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RE: TRANSIENT LOWER EXTREMITY NEURAPRAXIA ASSOCIATED WITH RADICAL PERINEAL PROSTATECTOMY
LETTERS TO THE EDITOR
171
prostatectomy, positive lymph nodes and PSA 14 FgA. The correlation of testosterone levels with PSA levels in our second patient indicates clearly that the testosterone level rather than the intermittent hormonal therapy impacts tumor status. All 3 cases occurred in 1year, and SO we are convinced that Oefelein describes an important issue and that testosterone measurements are important in neoadjuvant prostate carcinoma studies. Respectfully, Willem Meinhardt and Simon Horenblas Netherlands Cancer Znstitute Plesmanlaan 121 1066 CX Amsterdam The Netherlands
2. Walter, J. B. and Israel, M. S.: General Pathology, 6th ed. Edinburgh: Churchill Livingstone, chapt. 42,p. 547,1987. 3. Strachan, J. R., Corbishley, C. M. and Shearer, R. J.: Postoperative retention associated with acute prostatic infarction. Brit. J. Urol., 72 311,1993. 4. Spiro, L.H., Labay, G. and Orlin. L. A.: Prostatic infarction. Role in acute urinary retention. Urology, 3 345,1974. 5. Armitage, P. and Berry, G.: Statistical Methods in Medical Research, 3rd ed. Boston: Blackwell Scientific Publications, chapt. 4,p. 93,1994.
1. Kisman, 0. K.,de Voogt, H. J. and Baak, J. A.: Reversibility of the effect of LHRH agonists and other antiandrogenic hormones on the testis: a histomorphometric study. Eur. Urol.,
RE: TRANSIENT LOWER EXTREMITY NEURAPRAXIA ASSOCIATED WITH RADICAL PERINEAL PROSTATECTOMY: A COMPLICATION OF THE EXAGGERATED LITHOTOMY POSITION
18 299, 1990.
D. T. Price, J . Vieweg, F. Roland, L. Coetzee, T. Spalding, C. Iselin and D. F. Paulson
J. U d . , 160: 1376-1378,1998 RE: PROSTATIC INFARCTIONlINFECTION IN ACUTE URINARY RETENTION SECONDARY TO BENIGN PROSTATIC HYF'ERPLASIA
I. Anjum, M. Ahmed, A. Azzopardi and G. R. Mufti
J. Urol., 160: 792-793, 1998 To the Editor. The objective of this study was to define the role of some of the factors previously considered to be important in the pathophysiology of urinary retention. However, there are significant problems with the methods and results that render its final conclusion regarding the relevance of prostatic infarctions unsound. The authors define true infarcts as "sharply outlined areas of coagulative necrosis involving glands and stoma, often with squamous metaplasia a t the edges". This definition is too restrictive and is highly likely to lead to missing any early infarctions, particularly in view of the short time between hospitalization and transurethral prostatic resection (maximum 4 days). Early infarctions are known to be difficult to detect a t the best of times, particularly with the usual staining and under light microscopy. The dependence of the histological changes of infarction on the interval between the incident, and tissue sampling and processing is well known.'.' Consequently, the study design would be biased towards under detection and underreporting of this main outcome measure, namely prostatic infarction. Similarly, examination of the transurethral prostatic resection chips introduces another important error in this study. Some acute infarcts may be missed on specimens if they lie at the periphery of the gland.3 Sampling as well as distortion by resection cause a disadvantage in this study when compared to the study of Spiro et al who examined enucleated prostates.4 Spiro et a1 also examined more prostates (200versus 70)and larger specimens (average 75.1 and 69 gm.versus median 30 and 26 gm. in acute retention and elective groups respectively), and they had the added benefit of any macroscopic evidence of infarctions. Consequently, the 85% incidence of prostatic infarctions in patients presenting in acute retention reported by Spiro et al more likely reflects the true incidence of infarctions in this group.* The main evidence that Anjum et al offer to substantiate their conclusion is the statistical insignificance of the difference between the incidence of infarctions in the acute retention group (3 of 35 patients) and the elective group (1).Because of the small sample size, the conclusion would have been exactly the opposite if the number of infarctions in the acute retention group had changed from 3 (p = 0.3) to 6 (p = 0.046). We p e always reminded of the distinction between statistical and clinical significance.6 Respectfully, Magdi M.Kirollos 17 Shiphay Ave. Torquay Devon, United Kingdom TQ2 7ED
