to cover the shaft of the penis." The illustration that accompanied the description shows that there is resection of redundant preputial skin. The versatility of my procedure as described is that as much of the
RE: SELECTION OF OFTIMAL PROSTATE SPECIFIC ANTIGEN CUTOFFS FOR EARLY DETECTION OF PROSTATE CANCER RECEIVER OPERATING CHARACTERISTIC CURVES W. J . Catalona, M. A. Hudson, P. T . Scardino, J . P. Richie, F. R. Ahmann, R. C. Flanigan, J. B. deKernion, T.L. Ratlifi L. R. Kavoussi, B. L. Dalkin. W . B. Waters, M . T . MacFariane and P. C. Southwick
J. Urol., 1 5 2 2037-2042, 1994 To the Editor. We noted with interest the recent correspondence regarding the receiver operator characteristic curves for serum pros1395
THE JOURNAL
Vol. 155. 13951396, April 1996 Printed in U.S.A.
OF UROLOGY h E H I r A N UROLOC~CALASSOCIATION,INC.
Copyright 0 1996 by
Letters to the Editor RE: BUCCAL MUCOSAL URETHRAL REPLACEMENT
prepuce, either outer leaf andor inner leaf, can be used as needed. I congratulate the authors on their results. Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 72205 1. Redman, J. F.: A technique for the correction of penoscrotal fusion. J. Urol., 1 3 3 432, 1985.
J . W. Duckett, D. Coplen, D. Ewalt and L. S. Baskin
J. Urol., 1 5 3 1660-1663, 1995 To the Editor. Humby not only suggested the use of buccal mucosa for urethral replacement but actually initiated its use.' In the course of a review of buccal mucosal urethroplasties performed during the last 5 years at various centers of pediatric urology, I located the notes of the first operation on record as well. On April 26, 1939 Humby performed urethroplasty with buccal (labial) mucosa in a child at the Hospital for Sick Children, Great Ormond Street, London. During the procedure a mucosal graft was harvested from the lower lip, tubularized over a catheter and anastomosed to the hypospadiac urethral meatus. The glans was then tunneled to accommodate the tube graft. The shaft was covered with ventral skin flaps and the prepuce was reconstructed. Cystostomy was performed while the graft was being prepared to provide for urinary diversion. Postoperatively, the skin cover broke down leading to dehiscence of the mucosal suture line, which had otherwise taken completely. This graft was re-tubularized successfully at a stage 2 procedure 14 months later, a delay obviously caused by war. The patient was followed for a few years with gratifying results. We thus document that the technique of buccal mucosa graft urethroplasty was established with this case. Humby can now be duly credited for a surgical innovation.'.* It is most likely that the knowledge of this technique was communicated through contacts, because other early pediatric applications have been m e n t i ~ n e d . ~ Respectfully, Seref Etker Kurukahveci Sok., 2 / 2 2 Daiyan-Kiziltoprak TR-81030 Istanbul, Turkey 1. Humby, G.: One-stage operation for hypospadias. Brit. J. Surg., 29: 84, 1941. 2. Wallace, A. F.: Three g r e a t r y s (Sir Astley Paston Cooper, Thomas Bryant, Thomas raham Humby). Brit. J. Plast. Surg., 41: 74, 1988. 3. El-Kasaby, A. W., Fath-Alla, M., Noweir, A. M., El-Halaby, M. R., Zakaria, W. and El-Beialy, M. H.: The use of buccal mucosa patch graft in the management of anterior urethral strictures. J. Urol., 149 276, 1993.
Reply by Authors. We appreciate the comments of Redman and agree that, whether or not the prepuce is resected or unfurled, the initial steps of our technique for correction of a buried penis are similar to those he described for correction of penoscrotal fusion. We stated this point in our article and had referred to his study (reference 1 in Letter). However, in contrast to penoscrotal fusion, we strongly recommend not to resect any parts of the prepuce in the buried penis because of the preexistent deficiency of penile shaft skin. The novel and crucial part of our technique lies not in dissecting the penile shaft skin and prepuce off the penile shaft but in relocating i t by the ventral-lateral or cross-over technique.
