Vol. 121, May Printed in U.S.A.
0022-5347 /79/1215-0689 $02.00/0 THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Letters to the Editor 1. Heffernan, J.C., Lightwood, R. G. and Snell, M. E.: Horseshoe
DIABETES INSIPIDUS AND HYDRONEPHROSIS To the Editor. After having read the interesting Review Article on this subject' we thought that we should describe our 2 patients who were treated recently. The first patient was a 14-year-old girl with a complex of symptoms, including juvenile diabetes mellitus without peripheral neuropathy, diabetes insipidus, optic atrophy, hearing loss, dilatation of the upper urinary tract and a bladder without infravesical obstruction (probably Wolfram's syndrome).2 Many theories and explanations have been indicated for the etiology of Wolfram's syndrome. It is not yet clear whether dilatation of the upper urinary tract and bladder is the result of the diabetes insipidus or whether it is part of the syndrome. Urinary retention and urinary tract dilatation in our patient were managed by intermittent catheterization and oral administration of bethanechol bromide. A year after treatment residual urine was reduced to nil and dilatation was no longer present. The second patient was a man with diabetes insipidus and significant dilatation of the upper urinary tract and bladder. There was a large volume of residual urine. Bladder neck stenosis was found on a voiding cystogram, cystourethroscopy and urethral profile and this was confirmed on pathological examination. Transurethral resection of the bladder neck restored normal voiding and the upper urinary tract dilatation gradually returned to normal. Because of these cases we emphasize that dilatation of the upper urinary tract and bladder in patients with diabetes insipidus should not always be considered a necessary result of the diabetes. The dilatation could be part of a syndrome or the result of bladder neck obstruction. Our cases reveal the need for a physical examination as well as radiological and endoscopic studies for these patients. In this way an accurate diagnosis can be made, proper treatment will be administered and the renal damage will be avoided. Respectfully, C. Dimopoulos, M. Likourinas and M. Melekos Department of Urology University of Athens Hospital "Vassilevs Pavlas" Goudi, Athens, Greece 1. Shapiro, S. R., Woerner, S., Adelman, R. and Palmer, J. M.:
Diabetes insipidus and hydronephrosis. J. Urol., 119: 715, 1978. 2. Dimopoulos, C., Likourinas, M. and Dakou-Voutetakis, K.: Juvenile diabetes mellitus, diabetes insipidus, hearing loss, optic atrophy, dilatation of upper urinary tract and urinary bladder and other abnormalities. Presented at European Urology Congress, Monte Carlo, 1978.
kidney with retrocaval ureter: second reported case. J. Urol., 120: 358, 1978. 2. Eidelman, A., Yuval, E., Simon, D. and Sibi, Y.: Retrocaval ureter. Eur. Urol., 4; 279, 1978. RE: EXTRACTION OF URETERAL CALCULI FROM PATIENTS WITH ILEAL LOOPS: A NEW TECHNIQUE A. D. Smith, P.H. Lange, D. B. Reinke and R. P. Miller J. Urol., 120: 623-625, 1978 To the Editor. These authors have stated "In patients with an ileal conduit obstructing small calculi in the di;tal third of the ureter cannot be removed with a stone basket using standard procedures". In 1974 we described retrograde ureteral catheteriza-· tion and stone basket manipulation in a patient with an ileal conduit in whom we used a standard panendoscope. 1 The panendoscope was passed through a 24F Foley catheter with a 30 cc balloon, which provided for occlusion of the stoma of the conduit with subsequent distension of the conduit. We have continued to use this technique for observation and cannulation of the ureteral orifices. We would recommend that this procedure be used before percutaneous nephrostomy.
Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 1. Redman, J. F., Meacham, K. R., Rountree, G. A. and Bissada, N. K.: Endoscopy of ilea] conduit with ureteral instrumentation. Urology, 3: 565, 1974. Reply by Authors. We regret having overlooked the article by Redman and associates. We have made numerous attempts to catheterize ureteroileostomies without success. Nevertheless, in an uncomplicated case the approach described by these authors should be tried first. However, in the extremely ill patient percutaneous nephrostomy allows immediate decompression of the kidney and stabilization of the patient. We believe that subsequent antegrade manipulation past the calculus may be safer because there is less chance of a false pass. In addition, the operator using fluoroscopy has precise control of the stone basket and it is easy to place a silicone rubber ureteral splint postoperatively. IDIOPATHIC RETROPERITONEAL FIBROSIS
HORSESHOE KIDNEY WITH RETROCAVAL URETER To the Editor. It seems logical that in the presence of a persistent subcardinal infrarenal vena cava with a concurrent horseshoe kidney the isthmus of the latter would be located retrocavally too, because of the same anomalous development. A horseshoe kidney and retrocaval ureter are not necessarily the main causes of urinary tract obstruction in these cases, either separately or jointly. As depicted in the case of Heffernan and associates the contralateral (left) renal moiety was affected much more severely than the right side, which drained into the retrocaval ureter. 1 Similarly, in one of our recent cases (presumably making this the "third reported case") right hydronephrosis was caused by pelvioureteral stenosis and not by the associated horseshoe kidney, retrocaval ureter, retrocaval interrenal isthmus or coincidental aberrant renal vessels (case 3 in our article). 2
To the Editor. I enjoyed reading the report by Willscher and associates on the possible association of the HLA-B27 antigen with idiopathic retroperitoneal fibrosis and its potential usefulness as an immunologic marker in this disease. 1 I had a 46-year-old black male patient with surgically proved idiopathic retroperitoneal fibrosis who underwent histocompatibility antigen testing. He was tested for HLA-Al, A2, A3, A9, B7, BS, B12 and B27, and was positive only for Al and B7. The significance of these particular positive antigens in my patient is unclear; he did not respond to oral prednisone before right ureterolysis and omentopexy with eventual placement of a polyethylene ureteral stent. 2 Despite this failure to confirm the suspected association, I, too, believe that tissue typing should be continued in this condition to possibly obtmn much valuable information.
Respectfully, Avraham Eide/man of Urology Hospital
Respectfully, John H. Norton, III Adult and Pediatric Urology 2006 Dwight Way, Suite 204 Berkeley, California 94704 1. Willscher, !\ILK., Novicki, D.
of HLA-B27 antigen with 120: 631, 1978.
589
rP"r.rr,-cw-r11r.m1PB
W. F.: Association fibrosis. J. U rol.,
690
LETTERS TO THE EDITOR
2. Tresidder, G. C., Blandy, J.P. and Singh, M.: Omental sleeve to prevent recurrent retroperitoneal fibrosis under the ureter. Urol. Int., 27: 144, 1972. RE: RADIATION-INDUCED BLADDER TUMORS
R. E. Duncan, D. W. Bennett, A. T. Evans, B. S. Aron and H.F. Schellhas J. Urol., 118: 43-45, 1977
To the Editor. Duncan and associates concluded from their study that patients irradiated for cervical carcinoma had subsequent primary bladder malignancies 57 times more often than might be expected. Their 8 patients with bladder cancer do not reveal such a high increased risk. These 8 bladder carcinoma cases observed in 2,674 patients with cervical carcinoma in a 25-year period are compared to the incidence of 5.2/100,000 persons with bladder carcinoma in the white female population. However, the incidence of 5.2/ 100,000 relates to the number of new bladder carcinomas observed in 1 year, irrespective of age. Since the age of patients with cervical carcinoma varied from 43 to 80 years, with a mean of 60 years, and the mean age of patients with bladder carcinoma is 69 years the expected number of bladder carcinomas must be based on the mean incidence of bladder carcinoma in a female population more than 50 years old. In this age group the mean incidence is at least 5 to 6 times higher than in the female population as a whole and can, cautiously, be assumed to be 25/100,000. This estimation is based on the age-specific incidence of bladder cancer in Rotterdam (The Netherlands) and it is not probable that there will be a considerable difference with the situation in Ohio. This corrected incidence must be used to calculate the expected number of bladder cancers in reference to the population at risk. The population at risk is defined by the number of patients with cervical carcinoma