LETTERS TO THE EDITOR
Lavelle, M. T., Conlin, M. J. and Skoog, S. J.: Subureteral injection of Deflux for correction of reflux: analysis of factors predicting success. Urology, 65: 564, 2005 2. Stenberg, A., Larsson, E., Lindholm, A., Ronneus, B. and Lackgren, G.: Injectable dextranomer-based implant: histopathology, volume changes and DNA-analysis. Scand J Urol Nephrol, 33: 355, 1999 3. Stenberg, A., Larsson, E. and Lackgren, G.: Endoscopic treatment with dextranomer-hyaluronic acid for vesicoureteral reflux: histological findings. J Urol, 169: 1109, 2003 4. Putman, S., Wicher, C., Wayment, R., Harrell, B., Devries, C., Snow, B. et al: Unilateral extravesical ureteral reimplantation in children performed on an outpatient basis. J Urol, 174: 1987, 2005
Re: The Impact of Late Presentation of Posterior Urethral Valves on Bladder and Renal Function O. Ziylan, T. Oktar, H. Ander, E. Korgali, H. Rodoplu and T. Kocak J Urol, 175: 1894 –1897, 2006 To the Editor. The authors have reviewed the findings in patients who present late with urethral obstruction, and look for differences from the earlier presenting group. Across the group they found that renal and bladder function was similar but they infer that there is a lesser degree of obstruction in patients who present later. However, we would suggest that the variability of the condition is greater than suggested in their article. Our work, which was not referenced by the authors, has shown 2 features of the variability of congenital obstructive posterior urethral membrane (COPUM). The first feature, as Hendren found,1 is a range in the appearance of the obstruction endoscopically, which is a variable degree of the limitation of the posterior urethral lumen.2 The other variation we have demonstrated is a variable degree of proximal radiological obstructive changes with similar changes on endoscopic appearance of the COPUM.3 Thus, early and late presenting patients can have a range of bladder and renal function outcomes. We postulate that there may be different bladder reactions to the same limitation of the stream, a difference in the secondary obstruction from distal prolapsing of the COPUM or perhaps different diseases that have a COPUM as a common element. Study of the late presenting group in light of the detailed endoscopic findings would be of interest, and we thank the authors for their work. Respectfully, Paddy Dewan Urology Unit Women’s and Children’s Hospital North Adelaide, South Australia 1. 2.
Hendren, W. H.: Posterior urethral valves in boys. A broad clinical spectrum. J Urol, 106: 298, 1971 Dewan, P. A. and Goh, D. G.: Variable expression of the congenital membrane of the posterior urethra. Urology, 45: 507, 1995
Dewan, P. A., Pillay, S. and Kaye, K.: Correlation of the endoscopic and radiological anatomy of congenital obstruction of the posterior urethra and the external sphincter. Br J Urol, 79: 790, 1997
Reply by Authors. We appreciate the commentary about our article. However, there are several points to be clarified in the text. In our series renal function was significantly impaired in the late presenting group. Thus, what we tried to emphasize is that it is not always true that late presentation is a more favorable prognostic factor. Also, it may be misleading to describe the obstruction as “lesser” in the late presenting group, because renal function was significantly affected in this group of patients. Bladder dysfunction was similar between the 2 groups. However, it was more pronounced in the late presenting patients. We completely agree regarding the variability of obstruction in patients with posterior urethral valves. However, there are some difficulties in documenting the degree of obstruction. The interpretation of obstruction by endoscopic and radiological appearance is somehow a subjective analysis. The evaluation of voiding dynamics obtained by urodynamic studies may be a more reliable assessment. However, it also poses some technical challenges. Recently, in our clinic the endoscopic interventions of all patients with posterior urethral valves have begun to be recorded routinely. The assessment of these findings could lead to a better understanding of the pathophysiological process.
