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Re: Renal Candidiasis in the Neonate, H. Norman Noe and Ina L. D. Tonkin, J. Urol., 127: 517-519, 1982
0022-534 7/82/1284-0828$02.00/0
Vol. 128, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Letters to the Editor I encountered the difficulty described by the authors of pushing the proximal stent too far, that is in the upper ureter. Their solution involves cystoscopic retrieve! of the distal end of the stent and retrograde passage of a guide wire. Such a maneuver is not only dangerous, owing to the possibility that the wire might exit via one of the many side holes, but it also is difficult in that it essentially faces problems identical to those of the original retrograde attempt (except possibly for lower ureteral obstruction, in which case the proximal stent is still above the narrow site). It is simple to thread a trailing suture of 3-zero polypropylene through the most proximal side hole and out the proximal end hole. After removal of the guide wire both ends of the suture can be pulled to position the stent in the pelvis and the suture then can be removed by pulling on the strand exiting through the end hole. In addition, if there is significant hematuria I replace a nephrostomy tube that remains open until the urine clears to avoid the possibility of the stent being occluded with clots. Before the nephrostomy is removed a nephrostogram is performed to ensure adequate antegrade drainage.
RE: RENAL CANDIDIASIS IN THE NEONATE H. Norman Noe and Ina L. D. Tonkin
J. Urol., 127: 517-519, 1982
To the Editor. I wish to commend these authors on their study, which emphasizes the pervasive and pernicious nature of candidal infection of the kidney affecting the vulnerable patient, irrespective of age. However, I do take exception to the management as outlined. I question the use of miconazole as a first line drug in the management of this infant. Its use in the treatment of genitourinary candidiasis has not been well documented and experience with this drug in these cases is limited. Although the authors used miconazole because it lacks hepatic or renal toxicity, the first line antimycotic drugs, namely amphotericin B and flucytosine, could have been administered in modified dosages. In this seriously ill infant systemic amphotericin B in modified dosages, starting at 0.1 mg./kg. daily, would have been more efficacious. If laboratory facilities were available, sensitivities of the Candida to amphotericin B could have been established and serum levels of this drug could have been adjusted to 4 times the laboratory minimal inhibitory concentration determination. Flucytosine also could have been given through a nasogastric tube. The persistence of candiduria certainly indicates the presence of a chronic renal candidal infection with the possibility of fungal abscesses and, perhaps, even small fungal balls. The use of a percutaneous or intraoperative insertion of a small nephrostomy tube and irrigation of the kidney with amphotericin B, starting at the dose level of 0.2 mcg./ kg. hourly, would have been another modality to treat the renal candiduria.
Respectfully, Robert I. Kahn Department of Urology University of California San Francisco, California 94143
Reply by Authors. We appreciate the comments but we have found it difficult to work with a silicone catheter and a light 0.028-inch guide wire because this combination tends to kink. It is much easier to negotiate an obstructed ureteral segment with a 0.035-inch long, tapered tight J or a ring-torque guide with a 5F JBl catheter. Once the catheter is in the bladder it can be exchanged for the appropriate stent over a 0.035-inch exchange guide wire. It is easier to advance a stiffer, polyethylene double pigtail stent than a more flexible, silicone catheter through a stenotic ureter. We now are using a fine suture as an aid to position the proximal pigtail. Nevertheless, if the proximal pigtail is advanced too far but the stent remains across the narrowed ureteral segment we have had no problem with retrograde passage of a long, tapered straight guide wire up the stent. A J guide wire may exit from one of the side holes and should not be used. 1. Smith, A. D., Lange, P. H., Miller, R. P. and Reinke, D. B.: Introduction of the Gibbons ureteral stent facilitated by antecedent percutaneous nephrostomy. J. Urol., 120: 543, 1978.
Respectfully, Gilbert J. Wise Urology Division Maimonides Medical Center Brooklyn, New York 11219
Reply by Authors. We appreciate these comments. Miconazole is a relatively new drug, which is recommended primarily for use in patients with compromised renal function. We are not aware of a study in which modified dosage of amphotericin or flucytosine has been compared to miconazole and proved superior. However, the suggestions made by Doctor Wise should be kept in mind by our readers should they encounter a patient such as ours. It is only through sharing our experiences and ideas that we can progress in areas in which clearly superior therapeutic choices are yet to be established.
