Re: Quantification of Erection, by C. J. Godec and A. S. Cass, J. Urol., 126: 345-347, 1981

cases of lun1bcsac:ral plex-~s P8'JTCp&.thy had ncbladder of Greenvvood, v1ith concurrent ,u,uuv~a.u plexu.s neuYopand rhabdomyolysis after he:roin abuse, had normal bladder function. 9 Chronic neu:rogenic bladder develops in heYoin-associated transverse myelitis because of severity and extension of the 1Jacwv1c,;;1
Respectfully, Daniel E. Jacome Palm Springs Medical Plaza 1435 West 49th Place, Suite 306 Hialeah, Florida 33012 1. Richter, R. W. and Rosenberg, R. N.: Transverse myelitis associated with heroin addiction. J.A.Iv:!.A., 206: 1255, 1968.

2. Smith, W.R. and Wilson, A. F.: Guillain-Barre syndrome in heroin addiction. J.A.M.A., 231: 1367, 1975. 3. Adams, R. D. and Victor, M.: Diseases of peripheral and cranial nerves. In: Principles of Neurology. Edited by R. D. Adams and M. Victor. New York: McGraw-Hill Book Co., p. 448, 1977. 4. Evans, B. A., Stevens, J. C. and Dyck, P. J.: Lumbosacral plexus neuropathy. Neurology, 31: 1327, 1981. 5. Patel, R., Das, M., Palazzolo, M., Ansari, A. and Balasubramaniam, 8.: Myoglobinuric acute renal failure in phencyclidine overdose: report of observations in eight cases. Ann. Emerg. Med., 9: 549, 1980. 6. Cogen, F. C., Rigg, G., ouuu,vll,b, clidine-associated acute 210, 1978. 7. Richter, R. L. L. and heroin addiction. 8, Challenor, Y. B., Richter, R. W., Brunn, B. and Pearson, J.: Nontraumatic plexitis and heroin addiction. J.A.M.A., 225: 958, 1973. 9. Greenwood, R J.: Lumbar plexitis and rhabdomyolysis following abuse of heroin. Postgrnd. Med. 50: 1974. 10. Pearson, J., Richter, R. W., Baden, '"''""""'·m, Y. B. and Brunn, B.: Transverse myelopathy as an 111,str·Rt·,011 of the neurologic and neuropathologic features of heroin addiction. Hum. Path., 3: 107, 1972.

good as tiJat 1Mith the l\!Isrsh.aJl-IVIlli'Chetti-}{_:rantz nroced.ure b•-1t r.nuch less morbidity ~

ol IV.ledicine New Orleans, Louisiana 70112 1. Scott, F. B.: Treatment of urinary incontinence. J. Urol., 125: 799,

1981.

RE: SOCIAL AND SEXUAL ADJUSTMENT OF MEN OPERATED FOR HYPOSPADIAS DURING CHILDHOOD: A CONTROLLED STUDY Roland Berg, Jan Svensson and Gaby Astrom J. Urn!., 125: 313-317, 1981 To the Editor. A regrettable choice of words mars this important and otherwise commendable study of long-term psychosocial adjustment to genital surgery. The patients in this study are not "hypospadiacs". They are men who have been treated for hypospadias. Essential to their satisfactory adjustment is a wholesome image of self. Crucial to this self-image is the impression they receive from those they respect and trust. We would do well to avoid a word choice that labels the patient as a disease. Use of the term "hypospadiac", while journalistically convenient, is neither accurate nor fair. Patients are persons, not diseases, and our word choices should this uu.ue1N.aKJu1.u;(. Let there be in our vocabulary no more "lepers" rather leprosy under treatment for Hansen's disease. Let's banish noun forms of "ic" and "iac" - no more paraplegics, cuu,vc,cb, cardiacs, hypochondriacs or As ·health care professionals we are committed to the care of neither "ics;} nor aiacsn but persons - persons ·who need and deserve ourrespect. Let's get the word out! Respectfully, Richard A. Watson and Nina Z. Sanders Urology Service and Technical Publications Branch Letterman Medical Center Presidio of San J:l"ranc,sco. California 94129 RE: QUANTIFICATION OF ERECTION

RE: MODIFIED PEREYRA PROCEDURE FOR STRESS INCONTINENCE James A. Roberts, e.lames R, and

