- Email: [email protected]
Re: Ileocecal Valve Reconstruction During Continent Urinary Diversion
0022-5347/95/1531-0161$03.00/0 THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROL~GICAL ASSOCIATION, INC.
Vol. 153, 161-164, January 1995 Printed in U S A
Letters to the Editor RE: SPLENIC RUPTURE DURING OCCLUSION OF THE PORTA HEPATIS IN RESECTION OF TUMORS WITH VENA CAVAL EXTENSION
J. Baniel, R. Bihrle, G. R. Wahle and R. S. Foster J . Urol., 151: 992-994, 1994 To the Editor. We read with interest this article on 2 patients who suffered spontaneous splenic rupture during portal vein occlusion for resection of renal and adrenal tumors with vena caval extension. It is surprising that despite increasing experience with liver transplantation, which always requires portal vein occlusion, and hepatic resection, which sometimes requires portal vein occlusion, this complication is not observed more frequently. However, it is well known that humans, contrary to animals, tolerate portal vein clamping surprisingly well.' We recently observed 2 cases of spontaneous splenic rupture following occlusion of the portal vein: 1 occurred during right hepatectomy for hepatocellular carcinoma and 1 during orthotopic liver transplantation for fulminant hepatic failure. Splenectomy was performed in both patients and histological examination of the spleen revealed no abnormalities. We concur with the authors that supraceliac aortic clamping may prevent this complication. However, prolonged aortic clamping may be associated with ischemic complications. We suggest 2 alternatives: 1) veno-venous bypass, in which portal venous blood is diverted from the portal vein into the axillary vein, as is often performed during liver transplantation, and 2 ) selective control and occlusion of the splenic artery a t the superior edge of the body of the pancreas. These procedures should be necessary only in patients without cirrhosis and portal hypertension, who may not tolerate the increased portal venous pressure induced by occlusion of the portal vein, as is the case with our 2 patients and those reported on in this article. Respectfully, Viken Douzdjian Department of Surgery, E42 University of Terns Medical Branch 301 University Blvd. Galveston, Texas 77555-0542
1. Delva, E., Camus, Y., Paugam, C., Parc, R., Huguet, C. and Lienhart, A.: Hemodynamic effects of portal triad clamping in humans. Anesth. Analg., 66:864, 1987.
RE: EARLY PRESENTATION OF TUBEROUS SCLEROSIS AS BILATERAL RENAL CYSTS
imaging [MRII) recommended by the authors, we advocate direct funduscopy through dilated pupils (retinal phakomas) and echocardiography to search for cardiac rhabdomyoma. Examination of the skin should include a search for forehead fibrous plaques and a shagreen patch, both of which may be present at an early age. Periungual fibromas, on the other hand, are unlikely to be found before the age of 5 years. It also is noteworthy that cranial imaging may be normal in the first 6 months of lie. Although cranial MRI is more sensitive than computerized tomography (CT) in the detection of cerebral tumors, calcified subependymal nodules are more readily detected on CT. In the event that MRI is normal, CT should be done before concluding that an individual does not have tuberous sclerosis. The patient reported on by the authors did not have hepatic cysts but these may be found in autosomal dominant polycystic kidney disease and tuberous sclerosis, and therefore they are not diagnostically discriminating. In addition to a gene locus on chromosome:9 a second locus for tuberous sclerosis is on chromosome 16 on the proximal side of the PKD1 gene.3 This finding has fueled speculation on the relationship between tuberous sclerosis and autosomal dominant polycystic kidney disease but further advances in molecular genetics are required to define the relationship. As the authors state, renal cysts occur in a variety of conditions, most of which can be diagnosed readily because of other associated features. The main area of confusion will arise between the infantile presentation of adult polycystic kidney disease and tuberous sclerosis. We believe that in 80% of the individuals tuberous sclerosis arises as a new mutation and that seizures are expected in 80% of a hospital population. Therefore, the incidence reported by the authors is to be expected. Respectfully, Antonia Clarke, David Webb and John P. Osborne Bath Unit for Research into Paediatrics Royal United Hospital Combe Park, BATH Avon BAl3NG, England
1. Webb, D. W., Super, M., Normand, C. S. and Osborne, J. P.: Tuberous sclerosis and polycystic kidney disease. Brit. Med. J., 306.1258, 1993. 2. Fryer, A. E., Chalmers, A., Connor, J. M., Fraser, I., Povey, S., Yates, A., Yates, J. R. W. and Osborne, J. P.: Evidence that the gene for tuberous sclerosis is on chromosome 9.Lancet, 1: 659, 1987. 3. Kandt, R. S.,Haines, J. L., Smith, M., Northrup, H., Gardner, R. J., Short, M. P., Dumars, K., Roach, E. S., Steingold, S., Wall, S., Blanton, S. H., Flodman, P., Kwiatkowski, D. D., Jewell, A., Weber, J. L., Roses, A. D. and Pericak-Vance,M. A.: Linkage of an important gene locus for tuberous sclerosis to a chromosome 16 marker for polycystic kidney disease. Nature Genetics, 2 37, 1992.
