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Technique determines efficacy of local anesthetic for outpatient prostate biopsy
LETTERS TO THE EDITOR
Laparoscopic Gonadectomy and Excision of Mu¨llerian Remnant in an Adult Intersex Patient TO THE EDITOR:
Cadeddu and colleagues1 presented a laparoscopic gonadectomy and hysterosalpingectomy performed in a phenotypically-male intersex patient diagnosed in adulthood. The use of laparoscopic techniques in the management of patients with disorders of sex differentiation is not new. Laparoscopic gonadal biopsy was first described in 19862 and laparoscopic gonadectomy was first performed in 1990.3 Since then, many reports of laparoscopic removal of gonads with malignant potentials as well as ductal structures contrary to gender assignment have been published.4 – 6 According to the data reported, it seems that the case presented is a persistent mu¨llerian duct syndrome (hernia uterine inguinale), a rare syndrome resulting from failure of paracrine secretion of anti-mu¨llerian hormone (AMH) by the Sertoli cells or failure of the mu¨llerian ducts to respond to its secretion. Of note, AMH has already been purified, and immunohistochemical techniques are available to stain for AMH. It would be interesting to determine if AMH is present in the testicular tissue of this patient as it may be present in about 30% of patients with this syndrome.7 As the testes of these patients present propensity to develop malignancy, gonadectomy is usually indicated as it was in the presented case. Another indication of laparoscopy in some cases of sexual ambiguity is the resection of the vaginal portion of the urogenital sinus.8 We performed this procedure in 5 cases of a series of 31 patients with disorders of sex differentiation who underwent laparoscopic gonadectomy in our department. In 4 cases, the procedure was accomplished successfully. In 1 patient with a short urogenital sinus, a long vaginal component extended from the retroperitoneal space to the perineum, and a perineal approach was used to accomplish the complete resection of the vaginal distal stump. Laparoscopy is a very reasonable tool for use in patients with disorders of sexual differentiation. Besides the advantages of a minimally invasive approach, the better cosmetic result of this technique is an important factor for patients already involved in complex psychological6 and social relationships. Reports such as the one presented by Cadeddu and colleagues highlight the fact that the indications for laparoscopy are still evolving and that urologists must be aware of the possibility of using this technique in the management of patients with disorders of sex differentiation. REFERENCES 1. Cadeddu J, Watumull L, Corwin TS, et al: Laparoscopic gonadectomy and excision of mu¨llerian remnant in an adult intersex patient. Urology 57: 554xi–554xii, 2001. 2. Portuondo J, Neyro J, Barral A, et al: Management of phenotypic female patients with an XY karyotype. J Reprod Med 31: 611– 615, 1986. 3. Droesch K, Droesch J, Chumas J, et al: Laparoscopic gonadectomy for gonadal dysgenesis. Fertil Steril 53: 360 – 361, 1990. © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
4. Llorente J, Collins D, and Linarelli L: Laparoscopic bilateral orchiectomy for testicular feminization syndrome. J Laparoendosc Surg 1: 351–353, 1991. 5. McDougall E, Clayman R, Anderson K, et al: Laparoscopic gonadectomy in a case of testicular feminization. Urology 42: 201–204, 1993. 6. Fahlenkamp D, Winfield H, Scho¨nberger B, et al: Role of laparoscopic surgery in pediatric urology. Eur Urol 32: 75– 84, 1997. 7. Guerrier D, Tran D, Vanderwinden J, et al: The persistent mu¨llerian duct syndrome: a molecular approach. J Clin Endocrinol Metab 68: 46 –52, 1989. 8. Denes F, Mendonc¸a B, Costa E, et al: The role of diagnostic and therapeutic laparoscopy in intersex patients. J Endourol 12: S106, 1998.