Thonias) Tony ]YlcClung

UroL, 125: 787-789, 1981

To the Editor. Our article was criticized justly by Scott.' He pointed out that our patients were followed for a. year or less, &. short time to detern1ine success rate. Vile, therefore) :revie~¥ed ou:r data vvith foUovvup no:\r.J of mo:re than 3 in all cases v,,re vvere able to trace. 1JD.fortunately) :.-r;,re ,vere able to orJy 19 of the 30 Howeve1\ 84 per cent have no stress incontinence and 4 of h.ave mild incontinence. T'he 3. failures include the 1 reported in the in which a chromic suture was used. Thus, the success rate for the remainder, those with a nonabsorbable suture, is 89 per cent. Perhaps more important is to look at the failures. The absorbable suture is an easy explanation. However, another patient leaks when in bed when she coughs, a situation difficult to understand. third failure had prolonged inability to void handled by intermittent catheterization. One of the sutures was removed and she was still unable to void. Cystometric re-evaluation showed a flaccid bladder, which is being treated with bethanechol and phenoxybenzamine with success. This last patient obviously did not have a good urodynamic evaluation p:reoperatively. It may be that those 4 patients who continued to have mild urgency incontinence, have detrusor dyssynergia and this should have been found by urodynamic study. These facts stress the importance of careful urodynamic studies before surgical therapy of stress incontinence. We still believe that the operation is a sound method for the treatment of stress incontinence. Its success rate of 89 per cent is as

C. J. Godec and A S. Cass J. Urol., 126: 345-347, 1981

To the Editor. Figure 5 in this interesting article permits an alternative analysis. The authors' analysis line is represented as the correlation between volume of injected saline (V) and increase in penile circumference (C). The slope of the line to be the (C/V). A linear correlation of the Aln,covu•ah~n pairs ""'·"·c·auy extracted from figure 5 gives a reg-.ression line of C = 17.8 + the of the correlation coefficient being 0.07. R differs from zern is «0.10. 1 If were different from zero it would mean that only 7 ce3'.lt the variance in C is due to ·variance in V. Pathology is seen in the data that the lar-gest value of C belongs to the s·2cond smallest value 1_,c,nE:w,enrn1.e noise might have been removed from the data by normalizing C and V with respect to initial b~-,,,-,,,, This type of normalization also would offer an appraisal of anisotropy of expansion. Was the initial geometry measured before the needle was inserted? This is not clear from the methods section and it could exolain the experimental results in figure 5. " I v1ish to compliment and encourage the authors in their 'Nork If they had not attempted to quantitate their observations the opportunity for analysis and interpretation would be negligible. Respectfully, Birdwell Finlayson Division of Urology, Department of Surgery College of Medicine, University of Florida Gainesville, Florida 32610

Reply by Authors. The reviewer usefully points out that fitting the usual least-squares regression line (with a nonzero intercept) to the

996

LETTERS TO THE EDITOR

data of figure 5 would indicate a much smaller correlation between the change in penile circumference and amount of saline injection than suggested by our model. We agree that this difference may be due largely to the unwelcome presence of a few "outliers" in our data. The line presented in figure 5 was actually a least-squares regression line through the origin. The nature of our experiment entitled us to assume that the line went through the origin, for clearly a zero saline injection would have increased penile circumference by zero. However, the linearity of the relationship is, at best, only locally true. Geometric considerations suggest that penile circumference should be approximately proportional to the cube root of penile volume and, thus, change in circumference proportional to the change of the cube root of penile volume brought about by the saline injection. The presumed cubic nature of the relationship might well have been obscured by the variability of the data. Our early data did not include initial (pre-injection) penile circumference or length but we are now recording these values and expect to develop a more exact model of the geometry of erection in the future. 1. Bailey, N. T.: Statistical Methods in Biology. New York: John Wiley & Sons, Inc., p. 85, 1971. RE: PENILE IMPLANTS IN SPINAL CORD INJURY PATIENTS FOR MAINTAINING EXTERNAL APPLIANCES

Keith N. Van Arsdalen, Frederick A. Klein, Robert H. Hackler and Susan M. Brady J. Urol., 126: 331-332, 1981

