RE: ARGYROPHILIC NUCLEOLAR ORGANIZER REGION IN PROLIFERATING CELL HAS A PREDICTIVE VALUE FOR LOCAL RECURRENCE IN SUPERFICIAL BLADDER TUMOR

0022-5347/00/1635-1524/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 163, 1524 –1526, May 2000 Printed in U.S.A.

Letters to the Editor RE: UNSTENTED EXTRAVESICAL URETERONEOCYSTOSTOMY IN KIDNEY TRANSPLANTATION J. M. Barry J Urol, 129: 918, 1983 To the Editor. There are 2 possible reasons for urinary leakage after parallel incision extravesical ureteroneocystostomy. An insufficient number of interrupted stitches may be joining a widely spatulated ureter to the bladder mucosa. This problem can be corrected by placing additional interrupted sutures between the “heel” stitch and the “dog-ear” stitches, and between the “dog-ear” stitches and the full thickness anchoring suture at the “toe” of the ureter, resulting in a total of 8 rather than 4 interrupted sutures. The fullthickness toe suture may also be too far into the bladder. When this is pulled up and tied, the suture in the “heel” may be torn out. I continue to use the procedure and have been satisfied with the results.1 Respectfully, John M. Barry Division of Urology and Renal Transplantation The Oregon Health Sciences University 3181 S.W. Sam Jackson Park Rd. Portland, Oregon 97201 1. Gibbons, W. S., Barry, J. M. and Hefty, T. R.: Complications following unstented parallel incision extravesical ureteroneocystostomy in 1,000 kidney transplants. J Urol, 148: 38, 1992

normal, ill effects of this dilatation may not be clinically significant. Recurrent pathological conditions, such as stones, tuberculosis or medical renal disease, can tilt the balance, resulting in serious decompensation. Whether a nonrefluxing anastomosis can prevent this effect with prolonged followup is still not clear from the literature. Hence, prolonged followup of these patients is relevant and attention should be given to the draining renal unit as well as the contralateral kidney. Respectfully, R. Chahal Department of Urology Orchard House Pinderfields General Hospital Wakefield, West Yorkshire WF14DG United Kingdom 1. Gupta, N. P., Chahal, R. and Wadhwa, S. N.: Ileal substitution as a salvage procedure in the management of iatrogenic ureteropelvic junction and upper ureteric obstruction—a long-term followup. Indian J Urol, 13: 79, 1997 2. Amin, H. A.: Experience with the ileal ureter. Br J Urol, 48: 19, 1976

RE: ARGYROPHILIC NUCLEOLAR ORGANIZER REGION IN PROLIFERATING CELL HAS A PREDICTIVE VALUE FOR LOCAL RECURRENCE IN SUPERFICIAL BLADDER TUMOR M. Tomobe, T. Shimazui, K. Uchida, S. Hinotsu and H. Akaza

RE: ILEAL URETERAL SUBSTITUTION IN RECONSTRUCTIVE UROLOGICAL SURGERY: IS AN ANTIREFLUX PROCEDURE NECESSARY? M. Waldner, L. Hertle and S. Roth J Urol, 162: 323–326, 1999

J Urol, 162: 63– 68, 1999 To the Editor. The authors state that “in general, the overlaps between argyrophilic nucleolar organizer region (AgNOR) numbers that may be found among the various degrees of tumor grade limit the practical value of this method for evaluating individual cases.” Recently, we studied whether the AgNOR technique could be helpful for the cytological diagnosis of urinary lesions.1 The 3 different AgNOR parameters we evaluated were the average number of silver precipitations per nucleus, the range between the minimal and maximal AgNOR value, and the type of distribution of the silver precipitations (homogeneous or heterogeneous). The diseases were classified into 3 groups of nonneoplastic lesions, and low grade and high grade carcinomas. The final diagnosis was always established by histological analyses of subsequent bladder biopsies. Of course, there was considerable overlap of the values of each AgNOR parameter among the 3 diagnostic groups. We combined the AgNOR parameters in a linear discriminant analysis. This multivariate system “learned” to diagnose individual cases comparing simultaneously the values of the AgNOR parameters with the final histological diagnosis. An evaluation using the “jackknife” method indicated that the algorithm was able to classify correctly 84% of the cases based only on the AgNOR features. Comparable results had been obtained earlier in a study on the diagnostic value of AgNOR parameters in gastric biopsies.2 In conclusion, we think that AgNOR parameters can be useful for the diagnostic evaluation of individual cases when using different AgNOR features simultaneously in a discriminant analysis (or neuronal network system). However, there is considerable overlap for the values of the AgNOR parameters among the groups when analyzed univariately.