1. Underwood, J. C. E.: General and Systematic Pathology, 2nd ed. New York Churchill Livingstone, chapt. 8. p. 174,1996.
To the Editor. The authors investigated the 21% incidence (23of 111 patients) of lower extremity neurapraxia associated with the exaggerated lithotomy position in patients undergoing radical perineal prostatectomy. In this retrospective review they cite operation time and improper positioning by relatively inexperienced assistants as the most important risk factors. Mean duration of surgery for patients suffering neurapraxic complications was 188 minutes. Between September 1993 and 1998,444 radical perineal prostatectomies were performed by 4 different surgeons according to the technique described by Pau1son.l Positioning was always done by the surgeons themselves or under their supervision, and exactly the same way as described by Price e t al. Between August 1995 and September 1998 we prospectively investigated the perioperative morbidity of 284 consecutive patients. The complications recorded are listed in the table and were similar to those published by Price et al. There was no neuropraxia of the lower extremity. A possible explanation could be that the duration of surgery was significantly shorter with a mean operation time of 99 minutes (range 50 to 150). Of 35 patients in an exaggerated lithotomy position during urethroplasty 2 presented with neurapraxia of the lower extremity. The operation time for these patients was 210 and 240 minutes, respectively. Angermeier and Jordan reported no neurapraxia of the lower extremity with an operation time shorter than 180 minutes.' Therefore, the critical operation time for neurapraxia of the lower extremity as a complication of the exaggerated lithotomy position seems to be 180 minutes or more. Respectfully, Hanajorg Keller Department of Urology and Pediatric Urology Minikum menburg Ebertplatz 12 77654 Ofenburg Germany
1. Paulson, D. F.:Perineal Prostatectomy. In: Campbell's Urology, 6th 4. Edited by P. C.Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 79,pp. 2887-2897, 1992. 2. Angermeier, K. W. and Jordan, G. H.: Complications of the exaggerated lithotomy position: a review of 177 cases. J.Urol., 151: 866,1994.
Complications of radical perineal prostatectomy No. Pts. Blood transfusion Rectal lacerations Bladder neck obstruction Febrile urinary tract infeeton
14
Wound infection
23
9 10
3
(R)
(3.2) (3.5) (1) (4.9) (8.0)
171
prostatectomy, positive lymph nodes and PSA 14 FgA. The correlation of testosterone levels with PSA levels in our second patient indicates clearly that the testosterone level rather than the intermittent hormonal therapy impacts tumor status. All 3 cases occurred in 1year, and SO we are convinced that Oefelein describes an important issue and that testosterone measurements are important in neoadjuvant prostate carcinoma studies. Respectfully, Willem Meinhardt and Simon Horenblas Netherlands Cancer Znstitute Plesmanlaan 121 1066 CX Amsterdam The Netherlands
2. Walter, J. B. and Israel, M. S.: General Pathology, 6th ed. Edinburgh: Churchill Livingstone, chapt. 42,p. 547,1987. 3. Strachan, J. R., Corbishley, C. M. and Shearer, R. J.: Postoperative retention associated with acute prostatic infarction. Brit. J. Urol., 72 311,1993. 4. Spiro, L.H., Labay, G. and Orlin. L. A.: Prostatic infarction. Role in acute urinary retention. Urology, 3 345,1974. 5. Armitage, P. and Berry, G.: Statistical Methods in Medical Research, 3rd ed. Boston: Blackwell Scientific Publications, chapt. 4,p. 93,1994.
1. Kisman, 0. K.,de Voogt, H. J. and Baak, J. A.: Reversibility of the effect of LHRH agonists and other antiandrogenic hormones on the testis: a histomorphometric study. Eur. Urol.,
RE: TRANSIENT LOWER EXTREMITY NEURAPRAXIA ASSOCIATED WITH RADICAL PERINEAL PROSTATECTOMY: A COMPLICATION OF THE EXAGGERATED LITHOTOMY POSITION
18 299, 1990.
