- Email: [email protected]
RE: COMPLICATIONS OF RETROGRADE BALLOON CAUTERY ENDOPYELOTOMY
543
LETTERS TO THE EDITOR 3. Erturk, E., Burzon, D. T. and Waldman, D.: Treatment of transplant ureteral stenosis with endoureterotomy. J Urol, 161: 412, 1999 4. Lin, D. W., Bush, W. H. and Mayo, M. E.: Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol, 162: 696, 1999 5. Delvecchio, F. C., Kuo, R. L., Iselin, C. E. et al: Combined antegrade and retrograde endoscopic approach for the management of urinary diversion-associated pathology. J Endourol, 14: 251, 2000 6. Aslan, P. and Preminger, G. M.: Retrograde balloon cautery incision of ureteropelvic junction obstruction. Urol Clin North Am, 25: 295, 1998 7. Sampaio, F. J.: Vascular anatomy at the ureteropelvic junction. Urol Clin North Am, 25: 251, 1998 8. Van Cangh, P. J. and Nesa, S.: Endopyelotomy. Prognostic factors and patient selection. Urol Clin North Am, 25: 281, 1998 9. Nakada, S. Y.: Acucise endopyelotomy. Urology, 55: 277, 2000
Reply by Authors. We have stated at many meetings, in the original article and in a previous editorial reply1 that the purpose of our report was not to condemn a successful procedure. Rather, our goal was to make surgeons aware of the potential complications, some occurring up to 17 days postoperatively, of a procedure that has been popularized as minimally invasive and highly efficacious. Fulmer et al address the technical evolution of the balloon electrocautery device and the improved safety features of the newest available model. Unfortunately, 2 of the vascular complications that we reported, namely the ovarian vein and arterial injuries, occurred while using the latest commercially available model. Also, all complications occurred while directing incisions in the straight lateral plane as suggested by Sampaio (reference 7 in letter) and currently practiced by most endourologists. It should also be noted that when these data were presented at international conferences, including the annual meeting of the American Urological Association in Dallas and the World Congress on Endourology and Shock Wave Lithotripsy in Greece, and after publication we were approached by numerous physicians who encountered similar complications but never reported them. We believe that serious complications may occur more commonly than reported. Our article makes no mention of efficacy or success rates but endopyelotomy success rates using the device should approach 75% to 90% as reported by numerous authors. The procedure that resulted in open surgery and subsequent renal loss was the unpredictable result of extremely aberrant anatomy and right ovarian vein laceration. The purpose of our study was to inform the readership of the results of experienced surgeons in a major referral center. Our techniques and methods were identical to those reported by Fulmer et al and others in the endourology community. We agree that balloon cautery endopyelotomy is a safe and effective procedure that should be offered to adults with primary or secondary ureteropelvic junction obstruction. Surgeons who choose to use the device should be aware of and know how to manage potential complications. 1. Beaghler, M.: Re: Complications of retrograde balloon cautery endopyelotomy. J Urol, 164: 128, 2000
in part explains the need for hospitalization due to pyelonephritis and the relative increase in postoperative serum creatinine in some patients. The loss of 25 to 33 cm. of the right colon and 10 to 15 cm. of distal ileum for the efferent limb in addition to the original conduit length substantially increases the risk for changes in bowel habits, which the authors observed were most obvious in neuropathic and previously irradiated cases. The indication for conversion in this study was preference in only 11 of 23 patients (47.8%), while indications for undiversion in elderly patients and those who had undergone radical cystectomy for bladder cancer may be seriously questioned. Considering the potential hazards of repeat major intra-abdominal surgery, the possible need for revision surgery and late complications, the indications for undiversion need to be redefined. Although urinary diversion and sexual dysfunction were the most common quality of life problems in such patients, the type of