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Re: Glanuloplasty With Urethral Flap After Partial Penectomy
760
LETTERS TO THE EDITOR/ERRATA
groups 1 and 2, respectively. Given that only 1 patient (imaged at day 5) in group 1 had progression, multivariate analysis would be inappropriate. Additionally the American Association for the Surgery of Trauma grading system as originally described is an anatomically based score with no reference made to the clinical status of the patient.2 While classification of grades 1 to 4 and pedicle avulsion injuries is straightforward, we agree that the term “shattered kidney” is open to interpretation, although the most parsimonious definition is that suggested by the original classification of 2 separate grade 4 lacerations in the same renal unit. Therefore, we accept that other reviewers may classify injuries differently, as there will always be borderline cases. However, by suggesting that our grading is erroneous based on our progression rates, Yeung and Brandes seem to miss the point that the patients in this study were highly selected. The intention was to evaluate the usefulness of delayed imaging in patients successfully treated conservatively in the first 48 hours, and as clearly stated in the methods, all patients undergoing acute intervention were excluded from the main analysis. We recently looked at our overall experience with blunt renal trauma management, and found that the overall progression and intervention rates were 3.8%, 9.8% and 51.8% for grades 3, 4 and 5 injuries, respectively, which at least for grade 3 and 5 injuries are essentially identical to those from the National Trauma Data Bank® audit,4,5 and for grade 4 injuries certainly fall within the range suggested by Yeung and Brandes. The higher progression rates for grade 3 injuries in this study reflect the reality that grade 5 injuries requiring intervention usually manifest by 48 hours, whereas complications of lower grade injuries take longer to become apparent. We have always believed that the introduction of a clinical qualifier to the “shattered kidney” descriptor adds an unnecessary level of ambiguity, as a kidney is only ever “irretrievable” once it is in the specimen container, and clinicians differ significantly in their interpretation of “life threatening.” Certainly when we look at the 11 grade 5 injuries included in this study (having already excluded those requiring acute intervention), 8 of 11 patients had a systolic blood pressure of 80 mm Hg or less and/or a pulse rate of greater than 110 bpm at hospitalization, 9 required emergency blood transfusion (median 3 U packed cells, range 0 to 31) and 6 underwent emergency laparotomy, indicating that a cogent argument could be made to intervene on the basis of “life threatening” injury in most if not all patients, if this indeed was our motivation. However, the reality is that the patients responded appropriately to resuscitation and settled with conservative treatment, and ultimately avoided an intervention that would likely have ended in renal unit loss. Indeed, in our more recent analysis the presence of a grade 5 injury (based on radiological or surgical grading) and continuing blood loss (as indicated by the need for a massive transfusion protocol) significantly predicted the need for intervention, indicating that an anatomically based injury grading system and clinical status are independent variables that contribute significantly to the prognostic model.5 1. Altman AL, Haas C, Dinchman KH et al: Selective nonoperative management of blunt grade 5 renal injury. J Urol 2000; 164: 27. 2. Moore EE, Shackford SR, Pachter HL et al: Organ injury scaling: spleen, liver, and kidney. J Trauma 1989; 29: 1664. 3. Lynch TH, Martinez-Pineiro L, Plas E et al: EAU Guidelines on Urethral Trauma. Eur Urol 2005; 47: 1.
4. Wright JL, Nathens AB, Rivara FP et al: Renal and extrarenal predictors of nephrectomy from the National Trauma Data Bank. J Urol 2006; 175: 970. 5. McGuire J, Bultitude MF, Davis P et al: Predictors of outcome for blunt high grade renal injury treated with conservative intent. J Urol 2011; 185: 187.
Re: Glanuloplasty With Urethral Flap After Partial Penectomy J. J. Belinky, G. M. Cheliz, C. A. Graziano and H. M. Rey J Urol 2011; 185: 204 –206.
