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Endopyelotomy: Patient selection,results, and complications
LETTERS TO THE EDITOR
': Patient Selection, )mplications gh review, G e r b e r and Lyon 1994) note that "It is generally strictures (>2 cm) do not reendoscopic incision." The reae found in their reference 11. t partly by the regeneration of m remainder is by contracture. 1 muscle is arranged as a helix, oriented variously from longicontraction occurs in both the ldinal axes. If the defect left by ,nd a certain length, dependent f the ureter and the surroundcontraction will be inadequate : supplementation by contracLinal axis. This places a limit on t be closed effectively, whether [e by open exposure or instru-
Rudolf O.E Oppenheimer, M.D.
Frank Hinman, Jr., M.D. University of California San Francisco San Francisco, California 941 't3-0738 Hinman F Jr: Ureteral regeneration: ?lasia of smooth muscle. J Urol 74:
throcutaneous Fistulas the Table of Contents of the alized even before reading the menbaum and Palmer (Urology ) had mistitled their report rocutaneous Fistulas." I knew rave b e e n " C o m p l i c a t i o n s of ms." This thought was doubly ag the article. : fistulas were "noted immedicircumcision" and involved the eere in patients with a complete apletely normal glans, the au. . . . . . . ed dubious embryologic and/or ~OLOG¥
JULY1994 / VOLUMe44, NUMBEe1
etiologic theories to try to account for this complication. These fistulas were large enough (Fig. 1 of the article) that it would have been nigh impossible to overlook them at the time of the obstetrical circumcision unless the operator was as blind as is a clamp technique of doing a circumcision. We see approximately 100 to 125 patients a year whose parents are dissatisfied with the results of obstetrical circumcisions. Fortunately, the most c o m m o n complication is insufficient removal of the foreskin. Other complications have ranged from bleeding, injury to the glans, concealed penis, removal of the entire shaft skin, Fournier's gangrene, and urethrocutaneous fistulas. The urethra in infants lies just under the skin and can be easily injured when a blind technique (Gomco clamp or plastibell) of doing a circumcision is utilized. The authors state that the absence of urethral mucosa in the pathologic specimen eliminates the possibility of an iatrogenic causation. It would be difficult to identify urethral mucosa in the specimen unless microscopic serial sections of the resection line were examined. Almost all pathology departments do just a cursory gross examination of neonatal foreskins. This article represents the all too prevalent surgical mentality of blaming the patient for technical complications rather than facing the facts and trying to educate our obstetrical brethren to try to prevent the all too numerous complications of their circumcisions. They never see these infants in a follow-up visit. We might be kind and say "Father, forgive them for they know not what they do." I do w a n t to c o n g r a t u l a t e the a u t h o r s for successfully closing these fistulas. They frequently are difficult to close because of their locations. Arnold H. Colodny, M.D. Division of Urology Children's Hospital Medical Center Boston, Massachusetts 02115 REPLY BY THE AUTHORS"
We appreciate Dr Colodny's comments with respect to our case report. We too recognize and manage a significant number of boys with penile injuries following circumcision by obstetricians and other health care providers. However, we also recognize that a number of congenital anomalies I 49
': Patient Selection, )mplications gh review, G e r b e r and Lyon 1994) note that "It is generally strictures (>2 cm) do not reendoscopic incision." The reae found in their reference 11. t partly by the regeneration of m remainder is by contracture. 1 muscle is arranged as a helix, oriented variously from longicontraction occurs in both the ldinal axes. If the defect left by ,nd a certain length, dependent f the ureter and the surroundcontraction will be inadequate : supplementation by contracLinal axis. This places a limit on t be closed effectively, whether [e by open exposure or instru-
Rudolf O.E Oppenheimer, M.D.
Frank Hinman, Jr., M.D. University of California San Francisco San Francisco, California 941 't3-0738 Hinman F Jr: Ureteral regeneration: ?lasia of smooth muscle. J Urol 74:
throcutaneous Fistulas the Table of Contents of the alized even before reading the menbaum and Palmer (Urology ) had mistitled their report rocutaneous Fistulas." I knew rave b e e n " C o m p l i c a t i o n s of ms." This thought was doubly ag the article. : fistulas were "noted immedicircumcision" and involved the eere in patients with a complete apletely normal glans, the au. . . . . . . ed dubious embryologic and/or ~OLOG¥
JULY1994 / VOLUMe44, NUMBEe1
etiologic theories to try to account for this complication. These fistulas were large enough (Fig. 1 of the article) that it would have been nigh impossible to overlook them at the time of the obstetrical circumcision unless the operator was as blind as is a clamp technique of doing a circumcision. We see approximately 100 to 125 patients a year whose parents are dissatisfied with the results of obstetrical circumcisions. Fortunately, the most c o m m o n complication is insufficient removal of the foreskin. Other complications have ranged from bleeding, injury to the glans, concealed penis, removal of the entire shaft skin, Fournier's gangrene, and urethrocutaneous fistulas. The urethra in infants lies just under the skin and can be easily injured when a blind technique (Gomco clamp or plastibell) of doing a circumcision is utilized. The authors state that the absence of urethral mucosa in the pathologic specimen eliminates the possibility of an iatrogenic causation. It would be difficult to identify urethral mucosa in the specimen unless microscopic serial sections of the resection line were examined. Almost all pathology departments do just a cursory gross examination of neonatal foreskins. This article represents the all too prevalent surgical mentality of blaming the patient for technical complications rather than facing the facts and trying to educate our obstetrical brethren to try to prevent the all too numerous complications of their circumcisions. They never see these infants in a follow-up visit. We might be kind and say "Father, forgive them for they know not what they do." I do w a n t to c o n g r a t u l a t e the a u t h o r s for successfully closing these fistulas. They frequently are difficult to close because of their locations. Arnold H. Colodny, M.D. Division of Urology Children's Hospital Medical Center Boston, Massachusetts 02115 REPLY BY THE AUTHORS"
We appreciate Dr Colodny's comments with respect to our case report. We too recognize and manage a significant number of boys with penile injuries following circumcision by obstetricians and other health care providers. However, we also recognize that a number of congenital anomalies I 49