who lived long enough to be at risk for postradiation bladder cancer. As the authors mentioned, of the 3,091 patients with cervical carcinoma 1,393 (about 45 per cent) were alive at the end of the observation period. If one assumes that the entry of patients with cervical carcinoma was uniform in the period considered and that the death rate was approximately constant the given data allow a rough estimation of the total number of person-years involved. This quantity is then estimated to be about 20,000 personyears. With the corrected incidence of 25 bladder carcinomas in 100,000 person-years the expected number of bladder carcinomas is 5. Observed were 8 bladder cancers. The minor deviation from the expected number can hardly be judged to be of statistical significance and is in full agreement with the experience in the Rotterdamsch Radio-Therapeutisch Instituut. In an 18-year period (1954 to 1972) 2,772 patients with cervix carcinoma received radiotherapy. All patients were followed during the complete interval. In this population 5 bladder cancers were observed; if one assumes the same corrected incidence as described previously 4 bladder cancers would be expected. We conclude, therefore, that there certainly does not exist a 57 times increased risk of development of bladder cancer in irradiated patients with cervical carcinoma. At most it may be possible that there is a small increased risk but the data do not permit a reliable answer to this question. Respectfully, W. Fokkens and W. C. J. Hop Departments of Documentation and Epidemiology and Bio-statistics Rotterdamsch Radio-Therapeutisch Instituut Rotterdam
to 12 patients who had bladder cancer after irradiation for cervix carcinoma that is similar to ours and currently is under investigation.' 1. Dean, R. J. and Lytton, B.: Re: Urologic complications of pelvic irradiation (reply). J. Urol., 120: 387, 1978.
Editor's Comment. The reply by the authors was sent to Doctors Fokkens and Hop for their information, to which they replied, "We are not convinced by the authors' arguments. We remain of the opinion that one may not compare the incidence of new cases in 1 year with the incidence over a period of 25 years - here is talk of a semantic entanglement concerning the use of the word 'incidence'. On the other hand, we uphold our approach in relation to the calculation of the expected number of bladder cancers. For this calculation one has to proceed from the age-specific incidence, in relation to the involved number of person-years at risk. Based on these considerations we maintain our opinion that if there might be talk of an increased risk, this risk is far much smaller than indicated by the authors." Your Editor then sent all material to an independent consultant, Dr. Nelson H. Slack of the National Prostatic Cancer Project, for his consideration. His comments follow, "I believe that Doctors Fokkens and Hop are correct in their criticism to a point, and the authors also make a valid point in their response, in that one must consider the age distribution of the population at risk, not just the ages of those who had cancer. I would suggest a combination of the 2 points. Fokkens and Hop make the point that the 8 cases of bladder cancer were observed over 25 years from a population base of2,674 and were then compared to an annual incidence rate of 5.2/100,000. The population in the latter situation is in a dynamic state with new births adding to and deaths subtracting from the total. In the paper, however, 2,674 is the initial population at risk and deaths subtract from this over the 25-year period. It is incorrect to divide 8 by 2,674 = 0.00299 and call this an incidence rate to be compared with 0.000052. Fokkens and Hop have estimated the exposed population as 20,000 person-years. Then, with 5.2 as the annual incidence per 100,000, the expected number of cases is 1. The observed number of 8 cases, or 40/100,000, is then 8 times greater than expected. This is far less than the 57.6 times greater claimed in the paper but still enough larger to suggest some risk factor from the radiation." CLEFT GLANS PENIS
To the Editor. Leff and associates recently described a patient with cleft glans penis.' A similar case was described by us, along with a discussion of the suggested embryogenesis of this entity. 2 We agree with the authors that this anomaly is ofno clinical significance in the absence of meatal stenosis, except, perhaps, as it sheds some light on the development of the distal or glandular urethra. Respectfully, Harry W. Herr Division of Urology University of California Irvine, California 92717
1. Leff, R. G., Peterson, R. E. and Drago, J. R.: Cleft glans penis: a case report. J. Urol., 120: 767, 1978. 2. Herr, H. W., Jepson, P. M. and Bischoff, A. J.: Complete vertical cleft of the glans penis. J. Urol., 108: 282, 1972.