RE: PROMINENT LATERAL MUCOSAL FOLDS IN THE BULBOUS URETHRA
C. W. Bourne, R. F. Kilcoyne and E. J. Kraenzler RE: PERCUTANEOUS TRANSRENAL PLACEMENT OF INDWELLING URETERAL CATHETERS
A. D. Jenkins and C. J. Tegtmeyer J. Urol., 126: 730-733, 1981
To the Editor. Percutaneous transrenal placement of the indwelling double-J pigtail stents discussed by the authors is an effective, simple means of achieving upper tract diversion when the retrograde method is impossible. To date, I have placed 8 such ureteral stents and would like to offer the following comments. The ureteral stents described by these authors have an adequate inside diameter that will slide easily over a 0.035-inch guide wire. These stents are made of stiff, polyethylene tubing. However, I prefer the softer, more flexible silicone stent. The silicone stent can be advanced over a 0.028-inch guide wire and with only mineral oil lubrication. Moreover, pushing the stiff catheters over the thinner wire sometimes results in a kinked wire or an obstruction that cannot be bypassed. It is necessary then to retrieve the guide wire cystoscopically and to pull the stent through over the wire antegrade or retrograde. 1
J. Urol., 126: 326-330, 1981
To the Editor. These investigators report on several conditions of the bulbous urethra that previously have been called urethral diverticulum, anterior urethral valves and cyst of the Cowper's duct. They contribute anatomical data that, in their opinion, provide an explanation for such urethrographic findings and indicate that these would be caused by prominent lateral mucosa! folds in the wall of the urethra. At the same time they reject any possible relationship of this condition with Cowper's glands, based on the lateral position. Jeffs indicates in his Editorial Comment that he regrets the lack of endoscopic evidence of these lateral folds and offers urethroscopic observations of his own, which suggest that such a urethral structure is suggestive of " ... a ruptured cyst in the mucosa of the floor of the urethral bulb" rather than lateral mucosa! folds. He does not speculate on the origin of the ruptured cyst and points out the need for further definition. We have urethroscopic views of a similar case. Our patient was a 5year-old boy who was referred to us for urinary infection. An excretory urogram was normal and there was no vesicoureteral reflux. A voiding 828
Vol. 128, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Letters to the Editor I encountered the difficulty described by the authors of pushing the proximal stent too far, that is in the upper ureter. Their solution involves cystoscopic retrieve! of the distal end of the stent and retrograde passage of a guide wire. Such a maneuver is not only dangerous, owing to the possibility that the wire might exit via one of the many side holes, but it also is difficult in that it essentially faces problems identical to those of the original retrograde attempt (except possibly for lower ureteral obstruction, in which case the proximal stent is still above the narrow site). It is simple to thread a trailing suture of 3-zero polypropylene through the most proximal side hole and out the proximal end hole. After removal of the guide wire both ends of the suture can be pulled to position the stent in the pelvis and the suture then can be removed by pulling on the strand exiting through the end hole. In addition, if there is significant hematuria I replace a nephrostomy tube that remains open until the urine clears to avoid the possibility of the stent being occluded with clots. Before the nephrostomy is removed a nephrostogram is performed to ensure adequate antegrade drainage.
RE: RENAL CANDIDIASIS IN THE NEONATE H. Norman Noe and Ina L. D. Tonkin
J. Urol., 127: 517-519, 1982
To the Editor. I wish to commend these authors on their study, which emphasizes the pervasive and pernicious nature of candidal infection of the kidney affecting the vulnerable patient, irrespective of age. However, I do take exception to the management as outlined. I question the use of miconazole as a first line drug in the management of this infant. Its use in the treatment of genitourinary candidiasis has not been well documented and experience with this drug in these cases is limited. Although the authors used miconazole because it lacks hepatic or renal toxicity, the first line antimycotic drugs, namely amphotericin B and flucytosine, could have been administered in modified dosages. In this seriously ill infant systemic amphotericin B in modified dosages, starting at 0.1 mg./kg. daily, would have been more efficacious. If laboratory facilities were available, sensitivities of the Candida to amphotericin B could have been established and serum levels of this drug could have been adjusted to 4 times the laboratory minimal inhibitory concentration determination. Flucytosine also could have been given through a nasogastric tube. The persistence of candiduria certainly indicates the presence of a chronic renal candidal infection with the possibility of fungal abscesses and, perhaps, even small fungal balls. The use of a percutaneous or intraoperative insertion of a small nephrostomy tube and irrigation of the kidney with amphotericin B, starting at the dose level of 0.2 mcg./ kg. hourly, would have been another modality to treat the renal candiduria.
