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Re: The Endoscopic Fascial Sling for Treatment of Female Urinary Stress Incontinence
268
LETTERS TO THE EDITOR
form catheter that would mnfirm the proper location of the tip in the bladder. Furthermore, we have had only moderate success in obtaining bladder access with the spiral and straight tip filiforms available in this as well as standard filiform and follower kits. We realize that our concept of using a guide wire per urethra is not new. However, use of the Glidewire* in this capacity has greatly enhanced our success in obtaining bladder access in difficult cases. Furthermore, as Heyman et al described previously (reference 1 in Letter), we prefer to confirm our proper placement of the Glidewire before dilating or inserting a Foley catheter. We use a standard ureteral catheter for this step. Overall, in our hands the concept of passing the Glidewire per urethra has been extremely successful, including a number of occasions when filiforms and followers have failed. To OUT knowledge passage of a Glidewire per urethra in this manner, which is the key to our technique, has not been described previously.
RE: FOGARTY CATHETER EXTRACTION OF UNUSUAL URETHRAL FOREIGN BODIES
J. L. Phillips J. U d . , 1% 1374-1375, 1996 To the Editor. While retrograde ureterography performed in an emergency mom setting with fluoroscopy seemed to be an effective method of removing the foreign bodies in the elderly man described in this article, actual performance of such a procedure in the emergency mom, with attendant patient manipulation, fluoroscopic equipment and radiation exposure, can be tedious and difficult. At our institution we have a small mobile cart with a portable light source and flexible cystowope that can be moved to different areas in the hospital. In an emergency mom situation, such as that described, we would bring the cart directly to the patient and perform flexible cystoscopy at the bedside with the patient on the stretcher. A variety of flexible grasping forceps, alligator forceps and stone baskets in the cart can be used to extract foreign bodies or stones, and a set of dilating balloons can be used to negotiate difficult urethral strictures. With several yeam of experience using such a cart, I have found that the advantage of direct visualization and ease of use are superior to indirect methods of imaging. The advances in flexible cystoscopes have been dramatic during the last 5 years, and make such cases or those in which difficult urethras are impossible to negotiate with catheters simple, particularly in the middle of the night. RJ=pectfullY.
EvangeIns G.Gemniotis Urology Associates of Cape Cod Cape Cod Hospital 110 Main Street Hyannis, Massachusetts 02601
RE:THE ENDOSCOPIC FASCIAL. SLING FOR TREATMENT OF FEMALE URINARY STRESS INCONTINENCE
K R. Loughlin J. Urol., 1M: 1265-1267.1996
To the Editor. We were particularly interested in reading about this new technique, which reminded us of the procedure described in 1986 by Raz that still is performed at many centers today. This technique, called transvaginal needle suspension of the bladder neck with a fascial s h g , involved placement of a fascial patch under the entire length of the urethra. The major difference between this method and that of Laughlin is that the fascial strip was placed longitudinally to transversely. and that we used 4 sutures, 1 at each mrner of the fascial strip, compared to a running suture on the free edge of the fascial strip. We also commented on our experience with 22 patients and found the aame advantages with the fascial patch that hughlin suggested in his discussion, namely simplicity in harvesting the fascial patch with no need for abdominal diesection, compression of the urethra for ita entire length, no dissection in the retropubic space by using the modified Pereyra needle for transfer of the sutures from the vaginal area to the euprapubic area and, linally, use of autologous tissue * Mimvaaive, Watertown, Massachusetts.
compared to nonabsorbable material. We question the novelty of this new approach and further wonder why our article, published 10 years ago, was not referenced. Respectfully, Phillippe E. Zimmern and Roger Hadley Department of Surgery, Division of Urology University of Texas Southwestern Medical Center 5323 Harry Hines Blwd. Dallas, Texas 75235-9110 Reply by Author. When preparing my manuscript I relied on the MEDLINE index which contains 9,167,857 medical references compiled since 1966. I returned to this resource and searched common references for “Zimmern,” “Hadley,” “fascial” and “sling,” and found no matches. During a search for “Raz,” “fascial” and ‘‘sling“ 1 reference was cited from 1988, which referred to a n open retropubic procedure that used a fascial sling in 4 male patients with a neurogenic bladder. A search for “Raz” and “1985”revealed 11 references, 1 of which contained a section on a fascial sling technique to which I believe the authors refer.’ This procedure has several major differences from the Brigham sling technique that I described: 1) their technique involves making an inverted U incision in the anterior vaginal wall and raising a vaginal wall flap, which is later incorporated into the repair, 2) the retropubic space is entered from below the lesion and the endopelvic fascia is divided, 3) the sling is a composite that uses vaginal wall, a free rectus fascial graft and endopelvic fascia, whereas the Brigham sling uses the free rectus fascial graft only, 4 ) they used the 4 sutures to suspend the graft upward, whereas I used 2 and 5) they used 4 silicone mesh pledgets beneath the tied sutures on the abdominal side of the operation, whereas none is required with my procedure. Their technique is no more similar to the Brigham sling than the Raz needle suspension is to the Stamey needle suspension. The results of both techniques are also different, since they reported that 15 of 22 patients had retention and required the added burden of intermittent catheterization, compared to none of my patients. 1. Hadley, H. R., Zimmern, P. E., Staskin, D. R. and Raz, S.: Tmnsvaginal needle bladder neck suspension. Urol. Clin. N. Amer., 1 2 291, 1985.
