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Transurethral Electrovaporization of the Prostate
Letters to the Editor Transurethral Electrovaporization of the Prostate
asked whether they experience muscle soreness after an event. This symptom occurs because many more muscle units are spuriously recruited by the seizure discharge and because they are all working con currently-flexors and extensors-against each other. The lack of such electric al storms in the central nervou s system of patients with cardiac syncope makes similar complaints of muscle soreness rare.
To the Editor. In the article by Te and Kaplan on transurethral electrovaporization of the prostate, which was published in the July 1998 issue of Mayo Clinic Proceedings (pages 691 to 695), the authors did not address a problem that arises from use of this procedure-the lack of prostatic tissue for pathologic examination. In my experience, unsuspected carcinoma is often detected in specimens obtained by transurethral resection. Frequently, the disease is extensive enough to cause obstruction and require therapy. I believe that the destruction of prostatic tissue that could yield important pathologic information is a serious drawback to the use of transurethral electrovaporization and must be weighed against the benefits of the procedure.
Gregory A. Hood, M.D. Southern California Permanente Medical Group La Mesa, California
In reply: We thank Dr. Hood for his gracious comments. We agree that the repetitive motor activity associated with generalized tonic-clonic (grand mal) seizures usually differs from the myoclonic jerks that may occur during syncope. As Dr. Hood indicated, however, distinguishing cardiogenic syncope from seizures can be difficult in some patients. Movements associated with myoclonic, absence, tonic, atonic , or partial seizures may be similar to those that occur with cardiac asystole. In many patients, long -term video-electroencephalographic monitoring with an ictal recording may be necessary for appropriate diagnostic classification. Ictal semiology alone may not always be sufficient.
Donald G. Ross, M.D., Ph.D. Holy Family Hospital and Medical Center Methuen, Massachusetts
In reply: One of the original concerns about transurethral electro vaporization of the prostate was that prostate cancer might be undetected because of the absence of tissue for pathologic examination. This concern, however, applies equally to other noninvasive procedures for the treatment of benign prostatic hyperplasia, such as medical therapy (a-adrenergic blocking agents and finasteride), microwave thermotherapy, and interstitial laser therapy . Before (or concurrent with) any treatment regimen , the potential for prostate cancer should be explored thoroughl y, with determination of prostate-specific antigen levels, digital rectal examination, and, if indicated, transrectal ultrasonography and needle biopsy. Unlike the other previously mentioned procedures, the equipment used to perform electrovaporization is the same as that for standard transurethral loop resection of the prostate, with the exception of the resecting electrode. Thus, one of the advantages of transurethral electrovaporization is that tissue resection can be accomplished easily by exchanging the electrode during the procedure . In our experience, most such resections yield adequate amounts of tissue for pathologic examination .
Gregory D. Cascino, M.D . Mayo Clinic Rochester Rochester, Minnesota
Ahead to the Past To the Editor: After reading the extensive review of idiopathic pulmonary fibrosis (IPF) by Ryu and colleagues, which was published in the November 1998 issue of Mayo Clinic Proceedings (pages 1085 to 1101), my thoughts returned to a time more than a quarter of a century ago when my colleagues and I published our study, "The Concept of Classic Interstitial Pneumonitis-Fibrosis (CIP-F) as a Clinicopathologic Syndrome."! How far have we come in the past 25 years toward a better understanding of this murky area ? Not far, I fear . If anything, the concept of IPF is more muddled than ever. Ryu and colleagues have done a great service in pointing out that usual interstitial pneumonitis (UIP) should be the pathologic hallmark if we are to make any sense of our studies. We said that 25 years ago . . When a specific cause for a morbid process cannot be ascribed, it is proper to attempt the formulation of a syndrome from the common features of the proces s. Furthermore, a rigorou s attempt should be made to establish specific criteria to identify the most typical examples and thereby isolate feature s that ultimately define a common pathogenesis and cause. We did this in our investigations 25 years ago. What was interesting , and is still valid, was the overarching importance of the physical finding of Velcro rales (crackles) in identifying a cohort of patients with similar clinical courses. Digital clubbing was also a highly specific, but not as frequently identified, sign. In the absence of these findings, even patients with evidence of DIP on lung biopsy had different clinical courses, usually more benign. Because transbronchial lung bi-
Alexis E. Te, M.D . Squier Urological Clinic New York, New York
Cardiac Asystole Masquerading as Temporal Lobe Epilepsy To the Editor: The article by Dr. Ficker and associates on cardiac asystole masquerading as temporal lobe epilepsy, which was publi shed in the August 1998 issue of Mayo Clinic Proceedings (pages 784 to 786), was an excellent, concise summary of what can be a very difficult clinical distinction. As the author s quite correctly stated, the decision in this scenario is often made clinically. I would like to offer another "pearl"-although both patients with cardiac syncope and those with seizures have myoclonic jerks, the etiologies of the motions differ. Because of the intense electrical stimulation of the muscles during a seizure, affected patients almost universally respond affirmatively when Mayo Clin Proc 1999;74:533-535
533
© 1999 Mayo Foundation for Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
asked whether they experience muscle soreness after an event. This symptom occurs because many more muscle units are spuriously recruited by the seizure discharge and because they are all working con currently-flexors and extensors-against each other. The lack of such electric al storms in the central nervou s system of patients with cardiac syncope makes similar complaints of muscle soreness rare.
