Patient enrollment in the present study started in 1993. Sincethen, much has been learned about the pathogenesis of interstitialcystitis1 and therapeutic recommendations are more specific than in1993, resulting in a higher success rate. Some have reported excel-lent improvement rates of interstitial cystitis symptoms with substi-tution of the defective glycosaminoglycan layer.2, 3 In our experienceas many as 80% of patients with interstitial cystitis will experiencesignificant improvement with multimodal therapy for a longer pe-riod. However, disease chronicity makes lifelong urological caremandatory for most moderate and severe cases.

It is not helpful to state that therapy does not affect the course ofinterstitial cystitis. Patients who read this information might refuseany therapy and, more importantly, national health care systemsmight refuse to pay for any of the current therapies, referring to thepresent study.

In addition, the high dropout rate of 36% increases serious concernabout statistical analysis and the results of the present study, whichwas admitted by the authors.

Respectfully,Claus R. RiedlDepartment of UrologyMunicipal Hospital LainzWolkersbergenstrasse 11134 ViennaAustria

and

Gero HohlbruggerDepartment of UrologyUniversity of Innsbruck6020 InnsbruckAustria

1. Hohlbrugger, G. and Riedl, C. R.: Non-bacterial cystitis. CurrOpin Urol, in press

2. Sant, G. R. and LaRock, R. R.: Standard intravesical therapiesfor interstitial cystitis. Urol Clin North Am, 21: 73, 1994

3. Morales, A., Emerson, L., Nickel, C. J. et al: Intravesical hyal-uronic acid in the treatment of refractory interstitial cystitis.J Urol, 156: 45, 1996

Reply by Authors. Treatments reported in the Interstitial CystitisData Base (ICDB) were not presented in our article due to spacelimitations. The frequencies of various treatments in the ICDB havebeen previously reported1 and a report is in progress. Briefly, morethan 183 different treatments were reported at baseline amongICDB patients and the majority of them were reported by fewer than5% of the patients. Treatments reported with time were even moreheterogeneous. We also recognize that, as Riedl and Hohlbruggermention, the ICDB enrolled the majority of the patients before theapproval in the United States of oral pentosanpolysulfate for thetreatment of interstitial cystitis and that the prevalence of its use atbaseline in the ICDB probably does not reflect current clinical prac-tice.

We certainly did not intend to imply that there is no therapy thatcontrols symptoms or affects the overall course of interstitial cystitis,but rather that there was a large cohort of patients in the UnitedStates who were not benefiting from therapies available during theperiod of our study. Since the ICDB was a prospective cohort study,the results of any treatment evaluation are seriously confounded bylack of randomization, placebo effects, regression to the mean and/ordifferential loss to followup. We believe that the only appropriatemeans to evaluate the effectiveness of treatments for interstitialcystitis is by high quality, randomized controlled clinical trials. Aseries of such trials are currently being conducted by the NationalInstitutes of Health sponsored Interstitial Cystitis Clinical TrialsGroup. We agree with the authors that until safe and effectivetreatments are identified, patients with interstitial cystitis will con-tinue to require long-term urological care. Regarding patient with-drawals, the dropout rate is typical for cohort studies of this length,and we agree as stated in the article that the higher rate of with-drawal could bias the observed long-term results. However, prelim-inary analyses of changes with time, using multivariate statisticalmethods which model the withdrawal process, have not significantlychanged the conclusion that the overall patient cohort is not wors-ening or improving with time.

1. Kirkemo, A., Landis, J. R., Matthews-Cook, Y. et al: Treatmentof interstitial cystitis: the Interstitial Cystitis Data Base(ICDB) study experience. J Urol, suppl., 159: 308, abstract1188, 1998

RE: DERMATOMYOSITIS ASSOCIATED WITH TESTICULARGERM CELL CANCER

S. M. Di Stasi, A. Poggi, A. Giannantoni and G. Zampa

J Urol, 163: 240, 2000

To the Editor. The authors report a case of dermatomyositis andnonseminomatous germ cell cancer in which the dermatomyositisacted as a tumor marker. We treated a similar case of a seminomainitially positive for b-human chorionic gonadotropin (b-HCG).

In March 1999 a 46-year-old man presented with itching, hyper-keratotic erythema of the fingers (particularly of the joints), andsymmetrical lilac erythema and edematous swelling of the face,which were more prominent on the eyelids. Muscle enzymes (creat-ine kinase, aldolase, lactate dehydrogenase) were elevated. Histolog-ical examination of the skin and muscle revealed characteristics ofdermatomyositis (interface dermatitis, muscle necrosis). Antibiotictreatment consisted of 100 mg. pyrimethamine on day 1 and 25 mg.daily thereafter, and 300 mg. clindamycin 4 times dialy. High toxo-plasmotic titers contraindicated oral steroids. With local steroids theitching and skin lesions initially improved but subsequently becameaggravated.

Evaluation revealed a seminoma of the left testis, Lugano classi-fication pT2 cN1 M0 or clinical stage IIa. a-Fetoprotein was normaland b-HCG increased to 55 mU./ml. The left testicle was removed inMay. At the same time the dermatomyositis was treated with oralsteroids. The patient was given 160 mg. initially and the dosage wasreduced by 20 mg. every 5 days until in June he was given 5 mg.daily. The skin lesions improved within weeks with stable remissioneven after steroids were discontinued. This improvement, which wasattributed to the removal of the seminoma, established the diagnosisof apraneoplastic dermatomyositis. From May to July the patientreceived 3 courses of carboplatin monotherapy (1,000 mg./cycle) in arandomized, multicenter prospective trial. At the end of July com-plete regression of all lymph nodes next to the aorta and left iliacartery was demonstrated. Followup was every 2 months.

In November abdominal computerized tomography revealed an8 3 4 3 3 cm. retroperitoneal mass next to the aorta. Althoughb-HCG remained normal, dermatomyositis recurred. Retroperito-neal lymphadenectomy performed before December 25 showed vitalseminoma in 1 of 6 nodes. The patient received 3 courses of chemo-therapy, consisting of cisplatin (5 3 20 mg./m.2 per cycle), etoposide(5 3 100 mg./m.2 per cycle) and bleomycin (3 3 30 mg. per cycle),which were well tolerated. Dermatomyositis improved visibly afterremoval of the metastasis and before chemotherapy, and at lastfollowup the patient had no symptoms.

Our case demonstrates that dermatomyositis may indicate notonly nonseminomatous germ cell cancer, but also may signal a sem-inoma. Repeat symptoms may indicate tumor recurrence, especiallywhen tumor markers, for example b-HCG, are negative.

Respectfully,B. von Heyden, S. Kliesch and D. NashanWestfalische Wilhelms-Universitat MunsterMunster, Germany

RE: RADICAL PROSTATECTOMY FOR LOCALIZED PROSTATECANCER PROVIDES DURABLE CANCER CONTROL WITHEXCELLENT QUALITY OF LIFE: A STRUCTURED DEBATE

M. S. Litwin

J Urol, 163: 1802–1807, 2000

To the Editor. If I want to purchase a car or television, I can readConsumer Reports and find an objective report and analysis of theseand many other products. If a patient has a health problem, he hasto rely on word-of-mouth, gut instinct, subjective data and littleobjective data about the physician and/or hospital. Patients shouldhave access to a report card on their physician whether they need toundergo radical prostatectomy, coronary bypass, routine checkup or

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