To the Editor. We reported on the long-term followup of total ileal replacement of the ureter in patients with previous iatrogenic injuries (recurrent surgery for calculus disease or pyeloplasty).1 We used a 20 to 25 cm. length of ileum in an isoperistaltic fashion. Bladder outlet obstruction was ruled out in all cases and the renal parameters were normal preoperatively. We have followed 4 patients for at least 14 years, of whom 3 had a refluxing ileovesical anastomosis and 1 had a nipple valve nonrefluxing anastomosis. In all patients a vesical button was excised at the time of the ileovesical anastomosis.2 Patients were followed at 1 to 2-year intervals, and renal parameters, blood gases and excretory urography/renography were performed. A voiding cystourethrogram was performed at 3-month followup and when dilatation of the ileal segment was observed. There was no evidence of dilatation of the ileal segment in the first 10 years of followup. Subsequently, progressive dilatation was observed in all 4 patients, which became severe with significant tortuousity and protracted excretion after 12 years. Bladder outlet obstruction, ileovesical anastomotic stenosis and bladder dyssynergia were ruled out as causes of dilatation. Reflux persisted in all cases. The interpretation of the diuretic renogram studies in this setting is difficult. There were no acid-base or electrolyte problems in any patient in the first 12 years of followup. One patient died of severe acidosis and dyselectrolemia as a consequence of recurrent stone formation and silent damage to the contralateral kidney. Another Respectfully, patient died after 18 years of followup of end stage renal disease. Of Konradin Metze, Erni M. Cia and Miriam Trevisan the remaining 2 patients with significant dilatation 1 has undergone Department of Pathology nephrostomy drainage. State University of Campinas Our experience suggests that slow gradual dilatation and tortuBR 13081-970 Campinas-SP, Brazil ousity of the ileal ureter occur after 10 to 12 years of followup. We could not identify obstruction as a cause. It is possible that gradually 1. Cia, E. M., Trevisan, M. and Metze, K.: AgNOR technique: a the effects of reflux override the dampening effects of the ileal perihelpful tool for the differential diagnosis in urinary cytology. stalsis. In our experience as long as the contralateral kidney is Cytopathology, 10: 30, 1999 1524

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LETTERS TO THE EDITOR 2. Irazusta, S. P., Vassallo, J., Magna, L. A. et al: The value of AgNOR and PCNA staining in endoscopic biopsies of gastric mucosa. Pathol Res Pract, 194: 33, 1998

Reply by Authors. We thought that we had mentioned in our article that the correct diagnostic ratio was useful for diagnosis of bladder tumors. Previously, several studies have also described the counting methods of AgNORs, for example typing according to number, size and distribution of AgNOR dots1 and nuclear ratio containing more than 4 AgNOR dots.2 Since AgNOR staining is a simple method, we consider simple counting methods more acceptable. In contrast, the AgNOR method could be influenced by the procedure of staining, that is fixation, duration of staining, thickness of the section and so forth. Therefore, to evaluate the reproducibility and standardization of complicated counting methods for AgNORs a prospective scale collaboration study will be needed. 1. Pich, A., Chiusa, L. and Margaria, E.: Role of the argyrophilic nucleolar organizer regions in tumor detection and prognosis. Cancer Detect Prev, 19: 282, 1995 2. Shiina, H., Urakami, S., Shirakawa, H. et al: Evaluation of the argyrophilic nucleolar organizer region, nuclear DNA content and mean nuclear area in transitional cell carcinoma of bladder using a quantitative image analyzer. Eur Urol, 29: 99, 1996

