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RE: COMPLICATIONS OF RETROGRADE BALLOON CAUTERY ENDOPYELOTOMY
0022-5347/01/1652-0542/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 542–545, February 2001 Printed in U.S.A.
Letters to the Editor RE: SPONTANEOUS REGRESSION OF METASTASES IN A CASE OF BILATERAL RENAL CELL CARCINOMA J. C. Kallmeyer and O. C. Dittrich J Urol, 148: 138 –140, 1992 To the Editor. In 1995 we wrote a followup to this case report.1 Our patient had undergone successful renal transplant 5 years after regression of metastases. He was treated with the immunosuppressive drugs cyclosporine and azathioprine, and was given low dose steroids. Renal function was excellent. At 4 years postoperatively he complained of chronic fatigue, dyspnea and lower back pain. Investigations, which included computerized tomography and radioisotope bone scans, showed metastases involving L3 vertebra and ribs. A chest x-ray revealed a right pleural effusion and infiltrates in the lung. Fine needle aspiration of the lung lesions demonstrated renal carcinoma. The patient received radiotherapy but during the following year general condition deteriorated and he died. I believe that the re-documentation of this case is warranted because of the unusual initial presentation, successful transplant and ultimate recurrence of metastatic disease. Respectfully, Jeffrey C. Kallmeyer Renal Unit St. Augustine’s Hospital Chelmsford Rd. Durban, 4001 South Africa 1. Kallmeyer, J. C. and Kallmeyer, I. J.: Re: Spontaneous regression of metastases in a case of bilateral renal cell carcinoma. J Urol, 153: 751, 1995
RE: COMPLICATIONS OF RETROGRADE BALLOON CAUTERY ENDOPYELOTOMY B. F. Schwartz and M. L. Stoller J Urol, 162: 1594 –1598, 1999 To the Editor. The authors present their experience with complications following the use of the Acucise* endopyelotomy catheter for ureteropelvic junction obstruction. A total of 52 retrograde endopyelotomies were performed and 5 uncommon complications, including 4 bleeding episodes and 1 balloon failure, occurred. We believe that the authors failed to recognize the significant evolution that has occurred with the Acucise device and the high degree of safety that others have experienced, which has led to the widespread acceptance of this procedure as a safe alternative to open pyeloplasty or antegrade endopyelotomy. The Acucise catheter was developed initially from work in the early 1990s on a large electrocautery balloon catheter, which was intended for use in cutting the anterior commisure of the prostate. This procedure was not durable in human studies. The technology advanced and the use of the electrocautery balloon catheter was extended to the proximal ureter. The first retrograde Acucise type incision of the ureteropelvic junction was performed in 1993 at Washington University.1 Acucise balloon endopyelotomy has since been proved to be efficacious and durable in the treatment of ureteropelvic junction obstruction,2 and more than 20,000 procedures have been performed worldwide. The use of this device has also been extended to the treatment of ureteral3 and ureteroenteral4, 5 strictures. In the 7 years since its introduction the Acucise catheter has undergone 2 major improvements and a number of design changes. When originally introduced, the catheter was a 10Fr system with a 14Fr profile over the balloon. Due to the size of the device ureteral stenting was required for a week before the procedure to allow the ureter to undergo sufficient passive dilation to accommodate the cutting balloon.6 The current catheter has been downsized to a 7Fr shaft with a 10Fr profile over the balloon, thereby largely obviating the need for preoperative stenting or ureteral dilation. In
addition, the entire catheter can now be easily and accurately placed with the use of a ureteral access sheath. Advances in our understanding of renal vasculature due to the work by Sampaio have led to changes from the initially described incision of the ureteropelvic junction in the posterolateral position to the currently recommended straight lateral incision.7 Preoperative patient evaluation has also been improved to identify those at risk for complications or failure after endopyelotomy, such as strictures greater than 2 cm., poor renal function and severe hydronephrosis.8 Finally, the development of a 30Fr tamponade balloon catheter has made the immediate management of hemorrhage after Acucise endopyelotomy quicker, simpler and less morbid.9 It is recommended that this balloon is available whenever an Acucise procedure is performed. In the rare occurrence of bleeding the balloon is placed retrograde to straddle the ureteropelvic junction area, and following inflation the bleeding is tamponaded, the patient is turned prone and a 10Fr nephrostomy tube is placed. On the second postoperative day the patient is brought to the interventional radiology department for observation. If there is no bleeding on deflation of the balloon a 7/10Fr endopyelotomy stent is placed but if bleeding occurs the involved artery is embolized. The nephrostomy tube remains in place for a week and is removed on an outpatient basis. Using this regimen, neither our group nor the group at Washington University have had to operate on any patient, no kidneys have been lost and in the past 3 years no patients have required