Respectfully, Robert I. Kahn Department of Urology University of California San Francisco, California 94143
Reply by Authors. We appreciate the comments but we have found it difficult to work with a silicone catheter and a light 0.028-inch guide wire because this combination tends to kink. It is much easier to negotiate an obstructed ureteral segment with a 0.035-inch long, tapered tight J or a ring-torque guide with a 5F JBl catheter. Once the catheter is in the bladder it can be exchanged for the appropriate stent over a 0.035-inch exchange guide wire. It is easier to advance a stiffer, polyethylene double pigtail stent than a more flexible, silicone catheter through a stenotic ureter. We now are using a fine suture as an aid to position the proximal pigtail. Nevertheless, if the proximal pigtail is advanced too far but the stent remains across the narrowed ureteral segment we have had no problem with retrograde passage of a long, tapered straight guide wire up the stent. A J guide wire may exit from one of the side holes and should not be used. 1. Smith, A. D., Lange, P. H., Miller, R. P. and Reinke, D. B.: Introduction of the Gibbons ureteral stent facilitated by antecedent percutaneous nephrostomy. J. Urol., 120: 543, 1978.
Respectfully, Gilbert J. Wise Urology Division Maimonides Medical Center Brooklyn, New York 11219
Reply by Authors. We appreciate these comments. Miconazole is a relatively new drug, which is recommended primarily for use in patients with compromised renal function. We are not aware of a study in which modified dosage of amphotericin or flucytosine has been compared to miconazole and proved superior. However, the suggestions made by Doctor Wise should be kept in mind by our readers should they encounter a patient such as ours. It is only through sharing our experiences and ideas that we can progress in areas in which clearly superior therapeutic choices are yet to be established.
RE: PROMINENT LATERAL MUCOSAL FOLDS IN THE BULBOUS URETHRA
C. W. Bourne, R. F. Kilcoyne and E. J. Kraenzler RE: PERCUTANEOUS TRANSRENAL PLACEMENT OF INDWELLING URETERAL CATHETERS
A. D. Jenkins and C. J. Tegtmeyer J. Urol., 126: 730-733, 1981
To the Editor. Percutaneous transrenal placement of the indwelling double-J pigtail stents discussed by the authors is an effective, simple means of achieving upper tract diversion when the retrograde method is impossible. To date, I have placed 8 such ureteral stents and would like to offer the following comments. The ureteral stents described by these authors have an adequate inside diameter that will slide easily over a 0.035-inch guide wire. These stents are made of stiff, polyethylene tubing. However, I prefer the softer, more flexible silicone stent. The silicone stent can be advanced over a 0.028-inch guide wire and with only mineral oil lubrication. Moreover, pushing the stiff catheters over the thinner wire sometimes results in a kinked wire or an obstruction that cannot be bypassed. It is necessary then to retrieve the guide wire cystoscopically and to pull the stent through over the wire antegrade or retrograde. 1
J. Urol., 126: 326-330, 1981
To the Editor. These investigators report on several conditions of the bulbous urethra that previously have been called urethral diverticulum, anterior urethral valves and cyst of the Cowper's duct. They contribute anatomical data that, in their opinion, provide an explanation for such urethrographic findings and indicate that these would be caused by prominent lateral mucosa! folds in the wall of the urethra. At the same time they reject any possible relationship of this condition with Cowper's glands, based on the lateral position. Jeffs indicates in his Editorial Comment that he regrets the lack of endoscopic evidence of these lateral folds and offers urethroscopic observations of his own, which suggest that such a urethral structure is suggestive of " ... a ruptured cyst in the mucosa of the floor of the urethral bulb" rather than lateral mucosa! folds. He does not speculate on the origin of the ruptured cyst and points out the need for further definition. We have urethroscopic views of a similar case. Our patient was a 5year-old boy who was referred to us for urinary infection. An excretory urogram was normal and there was no vesicoureteral reflux. A voiding 828