Recent eLetters

I too have dimples in both shoulders. I have never met or heard of anyone else having them, not even a family member. Until 2 years ago when my youngest grandson was born. He has them on both shoulders as well. This report is the first I've seen on this and hope to learn more. Thankyou

Conflict of Interest:

None declared

We read with great interest the case report by Demirel (1) et al. in the journal. The authors described the case showing severe hyponatremia and critical hypoxia during transurethral resection of the prostate (TURP) surgery in the patient under general anaesthesia. TURP syndrome is initiated by absorption of irrigating fluid (2) and is characterized by decreasing a serum sodium concentration, inducing cardiovascular depression and developing neurological abnormality (3). The large volume of fluid absorption is a major dangerous complication in patients undergoing endoscopic surgery (4) and the severity of TURP syndrome is dependent on the dose and the type of irrigating fluid used (5).

The case presentation1 was well documented by the authors, however, some of interpretation for the results has a room for discussion. First, notwithstanding a lack of precise description, the irrigation fluid, "Resectisol", they used (1) would contain mannitol. The solute minimizes a change in serum osmolality when it is largely absorbed (6). Thus, the attempt of aggressive treatment to avoid intravascular haemolysis by increasing of osmolality with administrating hypertonic saline1 is not acceptable despite of severe hyponatremia. Second, as the authors discussed, the fluid overload would reach maximal by the absorption of irrigation fluid in addition to 3-l intravenous hydration by the anesthesiologists. The findings of hypoxia could be developed as a result of pulmonary edema and further sodium loading is unsafe for the cardiovascular hemodynamics.

Wang et al. (7) reported the two cases of patients developed pulmonary edema in the TURP syndrome induced with mannitol 5%. The lowest serum sodium concentration was 99 and 97 mmol/l, respectively. They discussed that no convulsions or seizures were observed in their patients and severe neurological abnormalities have never been reported with mannitol 5% during TURP surgery (7). The vascular overload by hypertonic saline was also mentioned as a risk of cardiovascular complications during the treatment for TURP syndrome. We had also encountered the case of TURP syndrome induced with 3%-sorbitol irrigating fluid (8). The serum sodium concentration was decreased to 101 mmol/l. Despite of no sign of intravascular hemolysis, we administered much of physiological saline to recover sodium concentration and critical pulmonary edema was developed in the patient by misunderstandings of the pathophysiology.

When distilled water was used as irrigating fluid (9), hyponatremia simultaneously indicates the decrease in serum osmolality and lethal hemolysis could be followed. However, mild hypotonic or isotonic irrigating fluid reduces the risk of hemolysis-induced renal failure (10) and induces another threat of heart failure and pulmonary edema as a result of excessive volume overloading during TURP surgery (7,8). Hypervolemia with hypoosmolality are more pathogentetic factors than hyponatremia in TURP syndrome.

REFERENCES 1. Demirel I, Ozer AB, Bayar MK, Erhan OL. TURP syndrome and severe hyponatremia under general anaesthesia. BMJ Case Rep. 2012; Nov 19 2012. 2. Hahn RG. Fluid absorption in endoscopic surgery (review). Br J Anaesth 2006; 96: 8-20. 3. Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection syndrome using glycine as the irrigant. J Urol 1995; 154: 123-8. 4. Ichai C, Ciais JF, Roussel LJ, Levraut J, Candito M, Boileau P, Grimaud D. Intravascular absorption of glycine irrigating solution during shoulder arthroscopy: a case report and follow-up study. Anesthesiology 1996; 85: 1481-5. 5. Hahn RG, Stalberg HP, Gustafsson SA. Intravenous infusion of irrigating fluids containing glycine or mannitol with and without ethanol. J Urol 1989; 142: 1102-5. 6. Kirschenbaum MA. Severe mannitol-induced hyponatraemia complicating transurethral prostatic resection. J Urol 1979; 121: 687-8. 7. Wang JH, He Q, Liu YL, Hahn RG. Pulmonary edema in the transurethral resection syndrome induced with mannitol 5%. Acta Anaesthesiol Scand 2009; 53: 1094-6. 8. Adachi Y, Takigami J, Nakai T, Watanabe K, Uchihashi Y, Aramaki Y, Satoh T. Negative-pressure pulmonary edema associated with transurethral resection syndrome. Masui 2000; 49: 1226-30. [Japanese with English abstract] 9. McLaughlin WL, Holyoke JB, Bowler JP. Oliguria following transurethral resection of the prostate gland. J Urol 1947; 58: 47-60. 10. Nesbit RM, Glickman SI. The use of glycine solution as an irrigating medium during transurethral resection. J Urol 1948; 59: 1212-6.