RE: SIGNIFICANCE OF PYURIA IN URINARY SEDIMENT
Reply by Authors. To compare the incidence of bladder cancer in women irradiated for cervical carcinoma to that found in the general female population one must consider patients of all ages. Although we have stated that those patients with bladder tumors subsequent to radiotherapy for another pelvic malignancy had cervix carcinoma at a mean age of 60 years and bladder cancer at a mean age of 69 years other patients in the study group who did not have bladder cancer were irradiated at much younger ages from the second decade of life upward. By calculating the expected number of bladder cancers based on a female population more than 50 years old Fokkens and Hop have created an artificial distribution of patients for statistical comparison. Furthermore, we believe that regional variation in cancer trends is important. Attention should be directed
M. McGuckin, L. Cohen and R. B. MacGregor J. Urol., 120: 452-454, 1978
To the Editor. McGuckin and associates rightly acknowledge the value of microscopy of the urine as a rapid test for urinary tract infection but they show that its accuracy can be impaired seriously by an inadequate collection procedure. Many female subjects are unable to produce a satisfactory specimen, despite careful instruction by nursing staff. A good indication that this is so is the finding of vaginal epithelial cells in numbers equal to or exceeding the number of white blood cells seen on microscopy. The finding of many vaginal epithelial cells should alert the practitioner to the distinct
0022-5347 /79/1215-0689 $02.00/0 THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Letters to the Editor 1. Heffernan, J.C., Lightwood, R. G. and Snell, M. E.: Horseshoe
DIABETES INSIPIDUS AND HYDRONEPHROSIS To the Editor. After having read the interesting Review Article on this subject' we thought that we should describe our 2 patients who were treated recently. The first patient was a 14-year-old girl with a complex of symptoms, including juvenile diabetes mellitus without peripheral neuropathy, diabetes insipidus, optic atrophy, hearing loss, dilatation of the upper urinary tract and a bladder without infravesical obstruction (probably Wolfram's syndrome).2 Many theories and explanations have been indicated for the etiology of Wolfram's syndrome. It is not yet clear whether dilatation of the upper urinary tract and bladder is the result of the diabetes insipidus or whether it is part of the syndrome. Urinary retention and urinary tract dilatation in our patient were managed by intermittent catheterization and oral administration of bethanechol bromide. A year after treatment residual urine was reduced to nil and dilatation was no longer present. The second patient was a man with diabetes insipidus and significant dilatation of the upper urinary tract and bladder. There was a large volume of residual urine. Bladder neck stenosis was found on a voiding cystogram, cystourethroscopy and urethral profile and this was confirmed on pathological examination. Transurethral resection of the bladder neck restored normal voiding and the upper urinary tract dilatation gradually returned to normal. Because of these cases we emphasize that dilatation of the upper urinary tract and bladder in patients with diabetes insipidus should not always be considered a necessary result of the diabetes. The dilatation could be part of a syndrome or the result of bladder neck obstruction. Our cases reveal the need for a physical examination as well as radiological and endoscopic studies for these patients. In this way an accurate diagnosis can be made, proper treatment will be administered and the renal damage will be avoided. Respectfully, C. Dimopoulos, M. Likourinas and M. Melekos Department of Urology University of Athens Hospital "Vassilevs Pavlas" Goudi, Athens, Greece 1. Shapiro, S. R., Woerner, S., Adelman, R. and Palmer, J. M.:
Diabetes insipidus and hydronephrosis. J. Urol., 119: 715, 1978. 2. Dimopoulos, C., Likourinas, M. and Dakou-Voutetakis, K.: Juvenile diabetes mellitus, diabetes insipidus, hearing loss, optic atrophy, dilatation of upper urinary tract and urinary bladder and other abnormalities. Presented at European Urology Congress, Monte Carlo, 1978.
