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Re: Management of Anastomotic Stricture after Artificial Urinary Sphincter Placement in Patients Who Underwent Salvage Prostatectomy
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TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
definitions of success and failure, the most common mark of failure reported was the need for an additional surgical procedure, while a minority of respondents prefer cystoscopy passage. This is a complex issue that will become increasingly important to address. Patients and families are increasingly reluctant to spend their time driving in traffic, parking and waiting to be seen for simple face-to-face reassurance, especially when they are asymptomatic. Unhelpful negative studies and unnecessary procedures increase medical costs dramatically. As urological manpower in this country becomes increasingly scarce, allocation of health care resources must be purposeful and impactful, especially at regional referral centers, where travel costs may be considerable. Risk stratification may be the key to determining cost-effective urethroplasty followup. Just as the followup of stage T1 renal cancer differs from that for stage T3, recurrence risk after a straightforward excision and primary anastomosis urethroplasty done on a short bulbar stricture is less than that following an 8 cm buccal mucosa graft procedure. Should all of these patients be followed on the same schedule indefinitely? Allen F. Morey, MD
Re: Management of Anastomotic Stricture after Artificial Urinary Sphincter Placement in Patients Who Underwent Salvage Prostatectomy S. J. Weissbart, B. Chughtai, D. Elterman and J. S. Sandhu Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York Urology 2013; 82: 476e479.
Abstract available at http://jurology.com/ Editorial Comment: This technique of transurethral incision of bladder neck contracture (TUIBNC) involves using a laser and ureteroscope through an intact artificial urinary sphincter (AUS). I agree fully with the proposed strategy of ensuring bladder neck contracture stability before AUS placement and minimizing any urethral manipulation after AUS, especially in the 3.5 cm cuff era. All of these patients underwent salvage prostatectomy, so they were prone to bladder neck contracture. Interestingly the authors report a 6-week interval from initial bladder neck contracture treatment to AUS placement, and the repeat TUIBNC was done at an average of 57 weeks (range 14 to 85). We work along a similar timeline, waiting 2 months for cystoscopy following aggressive initial TUIBNC, then proceeding 1 month later with AUS, which usually works quite well. When it does not, we use the same technique of 8Fr rigid ureteroscopy with holmium:YAG laser through the deactivated AUS. Remember that none of your patients with AUS has a normal bladder neck, and many are quite functional with a stable 14 Fr bladder outlet. We use a 12Fr Foley catheter during AUS placement to avoid having to deal with subclinical bladder neck scarring, which often is not great, but usually is good enough. Allen F. Morey, MD
Re: The Utility of Abdominal Ultrasound during Percutaneous Suprapubic Catheter Placement S. Johnson, G. Fiscus, G. S. Sudakoff, R. C. O’Connor and M. L. Guralnick Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin Can J Urol 2013; 20: 6840e6843.
Abstract available at http://jurology.com/ Editorial Comment: We love suprapubic tubes and we place a lot of them, especially in patients with stricture presenting with indwelling Foley catheters or with failed recent endoscopic manipulation. I am happy to see this 9-year experience from Milwaukee in which 307 percutaneous suprapubic tubes were placed. We use the same techniqueda trocar with peel away sheath that allows
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
definitions of success and failure, the most common mark of failure reported was the need for an additional surgical procedure, while a minority of respondents prefer cystoscopy passage. This is a complex issue that will become increasingly important to address. Patients and families are increasingly reluctant to spend their time driving in traffic, parking and waiting to be seen for simple face-to-face reassurance, especially when they are asymptomatic. Unhelpful negative studies and unnecessary procedures increase medical costs dramatically. As urological manpower in this country becomes increasingly scarce, allocation of health care resources must be purposeful and impactful, especially at regional referral centers, where travel costs may be considerable. Risk stratification may be the key to determining cost-effective urethroplasty followup. Just as the followup of stage T1 renal cancer differs from that for stage T3, recurrence risk after a straightforward excision and primary anastomosis urethroplasty done on a short bulbar stricture is less than that following an 8 cm buccal mucosa graft procedure. Should all of these patients be followed on the same schedule indefinitely? Allen F. Morey, MD
Re: Management of Anastomotic Stricture after Artificial Urinary Sphincter Placement in Patients Who Underwent Salvage Prostatectomy S. J. Weissbart, B. Chughtai, D. Elterman and J. S. Sandhu Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York Urology 2013; 82: 476e479.
Abstract available at http://jurology.com/ Editorial Comment: This technique of transurethral incision of bladder neck contracture (TUIBNC) involves using a laser and ureteroscope through an intact artificial urinary sphincter (AUS). I agree fully with the proposed strategy of ensuring bladder neck contracture stability before AUS placement and minimizing any urethral manipulation after AUS, especially in the 3.5 cm cuff era. All of these patients underwent salvage prostatectomy, so they were prone to bladder neck contracture. Interestingly the authors report a 6-week interval from initial bladder neck contracture treatment to AUS placement, and the repeat TUIBNC was done at an average of 57 weeks (range 14 to 85). We work along a similar timeline, waiting 2 months for cystoscopy following aggressive initial TUIBNC, then proceeding 1 month later with AUS, which usually works quite well. When it does not, we use the same technique of 8Fr rigid ureteroscopy with holmium:YAG laser through the deactivated AUS. Remember that none of your patients with AUS has a normal bladder neck, and many are quite functional with a stable 14 Fr bladder outlet. We use a 12Fr Foley catheter during AUS placement to avoid having to deal with subclinical bladder neck scarring, which often is not great, but usually is good enough. Allen F. Morey, MD
Re: The Utility of Abdominal Ultrasound during Percutaneous Suprapubic Catheter Placement S. Johnson, G. Fiscus, G. S. Sudakoff, R. C. O’Connor and M. L. Guralnick Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin Can J Urol 2013; 20: 6840e6843.
Abstract available at http://jurology.com/ Editorial Comment: We love suprapubic tubes and we place a lot of them, especially in patients with stricture presenting with indwelling Foley catheters or with failed recent endoscopic manipulation. I am happy to see this 9-year experience from Milwaukee in which 307 percutaneous suprapubic tubes were placed. We use the same techniqueda trocar with peel away sheath that allows