RE: A LIVE BIRTH FROM INTRACYTOPLASMIC IN JECTlOX OF A SPERMATOZOON RETRIEVED FROM TESTICULAR PARENCHYMA M. A. Witt, C. Elsner, H . I . Kort. J . B. Massey, D. Mitchell-LwI: A. A. Toledo and M. J. Tucker J. Urol., 154: 1136-1137, 1995 To the Editor. We read with interest this report of a successful birth aRer intracytoplasmic injection of a testicular spermatozoon i n a patient with congenital bilateral aplasia of the vas deferens. The authors stated that there was no family hstory of cystic fibrosis or congenital bilateral aplasia of the vas deferens in this patient. \Ye believe thorough genetic counseling should have been offered to the couple before performing an assisted reproduction procedure. I t has been shown that congenital bilateral aplasia of the vas deferens 1 3 a mild form of cystic fibrosis, although the molecular basis of congmital bilateral aplasia of the vas deferens is not completely understood. The incidence of cystic fibrosis in the United States has heen estimated a t 1 in 2,500 live births and an estimated carrier trequency of 1 in 25 has been reported. More than 300 mutations have been found in cystic fibrosis affected families but the most common specific mutation was AF508 in 67% of the patients with cystic fibrosis. In congenital bilateral aplasia of the vas deferens a Irequency of 42 to 51%of AF508 mutations has been reported.’ P a t r i m et al found a t least 1 cystic fibrosis mutation in 59% of the patients with congenital bilateral aplasia of the vas deferens.2 If both partners were carriers the risk of giving birth to a child with cystic fibrosis would have been 25%.Recently, Liu et al reported on pre-unplantation diagnosis of AF508 mutations in embryos produced by a patient with congenital bilateral aplasia of the vas d e t w ens and a female partner with AF508 mutation.3 Blastomere analysis revealed 2 embryos homozygous for AF508 and 3 carriers The
LETTERS TO THE EDITOR
form catheter that would mnfirm the proper location of the tip in the bladder. Furthermore, we have had only moderate success in obtaining bladder access with the spiral and straight tip filiforms available in this as well as standard filiform and follower kits. We realize that our concept of using a guide wire per urethra is not new. However, use of the Glidewire* in this capacity has greatly enhanced our success in obtaining bladder access in difficult cases. Furthermore, as Heyman et al described previously (reference 1 in Letter), we prefer to confirm our proper placement of the Glidewire before dilating or inserting a Foley catheter. We use a standard ureteral catheter for this step. Overall, in our hands the concept of passing the Glidewire per urethra has been extremely successful, including a number of occasions when filiforms and followers have failed. To OUT knowledge passage of a Glidewire per urethra in this manner, which is the key to our technique, has not been described previously.
RE: FOGARTY CATHETER EXTRACTION OF UNUSUAL URETHRAL FOREIGN BODIES
J. L. Phillips J. U d . , 1% 1374-1375, 1996 To the Editor. While retrograde ureterography performed in an emergency mom setting with fluoroscopy seemed to be an effective method of removing the foreign bodies in the elderly man described in this article, actual performance of such a procedure in the emergency mom, with attendant patient manipulation, fluoroscopic equipment and radiation exposure, can be tedious and difficult. At our institution we have a small mobile cart with a portable light source and flexible cystowope that can be moved to different areas in the hospital. In an emergency mom situation, such as that described, we would bring the cart directly to the patient and perform flexible cystoscopy at the bedside with the patient on the stretcher. A variety of flexible grasping forceps, alligator forceps and stone baskets in the cart can be used to extract foreign bodies or stones, and a set of dilating balloons can be used to negotiate difficult urethral strictures. With several yeam of experience using such a cart, I have found that the advantage of direct visualization and ease of use are superior to indirect methods of imaging. The advances in flexible cystoscopes have been dramatic during the last 5 years, and make such cases or those in which difficult urethras are impossible to negotiate with catheters simple, particularly in the middle of the night. RJ=pectfullY.