A. Campos, E. T. Figueroa, S. Gunasekaran and E. H. Garin
J. Urol., 149 1077-1079, 1993 To the Editor. The authors draw attention to an important and frequently misdiagnosed presentation of tuberous sclerosis in childRE: ILEOCECAL VALVE RECONSTRUCTION DURING hood, that is bilateral cystic renal disease. They review 11 cases from CONTINENT URINARY DIVERSION the literature and emphasize the difficulty in establishing a diagnoM. Fisch, R. Wammack, F. Spies, S. C. Miiller, A. Mokthur, M. sis of tuberous sclerosis in the absence of classical features of the Ghoneim and R. Hohenfellner disease. We reviewed 36 cases of cystic renal disease in patients with tuberous sclerosis reported in the literature, 14 of whom had preJ. U d . , 161: 861-865, 1994 sented by the age of 1 year.' Cystic renal disease occurs more freTo the Editor. The authors are to be commended for bringing to the quently in male than in female patients (ratio 1.5:1), in contrast to angiomyolipomas in which there is a female preponderance. Al- attention of urological surgeons again the problem of accelerated though cystic renal disease frequently antedates other features of intestinal transit following removal of the ileocecal valve from the tuberous sclerosis, in many of the cases reported features were intestinal tract. The procedure they designed to replace it is interpresent that could have aroused suspicion of tuberous sclerosis dur- esting but failed to prevent multiple daily bowel movements in 2 of ing the renal presentation. We agree with the authors that a greater 3 patients with myelomeningocele. I have contended for many years that the ileocecal segment should appreciation of this presentation and a more vigilant search for tuberous sclerosis may allow for an earlier diagnosis, and obviate the not be used for genitourinary reconstruction in patients with myelonecessity for a renal biopsy. In addition to the investigations (skin meningocele and other forms of neurogenic bladder dysfundion that with ultraviolet light with or without cranial magnetic resonance also involve the rectal sphincter. Them patients d y on formed stools 161
162
LETTERS TO THE EDITOR
to achieve rectal continence with a program of regular bowel evacuation. Any acceleration of intestinal transit is detrimental to rectal control.'-4 After reading this report, I continue to stand by my recommendation to avoid the use of the ileocecal segment in myelomeningocele patients. Respectfully, Ricardo Gonzalez Department of Urologic Surgery Section of Pediatric Urology University of Minnesota Medical School Box 45 Mayo Memorial Building 420 Delaware Street, S.E. Minneapolis, Minnesota 55455 1. Gonzalez, R., Sidi, A. A. and Zhang, G.: Urinary undiversion: indications, techniques and results in 50 cases. J. Urol., 136: 13,1986. 2. Gonzalez, R. and Cabral, B. H. P.: Rectal continence &r enterocystoplasty. Dial. Ped. Urol., 10: 4,December 1987. 3. Gonzalez, R. and Sidi, A. A: The use of bowel in the reconstruction of the urinary tract in children. In: Modem Technics in Surgery. Edited by R. Ehrlieh. Mount Kisko, New York: Futura Publishing Co., pp. 42.1-42.21, 1988. 4. Gonzalez, R.: Bladder augmentation with sigmoid or descending colon. In: Reconstructive Urology. Edited by G. Webster, R. Kirby, L. King and B. Goldwasser. Oxford Blackwell Scientific, vol. 1, chapt. 30,p. 433, 1993.