Conflict of Interest:

None declared

The prostatic utricle is a cul-de-sac of the prostatic urethra and extends backward and slightly upward for a very short distance within the middle lobe of the prostate. It is composed of fibrous tissue, muscular fibers, and mucous membrane. The prostatic utricle is 10-12 mm long, sometimes it is 20-25 mm, rarely it is 6-8 cm long.1 It is located in the seminal colliculus (i.e. veru montanum): this is a prominence of the dorsal surface of the prostatic urethra in which the two ejaculatory ducts open and among them exists the prostatic utricle, besides sometimes the ejaculatory ducts open into the prostatic utricle and not into the prostatic urethra.1,2 The prostatic utricle and the female vagina develop from the sinovaginal bulb that grows from the dorsal wall of the urogenital sinus to the level of the Mullerian tubercle, without the contribution of the Mullerian ducts.1,2 The fused Mullerian ducts form the uterus up to the external cervical os, and the inducing mesonephric ducts regress cranially, although they enlarge caudally from the level of the cervical os, form the sinuvaginal bulbs, incorporate the Mullerian tubercle's cells, and give rise to the vaginal plate. The embryological development of the human vagina does not proceed from the Mullerian ducts (as classically thought) but from the Wolffian ducts and Mullerian tubercle.3 In females, only the body of the uterus and the uterine tubes are formed by the Mullerian ducts.1,2 This has been known for many decades, but according to current opinion in urology textbooks the female vagina is still a mixed structure, formed by the urogenital sinus and from the Mullerian ducts, even if we know that the vagina always has the same structure for all of its length, furthermore the glycogen is present in the epithelium of the urogenital sinus, in the vagina, and cervix, while it is missing in the Mullerian ducts.1 The prostate utricle is of urogenital sinus origin and forms as a separate structure as the entire caudal ends of the mullerian ducts undergo complete regression.4 In conclusion, the prostate utricle is the homologue of the female vagina: male vagina is a more accurate term than prostatic utricle. References 1. Testut L, Latarjet A. Traite d'Anatomie Humaine, neuvieme edition. Paris: G. Doin & C.ie; 1972. 2. Puppo V. Anatomy and Physiology of the Clitoris, Vestibular Bulbs, and Labia Minora With a Review of the Female Orgasm and the Prevention of Female Sexual Dysfunction. Clin Anat 2013; 26: 134-52. 3. Acien P, Acien MI. The history of female genital tract malformation classifications and proposal of an updated system. Hum Reprod Update 2011;17:693-705. 4. Shapiro E, et al. The prostatic utricle is not a Mullerian duct remnant: Immunohistochemical evidence for a distinct urogenital sinus origin. J Urol. 2004;172:1753-56.

Conflict of Interest:

None declared

After reading this article, we are prompted to ask whether the use of functional magnetic resonance imaging (fMRI) or a fluoro-desoxy-glucose positron emission tomography (FDG-PET) can help solve ambiguities associated with clinical and computed tomography angioraphy (CTA) based techniques for affirming brain-death.

Conflict of Interest:

None declared

This oversight indicates the shortcomings of present day medical training. The emphasis is on technology and newer diagnostics at the cost of patient centered clinical skills, which included detailed history taking. We are in danger of churning out technicians rather than doctors.

This case report is a wake up call.

Conflict of Interest:

None declared