To the Editor. In the article by Te and Kaplan on transurethral electrovaporization of the prostate, which was published in the July 1998 issue of Mayo Clinic Proceedings (pages 691 to 695), the authors did not address a problem that arises from use of this procedure-the lack of prostatic tissue for pathologic examination. In my experience, unsuspected carcinoma is often detected in specimens obtained by transurethral resection. Frequently, the disease is extensive enough to cause obstruction and require therapy. I believe that the destruction of prostatic tissue that could yield important pathologic information is a serious drawback to the use of transurethral electrovaporization and must be weighed against the benefits of the procedure.
Gregory A. Hood, M.D. Southern California Permanente Medical Group La Mesa, California
In reply: We thank Dr. Hood for his gracious comments. We agree that the repetitive motor activity associated with generalized tonic-clonic (grand mal) seizures usually differs from the myoclonic jerks that may occur during syncope. As Dr. Hood indicated, however, distinguishing cardiogenic syncope from seizures can be difficult in some patients. Movements associated with myoclonic, absence, tonic, atonic , or partial seizures may be similar to those that occur with cardiac asystole. In many patients, long -term video-electroencephalographic monitoring with an ictal recording may be necessary for appropriate diagnostic classification. Ictal semiology alone may not always be sufficient.
Donald G. Ross, M.D., Ph.D. Holy Family Hospital and Medical Center Methuen, Massachusetts
In reply: One of the original concerns about transurethral electro vaporization of the prostate was that prostate cancer might be undetected because of the absence of tissue for pathologic examination. This concern, however, applies equally to other noninvasive procedures for the treatment of benign prostatic hyperplasia, such as medical therapy (a-adrenergic blocking agents and finasteride), microwave thermotherapy, and interstitial laser therapy . Before (or concurrent with) any treatment regimen , the potential for prostate cancer should be explored thoroughl y, with determination of prostate-specific antigen levels, digital rectal examination, and, if indicated, transrectal ultrasonography and needle biopsy. Unlike the other previously mentioned procedures, the equipment used to perform electrovaporization is the same as that for standard transurethral loop resection of the prostate, with the exception of the resecting electrode. Thus, one of the advantages of transurethral electrovaporization is that tissue resection can be accomplished easily by exchanging the electrode during the procedure . In our experience, most such resections yield adequate amounts of tissue for pathologic examination .
Gregory D. Cascino, M.D . Mayo Clinic Rochester Rochester, Minnesota
Ahead to the Past To the Editor: After reading the extensive review of idiopathic pulmonary fibrosis (IPF) by Ryu and colleagues, which was published in the November 1998 issue of Mayo Clinic Proceedings (pages 1085 to 1101), my thoughts returned to a time more than a quarter of a century ago when my colleagues and I published our study, "The Concept of Classic Interstitial Pneumonitis-Fibrosis (CIP-F) as a Clinicopathologic Syndrome."! How far have we come in the past 25 years toward a better understanding of this murky area ? Not far, I fear . If anything, the concept of IPF is more muddled than ever. Ryu and colleagues have done a great service in pointing out that usual interstitial pneumonitis (UIP) should be the pathologic hallmark if we are to make any sense of our studies. We said that 25 years ago . . When a specific cause for a morbid process cannot be ascribed, it is proper to attempt the formulation of a syndrome from the common features of the proces s. Furthermore, a rigorou s attempt should be made to establish specific criteria to identify the most typical examples and thereby isolate feature s that ultimately define a common pathogenesis and cause. We did this in our investigations 25 years ago. What was interesting , and is still valid, was the overarching importance of the physical finding of Velcro rales (crackles) in identifying a cohort of patients with similar clinical courses. Digital clubbing was also a highly specific, but not as frequently identified, sign. In the absence of these findings, even patients with evidence of DIP on lung biopsy had different clinical courses, usually more benign. Because transbronchial lung bi-
Alexis E. Te, M.D . Squier Urological Clinic New York, New York
Cardiac Asystole Masquerading as Temporal Lobe Epilepsy To the Editor: The article by Dr. Ficker and associates on cardiac asystole masquerading as temporal lobe epilepsy, which was publi shed in the August 1998 issue of Mayo Clinic Proceedings (pages 784 to 786), was an excellent, concise summary of what can be a very difficult clinical distinction. As the author s quite correctly stated, the decision in this scenario is often made clinically. I would like to offer another "pearl"-although both patients with cardiac syncope and those with seizures have myoclonic jerks, the etiologies of the motions differ. Because of the intense electrical stimulation of the muscles during a seizure, affected patients almost universally respond affirmatively when Mayo Clin Proc 1999;74:533-535
533
© 1999 Mayo Foundation for Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.