Oscar Fugita, M.D. Francisco Denes, M.D. Division of Urology Sa˜o Paulo University–Hospital of Clinics Sa˜o Paulo, SP, Brazil PII S0090-4295(01)01296-1
Technique Determines Efficacy of Local Anesthetic for Outpatient Prostate Biopsy TO THE EDITOR:
From the urologist’s end of the needle, prostate biopsy may be described as “uncomfortable,” but from the sharp end, it is regarded as “painful” by up to 90% of recipients.1 Although few men will refuse the urologist’s initial recommendation to undergo transrectal prostate biopsy, consent for a repeat biopsy is often much more difficult to obtain. Asked to explain why they resist, a majority will blame pain. Urologists, including the undersigned, have traditionally overlooked this discomfort as a necessary evil in the evaluation of possible prostate cancer. Dr. Wu and colleagues2 are among several investigators to be lauded for recent efforts to minimize this discomfort. However, the conclusion of this study is potentially misleading and should not dissuade further efforts at improving patient acceptance of biopsy. The authors sought to corroborate the findings of Nash et al.3 and Soloway and Obek,4 in which periprostatic injection of local anesthesia decreased prostate biopsy pain. Unfortunately, this study did not follow the technique of either of those reports, opting instead for an injection at the tip of the seminal vesicles well away from the prostate. Those reports showing efficacy injected local anesthetic either in three sites alongside the prostate (Soloway) or in the region of the prostatic vascular pedicle at the base of the prostate just lateral to the junction between the prostate and seminal vesicles (Nash). We have found the latter technique to be effective in minimizing or totally eliminating discomfort in the outpatient setting. Randomized trials at our institution are ongoUROLOGY 58: 635– 638, 2001 • 0090-4295/01/$20.00 635
ing in an effort to determine the best method to make prostate biopsy a less unpleasant outpatient procedure.
REFERENCES 1. Collins GN, Lloyd SN, Hehir M, et al: Multiple transrectal ultrasound-guided prostatic biopsies—true morbidity and patient acceptance. Br J Urol 71: 460, 1993. 2. Wu CL, Carter HB, Naqibuddin M, et al: Effect of local anesthetics on patient recovery after transrectal biopsy. Urology 57: 925–929, 2001. 3. Nash PA, Bruce JE, Indudhara R, et al: Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 155: 607– 609, 1996. 4. Soloway MS, and Obek C: Periprostatic local anesthesia before ultrasound guided prostate biopsy. J Urol 163: 172– 173, 2000.
J. Stephen Jones, M.D. Cleveland Clinic Urological Institute Beachwood, Ohio PII S0090-4295(01)01379-6
REPLY BY THE AUTHORS: We thank Dr. Jones for his interest in our article investigating the use of local anesthetic during transrectal prostate biopsy. He is correct in stating that there are differences between discomfort and pain. Our trial actually did assess pain on a visual analog scale (VAS) and, as indicated in our article, there are important methodologic issues which need to be considered during a trial assessing the effect of local anesthetic on pain during transrectal prostate biopsy. First, pain should be properly assessed. This score is typically obtained on a VAS consisting of an unmarked 10-cm horizontal line with the left end (0 cm) marked as “no pain” and the right end (10 cm) marked as “worst pain imaginable.” There should be no other markings or words surrounding this line. Verbal rating scales (VRS) can be used in place of a VAS score, but there has been some concern raised in the use of VRS.1 Second, proper statistical analysis should be used. VAS scores can be averaged (mean ⫾ SD) and compared with the t-test; however, VRS scores should realistically not be averaged and statistically analyzed as above, as these are technically nonparametric data. Finally, randomized, double-blind, placebo-controlled trials are essential (if there are no ethical conflicts) in assessing the effect of an intervention such as local anesthetic injection on prostate biopsy pain, especially considering the fact that pain is a subjective symptom and may be influenced by investigator and other biases. Thus, there are several design and outcome measurement issues that every investigator needs to address before conducting “pain” trials; otherwise, the validity of the results may be questioned. We applaud the efforts of Dr. Jones in conducting additional randomized trials to elucidate this issue, but would hope that future investigators will consider some of the points that we have addressed.
REFERENCE 1. Ananth K, and Adejoyu B: The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography636
guided biopsy of the prostate: a prospective randomized placebo-controlled study (letter). BJU Int 86: 405– 406, 2000.