Reply by Authors. Only patients 4, 9 and 11 of the 12 patients mentioned in our article had myelomeningocele and, in contrast to the comment of Doctor Gonzalez, stool frequency did not increase in any of these patients. To date, we have reconstructed the ileocecal valve during continent urinary diversion in 10 patients with myelomeningocele. Four patients have identical bowel habits &r urinary diversion and ileocecal reconstruction, and stool frequency has even normalized in 4 suffering from diarrhea preoperatively. Only 2 of these 10 patients have irregular defecations: 1 underwent diversion only 7 weeks ago and 1 has constipation and diarrhea, although preoperatively he had diarrhea 3 to 4 times a day! The implementation of alternative forms of urinary diversion as suggested by Gonzalez whereby the reservoir is constructed from ileum does not decrease the risk of diarrhea in myelomeningocele patients, since a substantial amount of small bowel must be resected during these procedures. We are currently undertaking experiments to determine intestinal transit time preoperatively, and after continent urinary diversion and ileocecal valve reconstruction. Nonetheless, with experience with 40 myelomeningocele patients in our entire series of more than 400 Mainz pouch I operations, ileocecal valve reconstruction produces the most beneficial clinical results in myelomeningocele patients.
RE: VESICAL LITHIASIS: OPEN SURGERY VERSUS CYSTOLITHOTRIPSY VERSUS EXTRACORPOREAL SHOCK WAVE THERAPY V. Bhatia and C. S. Biyani J . Urol., 151:660-662, 1994
To the Editor. I do not believe that extracorporeal shock wave lithotripsy (ESWL*) has any role in the treatment of bladder stones. There is no substitute for lithotripsy done under direct vision. ESWL will not completely fragment stones in all cases and, therefore, cystoscopy may be required. With the advent of laser lithotripsy and more refined electrohydraulic lithotripsy techniques, I do not believe there is any excuse for performing ESWL on a patient with bladder stones. Perhaps in Kuwait City this is an option that patients will accept. However, in Columbus, Ohio I doubt if most of our patients
* Dornier Medical Systems, Inc., Marietta, Georgia.
would accept 45 minutes of ESWL therapy to the genital region. I know I would not. Respectfully, William J. Somers Division of Urology Ohio State University Medical Center 456 West 10th Avenue Columbus, Ohio 43210-1228
Reply by Authors. We certainly have electrohydraulic lithotripsy, ultrasound and laser lithotripsy in our department and a comparative study with ESWL for vesical stones is under consideration for publication. We do not consider ESWL to be a panacea for vesical stones but continue to be convinced about its simplicity, safety and low complication rate over transurethral endoscopic techniques.' We also perform strictly outpatient ESWL for bladder stones in select patients insisting on noninvasive therapy.2 We believe t h a t the salient advantages of ESWL are avoidance of anesthesia, shortest catheterization time and minimal hospital stay. We, of course, do not recommend it as a n absolute substitute for direct vision lithotripsy but do include it in our therapeutic options for vesical stones.
1. Bhatia, V. and Biyani, C. S.: A comparative analysis of cystolithotripsy and ESWL for bladder stones. Int. Urol. Nephrol., in press. 2. Bhatia, V. and Biyani, C. S.: Outpatient ESWL therapy for vesical lithiasis. Jap. J. Endourol. ESWL, in press.