D. T. Price, J . Vieweg, F. Roland, L. Coetzee, T. Spalding, C. Iselin and D. F. Paulson
J. U d . , 160: 1376-1378,1998 RE: PROSTATIC INFARCTIONlINFECTION IN ACUTE URINARY RETENTION SECONDARY TO BENIGN PROSTATIC HYF'ERPLASIA
I. Anjum, M. Ahmed, A. Azzopardi and G. R. Mufti
J. Urol., 160: 792-793, 1998 To the Editor. The objective of this study was to define the role of some of the factors previously considered to be important in the pathophysiology of urinary retention. However, there are significant problems with the methods and results that render its final conclusion regarding the relevance of prostatic infarctions unsound. The authors define true infarcts as "sharply outlined areas of coagulative necrosis involving glands and stoma, often with squamous metaplasia a t the edges". This definition is too restrictive and is highly likely to lead to missing any early infarctions, particularly in view of the short time between hospitalization and transurethral prostatic resection (maximum 4 days). Early infarctions are known to be difficult to detect a t the best of times, particularly with the usual staining and under light microscopy. The dependence of the histological changes of infarction on the interval between the incident, and tissue sampling and processing is well known.'.' Consequently, the study design would be biased towards under detection and underreporting of this main outcome measure, namely prostatic infarction. Similarly, examination of the transurethral prostatic resection chips introduces another important error in this study. Some acute infarcts may be missed on specimens if they lie at the periphery of the gland.3 Sampling as well as distortion by resection cause a disadvantage in this study when compared to the study of Spiro et al who examined enucleated prostates.4 Spiro et a1 also examined more prostates (200versus 70)and larger specimens (average 75.1 and 69 gm.versus median 30 and 26 gm. in acute retention and elective groups respectively), and they had the added benefit of any macroscopic evidence of infarctions. Consequently, the 85% incidence of prostatic infarctions in patients presenting in acute retention reported by Spiro et al more likely reflects the true incidence of infarctions in this group.* The main evidence that Anjum et al offer to substantiate their conclusion is the statistical insignificance of the difference between the incidence of infarctions in the acute retention group (3 of 35 patients) and the elective group (1).Because of the small sample size, the conclusion would have been exactly the opposite if the number of infarctions in the acute retention group had changed from 3 (p = 0.3) to 6 (p = 0.046). We p e always reminded of the distinction between statistical and clinical significance.6 Respectfully, Magdi M.Kirollos 17 Shiphay Ave. Torquay Devon, United Kingdom TQ2 7ED
1. Underwood, J. C. E.: General and Systematic Pathology, 2nd ed. New York Churchill Livingstone, chapt. 8. p. 174,1996.
To the Editor. The authors investigated the 21% incidence (23of 111 patients) of lower extremity neurapraxia associated with the exaggerated lithotomy position in patients undergoing radical perineal prostatectomy. In this retrospective review they cite operation time and improper positioning by relatively inexperienced assistants as the most important risk factors. Mean duration of surgery for patients suffering neurapraxic complications was 188 minutes. Between September 1993 and 1998,444 radical perineal prostatectomies were performed by 4 different surgeons according to the technique described by Pau1son.l Positioning was always done by the surgeons themselves or under their supervision, and exactly the same way as described by Price e t al. Between August 1995 and September 1998 we prospectively investigated the perioperative morbidity of 284 consecutive patients. The complications recorded are listed in the table and were similar to those published by Price et al. There was no neuropraxia of the lower extremity. A possible explanation could be that the duration of surgery was significantly shorter with a mean operation time of 99 minutes (range 50 to 150). Of 35 patients in an exaggerated lithotomy position during urethroplasty 2 presented with neurapraxia of the lower extremity. The operation time for these patients was 210 and 240 minutes, respectively. Angermeier and Jordan reported no neurapraxia of the lower extremity with an operation time shorter than 180 minutes.' Therefore, the critical operation time for neurapraxia of the lower extremity as a complication of the exaggerated lithotomy position seems to be 180 minutes or more. Respectfully, Hanajorg Keller Department of Urology and Pediatric Urology Minikum menburg Ebertplatz 12 77654 Ofenburg Germany
1. Paulson, D. F.:Perineal Prostatectomy. In: Campbell's Urology, 6th 4. Edited by P. C.Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 79,pp. 2887-2897, 1992. 2. Angermeier, K. W. and Jordan, G. H.: Complications of the exaggerated lithotomy position: a review of 177 cases. J.Urol., 151: 866,1994.
Complications of radical perineal prostatectomy No. Pts. Blood transfusion Rectal lacerations Bladder neck obstruction Febrile urinary tract infeeton
14
Wound infection
23
9 10
3
(R)
(3.2) (3.5) (1) (4.9) (8.0)