Christopher L. Wu, M.D. H. Ballentine Carter, M.D. Mohammad Naqibuddin, M.B.B.S., M.P.H. Lee A. Fleisher, M.D. Department of Anesthesiology and Critical Care Medicine Johns Hopkins Hospital Baltimore, Maryland PII S0090-4295(01)01380-2
Do the Eastern and Northern Parts of The Netherlands Differ in Testicular Cancer? TO THE EDITOR:
Spermon et al.1 conclude in their article that in The Netherlands, brothers of patients with testicular cancer have an increased risk of developing testicular cancer (TC). Recently, we also studied familial TC in the northern part of The Netherlands and reviewed the medical records of 686 TC patients treated at the Groningen University Hospital.2 These results compared with the results of Spermon et al. are presented in Table I. In addition to familial TC, we studied the age-adjusted incidence rates of TC in The Netherlands. Within a small country like The Netherlands, there are geographic differences in incidence of TC present, with a statistically significant highest incidence in the northern part of The Netherlands.3 These results are in contrast to the findings of Spermon et al., who mention that the incidence rates for cancer in the eastern parts of The Netherlands are similar to other parts of The Netherlands. Shared environmental factors, as well as genetic drift, might have resulted in the higher incidence of TC found in the stable founder population in the northern part of The Netherlands.3 The geographic clustering of TC in stable founder populations in the northern Netherlands may lend support to a genetic susceptibility to TC de-
TABLE I. Familial testicular cancer: Nijmegen compared to Groningen Item Period Patients FTC patients Seminomas Nonseminomas Bilateral TC in FTC Prevalence of UDT in FTCs* Inguinal hernia in FTC RR father-son RR for TC in brothers of TC patients
Nijmegen
Groningen
1986–1997 379 7 (1.8%) 114 (30%) 265 (70%) 1 (14.3%) 0 or 1 (0 or 14.3%) ? 0.96 5.9
1977–1997 686 17 (2.5%) 153 (22%) 540 (78%) 1 (5.9%) 3 (17.6%) 1 (5.9%) 1.75 9–13
KEY: TC ⫽ testicular cancer; FTC ⫽ familial testicular cancer; UDT ⫽ undescended testis; RR ⫽ relative risk. * Spermon et al.1 mention in their Results section that, in their population, patients with FTC had no history of undescended testes, whereas in their Comment section (at page 751) they mention that one of the FTC patients had an undescended testis.
UROLOGY 58 (4), 2001
Laparoscopic Gonadectomy and Excision of Mu¨llerian Remnant in an Adult Intersex Patient TO THE EDITOR:
Cadeddu and colleagues1 presented a laparoscopic gonadectomy and hysterosalpingectomy performed in a phenotypically-male intersex patient diagnosed in adulthood. The use of laparoscopic techniques in the management of patients with disorders of sex differentiation is not new. Laparoscopic gonadal biopsy was first described in 19862 and laparoscopic gonadectomy was first performed in 1990.3 Since then, many reports of laparoscopic removal of gonads with malignant potentials as well as ductal structures contrary to gender assignment have been published.4 – 6 According to the data reported, it seems that the case presented is a persistent mu¨llerian duct syndrome (hernia uterine inguinale), a rare syndrome resulting from failure of paracrine secretion of anti-mu¨llerian hormone (AMH) by the Sertoli cells or failure of the mu¨llerian ducts to respond to its secretion. Of note, AMH has already been purified, and immunohistochemical techniques are available to stain for AMH. It would be interesting to determine if AMH is present in the testicular tissue of this patient as it may be present in about 30% of patients with this syndrome.7 As the testes of these patients present propensity to develop malignancy, gonadectomy is usually indicated as it was in the presented case. Another indication of laparoscopy in some cases of sexual ambiguity is the resection of the vaginal portion of the urogenital sinus.8 We performed this procedure in 5 cases of a series of 31 patients with disorders of sex differentiation who underwent laparoscopic gonadectomy in our department. In 4 cases, the procedure was accomplished successfully. In 1 patient with a short urogenital sinus, a long vaginal component extended from the retroperitoneal space to the perineum, and a perineal approach was used to accomplish the complete resection of the vaginal distal stump. Laparoscopy