EvangeIns G.Gemniotis Urology Associates of Cape Cod Cape Cod Hospital 110 Main Street Hyannis, Massachusetts 02601
RE:THE ENDOSCOPIC FASCIAL. SLING FOR TREATMENT OF FEMALE URINARY STRESS INCONTINENCE
K R. Loughlin J. Urol., 1M: 1265-1267.1996
To the Editor. We were particularly interested in reading about this new technique, which reminded us of the procedure described in 1986 by Raz that still is performed at many centers today. This technique, called transvaginal needle suspension of the bladder neck with a fascial s h g , involved placement of a fascial patch under the entire length of the urethra. The major difference between this method and that of Laughlin is that the fascial strip was placed longitudinally to transversely. and that we used 4 sutures, 1 at each mrner of the fascial strip, compared to a running suture on the free edge of the fascial strip. We also commented on our experience with 22 patients and found the aame advantages with the fascial patch that hughlin suggested in his discussion, namely simplicity in harvesting the fascial patch with no need for abdominal diesection, compression of the urethra for ita entire length, no dissection in the retropubic space by using the modified Pereyra needle for transfer of the sutures from the vaginal area to the euprapubic area and, linally, use of autologous tissue * Mimvaaive, Watertown, Massachusetts.
compared to nonabsorbable material. We question the novelty of this new approach and further wonder why our article, published 10 years ago, was not referenced. Respectfully, Phillippe E. Zimmern and Roger Hadley Department of Surgery, Division of Urology University of Texas Southwestern Medical Center 5323 Harry Hines Blwd. Dallas, Texas 75235-9110 Reply by Author. When preparing my manuscript I relied on the MEDLINE index which contains 9,167,857 medical references compiled since 1966. I returned to this resource and searched common references for “Zimmern,” “Hadley,” “fascial” and “sling,” and found no matches. During a search for “Raz,” “fascial” and ‘‘sling“ 1 reference was cited from 1988, which referred to a n open retropubic procedure that used a fascial sling in 4 male patients with a neurogenic bladder. A search for “Raz” and “1985”revealed 11 references, 1 of which contained a section on a fascial sling technique to which I believe the authors refer.’ This procedure has several major differences from the Brigham sling technique that I described: 1) their technique involves making an inverted U incision in the anterior vaginal wall and raising a vaginal wall flap, which is later incorporated into the repair, 2) the retropubic space is entered from below the lesion and the endopelvic fascia is divided, 3) the sling is a composite that uses vaginal wall, a free rectus fascial graft and endopelvic fascia, whereas the Brigham sling uses the free rectus fascial graft only, 4 ) they used the 4 sutures to suspend the graft upward, whereas I used 2 and 5) they used 4 silicone mesh pledgets beneath the tied sutures on the abdominal side of the operation, whereas none is required with my procedure. Their technique is no more similar to the Brigham sling than the Raz needle suspension is to the Stamey needle suspension. The results of both techniques are also different, since they reported that 15 of 22 patients had retention and required the added burden of intermittent catheterization, compared to none of my patients. 1. Hadley, H. R., Zimmern, P. E., Staskin, D. R. and Raz, S.: Tmnsvaginal needle bladder neck suspension. Urol. Clin. N. Amer., 1 2 291, 1985.
RE: A LIVE BIRTH FROM INTRACYTOPLASMIC IN JECTlOX OF A SPERMATOZOON RETRIEVED FROM TESTICULAR PARENCHYMA M. A. Witt, C. Elsner, H . I . Kort. J . B. Massey, D. Mitchell-LwI: A. A. Toledo and M. J. Tucker J. Urol., 154: 1136-1137, 1995 To the Editor. We read with interest this report of a successful birth aRer intracytoplasmic injection of a testicular spermatozoon i n a patient with congenital bilateral aplasia of the vas deferens. The authors stated that there was no family hstory of cystic fibrosis or congenital bilateral aplasia of the vas deferens in this patient. \Ye believe thorough genetic counseling should have been offered to the couple before performing an assisted reproduction procedure. I t has been shown that congenital bilateral aplasia of the vas deferens 1 3 a mild form of cystic fibrosis, although the molecular basis of congmital bilateral aplasia of the vas deferens is not completely understood. The incidence of cystic fibrosis in the United States has heen estimated a t 1 in 2,500 live births and an estimated carrier trequency of 1 in 25 has been reported. More than 300 mutations have been found in cystic fibrosis affected families but the most common specific mutation was AF508 in 67% of the patients with cystic fibrosis. In congenital bilateral aplasia of the vas deferens a Irequency of 42 to 51%of AF508 mutations has been reported.’ P a t r i m et al found a t least 1 cystic fibrosis mutation in 59% of the patients with congenital bilateral aplasia of the vas deferens.2 If both partners were carriers the risk of giving birth to a child with cystic fibrosis would have been 25%.Recently, Liu et al reported on pre-unplantation diagnosis of AF508 mutations in embryos produced by a patient with congenital bilateral aplasia of the vas d e t w ens and a female partner with AF508 mutation.3 Blastomere analysis revealed 2 embryos homozygous for AF508 and 3 carriers The