RE: PERIURETHRAL INJECTION OF AUTOLOGOUS FAT FOR THE TREATMENT OF SPHINCTERIC INCONTINENCE R. P. Santarosa and J. G. Blaiuas
J. Urol., 151: 607-611, 1994 To the Editor. The authors presented their early experience with periurethral injection of autologous fat in treating sphincteric incontinence. Their conclusions, however, seem to be excessively optimistic. The injection of autologous fat is not a new idea. The method was actually tested 100 years ago' and subsequently abandoned because of discouraging long-term results? As stated by the authors, the ultimate fate of the injected fat is the subject of controversy. In our opinion, the answer depends on the nature of aspirated material, which is approximately 25% blood3 and the remainder consists of fragments with destroyed fat cells at the periphery. It seems difficult to suppose that fat cells removed by strong aspiration can tolerate the trauma of harvesting and transplantation without undergoing cellular lysis. Moreover, the injection of broken cell pieces and fat causes mainly a foreign body reaction that, at best, could result in total resorption of the injected material in the long term.4 The implant of fat tissue has a rationale if unimpaired adipose lobules are used and all artifacts due to fragmentation during harvest are avoided. McFarland postulated that reimplanted fat derives nutrients osmotically from surrounding extracellular fluid before vascularization by host blood vessel^.^ Nevertheless, a good perfusion supposes the existence of favorable volume-to-surface ratio as in small adipose tissue fragment reimplantation. In the proposed technique fat fragments are pressed together so that the theoretical advantages of a favorable volume-to-surface ratio is lost. It is also noteworthy that the fragments have no anatomical relationship, so that revascularization of 1 fragment does not affect adjacent fragments, since there is no vascular connection between them. This results in extensive necrosis in the adipose tissue graft. The report released in 1987 by the Ad Hoc Committee on New Procedures of the American Society of Plastic and Reconstructive Surgeons concluded that only 30% of injected fat can be expected to survive for 1 year.6 A preliminary report by Weber indicated only a 10% survival rate of fat graft^.^ Presently, it appears that little, if any, of the injected autologous fat survives a t the new site for 1year.' The long-term persistence of oil cysts makes it obvious why failure of the graft may not be fully apparent until months after implantation. This finding also helps to explain the good short-term and discouraging long-term results of autologous fat injections reported in the literature. The report by the authors of a n 84% overall success rate a t 1 year seems even more impressive because the results are different from
Vol. 153, 161-164, January 1995 Printed in U S A
Letters to the Editor RE: SPLENIC RUPTURE DURING OCCLUSION OF THE PORTA HEPATIS IN RESECTION OF TUMORS WITH VENA CAVAL EXTENSION
J. Baniel, R. Bihrle, G. R. Wahle and R. S. Foster J . Urol., 151: 992-994, 1994 To the Editor. We read with interest this article on 2 patients who suffered spontaneous splenic rupture during portal vein occlusion for resection of renal and adrenal tumors with vena caval extension. It is surprising that despite increasing experience with liver transplantation, which always requires portal vein occlusion, and hepatic resection, which sometimes requires portal vein occlusion, this complication is not observed more frequently. However, it is well known that humans, contrary to animals, tolerate portal vein clamping surprisingly well.' We recently observed 2 cases of spontaneous splenic rupture following occlusion of the portal vein: 1 occurred during right hepatectomy for hepatocellular carcinoma and 1 during orthotopic liver transplantation for fulminant hepatic failure. Splenectomy was performed in both patients and histological examination of the spleen revealed no abnormalities. We concur with the authors that supraceliac aortic clamping may prevent this complication. However, prolonged aortic clamping may be associated with ischemic complications. We suggest 2 alternatives: 1) veno-venous bypass, in which portal venous blood is diverted from the portal vein into the axillary vein, as is often performed during liver transplantation, and 2 ) selective control and occlusion of the splenic artery a t the superior edge of the body of the pancreas. These procedures should be necessary only in patients without cirrhosis and portal hypertension, who may not tolerate the increased portal venous pressure induced by occlusion of the portal vein, as is the case with our 2 patients and those reported on in this article. Respectfully, Viken Douzdjian Department of Surgery, E42 University of Terns Medical Branch 301 University Blvd. Galveston, Texas 77555-0542
1. Delva, E., Camus, Y., Paugam, C., Parc, R., Huguet, C. and Lienhart, A.: Hemodynamic effects of portal triad clamping in humans. Anesth. Analg., 66:864, 1987.