kidney with retrocaval ureter: second reported case. J. Urol., 120: 358, 1978. 2. Eidelman, A., Yuval, E., Simon, D. and Sibi, Y.: Retrocaval ureter. Eur. Urol., 4; 279, 1978. RE: EXTRACTION OF URETERAL CALCULI FROM PATIENTS WITH ILEAL LOOPS: A NEW TECHNIQUE A. D. Smith, P.H. Lange, D. B. Reinke and R. P. Miller J. Urol., 120: 623-625, 1978 To the Editor. These authors have stated "In patients with an ileal conduit obstructing small calculi in the di;tal third of the ureter cannot be removed with a stone basket using standard procedures". In 1974 we described retrograde ureteral catheteriza-· tion and stone basket manipulation in a patient with an ileal conduit in whom we used a standard panendoscope. 1 The panendoscope was passed through a 24F Foley catheter with a 30 cc balloon, which provided for occlusion of the stoma of the conduit with subsequent distension of the conduit. We have continued to use this technique for observation and cannulation of the ureteral orifices. We would recommend that this procedure be used before percutaneous nephrostomy.
Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 1. Redman, J. F., Meacham, K. R., Rountree, G. A. and Bissada, N. K.: Endoscopy of ilea] conduit with ureteral instrumentation. Urology, 3: 565, 1974. Reply by Authors. We regret having overlooked the article by Redman and associates. We have made numerous attempts to catheterize ureteroileostomies without success. Nevertheless, in an uncomplicated case the approach described by these authors should be tried first. However, in the extremely ill patient percutaneous nephrostomy allows immediate decompression of the kidney and stabilization of the patient. We believe that subsequent antegrade manipulation past the calculus may be safer because there is less chance of a false pass. In addition, the operator using fluoroscopy has precise control of the stone basket and it is easy to place a silicone rubber ureteral splint postoperatively. IDIOPATHIC RETROPERITONEAL FIBROSIS
HORSESHOE KIDNEY WITH RETROCAVAL URETER To the Editor. It seems logical that in the presence of a persistent subcardinal infrarenal vena cava with a concurrent horseshoe kidney the isthmus of the latter would be located retrocavally too, because of the same anomalous development. A horseshoe kidney and retrocaval ureter are not necessarily the main causes of urinary tract obstruction in these cases, either separately or jointly. As depicted in the case of Heffernan and associates the contralateral (left) renal moiety was affected much more severely than the right side, which drained into the retrocaval ureter. 1 Similarly, in one of our recent cases (presumably making this the "third reported case") right hydronephrosis was caused by pelvioureteral stenosis and not by the associated horseshoe kidney, retrocaval ureter, retrocaval interrenal isthmus or coincidental aberrant renal vessels (case 3 in our article). 2
To the Editor. I enjoyed reading the report by Willscher and associates on the possible association of the HLA-B27 antigen with idiopathic retroperitoneal fibrosis and its potential usefulness as an immunologic marker in this disease. 1 I had a 46-year-old black male patient with surgically proved idiopathic retroperitoneal fibrosis who underwent histocompatibility antigen testing. He was tested for HLA-Al, A2, A3, A9, B7, BS, B12 and B27, and was positive only for Al and B7. The significance of these particular positive antigens in my patient is unclear; he did not respond to oral prednisone before right ureterolysis and omentopexy with eventual placement of a polyethylene ureteral stent. 2 Despite this failure to confirm the suspected association, I, too, believe that tissue typing should be continued in this condition to possibly obtmn much valuable information.
