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Re: Traumatic Rupture of the Testicle and a Review of the Literature, by George Schuster, J. Urol., 127: 1194–1196, 1982
393
LETTERS TO THE EDITOR
my patients has been 4 days, with some of these patients being sent home with an indwelling Foley catheter if they are unable to void on the first trial. Therefore, it seems to me that the cost for the open operative procedure should be no greater than that for the PereyraStamey procedure. I believe that the conclusion of these authors, that the Pereyra-Stamey technique is preferred because of economic reasons, is not appropriate. Furthermore, it is still to be determined whether the long-range results for this procedure will be equivalent to the excellent results obtained by the open operation.
them to supply us with this information. They stated, "We used electrocautery and the knife that we used in conjunction with the Storz resectoscope is a coagulating electrode: No. 27040 K when we used the 27 Ch. sheath and 27040 L when we used the 24 Ch. sheath."
RE: IMPOTENCE FOLLOWING RADICAL PROST A TECTOMY: INSIGHT INTO ETIOLOGY AND PREVENTION
Patrick C. Walsh and PieterJ. Danker
Morton Palken 120 Northgate Plaza, Suite 455 Seattle, Washington 98125
J. Urol., 128: 492-497, 1982
To the Editor. This study adds an important contribution to our Reply by Authors. When we studied the relative costs of the PereyraStamey versus the Marshall-Marchetti-Krantz procedures we wanted to ensure that any differences were not caused by the operative skill or postoperative regimen of any individual surgeon. Therefore, we reviewed the records from 3 institutions, which included the patients of multiple urologists, gynecologists and a few general surgeons. It is not surprising that an individual surgeon may be more facile with one procedure or the other but, since Doctor Palken does not state whether he performs Pereyra-Stamey urethropexies, it is hard to assess the relative merits of each procedure in his hands. It has been the experience at our institution that the superficial dissection required for the Pereyra-Stamey method results in substantially less postoperative morbidity than the open techniques, which require a generous incision in the abdominal fascia and dissection of the retropubic space. This decreased postoperative morbidity contributes to the shorter hospital stay. Since we have become experienced with the endoscopically controlled technique these advantages have become increasingly obvious. Although long-term results from multiple centers are still awaited no one has yet published a series demonstrating that postoperative success is not comparable in each procedure. In a consecutive series of 203 patients, including 188 cases that had failed a prior open operation, Stamey reported a 91 per cent cure rate, with followup of 1 to 10 years. 1 1. Stamey, T. A.: Endoscopic suspension of the vesical neck for
surgically curable urinary incontinence in the female. In: Monographs in Urology. Pennington, New Jersey: Custom Publishing Service, Inc., pp. 65-82, 1981.
RE: TRAUMATIC RUPTURE OF THE TESTICLE AND A REVIEW OF THE LITERATURE
George Schuster
understanding of the mechanism of impotence after a perinea! approach for an operation on the prostate. The work proves that the loss of erection in such an operation is caused by damage to the nervous bundles innervating the corpora cavernosa and that these nerves are adrenergic. These branches, as shown by the authors, "run immediately adjacent to and through the wall of the membranous urethra as they exit through the urogenital diaphragm and pass close to the glands of Cowper, which they innervate as well, before they enter the dorsal medial side of the corpora cavernosa". The assumption regarding the importance of sympathetic nerves in the mechanism of erection is supported by previous work that shows a majority of adrenergic fibers in the parenchyma of the corpora cavernosa.1' 2 The authors also conclude that the finding of normal penile blood flow in impotent patients suggests that arterial insufficiency is not an important factor in the cause of impotence. One point that appears insufficiently clear to us is when the authors refer to the innervation of the corpora cavernosa without mentioning specifically which component of the corpora receives this innervation. Recently, we have defined the corpora as being muscular masses in which irregular intercommunicating vascular spaces are embedded. 3 This definition has the intention to emphasize the fact that the bulk of the corpora is made up of smooth muscle and to show the importance we attribute to this muscle in the development of erection. We also insisted, based on recent work, 4' 5 that the mechanism of erection cannot be caused by a pure vascular phenomenon. Using a noninvasive technique we have shown that in man the intracorpora cavernosa pressure is at least 10 times higher than the systolic pressure.'· 5 These observations support the authors' contention that arterial insufficiency is not an important factor in causing impotence. This article is of extreme importance to the urologist in his attempt to eliminate the complication of impotence after radical operation on the prostate. Respectfully,
J. Urol., 127: 1194-1196, 1982
To the Editor. In this report a patient with epididymal rupture after blunt trauma to the scrotum was presented and a further case was cited. For completeness it should be noted that a third case of epididymal avulsion has been described, substantiating the admonition that surgical exploration is indicated in patients with blunt trauma and ecchymosis of the scrotum. 1 Three unusual injuries to the scrotal contents, a ruptured testicle, an avulsed epididymis and a laceration of a varicocele, were identified on 3 consecutive scrotal explorations in a 9-month period. Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 72205 1. Redman, J. F., Rountree, G. A. and Bissada, N. K.: Injuries to
scrotal contents by blunt trauma. Urology, 7: 190, 1976.