RE: EARLY PRESENTATION OF TUBEROUS SCLEROSIS AS BILATERAL RENAL CYSTS
imaging [MRII) recommended by the authors, we advocate direct funduscopy through dilated pupils (retinal phakomas) and echocardiography to search for cardiac rhabdomyoma. Examination of the skin should include a search for forehead fibrous plaques and a shagreen patch, both of which may be present at an early age. Periungual fibromas, on the other hand, are unlikely to be found before the age of 5 years. It also is noteworthy that cranial imaging may be normal in the first 6 months of lie. Although cranial MRI is more sensitive than computerized tomography (CT) in the detection of cerebral tumors, calcified subependymal nodules are more readily detected on CT. In the event that MRI is normal, CT should be done before concluding that an individual does not have tuberous sclerosis. The patient reported on by the authors did not have hepatic cysts but these may be found in autosomal dominant polycystic kidney disease and tuberous sclerosis, and therefore they are not diagnostically discriminating. In addition to a gene locus on chromosome:9 a second locus for tuberous sclerosis is on chromosome 16 on the proximal side of the PKD1 gene.3 This finding has fueled speculation on the relationship between tuberous sclerosis and autosomal dominant polycystic kidney disease but further advances in molecular genetics are required to define the relationship. As the authors state, renal cysts occur in a variety of conditions, most of which can be diagnosed readily because of other associated features. The main area of confusion will arise between the infantile presentation of adult polycystic kidney disease and tuberous sclerosis. We believe that in 80% of the individuals tuberous sclerosis arises as a new mutation and that seizures are expected in 80% of a hospital population. Therefore, the incidence reported by the authors is to be expected. Respectfully, Antonia Clarke, David Webb and John P. Osborne Bath Unit for Research into Paediatrics Royal United Hospital Combe Park, BATH Avon BAl3NG, England
1. Webb, D. W., Super, M., Normand, C. S. and Osborne, J. P.: Tuberous sclerosis and polycystic kidney disease. Brit. Med. J., 306.1258, 1993. 2. Fryer, A. E., Chalmers, A., Connor, J. M., Fraser, I., Povey, S., Yates, A., Yates, J. R. W. and Osborne, J. P.: Evidence that the gene for tuberous sclerosis is on chromosome 9.Lancet, 1: 659, 1987. 3. Kandt, R. S.,Haines, J. L., Smith, M., Northrup, H., Gardner, R. J., Short, M. P., Dumars, K., Roach, E. S., Steingold, S., Wall, S., Blanton, S. H., Flodman, P., Kwiatkowski, D. D., Jewell, A., Weber, J. L., Roses, A. D. and Pericak-Vance,M. A.: Linkage of an important gene locus for tuberous sclerosis to a chromosome 16 marker for polycystic kidney disease. Nature Genetics, 2 37, 1992.