urinary diversion did not seem to be associated with a differential quality of life.1 We reported our experience with continent undiversion of the conduit diversion to a modified ureterosigmoidostomy in 5 male patients 14 to 21 years old (mean 17.8) born with bladder exstrophy.2 The indications for undiversion were exclusively patient preference and high motivation to be free of the skin stoma, which they had had for an average of 9.4 years. All patients declined continent catheterizable skin stoma. The original technique of the valved S shaped rectosigmoid pouch was described in 1993,3 and we introduced some modifications to incorporate the original conduit in the construction with the ureters reimplanted with a nonrefluxing technique. The functional and dynamic results in these patients were excellent at a mean followup of 19.8 months. Only 10 cm. of ileum were used in patients with previous colonic conduit, and no ileum was used in those with previous ileal conduit. Our experience confirms that continent undiversion contributes significantly to the maintenance of a favorable body image and improvement in the quality of life in these patients. Respectfully, Mostafa K. Mansi Division of Urology and Kidney Transplantation Department of Surgery MBC 1446 King Fahad National Guard Hospital P.O. Box 22490, Riyadh 11426 Saudi Arabia 1. Hart, S., Skinner, E. C., Mayerowitz, B. E. et al: Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, or cutaneous or urethral Kock pouch. J Urol, 162: 77, 1999. 2. Mansi, M.: Continent urinary undiversion to modified ureterosigmoidostomy in bladder extrophy patients. World J Surg, 23: 207, 1999. 3. Sundin, T. and Mansi, M. K.: The valved S-shaped rectosigmoid pouch for continent urinary diversion. J Urol, 150: 838, 1993.
RE: PRESERVATION OF THE THIN DISTAL URETHRA IN HYPOSPADIAS REPAIR S. S. D. Yang, Y. T. Chen, C. H. Hsieh
AND
S. C. Chen
J Urol, 164: 151–153, 2000 RE: SIMPLIFIED TECHNIQUE WITH SHORT AND LONGTERM FOLLOWUP OF CONVERSION OF AN ILEAL CONDUIT TO AN INDIANA POUCH T. E. Ahlering, G. Gholdoian, D. Skarecky, A. C. Weinberg and T. G. Wilson J Urol, 163: 1428 –1431, 2000 To the Editor. The authors report their experience with conversion of the cutaneous conduit urinary diversion to the Indiana pouch continent cutaneous diversion with preservation of the native ureteral anastomoses. Although it was not specifically noted in the article, one can assume that the ureters were originally implanted into the conduit via a refluxing technique. The conduit was incised along its antimesenteric border from the stoma down to approximately 2 cm. from the ureters, and the detubularized conduit was attached to the Indiana pouch. This method is not similar to the Studer neobladder in which a 15 to 20 cm. afferent ileal segment provides some protection against reflux from the neobladder, which is constructed from ileum. The pressure inside the Indiana pouch may be different from ileal neobladder and the risk of reflux may
To the Editor. The authors recommended preservation of the distal thin urethral segment adjacent to the hypospadiac orifice in neourethral reconstruction. The congenital or iatrogenic paper-like thin distal urethral segment in hypospadias is composed of a thin mucosal layer which is devoid of adequate blood supply and, thus, may be unsuitable for neourethra reconstruction as it is susceptible to ischemic changes.1, 2 In cases suitable for onlay urethroplasty the onlay flap should be anastomosed to a well vascularized urethral edge covered by healthy spongiosal tissue because the proximal anastomosis is usually a critical site for healing.3 Also, there may be a relative decrease in blood supply to the proximal and distal edges of the onlay flap (the most distant points from the axial vascular pedicle).4, 5 The direct proportional relationship between the complication rates and proximity of the hypospadiac orifice is a true clinical observation because more sophisticated techniques are used to repair more proximal hypospadias.3 Despite compromised blood supply, this finding does not imply that one must preserve the distal few mm. of an uncovered thin urethral mucosa. The authors report that the length of a thin distal urethral mucosa was 4 to 10 mm. (mean 6.5) in 15 of 18 patients, which may not deserve preservation in onlay