RE: AN OBJECTIVE COMPARISON OF TRANSURETHRAL RESECTION AND BLADDER NECK INCISION IN THE TREATMENT OF PROSTATIC HYPERTROPHY
A. M. B. Goldstein and J.P. Meehan Departments of Urology and Physiology University of Southern California School of Medicine Los Angeles, California 90033 1. Benson, G. S., McConnel, J. A., Lipshultz, L. I., Corriere, J. N., Jr.
2. 3.
4.
5.
and Wood, J.: Neuromorphology and neuropha:rmacology of the human penis: an in vitro study. J. Clin. Invest., 65: 506, 1980. Levin, R. M. and Wein, A. J.: Adrenergic alpha receptors outnumber beta receptors in human penile corpus cavernosum. Invest. Urol., 18: 225, 1980. Goldstein, A. M. B., Meehan, J.P., Zakhary, R., Buckley, P.A. and Rogers, F. A.: New observations on microarchitecture of corpora cavernosa in man and possible relationship to mechanism of erection. Urology, 20: 259, 1982. Meehan, J.P. and Goldstein, A. M. B.: La presion intracavernosa en el hombre durante la erecion. Primer Simposio International de Diagnostica y Tratamiento de la Impotencia Sexual Masculina. Mar de! Plata, Argentina, October 18-23, 1981. Meehan, J. P. and Goldstein, A. M. B.: The high intracorpora cavernosa pressure during erection in man and its probable mechanism. Urology, in press.
Lynn Edwards and Chris Powell J. Urol., 128: 325-327, 1982
ACYCLOVIR
Note by Editor. Because of several inquiries concerning the type of knife used by these authors in making the bladder neck incision I asked
To the Editor. Recently the Food and Drug Administration has made available acyclovir in 5 per cent ointment for the treatment of
LETTERS TO THE EDITOR
my patients has been 4 days, with some of these patients being sent home with an indwelling Foley catheter if they are unable to void on the first trial. Therefore, it seems to me that the cost for the open operative procedure should be no greater than that for the PereyraStamey procedure. I believe that the conclusion of these authors, that the Pereyra-Stamey technique is preferred because of economic reasons, is not appropriate. Furthermore, it is still to be determined whether the long-range results for this procedure will be equivalent to the excellent results obtained by the open operation.
them to supply us with this information. They stated, "We used electrocautery and the knife that we used in conjunction with the Storz resectoscope is a coagulating electrode: No. 27040 K when we used the 27 Ch. sheath and 27040 L when we used the 24 Ch. sheath."
RE: IMPOTENCE FOLLOWING RADICAL PROST A TECTOMY: INSIGHT INTO ETIOLOGY AND PREVENTION
Patrick C. Walsh and PieterJ. Danker
Morton Palken 120 Northgate Plaza, Suite 455 Seattle, Washington 98125
J. Urol., 128: 492-497, 1982
To the Editor. This study adds an important contribution to our Reply by Authors. When we studied the relative costs of the PereyraStamey versus the Marshall-Marchetti-Krantz procedures we wanted to ensure that any differences were not caused by the operative skill or postoperative regimen of any individual surgeon. Therefore, we reviewed the records from 3 institutions, which included the patients of multiple urologists, gynecologists and a few general surgeons. It is not surprising that an individual surgeon may be more facile with one procedure or the other but, since Doctor Palken does not state whether he performs Pereyra-Stamey urethropexies, it is hard to assess the relative merits of each procedure in his hands. It has been the experience at our institution that the superficial dissection required for the Pereyra-Stamey method results in substantially less postoperative morbidity than the open techniques, which require a generous incision in the abdominal fascia and dissection of the retropubic space. This decreased postoperative morbidity contributes to the shorter hospital stay. Since we have become experienced with the endoscopically controlled technique these advantages have become increasingly obvious. Although long-term results from multiple centers are still awaited no one has yet published a series demonstrating that postoperative success is not comparable in each procedure. In a consecutive series of 203 patients, including 188 cases that had failed a prior open operation, Stamey reported a 91 per cent cure rate, with followup of 1 to 10 years. 1 1. Stamey, T. A.: Endoscopic suspension of the vesical neck for
surgically curable urinary incontinence in the female. In: Monographs in Urology. Pennington, New Jersey: Custom Publishing Service, Inc., pp. 65-82, 1981.