Respectfully, Avraham Eide/man of Urology Hospital
Respectfully, John H. Norton, III Adult and Pediatric Urology 2006 Dwight Way, Suite 204 Berkeley, California 94704 1. Willscher, !\ILK., Novicki, D.
of HLA-B27 antigen with 120: 631, 1978.
589
rP"r.rr,-cw-r11r.m1PB
W. F.: Association fibrosis. J. U rol.,
690
LETTERS TO THE EDITOR
2. Tresidder, G. C., Blandy, J.P. and Singh, M.: Omental sleeve to prevent recurrent retroperitoneal fibrosis under the ureter. Urol. Int., 27: 144, 1972. RE: RADIATION-INDUCED BLADDER TUMORS
R. E. Duncan, D. W. Bennett, A. T. Evans, B. S. Aron and H.F. Schellhas J. Urol., 118: 43-45, 1977
To the Editor. Duncan and associates concluded from their study that patients irradiated for cervical carcinoma had subsequent primary bladder malignancies 57 times more often than might be expected. Their 8 patients with bladder cancer do not reveal such a high increased risk. These 8 bladder carcinoma cases observed in 2,674 patients with cervical carcinoma in a 25-year period are compared to the incidence of 5.2/100,000 persons with bladder carcinoma in the white female population. However, the incidence of 5.2/ 100,000 relates to the number of new bladder carcinomas observed in 1 year, irrespective of age. Since the age of patients with cervical carcinoma varied from 43 to 80 years, with a mean of 60 years, and the mean age of patients with bladder carcinoma is 69 years the expected number of bladder carcinomas must be based on the mean incidence of bladder carcinoma in a female population more than 50 years old. In this age group the mean incidence is at least 5 to 6 times higher than in the female population as a whole and can, cautiously, be assumed to be 25/100,000. This estimation is based on the age-specific incidence of bladder cancer in Rotterdam (The Netherlands) and it is not probable that there will be a considerable difference with the situation in Ohio. This corrected incidence must be used to calculate the expected number of bladder cancers in reference to the population at risk. The population at risk is defined by the number of patients with cervical carcinoma who lived long enough to be at risk for postradiation bladder cancer. As the authors mentioned, of the 3,091 patients with cervical carcinoma 1,393 (about 45 per cent) were alive at the end of the observation period. If one assumes that the entry of patients with cervical carcinoma was uniform in the period considered and that the death rate was approximately constant the given data allow a rough estimation of the total number of person-years involved. This quantity is then estimated to be about 20,000 personyears. With the corrected incidence of 25 bladder carcinomas in 100,000 person-years the expected number of bladder carcinomas is 5. Observed were 8 bladder cancers. The minor deviation from the expected number can hardly be judged to be of statistical significance and is in full agreement with the experience in the Rotterdamsch Radio-Therapeutisch Instituut. In an 18-year period (1954 to 1972) 2,772 patients with cervix carcinoma received radiotherapy. All patients were followed during the complete interval. In this population 5 bladder cancers were observed; if one assumes the same corrected incidence as described previously 4 bladder cancers would be expected. We conclude, therefore, that there certainly does not exist a 57 times increased risk of development of bladder cancer in irradiated patients with cervical carcinoma. At most it may be possible that there is a small increased risk but the data do not permit a reliable answer to this question. Respectfully, W. Fokkens and W. C. J. Hop Departments of Documentation and Epidemiology and Bio-statistics Rotterdamsch Radio-Therapeutisch Instituut Rotterdam
to 12 patients who had bladder cancer after irradiation for cervix carcinoma that is similar to ours and currently is under investigation.' 1. Dean, R. J. and Lytton, B.: Re: Urologic complications of pelvic irradiation (reply). J. Urol., 120: 387, 1978.