To the Editor. In the editorial comment following this article Rossier states, "We agree with the authors that in spinal cord injuries the complication rate is not insignificant and resulted in 15.6 per cent of penile implant loss in our patients". If I understand this statement correctly Rossier implies that a 15.6 per cent penile implant loss occurred in the spinal cord injury patients of his institution. Since I happen to be chief of urology at that institution and principally involved in the surgical aspects of the spinal cord injury population I venture to mention some facts. The implications of your consultant's statement could be misleading and confuse the readers if we do not qualify the statement correctly. The penile implant loss (15.6 per cent) in the spinal cord injury group has occurred during the immediate postoperative period. This was presumed to result from poor execution of the technique. The implant loss (in our 4 patients) did not occur as a consequence of delayed erosion which, in fact, was the experience of Van Arsdalen and associates (7 to 13 months). Our first patient had the penile prosthesis implantation via perinea! route within a week to 10 days after an external sphincterotomy and extrusion of the prosthesis occurred in the immediate postoperative period. Since the distal end of the sphincterotomy incision usually is carried towards the bulbous urethra and encroaches the superficial perinea! pouch the surgical approach through the perineum in the immediate postoperative period of sphincterotomy in this patient had led to a perinea! fistula and the inevitable extrusion of the penile prosthesis through the perinea! wound. The second patient had intraoperative trauma to the urethra during the insertion of the prosthesis as evidenced by urethral bleeding. This prosthesis extruded through the urethra during the immediate postoperative course. The third patient was given a larger prosthesis for upgrading the original size and it extruded during the immediate postoperative period. The fourth patient had severe meatal necrosis in the immediate postoperative period, suggesting some type of intraoperative trauma (vascular or direct injury) to the meatal area during instrumental dilatation of the corpora. The prosthesis finally extruded through the urethra. None of the remaining 24 spinal cord injury patients who had an uneventful postoperative course had any late sequelae resulting in any type of implant loss. The penile implant loss described by Van Arsdalen and associates was caused by poor nursing care during the sacral decubiti care in 2 patients. Thus, by careful analysis of their data it appears that the extrusion rate would be 15 per cent in a properly managed (including nursing care) spinal cord injury population of patients who also had an uneventful postoperative course. Our recent analysis of the 28 patients with and the 27 patients without spinal cord injury suggests that the extrusion rate of the prosthesis in patients with spinal cord injury is no greater than that of those without. On the other hand, 4 patients without spinal cord injury had extrusion of the prosthesis, 3 of whom had delayed extrusions. None from the spinal cord injury group had

any delayed erosions. Both groups of patients were operated upon by the resident staff under the direction of the staff urologists. Respectfully, Subbarao V. Y alla Urology Section Veterans Administration Medical Center 1400 VFW Parkway West Roxbury, Massachusetts 02132 RE: TREATMENT OF IDIOPATHIC VARICOCELES BY TRANSFEMORAL TESTICULAR VEIN OCCLUSION

L. Weissbach, M. Thelen and H. D. Adolphs J. Urol., 126: 354-356, 1981

To the Editor. Ligation of the internal,spermaticveiniforvaricocele is a safe and effective procedure that has been performed in thousands of patients with an insignificant incidence of complications. The patients generally are young and vigorous, and the surgical morbidity and anesthetic risk are extremely low. In our practice the operation is performed under a brief general anesthetic and usually on outpatients. Vascular embolization using the Gianturco coil is, in my opinion, a significantly more invasive procedure. There is greater risk and little if any cost advantage. The lost coil phenomenon is well known in arterial embolization. 1 A lost coil moving centrally in the venous system is a frightening thought. Although I am unaware of this latter problem having been reported its eventual occurrence would seem predictable. Selective and superselective angiographic techniques can be of great value in life-threatening disorders when the alternative is a major surgical procedure. The technique described by Weissbach and associates would seem to have little clinical relevance. Respectfully, James S. Robbins Greenwood Urology Clinic Greenwood, Mississippi 38930

Reply by Authors. The main problem related to operative ligation of the testicular vein is persistence of varicocele. C.ollateral circulations and atypias owing to the variability of the retroperitoneal venous system can be demonstrated by phlebography, which is obligatory before embolization. With the precise embolization technique the rate of persistence should be reduced. Transfemoral phlebography generally should be recommended before an operation. Any treatment modality that can be performed under local anesthesia is superior to that requiring general anesthesia. In Germany varicocele operations are not done on an outpatient basis. 1. Swanson, D. A., Wallace, S. and Johnson, D. E.: The role of embolization and nephrectomy in the treatment of renal carcinoma. Urol. Clin. N. Amer., 7: 719, 1980. RE: THE VALUE OF COMPUTERIZED TOMOGRAPHY IN EVALUATION OF PELVIC LYMPH NODES

Kenneth H. Benson, Richard A. Watson, David B. Spring and Robert E. Agee J. Urol., 126: 63-64, 1981

To the Editor. We wish to correct a typographical error. The estimated total cost for 23 computerized tomography (CT) scans should be $7,200, not $72,000. In addition, recent developments lead us to offer the following comments. Improvements in CT technology may affect the sensitivity of CT evaluations for pelvic lymph node enlargement. Golimbu and associates used an 18-second scanner and found a high specificity (93 per cent) but a low sensitivity (30 per cent)1 as did we. On the other hand, Levine and associates used a 2-second scanner, and reported high specificity and 100 per cent sensitivity (no false negative results). 2 Regardless of these and anticipated technological advances inherent limitations of CT preclude its use alone for detecting pelvic nodal metastases. Micrometastases, that is metastatic deposits within nonenlarged nodes, are not uncommon in patients with prostatic carcinoma. Conversely, enlarged benign nodes may occur in the absence of metastases. CT scans detect nodes that are abnormal in size, not in content.