LETTERS TO THE EDITOR 3. Erturk, E., Burzon, D. T. and Waldman, D.: Treatment of transplant ureteral stenosis with endoureterotomy. J Urol, 161: 412, 1999 4. Lin, D. W., Bush, W. H. and Mayo, M. E.: Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol, 162: 696, 1999 5. Delvecchio, F. C., Kuo, R. L., Iselin, C. E. et al: Combined antegrade and retrograde endoscopic approach for the management of urinary diversion-associated pathology. J Endourol, 14: 251, 2000 6. Aslan, P. and Preminger, G. M.: Retrograde balloon cautery incision of ureteropelvic junction obstruction. Urol Clin North Am, 25: 295, 1998 7. Sampaio, F. J.: Vascular anatomy at the ureteropelvic junction. Urol Clin North Am, 25: 251, 1998 8. Van Cangh, P. J. and Nesa, S.: Endopyelotomy. Prognostic factors and patient selection. Urol Clin North Am, 25: 281, 1998 9. Nakada, S. Y.: Acucise endopyelotomy. Urology, 55: 277, 2000
Reply by Authors. We have stated at many meetings, in the original article and in a previous editorial reply1 that the purpose of our report was not to condemn a successful procedure. Rather, our goal was to make surgeons aware of the potential complications, some occurring up to 17 days postoperatively, of a procedure that has been popularized as minimally invasive and highly efficacious. Fulmer et al address the technical evolution of the balloon electrocautery device and the improved safety features of the newest available model. Unfortunately, 2 of the vascular complications that we reported, namely the ovarian vein and arterial injuries, occurred while using the latest commercially available model. Also, all complications occurred while directing incisions in the straight lateral plane as suggested by Sampaio (reference 7 in letter) and currently practiced by most endourologists. It should also be noted that when these data were presented at international conferences, including the annual meeting of the American Urological Association in Dallas and the World Congress on Endourology and Shock Wave Lithotripsy in Greece, and after publication we were approached by numerous physicians who encountered similar complications but never reported them. We believe that serious complications may occur more commonly than reported. Our article makes no mention of efficacy or success rates but endopyelotomy success rates using the device should approach 75% to 90% as reported by numerous authors. The procedure that resulted in open surgery and subsequent renal loss was the unpredictable result of extremely aberrant anatomy and right ovarian vein laceration. The purpose of our study was to inform the readership of the results of experienced surgeons in a major referral center. Our techniques and methods were identical to those reported by Fulmer et al and others in the endourology community. We agree that balloon cautery endopyelotomy is a safe and effective procedure that should be offered to adults with primary or secondary ureteropelvic junction obstruction. Surgeons who choose to use the device should be aware of and know how to manage potential complications. 1. Beaghler, M.: Re: Complications of retrograde balloon cautery endopyelotomy. J Urol, 164: 128, 2000
in part explains the need for hospitalization due to pyelonephritis and the relative increase in postoperative serum creatinine in some patients. The loss of 25 to 33 cm. of the right colon and 10 to 15 cm. of distal ileum for the efferent limb in addition to the original conduit length substantially increases the risk for changes in bowel habits, which the authors observed were most obvious in neuropathic and previously irradiated cases. The indication for conversion in this study was preference in only 11 of 23 patients (47.8%), while indications for undiversion in elderly patients and those who had undergone radical cystectomy for bladder cancer may be seriously questioned. Considering the potential hazards of repeat major intra-abdominal surgery, the possible need for revision surgery and late complications, the indications for undiversion need to be redefined. Although urinary diversion and sexual dysfunction were the most common quality of life problems in such patients, the type of urinary diversion did not seem to be associated