is a very reasonable tool for use in patients with disorders of sexual differentiation. Besides the advantages of a minimally invasive approach, the better cosmetic result of this technique is an important factor for patients already involved in complex psychological6 and social relationships. Reports such as the one presented by Cadeddu and colleagues highlight the fact that the indications for laparoscopy are still evolving and that urologists must be aware of the possibility of using this technique in the management of patients with disorders of sex differentiation. REFERENCES 1. Cadeddu J, Watumull L, Corwin TS, et al: Laparoscopic gonadectomy and excision of mu¨llerian remnant in an adult intersex patient. Urology 57: 554xi–554xii, 2001. 2. Portuondo J, Neyro J, Barral A, et al: Management of phenotypic female patients with an XY karyotype. J Reprod Med 31: 611– 615, 1986. 3. Droesch K, Droesch J, Chumas J, et al: Laparoscopic gonadectomy for gonadal dysgenesis. Fertil Steril 53: 360 – 361, 1990. © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
4. Llorente J, Collins D, and Linarelli L: Laparoscopic bilateral orchiectomy for testicular feminization syndrome. J Laparoendosc Surg 1: 351–353, 1991. 5. McDougall E, Clayman R, Anderson K, et al: Laparoscopic gonadectomy in a case of testicular feminization. Urology 42: 201–204, 1993. 6. Fahlenkamp D, Winfield H, Scho¨nberger B, et al: Role of laparoscopic surgery in pediatric urology. Eur Urol 32: 75– 84, 1997. 7. Guerrier D, Tran D, Vanderwinden J, et al: The persistent mu¨llerian duct syndrome: a molecular approach. J Clin Endocrinol Metab 68: 46 –52, 1989. 8. Denes F, Mendonc¸a B, Costa E, et al: The role of diagnostic and therapeutic laparoscopy in intersex patients. J Endourol 12: S106, 1998.
Oscar Fugita, M.D. Francisco Denes, M.D. Division of Urology Sa˜o Paulo University–Hospital of Clinics Sa˜o Paulo, SP, Brazil PII S0090-4295(01)01296-1
Technique Determines Efficacy of Local Anesthetic for Outpatient Prostate Biopsy TO THE EDITOR:
From the urologist’s end of the needle, prostate biopsy may be described as “uncomfortable,” but from the sharp end, it is regarded as “painful” by up to 90% of recipients.1 Although few men will refuse the urologist’s initial recommendation to undergo transrectal prostate biopsy, consent for a repeat biopsy is often much more difficult to obtain. Asked to explain why they resist, a majority will blame pain. Urologists, including the undersigned, have traditionally overlooked this discomfort as a necessary evil in the evaluation of possible prostate cancer. Dr. Wu and colleagues2 are among several investigators to be lauded for recent efforts to minimize this discomfort. However, the conclusion of this study is potentially misleading and should not dissuade further efforts at improving patient acceptance of biopsy. The authors sought to corroborate the findings of Nash et al.3 and Soloway and Obek,4 in which periprostatic injection of local anesthesia decreased prostate biopsy pain. Unfortunately, this study did not follow the technique of either of those reports, opting instead for an injection at the tip of the seminal vesicles well away from the prostate. Those reports showing efficacy injected local anesthetic either in three sites alongside the prostate (Soloway) or in the region of the prostatic vascular pedicle at the base of the prostate just lateral to the junction between the prostate and seminal vesicles (Nash). We have found the latter technique to be effective in minimizing or totally eliminating discomfort in the outpatient setting. Randomized trials at our institution are ongoUROLOGY 58: 635– 638, 2001 • 0090-4295/01/$20.00 635
ing in an effort to determine the best method to make prostate biopsy a less unpleasant outpatient procedure.
REFERENCES 1. Collins GN, Lloyd SN, Hehir M, et al: Multiple transrectal ultrasound-guided prostatic biopsies—true morbidity and patient acceptance. Br J Urol 71: 460, 1993. 2. Wu CL, Carter HB, Naqibuddin M, et al: Effect of local anesthetics on patient recovery after transrectal biopsy. Urology 57: 925–929, 2001. 3. Nash PA, Bruce JE, Indudhara R, et al: Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 155: 607– 609, 1996. 4. Soloway MS, and Obek C: Periprostatic local anesthesia before ultrasound guided prostate biopsy. J Urol 163: 172– 173, 2000.