embolization. Thus, with the evolution of the Acucise device and the use of the aforementioned regimen none of the complications noted in this article has occurred during the last several years. Controversy also exists regarding the appropriate ureteral stent size to be left after incision of the ureteropelvic junction but many groups have switched to a 7/10Fr stent or a simple 7Fr stent in lieu of the 7/14Fr endopyelotomy stent.6 In addition, placement of the stent in the upper pole has precluded any chance of stent migration beyond the endopyelotomy site. In our experience with more than 140 Acucise endopyelotomy procedures 3 patients had significant bleeding evidenced by decreases in postoperative hematocrit level. All were hemodynamically stable and 2 patients required transfusion. Importantly, these 3 patients underwent incision of the ureteropelvic junction in the posterolateral position early in our experience. Since switching to an incision in the pure lateral position, we have encountered no significant bleeding. Minor complications, such as urinary tract infection and stent migration, were 1% to 2% in our patients. Given the significant changes in the device and procedure, care must be taken to evaluate accurately any patients undergoing Acucise endopyelotomy. If patients are not grouped by standardizing for device design and technique the results may be misleading. For example, changing the position of the incision has had a significant impact in reducing bleeding events in our patients. We believe that the authors did not take into account the changes in the Acucise catheter or the retrograde balloon endopyelotomy procedure, which occurred during the 5-year course of their study. The evolution of any surgical procedure, which can be related to the tools and/or technique, includes refinements aimed at increasing procedural efficacy and reducing complications and morbidity. Acucise endopyelotomy is a contemporary example of this evolutionary process, and we believe that with proper patient selection and strict adherence to established guidelines Acucise endopyelotomy safely and effectively treats ureteropelvic junction obstruction.
* Applied Medical, Laguna Hills, California. 542
Respectfully, Brant R. Fulmer, Thomas M. T. Turk and David M. Albala Department of Urology Loyola University Medical Center 2160 South First Avenue Maywood, Illinois 60153 1. Chandhoke, P. S., Clayman, R. V., Stone, A. M. et al: Endopyelotomy and endoureterotomy with the acucise ureteral cutting balloon device: preliminary experience. J Endourol, 7: 45, 1993 2. Nadler, R. B., Rao, G. S., Pearle, M. S. et al: Acucise endopyelotomy: assessment of long-term durability. J Urol, 156: 1094, 1996
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
Vol. 165, 542–545, February 2001 Printed in U.S.A.
Letters to the Editor RE: SPONTANEOUS REGRESSION OF METASTASES IN A CASE OF BILATERAL RENAL CELL CARCINOMA J. C. Kallmeyer and O. C. Dittrich J Urol, 148: 138 –140, 1992 To the Editor. In 1995 we wrote a followup to this case report.1 Our patient had undergone successful renal transplant 5 years after regression of metastases. He was treated with the immunosuppressive drugs cyclosporine and azathioprine, and was given low dose steroids. Renal function was excellent. At 4 years postoperatively he complained of chronic fatigue, dyspnea and lower back pain. Investigations, which included computerized tomography and radioisotope bone scans, showed metastases involving L3 vertebra and ribs. A chest x-ray revealed a right pleural effusion and infiltrates in the lung. Fine needle aspiration of the lung lesions demonstrated renal carcinoma. The patient received radiotherapy but during the following year general condition deteriorated and he died. I believe that the re-documentation of this case is warranted because of the unusual initial presentation, successful transplant and ultimate recurrence of metastatic disease. Respectfully, Jeffrey C. Kallmeyer Renal Unit St. Augustine’s Hospital Chelmsford Rd. Durban, 4001 South Africa 1. Kallmeyer, J. C. and Kallmeyer, I. J.: Re: Spontaneous regression of metastases in a case of bilateral renal cell carcinoma. J Urol, 153: 751, 1995
RE: COMPLICATIONS OF RETROGRADE BALLOON CAUTERY ENDOPYELOTOMY B. F. Schwartz and M. L. Stoller J Urol, 162: 1594 –1598, 1999 To the Editor. The authors present their experience with complications following the use of the Acucise* endopyelotomy catheter for ureteropelvic junction obstruction. A total of 52 retrograde endopyelotomies were performed and 5 uncommon complications, including 4 bleeding episodes and 1 balloon failure, occurred. We believe that the authors failed to recognize the significant evolution that has occurred with the Acucise device and the high degree of safety that others have experienced, which has led to the widespread acceptance of this procedure as a safe alternative to open pyeloplasty or antegrade endopyelotomy. The Acucise catheter was developed initially from work in the early 1990s on a large electrocautery balloon catheter, which was intended for use in cutting the anterior commisure of the prostate. This procedure was not durable in human studies. The technology advanced and the use of the electrocautery balloon catheter was extended to the proximal ureter. The first retrograde Acucise type incision of