A. Campos, E. T. Figueroa, S. Gunasekaran and E. H. Garin
J. Urol., 149 1077-1079, 1993 To the Editor. The authors draw attention to an important and frequently misdiagnosed presentation of tuberous sclerosis in childRE: ILEOCECAL VALVE RECONSTRUCTION DURING hood, that is bilateral cystic renal disease. They review 11 cases from CONTINENT URINARY DIVERSION the literature and emphasize the difficulty in establishing a diagnoM. Fisch, R. Wammack, F. Spies, S. C. Miiller, A. Mokthur, M. sis of tuberous sclerosis in the absence of classical features of the Ghoneim and R. Hohenfellner disease. We reviewed 36 cases of cystic renal disease in patients with tuberous sclerosis reported in the literature, 14 of whom had preJ. U d . , 161: 861-865, 1994 sented by the age of 1 year.' Cystic renal disease occurs more freTo the Editor. The authors are to be commended for bringing to the quently in male than in female patients (ratio 1.5:1), in contrast to angiomyolipomas in which there is a female preponderance. Al- attention of urological surgeons again the problem of accelerated though cystic renal disease frequently antedates other features of intestinal transit following removal of the ileocecal valve from the tuberous sclerosis, in many of the cases reported features were intestinal tract. The procedure they designed to replace it is interpresent that could have aroused suspicion of tuberous sclerosis dur- esting but failed to prevent multiple daily bowel movements in 2 of ing the renal presentation. We agree with the authors that a greater 3 patients with myelomeningocele. I have contended for many years that the ileocecal segment should appreciation of this presentation and a more vigilant search for tuberous sclerosis may allow for an earlier diagnosis, and obviate the not be used for genitourinary reconstruction in patients with myelonecessity for a renal biopsy. In addition to the investigations (skin meningocele and other forms of neurogenic bladder dysfundion that with ultraviolet light with or without cranial magnetic resonance also involve the rectal sphincter. Them patients d y on formed stools 161
162
LETTERS TO THE EDITOR
to achieve rectal continence with a program of regular bowel evacuation. Any acceleration of intestinal transit is detrimental to rectal control.'-4 After reading this report, I continue to stand by my recommendation to avoid the use of the ileocecal segment in myelomeningocele patients. Respectfully, Ricardo Gonzalez Department of Urologic Surgery Section of Pediatric Urology University of Minnesota Medical School Box 45 Mayo Memorial Building 420 Delaware Street, S.E. Minneapolis, Minnesota 55455 1. Gonzalez, R., Sidi, A. A. and Zhang, G.: Urinary undiversion: indications, techniques and results in 50 cases. J. Urol., 136: 13,1986. 2. Gonzalez, R. and Cabral, B. H. P.: Rectal continence &r enterocystoplasty. Dial. Ped. Urol., 10: 4,December 1987. 3. Gonzalez, R. and Sidi, A. A: The use of bowel in the reconstruction of the urinary tract in children. In: Modem Technics in Surgery. Edited by R. Ehrlieh. Mount Kisko, New York: Futura Publishing Co., pp. 42.1-42.21, 1988. 4. Gonzalez, R.: Bladder augmentation with sigmoid or descending colon. In: Reconstructive Urology. Edited by G. Webster, R. Kirby, L. King and B. Goldwasser. Oxford Blackwell Scientific, vol. 1, chapt. 30,p. 433, 1993.
Reply by Authors. Only patients 4, 9 and 11 of the 12 patients mentioned in our article had myelomeningocele and, in contrast to the comment of Doctor Gonzalez, stool frequency did not increase in any of these patients. To date, we have reconstructed the ileocecal valve during continent urinary diversion in 10 patients with myelomeningocele. Four patients have identical bowel habits &r urinary diversion and ileocecal reconstruction, and stool frequency has even normalized in 4 suffering from diarrhea preoperatively. Only 2 of these 10 patients have irregular defecations: 1 underwent diversion only 7 weeks ago and 1 has constipation and diarrhea, although preoperatively he had diarrhea 3 to 4 times a day! The implementation of alternative forms of urinary diversion as suggested by Gonzalez whereby the reservoir is constructed from ileum does not decrease the risk of diarrhea in myelomeningocele patients, since a substantial amount of small bowel must be resected during these procedures. We are currently undertaking experiments to determine intestinal transit time preoperatively, and after continent urinary diversion and ileocecal valve reconstruction. Nonetheless, with experience with 40 myelomeningocele patients in our entire series of more than 400 Mainz pouch I operations, ileocecal valve reconstruction produces the most beneficial clinical results in myelomeningocele patients.