Editor's Comment. The reply by the authors was sent to Doctors Fokkens and Hop for their information, to which they replied, "We are not convinced by the authors' arguments. We remain of the opinion that one may not compare the incidence of new cases in 1 year with the incidence over a period of 25 years - here is talk of a semantic entanglement concerning the use of the word 'incidence'. On the other hand, we uphold our approach in relation to the calculation of the expected number of bladder cancers. For this calculation one has to proceed from the age-specific incidence, in relation to the involved number of person-years at risk. Based on these considerations we maintain our opinion that if there might be talk of an increased risk, this risk is far much smaller than indicated by the authors." Your Editor then sent all material to an independent consultant, Dr. Nelson H. Slack of the National Prostatic Cancer Project, for his consideration. His comments follow, "I believe that Doctors Fokkens and Hop are correct in their criticism to a point, and the authors also make a valid point in their response, in that one must consider the age distribution of the population at risk, not just the ages of those who had cancer. I would suggest a combination of the 2 points. Fokkens and Hop make the point that the 8 cases of bladder cancer were observed over 25 years from a population base of2,674 and were then compared to an annual incidence rate of 5.2/100,000. The population in the latter situation is in a dynamic state with new births adding to and deaths subtracting from the total. In the paper, however, 2,674 is the initial population at risk and deaths subtract from this over the 25-year period. It is incorrect to divide 8 by 2,674 = 0.00299 and call this an incidence rate to be compared with 0.000052. Fokkens and Hop have estimated the exposed population as 20,000 person-years. Then, with 5.2 as the annual incidence per 100,000, the expected number of cases is 1. The observed number of 8 cases, or 40/100,000, is then 8 times greater than expected. This is far less than the 57.6 times greater claimed in the paper but still enough larger to suggest some risk factor from the radiation." CLEFT GLANS PENIS
To the Editor. Leff and associates recently described a patient with cleft glans penis.' A similar case was described by us, along with a discussion of the suggested embryogenesis of this entity. 2 We agree with the authors that this anomaly is ofno clinical significance in the absence of meatal stenosis, except, perhaps, as it sheds some light on the development of the distal or glandular urethra. Respectfully, Harry W. Herr Division of Urology University of California Irvine, California 92717
1. Leff, R. G., Peterson, R. E. and Drago, J. R.: Cleft glans penis: a case report. J. Urol., 120: 767, 1978. 2. Herr, H. W., Jepson, P. M. and Bischoff, A. J.: Complete vertical cleft of the glans penis. J. Urol., 108: 282, 1972.
RE: SIGNIFICANCE OF PYURIA IN URINARY SEDIMENT
Reply by Authors. To compare the incidence of bladder cancer in women irradiated for cervical carcinoma to that found in the general female population one must consider patients of all ages. Although we have stated that those patients with bladder tumors subsequent to radiotherapy for another pelvic malignancy had cervix carcinoma at a mean age of 60 years and bladder cancer at a mean age of 69 years other patients in the study group who did not have bladder cancer were irradiated at much younger ages from the second decade of life upward. By calculating the expected number of bladder cancers based on a female population more than 50 years old Fokkens and Hop have created an artificial distribution of patients for statistical comparison. Furthermore, we believe that regional variation in cancer trends is important. Attention should be directed
M. McGuckin, L. Cohen and R. B. MacGregor J. Urol., 120: 452-454, 1978
To the Editor. McGuckin and associates rightly acknowledge the value of microscopy of the urine as a rapid test for urinary tract infection but they show that its accuracy can be impaired seriously by an inadequate collection procedure. Many female subjects are unable to produce a satisfactory specimen, despite careful instruction by nursing staff. A good indication that this is so is the finding of vaginal epithelial cells in numbers equal to or exceeding the number of white blood cells seen on microscopy. The finding of many vaginal epithelial cells should alert the practitioner to the distinct