the ureteropelvic junction was performed in 1993 at Washington University.1 Acucise balloon endopyelotomy has since been proved to be efficacious and durable in the treatment of ureteropelvic junction obstruction,2 and more than 20,000 procedures have been performed worldwide. The use of this device has also been extended to the treatment of ureteral3 and ureteroenteral4, 5 strictures. In the 7 years since its introduction the Acucise catheter has undergone 2 major improvements and a number of design changes. When originally introduced, the catheter was a 10Fr system with a 14Fr profile over the balloon. Due to the size of the device ureteral stenting was required for a week before the procedure to allow the ureter to undergo sufficient passive dilation to accommodate the cutting balloon.6 The current catheter has been downsized to a 7Fr shaft with a 10Fr profile over the balloon, thereby largely obviating the need for preoperative stenting or ureteral dilation. In
addition, the entire catheter can now be easily and accurately placed with the use of a ureteral access sheath. Advances in our understanding of renal vasculature due to the work by Sampaio have led to changes from the initially described incision of the ureteropelvic junction in the posterolateral position to the currently recommended straight lateral incision.7 Preoperative patient evaluation has also been improved to identify those at risk for complications or failure after endopyelotomy, such as strictures greater than 2 cm., poor renal function and severe hydronephrosis.8 Finally, the development of a 30Fr tamponade balloon catheter has made the immediate management of hemorrhage after Acucise endopyelotomy quicker, simpler and less morbid.9 It is recommended that this balloon is available whenever an Acucise procedure is performed. In the rare occurrence of bleeding the balloon is placed retrograde to straddle the ureteropelvic junction area, and following inflation the bleeding is tamponaded, the patient is turned prone and a 10Fr nephrostomy tube is placed. On the second postoperative day the patient is brought to the interventional radiology department for observation. If there is no bleeding on deflation of the balloon a 7/10Fr endopyelotomy stent is placed but if bleeding occurs the involved artery is embolized. The nephrostomy tube remains in place for a week and is removed on an outpatient basis. Using this regimen, neither our group nor the group at Washington University have had to operate on any patient, no kidneys have been lost and in the past 3 years no patients have required embolization. Thus, with the evolution of the Acucise device and the use of the aforementioned regimen none of the complications noted in this article has occurred during the last several years. Controversy also exists regarding the appropriate ureteral stent size to be left after incision of the ureteropelvic junction but many groups have switched to a 7/10Fr stent or a simple 7Fr stent in lieu of the 7/14Fr endopyelotomy stent.6 In addition, placement of the stent in the upper pole has precluded any chance of stent migration beyond the endopyelotomy site. In our experience with more than 140 Acucise endopyelotomy procedures 3 patients had significant bleeding evidenced by decreases in postoperative hematocrit level. All were hemodynamically stable and 2 patients required transfusion. Importantly, these 3 patients underwent incision of the ureteropelvic junction in the posterolateral position early in our experience. Since switching to an incision in the pure lateral position, we have encountered no significant bleeding. Minor complications, such as urinary tract infection and stent migration, were 1% to 2% in our patients. Given the significant changes in the device and procedure, care must be taken to evaluate accurately any patients undergoing Acucise endopyelotomy. If patients are not grouped by standardizing for device design and technique the results may be misleading. For example, changing the position of the incision has had a significant impact in reducing bleeding events in our patients. We believe that the authors did not take into account the changes in the Acucise catheter or the retrograde balloon endopyelotomy procedure, which occurred during the 5-year course of their study. The evolution of any surgical procedure, which can be related to the tools and/or technique, includes refinements aimed at increasing procedural efficacy and reducing complications and morbidity. Acucise endopyelotomy is a contemporary example of this evolutionary process, and we believe that with proper patient selection and strict adherence to established guidelines Acucise endopyelotomy safely and effectively treats ureteropelvic junction obstruction.
* Applied Medical, Laguna Hills, California. 542
Respectfully, Brant R. Fulmer, Thomas M. T. Turk and David M. Albala Department of Urology Loyola University Medical Center 2160 South First Avenue Maywood, Illinois 60153 1. Chandhoke, P. S., Clayman, R. V., Stone, A. M. et al: Endopyelotomy and endoureterotomy with the acucise ureteral cutting balloon device: preliminary experience. J Endourol, 7: 45, 1993 2. Nadler, R. B., Rao, G. S., Pearle, M. S. et al: Acucise endopyelotomy: assessment of long-term durability. J Urol, 156: 1094, 1996
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