RE: VESICAL LITHIASIS: OPEN SURGERY VERSUS CYSTOLITHOTRIPSY VERSUS EXTRACORPOREAL SHOCK WAVE THERAPY V. Bhatia and C. S. Biyani J . Urol., 151:660-662, 1994
To the Editor. I do not believe that extracorporeal shock wave lithotripsy (ESWL*) has any role in the treatment of bladder stones. There is no substitute for lithotripsy done under direct vision. ESWL will not completely fragment stones in all cases and, therefore, cystoscopy may be required. With the advent of laser lithotripsy and more refined electrohydraulic lithotripsy techniques, I do not believe there is any excuse for performing ESWL on a patient with bladder stones. Perhaps in Kuwait City this is an option that patients will accept. However, in Columbus, Ohio I doubt if most of our patients
* Dornier Medical Systems, Inc., Marietta, Georgia.
would accept 45 minutes of ESWL therapy to the genital region. I know I would not. Respectfully, William J. Somers Division of Urology Ohio State University Medical Center 456 West 10th Avenue Columbus, Ohio 43210-1228
Reply by Authors. We certainly have electrohydraulic lithotripsy, ultrasound and laser lithotripsy in our department and a comparative study with ESWL for vesical stones is under consideration for publication. We do not consider ESWL to be a panacea for vesical stones but continue to be convinced about its simplicity, safety and low complication rate over transurethral endoscopic techniques.' We also perform strictly outpatient ESWL for bladder stones in select patients insisting on noninvasive therapy.2 We believe t h a t the salient advantages of ESWL are avoidance of anesthesia, shortest catheterization time and minimal hospital stay. We, of course, do not recommend it as a n absolute substitute for direct vision lithotripsy but do include it in our therapeutic options for vesical stones.
1. Bhatia, V. and Biyani, C. S.: A comparative analysis of cystolithotripsy and ESWL for bladder stones. Int. Urol. Nephrol., in press. 2. Bhatia, V. and Biyani, C. S.: Outpatient ESWL therapy for vesical lithiasis. Jap. J. Endourol. ESWL, in press.
RE: PERIURETHRAL INJECTION OF AUTOLOGOUS FAT FOR THE TREATMENT OF SPHINCTERIC INCONTINENCE R. P. Santarosa and J. G. Blaiuas
J. Urol., 151: 607-611, 1994 To the Editor. The authors presented their early experience with periurethral injection of autologous fat in treating sphincteric incontinence. Their conclusions, however, seem to be excessively optimistic. The injection of autologous fat is not a new idea. The method was actually tested 100 years ago' and subsequently abandoned because of discouraging long-term results? As stated by the authors, the ultimate fate of the injected fat is the subject of controversy. In our opinion, the answer depends on the nature of aspirated material, which is approximately 25% blood3 and the remainder consists of fragments with destroyed fat cells at the periphery. It seems difficult to suppose that fat cells removed by strong aspiration can tolerate the trauma of harvesting and transplantation without undergoing cellular lysis. Moreover, the injection of broken cell pieces and fat causes mainly a foreign body reaction that, at best, could result in total resorption of the injected material in the long term.4 The implant of fat tissue has a rationale if unimpaired adipose lobules are used and all artifacts due to fragmentation during harvest are avoided. McFarland postulated that reimplanted fat derives nutrients osmotically from surrounding extracellular fluid before vascularization by host blood vessel^.^ Nevertheless, a good perfusion supposes the existence of favorable volume-to-surface ratio as in small adipose tissue fragment reimplantation. In the proposed technique fat fragments are pressed together so that the theoretical advantages of a favorable volume-to-surface ratio is lost. It is also noteworthy that the fragments have no anatomical relationship, so that revascularization of 1 fragment does not affect adjacent fragments, since there is no vascular connection between them. This results in extensive necrosis in the adipose tissue graft. The report released in 1987 by the Ad Hoc Committee on New Procedures of the American Society of Plastic and Reconstructive Surgeons concluded that only 30% of injected fat can be expected to survive for 1 year.6 A preliminary report by Weber indicated only a 10% survival rate of fat graft^.^ Presently, it appears that little, if any, of the injected autologous fat survives a t the new site for 1year.' The long-term persistence of oil cysts makes it obvious why failure of the graft may not be fully apparent until months after implantation. This finding also helps to explain the good short-term and discouraging long-term results of autologous fat injections reported in the literature. The report by the authors of a n 84% overall success rate a t 1 year seems even more impressive because the results are different from