with a differential quality of life.1 We reported our experience with continent undiversion of the conduit diversion to a modified ureterosigmoidostomy in 5 male patients 14 to 21 years old (mean 17.8) born with bladder exstrophy.2 The indications for undiversion were exclusively patient preference and high motivation to be free of the skin stoma, which they had had for an average of 9.4 years. All patients declined continent catheterizable skin stoma. The original technique of the valved S shaped rectosigmoid pouch was described in 1993,3 and we introduced some modifications to incorporate the original conduit in the construction with the ureters reimplanted with a nonrefluxing technique. The functional and dynamic results in these patients were excellent at a mean followup of 19.8 months. Only 10 cm. of ileum were used in patients with previous colonic conduit, and no ileum was used in those with previous ileal conduit. Our experience confirms that continent undiversion contributes significantly to the maintenance of a favorable body image and improvement in the quality of life in these patients. Respectfully, Mostafa K. Mansi Division of Urology and Kidney Transplantation Department of Surgery MBC 1446 King Fahad National Guard Hospital P.O. Box 22490, Riyadh 11426 Saudi Arabia 1. Hart, S., Skinner, E. C., Mayerowitz, B. E. et al: Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, or cutaneous or urethral Kock pouch. J Urol, 162: 77, 1999. 2. Mansi, M.: Continent urinary undiversion to modified ureterosigmoidostomy in bladder extrophy patients. World J Surg, 23: 207, 1999. 3. Sundin, T. and Mansi, M. K.: The valved S-shaped rectosigmoid pouch for continent urinary diversion. J Urol, 150: 838, 1993.
RE: PRESERVATION OF THE THIN DISTAL URETHRA IN HYPOSPADIAS REPAIR S. S. D. Yang, Y. T. Chen, C. H. Hsieh
AND
S. C. Chen
J Urol, 164: 151–153, 2000 RE: SIMPLIFIED TECHNIQUE WITH SHORT AND LONGTERM FOLLOWUP OF CONVERSION OF AN ILEAL CONDUIT TO AN INDIANA POUCH T. E. Ahlering, G. Gholdoian, D. Skarecky, A. C. Weinberg and T. G. Wilson J Urol, 163: 1428 –1431, 2000 To the Editor. The authors report their experience with conversion of the cutaneous conduit urinary diversion to the Indiana pouch continent cutaneous diversion with preservation of the native ureteral anastomoses. Although it was not specifically noted in the article, one can assume that the ureters were originally implanted into the conduit via a refluxing technique. The conduit was incised along its antimesenteric border from the stoma down to approximately 2 cm. from the ureters, and the detubularized conduit was attached to the Indiana pouch. This method is not similar to the Studer neobladder in which a 15 to 20 cm. afferent ileal segment provides some protection against reflux from the neobladder, which is constructed from ileum. The pressure inside the Indiana pouch may be different from ileal neobladder and the risk of reflux may
To the Editor. The authors recommended preservation of the distal thin urethral segment adjacent to the hypospadiac orifice in neourethral reconstruction. The congenital or iatrogenic paper-like thin distal urethral segment in hypospadias is composed of a thin mucosal layer which is devoid of adequate blood supply and, thus, may be unsuitable for neourethra reconstruction as it is susceptible to ischemic changes.1, 2 In cases suitable for onlay urethroplasty the onlay flap should be anastomosed to a well vascularized urethral edge covered by healthy spongiosal tissue because the proximal anastomosis is usually a critical site for healing.3 Also, there may be a relative decrease in blood supply to the proximal and distal edges of the onlay flap (the most distant points from the axial vascular pedicle).4, 5 The direct proportional relationship between the complication rates and proximity of the hypospadiac orifice is a true clinical observation because more sophisticated techniques are used to repair more proximal hypospadias.3 Despite compromised blood supply, this finding does not imply that one must preserve the distal few mm. of an uncovered thin urethral mucosa. The authors report that the length of a thin distal urethral mucosa was 4 to 10 mm. (mean 6.5) in 15 of 18 patients, which may not deserve preservation in onlay