J. Stephen Jones, M.D. Cleveland Clinic Urological Institute Beachwood, Ohio PII S0090-4295(01)01379-6
REPLY BY THE AUTHORS: We thank Dr. Jones for his interest in our article investigating the use of local anesthetic during transrectal prostate biopsy. He is correct in stating that there are differences between discomfort and pain. Our trial actually did assess pain on a visual analog scale (VAS) and, as indicated in our article, there are important methodologic issues which need to be considered during a trial assessing the effect of local anesthetic on pain during transrectal prostate biopsy. First, pain should be properly assessed. This score is typically obtained on a VAS consisting of an unmarked 10-cm horizontal line with the left end (0 cm) marked as “no pain” and the right end (10 cm) marked as “worst pain imaginable.” There should be no other markings or words surrounding this line. Verbal rating scales (VRS) can be used in place of a VAS score, but there has been some concern raised in the use of VRS.1 Second, proper statistical analysis should be used. VAS scores can be averaged (mean ⫾ SD) and compared with the t-test; however, VRS scores should realistically not be averaged and statistically analyzed as above, as these are technically nonparametric data. Finally, randomized, double-blind, placebo-controlled trials are essential (if there are no ethical conflicts) in assessing the effect of an intervention such as local anesthetic injection on prostate biopsy pain, especially considering the fact that pain is a subjective symptom and may be influenced by investigator and other biases. Thus, there are several design and outcome measurement issues that every investigator needs to address before conducting “pain” trials; otherwise, the validity of the results may be questioned. We applaud the efforts of Dr. Jones in conducting additional randomized trials to elucidate this issue, but would hope that future investigators will consider some of the points that we have addressed.
REFERENCE 1. Ananth K, and Adejoyu B: The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography636
guided biopsy of the prostate: a prospective randomized placebo-controlled study (letter). BJU Int 86: 405– 406, 2000.
Christopher L. Wu, M.D. H. Ballentine Carter, M.D. Mohammad Naqibuddin, M.B.B.S., M.P.H. Lee A. Fleisher, M.D. Department of Anesthesiology and Critical Care Medicine Johns Hopkins Hospital Baltimore, Maryland PII S0090-4295(01)01380-2
Do the Eastern and Northern Parts of The Netherlands Differ in Testicular Cancer? TO THE EDITOR:
Spermon et al.1 conclude in their article that in The Netherlands, brothers of patients with testicular cancer have an increased risk of developing testicular cancer (TC). Recently, we also studied familial TC in the northern part of The Netherlands and reviewed the medical records of 686 TC patients treated at the Groningen University Hospital.2 These results compared with the results of Spermon et al. are presented in Table I. In addition to familial TC, we studied the age-adjusted incidence rates of TC in The Netherlands. Within a small country like The Netherlands, there are geographic differences in incidence of TC present, with a statistically significant highest incidence in the northern part of The Netherlands.3 These results are in contrast to the findings of Spermon et al., who mention that the incidence rates for cancer in the eastern parts of The Netherlands are similar to other parts of The Netherlands. Shared environmental factors, as well as genetic drift, might have resulted in the higher incidence of TC found in the stable founder population in the northern part of The Netherlands.3 The geographic clustering of TC in stable founder populations in the northern Netherlands may lend support to a genetic susceptibility to TC de-
TABLE I. Familial testicular cancer: Nijmegen compared to Groningen Item Period Patients FTC patients Seminomas Nonseminomas Bilateral TC in FTC Prevalence of UDT in FTCs* Inguinal hernia in FTC RR father-son RR for TC in brothers of TC patients
Nijmegen
Groningen
1986–1997 379 7 (1.8%) 114 (30%) 265 (70%) 1 (14.3%) 0 or 1 (0 or 14.3%) ? 0.96 5.9
1977–1997 686 17 (2.5%) 153 (22%) 540 (78%) 1 (5.9%) 3 (17.6%) 1 (5.9%) 1.75 9–13
KEY: TC ⫽ testicular cancer; FTC ⫽ familial testicular cancer; UDT ⫽ undescended testis; RR ⫽ relative risk. * Spermon et al.1 mention in their Results section that, in their population, patients with FTC had no history of undescended testes, whereas in their Comment section (at page 751) they mention that one of the FTC patients had an undescended testis.
UROLOGY 58 (4), 2001