RE:OSTEOPOROSIS A S A COMPLICATION OF ORCHIECTOMY IN 2 ELDERLY MEN WITH PROSTATIC CANCER S.A. McCrath and T. Diamond
J. Urol., 154: 535-536, 1995 To the Editor. While I was delighted to see the correlation of 0sporosis and orchiectomy published nationally, I am surprised that the authors could not ". . .find a report linkmg androgen deprivation for prostatic cancer to osteoporosis in elderly men." In fact 3 reports exist.13 I found a 16%incidence of fractures or visible osteoporosis in the first 21 charts of patients on leuprolide that I surveyed.3 The authors are absolutely correct to emphasize the therapeutic effect of the diphosphonate, etidronate disodium. I have cured 2 compression fractures with it myself. A new drug, alendronate, should be even better at improving bone density. Not to be discounted also is a more direct effect on the tumor, since 2 diphosphonates prevented or delayed hind leg paralysis in the R3327-MATLyLurat model.4 Respectfully, Anthony H. Horan Department of Surgery 2615 East Clinton Fresno, California 93703 1. Goldray, D., Weisman, Y., Jaccard, N., Merdler, C., Chen, J. and Matzkin, H.: Decreased bone density in elderly men treated with the gonadotropin-releasing hormone agonist decapeptyl (D-Trp6-GnRH). J. Clin. Endocr. Metab., 7 6 288, 1993. 2. Clarke, N. W., McClure, J. and George, N. J.: The effects of orchidectomy on skeletal metabolism in metastatic prostate cancer. Scand. J. Urol. Nephrol., 21: 475, 1993. 3. Horan, A. H.: The incidence of Fracture ascribable to osteoporosis followingiatm enic hypogonadism for carrhoma of the prostate. Read at a n n u s meeting of Western Section of American Urological Association, Seattle, Washington,August 21-25, 1994. 4. Yu-Cheng,.S., Geldof, A. A., Newling, D. W. W. and Rao, B. R.: Progression delay of prostate tumor skeletal metastasis effects by bisphosphonates. J. Urol., 148: 1270, 1992.
Reply by Authors. We were pleased to read the account of Humby's case using buccal (labial) mucosa, which was not detailed in the 1941 report (reference 1 in Letter). One must remember that no antibiotics were available at the time, making a buccal graft a bold attempt. That it broke down is not a surprise. The cheek seems to be a more abundant donor site than the lip and i t can be closed primarily, which is another advantage. The importance of thinning the graft must be reemphasized. Humby missed a great contribution by not trying again. Buccal grafts are the best urethral replacement to date when the flaps are used up.
RE: THE SURGICAL CORRECTION OF BURIED PENIS: A NEW TECHNIQUE T . M. L. Boemers and T . P. V. M . De Jong
J. Urol., 154: 550452, 1995 To the Editor. I appreciated learning that the authors found my technique for correction of penoscrotal fusion to have satisfactory applications. However, I wish to correct a n apparent misinterpretation of my description. They stated, "In the Redman procedure, the Prepuce is resected but we used the unfurled prepuce as a substitute for the deficient shaft skin." In my description I stated, " h e p r e p tial layers were separated to provide a blanket of hairless skin to cover the shaft of the penis." The illustration that accompanied the description shows that there is resection of redundant preputial skin. The versatility of my procedure as described is that as much of the
RE: SELECTION OF OFTIMAL PROSTATE SPECIFIC ANTIGEN CUTOFFS FOR EARLY DETECTION OF PROSTATE CANCER RECEIVER OPERATING CHARACTERISTIC CURVES W. J . Catalona, M. A. Hudson, P. T . Scardino, J . P. Richie, F. R. Ahmann, R. C. Flanigan, J. B. deKernion, T.L. Ratlifi L. R. Kavoussi, B. L. Dalkin. W . B. Waters, M . T . MacFariane and P. C. Southwick
J. Urol., 1 5 2 2037-2042, 1994 To the Editor. We noted with interest the recent correspondence regarding the receiver operator characteristic curves for serum pros1395