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Re: Two-Sided Urethra-Sparing Reconstruction Combining Dorsal Preputial Skin plus Ventral Buccal Mucosa Grafts for Tight Bulbar Strictures
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Trauma, and Genital and Urethral Reconstruction Re: Two-Sided Urethra-Sparing Reconstruction Combining Dorsal Preputial Skin plus Ventral Buccal Mucosa Grafts for Tight Bulbar Strictures E. Palminteri, E. Berdondini, M. Florio, G. Cucchiarale, G. Milan, F. Valentino, O. Sedigh and G. B. Di Pierro Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Department of Urology, Tor Vergata University and Department of Obstetrics, Gynecology and Urology, Sapienza University, Rome and Departments of Urology, Clinica Cellini, Humanitas Institute and Le Molinette University, Torino, Italy Int J Urol 2015; 22: 861e866. doi: 10.1111/iju.12822
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26010048 Editorial Comment: Palminteri has again made a nice contribution to the urethroplasty literature, this time by resurrecting the preputial skin graft, applying it dorsally and combining it with a ventrally placed oral mucosa graft. We like the concept of overlapping grafts and have had virtually identical success rates.1 We also like the Asopa dorsal graft approach applied through a ventral urethral incision, especially in the penile urethra, although sometimes the closure can be tight because it is difficult to get the same width of graft into the defect compared to a straightforward ventral approach. In addition, we like to use short segments of preputial skin when a small amount of additional tissue is needed (“minipatch”) because of the convenience and reliable results, and we are always amazed that the residents and fellows in the age of oral mucosa grafting have never seen penile skin grafts used in this manner. Allen F. Morey, MD 1. Hudak SJ, Lubahn JD, Kulkarni S et al: Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosa grafts. BJU Int 2012; 110: 592.
Re: The Vascular and Neurogenic Factors Associated with Erectile Dysfunction in Patients after Pelvic Fractures Y. Guan, S. Wendong, S. Zhao, T. Liu, Y. Liu, X. Zhang and M. Yuan Department of Urology, Second Hospital of ShanDong University, Jinan, China Int Braz J Urol 2015; 41: 959e966. doi: 10.1590/S1677-5538.IBJU.2014.0170
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26689522 Editorial Comment: It is not uncommon for patients with pelvic fracture urethral injury to be rendered impotent, even at a young age. In this large series from China 120 patients with traumatic urethral disruption underwent nocturnal penile tumescence testing along with duplex ultrasonography and cavernosography. A variety of somatic neurophysiological tests were also performed, including posterior tibial and pudendal nerve evoked potentials and bulbocavernosus reflex. Based on
0022-5347/16/1962-0001/0 THE JOURNAL OF UROLOGY® Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2016.05.052 Vol. 196, 1-2, August 2016 Printed in U.S.A.
www.jurology.com Dochead: Urological Survey
LIT 5.4.0 DTD JURO13737_proof 14 May 2016 6:18 pm EO:
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International Index of Erectile Function questionnaire results, erectile dysfunction was observed in more than 95% of these young men, with most having a variety of abnormal neurogenic results and/or vascular problems, including venous leak components, which were identified more commonly than arteriogenic erectile dysfunction. The role of invasive arteriography seems to be limited in patients with pelvic fracture urethral injury since most are impotent due to some reason other than arterial insufficiency. Allen F. Morey, MD
Re: Substitution Urethroplasty or Anastomotic Urethroplasty for Bulbar Urethra Strictures? Or Endoscopic Urethrotomy? Opinion: Substitution Urethroplasty R. A. Santucci Department of Urology, Detroit Medical Center, Center for Urologic Reconstruction, Detroit Receiving Hospital and Department of Surgical Specialties, Michigan State University College of Medicine, Detroit, Michigan Int Braz J Urol 2015; 41: 613e614. doi: 10.1590/S1677-5538.IBJU.2015.04.02
No Abstract Editorial Comment: In this point/counterpoint article Santucci makes the case that oral mucosa graft is preferred for virtually any urethral stricture, no matter how short. This opinion is based largely on a report I wrote 10 years ago in which anastomotic urethroplasty was expanded for strictures of several centimeters (a practice we continue to be quite happy with nowadays). Although a third of the patients in that old article complained of decreased penile length and chordee, the results were reported on a self-administered questionnaire (not a surgeon reported interview) soon postoperatively and were no different than those of men undergoing circumcision. Santucci cautions that others have reported the dreaded “cold glans” in a grand total of 1 of 153 patients surveyed who had undergone anastomotic urethroplasty. The reality is that while surgeons under report their complications, patients inflate their problems, especially on questionnaires and especially when it comes to penile surgery. Through the years I have observed that when you perform any operation on the penis (penile implant, plication, urethroplasty, circumcision, etc), patients will always tell you that the penis has become shorter if you ask. These negative consequences appear to be transient and negligible from a practical standpoint after urethroplasty, when present at all, and are far outweighed by the relief patients express when they learn we did not need to dig a mucosal patch out of their cheek (which usually hurts far worse and far longer than the perineal incision). Anastomotic urethroplasty continues to yield lower restricture and extravasation rates compared to graft procedures (outside Detroit), and we have successfully salvaged numerous recurrent strictures by simply excising previously grafted areas. Furthermore, because we do not separate the corpora during our anastomotic procedures, we do not interfere with the antegrade corporeal circulation. Generally we continue to subscribe to the philosophy of avoiding or minimizing grafts in genital or urethral reconstruction when possible, and we strongly believe that the best strategy for dealing with strictures centers around complete excision. Allen F. Morey, MD
Dochead: Urological Survey
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Trauma, and Genital and Urethral Reconstruction Re: Two-Sided Urethra-Sparing Reconstruction Combining Dorsal Preputial Skin plus Ventral Buccal Mucosa Grafts for Tight Bulbar Strictures E. Palminteri, E. Berdondini, M. Florio, G. Cucchiarale, G. Milan, F. Valentino, O. Sedigh and G. B. Di Pierro Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Department of Urology, Tor Vergata University and Department of Obstetrics, Gynecology and Urology, Sapienza University, Rome and Departments of Urology, Clinica Cellini, Humanitas Institute and Le Molinette University, Torino, Italy Int J Urol 2015; 22: 861e866. doi: 10.1111/iju.12822
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26010048 Editorial Comment: Palminteri has again made a nice contribution to the urethroplasty literature, this time by resurrecting the preputial skin graft, applying it dorsally and combining it with a ventrally placed oral mucosa graft. We like the concept of overlapping grafts and have had virtually identical success rates.1 We also like the Asopa dorsal graft approach applied through a ventral urethral incision, especially in the penile urethra, although sometimes the closure can be tight because it is difficult to get the same width of graft into the defect compared to a straightforward ventral approach. In addition, we like to use short segments of preputial skin when a small amount of additional tissue is needed (“minipatch”) because of the convenience and reliable results, and we are always amazed that the residents and fellows in the age of oral mucosa grafting have never seen penile skin grafts used in this manner. Allen F. Morey, MD 1. Hudak SJ, Lubahn JD, Kulkarni S et al: Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosa grafts. BJU Int 2012; 110: 592.