RE: TRAUMATIC RUPTURE OF THE TESTICLE AND A REVIEW OF THE LITERATURE
George Schuster
understanding of the mechanism of impotence after a perinea! approach for an operation on the prostate. The work proves that the loss of erection in such an operation is caused by damage to the nervous bundles innervating the corpora cavernosa and that these nerves are adrenergic. These branches, as shown by the authors, "run immediately adjacent to and through the wall of the membranous urethra as they exit through the urogenital diaphragm and pass close to the glands of Cowper, which they innervate as well, before they enter the dorsal medial side of the corpora cavernosa". The assumption regarding the importance of sympathetic nerves in the mechanism of erection is supported by previous work that shows a majority of adrenergic fibers in the parenchyma of the corpora cavernosa.1' 2 The authors also conclude that the finding of normal penile blood flow in impotent patients suggests that arterial insufficiency is not an important factor in the cause of impotence. One point that appears insufficiently clear to us is when the authors refer to the innervation of the corpora cavernosa without mentioning specifically which component of the corpora receives this innervation. Recently, we have defined the corpora as being muscular masses in which irregular intercommunicating vascular spaces are embedded. 3 This definition has the intention to emphasize the fact that the bulk of the corpora is made up of smooth muscle and to show the importance we attribute to this muscle in the development of erection. We also insisted, based on recent work, 4' 5 that the mechanism of erection cannot be caused by a pure vascular phenomenon. Using a noninvasive technique we have shown that in man the intracorpora cavernosa pressure is at least 10 times higher than the systolic pressure.'· 5 These observations support the authors' contention that arterial insufficiency is not an important factor in causing impotence. This article is of extreme importance to the urologist in his attempt to eliminate the complication of impotence after radical operation on the prostate. Respectfully,
J. Urol., 127: 1194-1196, 1982
To the Editor. In this report a patient with epididymal rupture after blunt trauma to the scrotum was presented and a further case was cited. For completeness it should be noted that a third case of epididymal avulsion has been described, substantiating the admonition that surgical exploration is indicated in patients with blunt trauma and ecchymosis of the scrotum. 1 Three unusual injuries to the scrotal contents, a ruptured testicle, an avulsed epididymis and a laceration of a varicocele, were identified on 3 consecutive scrotal explorations in a 9-month period. Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 72205 1. Redman, J. F., Rountree, G. A. and Bissada, N. K.: Injuries to
scrotal contents by blunt trauma. Urology, 7: 190, 1976.
RE: AN OBJECTIVE COMPARISON OF TRANSURETHRAL RESECTION AND BLADDER NECK INCISION IN THE TREATMENT OF PROSTATIC HYPERTROPHY
A. M. B. Goldstein and J.P. Meehan Departments of Urology and Physiology University of Southern California School of Medicine Los Angeles, California 90033 1. Benson, G. S., McConnel, J. A., Lipshultz, L. I., Corriere, J. N., Jr.
2. 3.
4.
5.
and Wood, J.: Neuromorphology and neuropha:rmacology of the human penis: an in vitro study. J. Clin. Invest., 65: 506, 1980. Levin, R. M. and Wein, A. J.: Adrenergic alpha receptors outnumber beta receptors in human penile corpus cavernosum. Invest. Urol., 18: 225, 1980. Goldstein, A. M. B., Meehan, J.P., Zakhary, R., Buckley, P.A. and Rogers, F. A.: New observations on microarchitecture of corpora cavernosa in man and possible relationship to mechanism of erection. Urology, 20: 259, 1982. Meehan, J.P. and Goldstein, A. M. B.: La presion intracavernosa en el hombre durante la erecion. Primer Simposio International de Diagnostica y Tratamiento de la Impotencia Sexual Masculina. Mar de! Plata, Argentina, October 18-23, 1981. Meehan, J. P. and Goldstein, A. M. B.: The high intracorpora cavernosa pressure during erection in man and its probable mechanism. Urology, in press.
Lynn Edwards and Chris Powell J. Urol., 128: 325-327, 1982
ACYCLOVIR
Note by Editor. Because of several inquiries concerning the type of knife used by these authors in making the bladder neck incision I asked
To the Editor. Recently the Food and Drug Administration has made available acyclovir in 5 per cent ointment for the treatment of