To the Editor: We read this article with great interest, as any new procedure that may improve the functional and cosmetic result after partial penectomy for penile squamous cell carcinoma (SCC) or trauma is welcomed. However, we would like to comment on several issues. This small retrospective series of 10 patients includes individuals with penile cancer and not trauma. To suggest that the full length of the urethra would be intact and available to use following partial penile amputation due to trauma is supposition. Conservative, organ sparing surgery such as
LETTERS TO THE EDITOR/ERRATA
761
glansectomy and reconstruction should always be considered (if possible) in penile SCC to reduce the need for classic partial penectomy— especially in patients as young as in this series (18 years). It is well recognized that penile SCC is often associated with glanular (and retrograde urethral extension of) lichen sclerosis/balanitis xerotica obliterans (BXO). Using this potentially affected skin to create a neoglans may be inadvisable. It is not uncommon for penile SCC to spread proximally in the urethral sponge, and maintenance of as much urethra as possible to attempt this technique might prove to be oncologically unsound in these circumstances. Importing a split-thickness skin graft of nongenital tissue (we usually use skin from the anterior/medial thigh) is easy to perform and has a much lower risk of involvement with BXO. Similar to several other published series, at our center split-thickness skin graft reconstruction following glansectomy or partial penectomy provides excellent functional results and cosmesis.1,2 We are concerned by the high recurrence rate of 10% in the short followup (5 to 17 months, mean 11), although this percentage equates to only 1 patient. This finding was made despite “observing the appropriate surgical margins from the oncologic standpoint.” This margin is not quantified or reported in the methodology, but a 2 cm proximal clearance is mentioned in the case that recurred. The previously accepted application of such a large proximal clearance margin has been proved unnecessary.3 Indeed, more certain clearance is achieved with use of intraoperative frozen section than by relying on clinical guesswork. Our concern is that without further pathological details of the grade, stage and extent of disease in these cases this article may encourage partial penectomy rather than more conservative methods such as glansectomy. Certainly the urethral flap technique could be considered in addition to the standard techniques of penile shaft skin advancement with buttonholing or circumferential closure onto a spatulated urethra. This procedure may, by definition, have less risk of meatal stenosis— but at what cost in terms of ventral curvature and/or urinary and sexual function? In the single reported case of a 20-degree ventral curvature the authors state that it “did not hinder penetration.” A validated questionnaire looking into sexual function preoperatively and postoperatively would have been most instructive. Patients who have undergone wide spatulation of the neomeatus in penile surgery often complain of spraying of the urinary stream and are sometimes concerned about the redness of the exteriorized urethral mucosa. We assume that these complications would be more marked with this technique, although these potential complications were not mentioned. A report on the results of longer followup of more patients would be interesting, although we fail to see that the benefits of this approach are superior to the techniques currently available. Respectfully, Duncan J. Summerton and Timothy R. Terry Department of Urology University Hospitals of Leicester NHS Trust Leicester, United Kingdom 1. Bracka A: Glans resection and plastic repair. BJU Int 2010; 105: 136. 2. Smith Y, Hadway P, Biedrzycki O et al: Reconstructive surgery for invasive squamous carcinoma of the glans penis. Eur Urol 2007; 52: 1179.
3. Minhas S, Kayes O, Hegarty P et al: What surgical resection margins are required to achieve oncological control in men with primary penile cancer? BJU Int 2005; 96: 1040.
Reply by Authors: Surgical margins were revised with frozen sections at operation. However, our tumor recurrence rate was the one reported. Summerton and Terry comment that this technique might be oncologically incorrect when using tissue that might be affected with BXO, which could be the case if during standard partial penectomy this urethra were resected. In this procedure we only use the urethra that would be left in situ when implementing the original (conventional) technique. The observation on the use of split-thickness skin graft as simple is correct. So is this technique, and in our view cosmetic results are more satisfactory than when using skin. Patients have not communicated problems related to the urinary stream or the reddening of the spatulated urethral mucosa. These conditions were transitory in all cases. Finally, results of longer followup and a greater caseload will be provided in the future.