RE: DOES TUBULARIZED INCISED PLATE HYPOSPADIAS REPAIR CREATE NEOURETHRAL STRICTURES? W. Snodgrass J Urol, 162: 1159 –1161, 1999 To the Editor: The author addressed an important question about the possibility of neourethral stenosis following tubularized incised urethral plate urethroplasty. In that technique a raw area of the incised plate forms the roof and sometimes the side walls of the neourethra, particularly when the urethral plate is flat and a deeper incision is made.1, 2 The urethral plate is actually incised and transposed ventrally to form the floor of the neourethra rather than tubularized. Although epithelial creeping is necessary to cover the raw area and, thus, to create a neourethra with adequate diameter, it is unfair to compare the cut wound of an untouched, healthy and well vascularized urethral plate to that of fibrous scar in cases of urethrotomy for urethral stricture. To settle the debate concerning whether the tubularized incised plate technique can cause neourethral stenosis we have to return to the basic scientific facts of the urethral wound healing that may obviate any confusion or skepticism. As described by Jordan et al the clean cut wound of the healthy urethra has a natural tendency to contract, which is not to be confused with scar contraction, to approximate both epithelial edges, and healing can occur by primary intent, resulting in stenosis.3 When epithelial apposition is prevented by separating both sides of the wound away from each other, healing will occur by secondary intent and epithelium progresses slowly from the edges of the wound to cover the raw area. Thus, epithelialization of the wound defect should progress completely before wound contraction causes narrowing of the urethra. From my experience4 and that of Decter and Franzoni5 stenosis of the neourethra following tubularized incised urethral plate urethroplasty has occurred. We noticed that healing by primary intent started from the deepest point of the incision towards the lumen that narrows gradually. The vertically oriented slit-like meatus obliterated from above downward to near the ventrum of the neourethra. The author does not recommend postoperative dilation or even calibration of the neourethra. However, I addressed regular dilation that disrupted adhesions between 2 surfaces of the raw area and allowed epithelial creeping until covering of the raw area was completed and adequate urethral diameter (10Fr) had been attained.4 Thus, after

removal of the stent, what will prevent the adhesion of both surfaces of the midline incision of the urethral plate to heal with primary intent if the neourethra is not dilated or calibrated? Respectfully, Adel Elbakry Department of Urology Suez Canal University Mansoura 35511–76 Egypt 1. Snodgrass, W., Koyle, M., Manzoni, G. et al: Tubularized incised plate hypospadias repair: results of a multicenter experience. J Urol, 156: 839, 1996 2. Elbakry, A.: Re: Tubularized incised plate repair for proximal hypospadias. J Urol, 161: 1286, 1999 3. Jordan, G. H., Schlossberg, S. M. and Devine, C. J.: Surgery of the penis and urethra. In: Campbell’s Urology, 7th ed., Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. et al. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 107, pp. 3316 –3378, 1998 4. Elbakry, A.: Tubularized-incised urethral plate urethroplasty: is regular dilatation necessary for success? BJU Int, 84: 683, 1999 5. Decter, R. M. and Franzoni, D. F.: Distal hypospadias repair by the modified Thiersch-Duplay technique with or without hinging the urethral plate: a near ideal way to correct hypospadias. J Urol, part 2, 162: 1156, 1999

Reply by Author. This study indicated that the relaxing incision of the tubularized incised plate repair heals without neourethral stricture even when applied to penoscrotal hypospadias. Furthermore, as others have gained experience with the technique there has not been a stricture of the neourethra reported to my knowledge. In contrast, meatal stenosis has occurred as noted by Elbakry in his series (reference 4 in letter). However, I suspect that most cases of meatal stenosis develop from technical errors rather than from normal healing processes. Probably the most common of these errors is failure to incise the plate deeply enough to achieve an adequate neourethral diameter and/or sewing the plate too far distally during the process of tubularization. There is no direct evidence to support or refute the hypothesis of wound healing Elbakry cites to promote routine postoperative meatal dilation. However, indirect clinical observations suggest that his concerns may be unfounded. Successful outcomes of the tubularized incised plate repair have been described without use of a stent1 and most surgeons, including me, do not perform dilation in asymptomatic patients postoperatively. Most importantly, the cumulative experience of 328 cases from several reported series indicated only a 1.5% incidence of meatal stenosis, although no others mentioned use of routine dilation.2 1. Steckler, R. E. and Zaontz, M. R.: Stent-free Thiersch-Duplay hypospadias repair with the Snodgrass modification. J Urol, 158: 1178, 1997 2. Snodgrass, W.: Tubularized incised plate hypospadias repair: indications, technique, and complications. Urology, 54: 6, 1999

RE: IMMEDIATE AND POSTOPERATIVE COMPLICATIONS OF TRANSURETHRAL PROSTATECTOMY IN THE 1990s P. G. Borboroglu, C. J. Kane, J. F. Ward, J. L. Roberts and J. P. Sands J Urol, 162: 1307–1310, 1999 To the Editor. The authors compared 43 data points. Their less than 1% incidence rate of transurethral resection syndrome is outstanding in a series of predominately resident in training cases. In their description of clinical signs and symptoms using 1.5% glycine (isotonic) irrigating media absorption there was no mention of