Re: The Vascular and Neurogenic Factors Associated with Erectile Dysfunction in Patients after Pelvic Fractures Y. Guan, S. Wendong, S. Zhao, T. Liu, Y. Liu, X. Zhang and M. Yuan Department of Urology, Second Hospital of ShanDong University, Jinan, China Int Braz J Urol 2015; 41: 959e966. doi: 10.1590/S1677-5538.IBJU.2014.0170
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26689522 Editorial Comment: It is not uncommon for patients with pelvic fracture urethral injury to be rendered impotent, even at a young age. In this large series from China 120 patients with traumatic urethral disruption underwent nocturnal penile tumescence testing along with duplex ultrasonography and cavernosography. A variety of somatic neurophysiological tests were also performed, including posterior tibial and pudendal nerve evoked potentials and bulbocavernosus reflex. Based on
0022-5347/16/1962-0001/0 THE JOURNAL OF UROLOGY® Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2016.05.052 Vol. 196, 1-2, August 2016 Printed in U.S.A.
www.jurology.com Dochead: Urological Survey
LIT 5.4.0 DTD JURO13737_proof 14 May 2016 6:18 pm EO:
j
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 1 113 114
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
2
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172
International Index of Erectile Function questionnaire results, erectile dysfunction was observed in more than 95% of these young men, with most having a variety of abnormal neurogenic results and/or vascular problems, including venous leak components, which were identified more commonly than arteriogenic erectile dysfunction. The role of invasive arteriography seems to be limited in patients with pelvic fracture urethral injury since most are impotent due to some reason other than arterial insufficiency. Allen F. Morey, MD
Re: Substitution Urethroplasty or Anastomotic Urethroplasty for Bulbar Urethra Strictures? Or Endoscopic Urethrotomy? Opinion: Substitution Urethroplasty R. A. Santucci Department of Urology, Detroit Medical Center, Center for Urologic Reconstruction, Detroit Receiving Hospital and Department of Surgical Specialties, Michigan State University College of Medicine, Detroit, Michigan Int Braz J Urol 2015; 41: 613e614. doi: 10.1590/S1677-5538.IBJU.2015.04.02
No Abstract Editorial Comment: In this point/counterpoint article Santucci makes the case that oral mucosa graft is preferred for virtually any urethral stricture, no matter how short. This opinion is based largely on a report I wrote 10 years ago in which anastomotic urethroplasty was expanded for strictures of several centimeters (a practice we continue to be quite happy with nowadays). Although a third of the patients in that old article complained of decreased penile length and chordee, the results were reported on a self-administered questionnaire (not a surgeon reported interview) soon postoperatively and were no different than those of men undergoing circumcision. Santucci cautions that others have reported the dreaded “cold glans” in a grand total of 1 of 153 patients surveyed who had undergone anastomotic urethroplasty. The reality is that while surgeons under report their complications, patients inflate their problems, especially on questionnaires and especially when it comes to penile surgery. Through the years I have observed that when you perform any operation on the penis (penile implant, plication, urethroplasty, circumcision, etc), patients will always tell you that the penis has become shorter if you ask. These negative consequences appear to be transient and negligible from a practical standpoint after urethroplasty, when present at all, and are far outweighed by the relief patients express when they learn we did not need to dig a mucosal patch out of their cheek (which usually hurts far worse and far longer than the perineal incision). Anastomotic urethroplasty continues to yield lower restricture and extravasation rates compared to graft procedures (outside Detroit), and we have successfully salvaged numerous recurrent strictures by simply excising previously grafted areas. Furthermore, because we do not separate the corpora during our anastomotic procedures, we do not interfere with the antegrade corporeal circulation. Generally we continue to subscribe to the philosophy of avoiding or minimizing grafts in genital or urethral reconstruction when possible, and we strongly believe that the best strategy for dealing with strictures centers around complete excision. Allen F. Morey, MD
Dochead: Urological Survey
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