LETTERS TO THE EDITOR/ERRATA
groups 1 and 2, respectively. Given that only 1 patient (imaged at day 5) in group 1 had progression, multivariate analysis would be inappropriate. Additionally the American Association for the Surgery of Trauma grading system as originally described is an anatomically based score with no reference made to the clinical status of the patient.2 While classification of grades 1 to 4 and pedicle avulsion injuries is straightforward, we agree that the term “shattered kidney” is open to interpretation, although the most parsimonious definition is that suggested by the original classification of 2 separate grade 4 lacerations in the same renal unit. Therefore, we accept that other reviewers may classify injuries differently, as there will always be borderline cases. However, by suggesting that our grading is erroneous based on our progression rates, Yeung and Brandes seem to miss the point that the patients in this study were highly selected. The intention was to evaluate the usefulness of delayed imaging in patients successfully treated conservatively in the first 48 hours, and as clearly stated in the methods, all patients undergoing acute intervention were excluded from the main analysis. We recently looked at our overall experience with blunt renal trauma management, and found that the overall progression and intervention rates were 3.8%, 9.8% and 51.8% for grades 3, 4 and 5 injuries, respectively, which at least for grade 3 and 5 injuries are essentially identical to those from the National Trauma Data Bank® audit,4,5 and for grade 4 injuries certainly fall within the range suggested by Yeung and Brandes. The higher progression rates for grade 3 injuries in this study reflect the reality that grade 5 injuries requiring intervention usually manifest by 48 hours, whereas complications of lower grade injuries take longer to become apparent. We have always believed that the introduction of a clinical qualifier to the “shattered kidney” descriptor adds an unnecessary level of ambiguity, as a kidney is only ever “irretrievable” once it is in the specimen container, and clinicians differ significantly in their interpretation of “life threatening.” Certainly when we look at the 11 grade 5 injuries included in this study (having already excluded those requiring acute intervention), 8 of 11 patients had a systolic blood pressure of 80 mm Hg or less and/or a pulse rate of greater than 110 bpm at hospitalization, 9 required emergency blood transfusion (median 3 U packed cells, range 0 to 31) and 6 underwent emergency laparotomy, indicating that a cogent argument could be made to intervene on the basis of “life threatening” injury in most if not all patients, if this indeed was our motivation. However, the reality is that the patients responded appropriately to resuscitation and settled with conservative treatment, and ultimately avoided an intervention that would likely have ended in renal unit loss. Indeed, in our more recent analysis the presence of a grade 5 injury (based on radiological or surgical grading) and continuing blood loss (as indicated by the need for a massive transfusion protocol) significantly predicted the need for intervention, indicating that an anatomically based injury grading system and clinical status are independent variables that contribute significantly to the prognostic model.5 1. Altman AL, Haas C, Dinchman KH et al: Selective nonoperative management of blunt grade 5 renal injury. J Urol 2000; 164: 27. 2. Moore EE, Shackford SR, Pachter HL et al: Organ injury scaling: spleen, liver, and kidney. J Trauma 1989; 29: 1664. 3. Lynch TH, Martinez-Pineiro L, Plas E et al: EAU Guidelines on Urethral Trauma. Eur Urol 2005; 47: 1.
4. Wright JL, Nathens AB, Rivara FP et al: Renal and extrarenal predictors of nephrectomy from the National Trauma Data Bank. J Urol 2006; 175: 970. 5. McGuire J, Bultitude MF, Davis P et al: Predictors of outcome for blunt high grade renal injury treated with conservative intent. J Urol 2011; 185: 187.
Re: Glanuloplasty With Urethral Flap After Partial Penectomy J. J. Belinky, G. M. Cheliz, C. A. Graziano and H. M. Rey J Urol 2011; 185: 204 –206.