Re: A New Classification is Needed for Pelvic Pain Syndromes—Are Existing Terminologies of Spurious Diagnostic Authority Bad for Patients? P. Abrams, A. Baranowski, R. E. Berger, M. Fall, P. Hanno and U. Wesselmann J Urol, 175: 1989 –1990, 2006 To the Editor. The 6 experts who authored this editorial are to be applauded for their forthright statement regarding the deleterious effects of the use of conventional terminology for “diagnostic” authority in patients with chronic pelvic pain (CPP). The descriptive terms and symptoms used in this editorial are in the “territory” of the pudendal nerve. Fall et al have made brief reference to pudendal neuropathy in the European Association of Urology guidelines on chronic pelvic pain.1 However, no such reference was made in this editorial. Previous articles in The Journal of Urology® demonstrate the neuropathic issues affecting CPP. Ricchiuti identified abnormal neurophysiological testing in a cyclist with perineal pain.2 Amarenco and Kerdraon presented a scholarly discussion of pudendal nerve neurophysiological testing.3 Relief of CPP can be achieved using pudendal nerve blocks of local anesthetic and triamcinolone.4 Indeed, in the same issue as the editorial the pelvic symptoms that Cohen
LETTERS TO THE EDITOR et al5 use for placement of a sacral nerve root stimulator are precisely within the distribution of the pudendal nerve. For more than 20 years widespread international experience has demonstrated the role of pudendal neuropathy in scrotal pain, vulvodynia, stress urinary incontinence and fecal incontinence, and objective testing for pudendal neuropathy has been defined. Analysis of articles using the technique of “epidemiological evidence of causation” is an excellent method for evaluating the putative role of pudendal neuropathy in CPP. Pudendal neuropathy meets the tests of biological plausibility, strength of association, doseresponse relationship, temporality, consistency of findings, analogy and reversibility. A recent article concerning failed sacral neuromodulation outlines the precise history, and physical and neurophysiological testing that identifies pudendal neuropathy in women with the chronic pelvic pain syndrome.6 Responses to pudendal nerve perineural injections of bupivacaine and triamcinolone consistently define the protean symptomatology of pudendal neuropathy in our population with CPP, which exceeds 1,500. All patients have objective neurophysiological measures of pudendal neuropathy that include somatosensory and motor processes and autonomic dysfunction. This cohort would attest to the “bad” effect of spurious diagnostic authority. They feel abused by a medical profession that focuses on taxonomy rather than etiology/ pathogenesis. Patients would agree that it is “bad” to be misdiagnosed by 12, 17, 24 or more urologists, or treated using pounds of antibiotics, varicocelectomy, orchiectomy or cystectomy for CPP.
Evidence based medicine suggests that the pudendal nerve has a role in the chronic pelvic pain syndrome. I humbly request that the authors of this editorial not overlook the importance of pudendal neuropathic pain and its association with bladder, bowel and sexual dysfunction as they progress to a new classification for the pelvic pain syndrome. Respectfully, S. J. Antolak, Jr. Center for Urological and Pelvic Pain Lake Elmo, Minnesota 1.
Fall, M., Baranowski, A. P., Fowler, C. J., Lepinard, V., MaloneLee, J. G., Messelink, E. J. et al: EAU guidelines on chronic pelvic pain. Eur Urol, 46: 681, 2004 2. Ricchiuti, V. S., Haas, C. A., Seftel, A. D., Chelimsky, T. and Goldstein, I.: Pudendal nerve injury associated with avid bicycling. J Urol, 162: 2099, 2000 3. Amarenco, G. and Kerdraon, J.: Pudendal nerve terminal sensitive latency: techniques and normal values. J Urol, 161: 193, 1999 4. Antolak, S. J., Hough, D. M. and Pawlina, W.: The chronic pelvic pain syndrome after brachytherapy for carcinoma of the prostate. J Urol, 167: 2525, 2002 5. Cohen, B. L., Tunuguntla, H. S. and Gousse, A.: Predictors of success for first stage neuromodulation: motor versus sensory response. J Urol, 175: 2178, 2006 6. Antolak, S. J., Jr. and Antolak, C. M.: Failed sacral neuromodulation: simple tests demonstrate pudendal neuropathy. J Pelvic Med Surg, 12: 35, 2006
RETRACTION VOIDING DYSFUNCTION AFTER REMOVAL OF ERODED SLINGS Volume 176, Number 3, Page 1040: The authors, Drs. Jonathan S. Starkman, Christopher E. Wolder, Alex Gomelsky, Harriette M. Scarpero and Roger R. Dmochowski, acknowledge making an erroneous statement in this article regarding the recall of the ObTape™ (Mentor Corp., Santa Barbara, California) due to a high erosion rate. This statement is incorrect. Rather marketing of ObTape™ was discontinued because of an introduction of a second generation product, Aris™ by Mentor Corp., in March 2006. The authors apologize for this error and formally retract the statement in this article suggesting recall of the ObTape™.
C-CHOLINE POSITRON EMISSION/COMPUTERIZED TOMOGRAPHY
Volume 176, Number 3, Page 959: Acknowledgment: Robin M. T. Cooke provided writing assistance.
RELEASE OF SPINAL CORD TETHERING FOR NEUROGENIC BLADDER Volume 176, Number 4, Page 1601: The 4th author’s name is Ferruh Simsek.