To the Editor: We read this article with great interest, as any new procedure that may improve the functional and cosmetic result after partial penectomy for penile squamous cell carcinoma (SCC) or trauma is welcomed. However, we would like to comment on several issues. This small retrospective series of 10 patients includes individuals with penile cancer and not trauma. To suggest that the full length of the urethra would be intact and available to use following partial penile amputation due to trauma is supposition. Conservative, organ sparing surgery such as
LETTERS TO THE EDITOR/ERRATA
761
glansectomy and reconstruction should always be considered (if possible) in penile SCC to reduce the need for classic partial penectomy— especially in patients as young as in this series (18 years). It is well recognized that penile SCC is often associated with glanular (and retrograde urethral extension of) lichen sclerosis/balanitis xerotica obliterans (BXO). Using this potentially affected skin to create a neoglans may be inadvisable. It is not uncommon for penile SCC to spread proximally in the urethral sponge, and maintenance of as much urethra as possible to attempt this technique might prove to be oncologically unsound in these circumstances. Importing a split-thickness skin graft of nongenital tissue (we usually use skin from the anterior/medial thigh) is easy to perform and has a much lower risk of involvement with BXO. Similar to several other published series, at our center split-thickness skin graft reconstruction following glansectomy or partial penectomy provides excellent functional results and cosmesis.1,2 We are concerned by the high recurrence rate of 10% in the short followup (5 to 17 months, mean 11), although this percentage equates to only 1 patient. This finding was made despite “observing the appropriate surgical margins from the oncologic standpoint.” This margin is not quantified or reported in the methodology, but a 2 cm proximal clearance is mentioned in the case that recurred. The previously accepted application of such a large proximal clearance margin has been proved unnecessary.3 Indeed, more certain clearance is achieved with use of intraoperative frozen section than by relying on clinical guesswork. Our concern is that without further pathological details of the grade, stage and extent of disease in these cases this article may encourage partial penectomy rather than more conservative methods such as glansectomy. Certainly the urethral flap technique could be considered in addition to the standard techniques of penile shaft skin advancement with buttonholing or circumferential closure onto a spatulated urethra. This procedure may, by definition, have less risk of meatal stenosis— but at what cost in terms of ventral curvature and/or urinary and sexual function? In the single reported case of a 20-degree ventral curvature the authors state that it “did not hinder penetration.” A validated questionnaire looking into sexual function preoperatively and postoperatively would have been most instructive. Patients who have undergone wide spatulation of the neomeatus in penile surgery often complain of spraying of the urinary stream and are sometimes concerned about the redness of the exteriorized urethral mucosa. We assume that these complications would be more marked with this technique, although these potential complications were not mentioned. A report on the results of longer followup of more patients would be interesting, although we fail to see that the benefits of this approach are superior to the techniques currently available. Respectfully, Duncan J. Summerton and Timothy R. Terry Department of Urology University Hospitals of Leicester NHS Trust Leicester, United Kingdom 1. Bracka A: Glans resection and plastic repair. BJU Int 2010; 105: 136. 2. Smith Y, Hadway P, Biedrzycki O et al: Reconstructive surgery for invasive squamous carcinoma of the glans penis. Eur Urol 2007; 52: 1179.
3. Minhas S, Kayes O, Hegarty P et al: What surgical resection margins are required to achieve oncological control in men with primary penile cancer? BJU Int 2005; 96: 1040.
Reply by Authors: Surgical margins were revised with frozen sections at operation. However, our tumor recurrence rate was the one reported. Summerton and Terry comment that this technique might be oncologically incorrect when using tissue that might be affected with BXO, which could be the case if during standard partial penectomy this urethra were resected. In this procedure we only use the urethra that would be left in situ when implementing the original (conventional) technique. The observation on the use of split-thickness skin graft as simple is correct. So is this technique, and in our view cosmetic results are more satisfactory than when using skin. Patients have not communicated problems related to the urinary stream or the reddening of the spatulated urethral mucosa. These conditions were transitory in all cases. Finally, results of longer followup and a greater caseload will be provided in the future.