RE: PRESERVATION OF THE THIN DISTAL URETHRA IN HYPOSPADIAS REPAIR

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LETTERS TO THE EDITOR 3. Erturk, E., Burzon, D. T. and Waldman, D.: Treatment of transplant ureteral stenosis with endoureterotomy. J Urol, 161: 412, 1999 4. Lin, D. W., Bush, W. H. and Mayo, M. E.: Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol, 162: 696, 1999 5. Delvecchio, F. C., Kuo, R. L., Iselin, C. E. et al: Combined antegrade and retrograde endoscopic approach for the management of urinary diversion-associated pathology. J Endourol, 14: 251, 2000 6. Aslan, P. and Preminger, G. M.: Retrograde balloon cautery incision of ureteropelvic junction obstruction. Urol Clin North Am, 25: 295, 1998 7. Sampaio, F. J.: Vascular anatomy at the ureteropelvic junction. Urol Clin North Am, 25: 251, 1998 8. Van Cangh, P. J. and Nesa, S.: Endopyelotomy. Prognostic factors and patient selection. Urol Clin North Am, 25: 281, 1998 9. Nakada, S. Y.: Acucise endopyelotomy. Urology, 55: 277, 2000

Reply by Authors. We have stated at many meetings, in the original article and in a previous editorial reply1 that the purpose of our report was not to condemn a successful procedure. Rather, our goal was to make surgeons aware of the potential complications, some occurring up to 17 days postoperatively, of a procedure that has been popularized as minimally invasive and highly efficacious. Fulmer et al address the technical evolution of the balloon electrocautery device and the improved safety features of the newest available model. Unfortunately, 2 of the vascular complications that we reported, namely the ovarian vein and arterial injuries, occurred while using the latest commercially available model. Also, all complications occurred while directing incisions in the straight lateral plane as suggested by Sampaio (reference 7 in letter) and currently practiced by most endourologists. It should also be noted that when these data were presented at international conferences, including the annual meeting of the American Urological Association in Dallas and the World Congress on Endourology and Shock Wave Lithotripsy in Greece, and after publication we were approached by numerous physicians who encountered similar complications but never reported them. We believe that serious complications may occur more commonly than reported. Our article makes no mention of efficacy or success rates but endopyelotomy success rates using the device should approach 75% to 90% as reported by numerous authors. The procedure that resulted in open surgery and subsequent renal loss was the unpredictable result of extremely aberrant anatomy and right ovarian vein laceration. The purpose of our study was to inform the readership of the results of experienced surgeons in a major referral center. Our techniques and methods were identical to those reported by Fulmer et al and others in the endourology community. We agree that balloon cautery endopyelotomy is a safe and effective procedure that should be offered to adults with primary or secondary ureteropelvic junction obstruction. Surgeons who choose to use the device should be aware of and know how to manage potential complications. 1. Beaghler, M.: Re: Complications of retrograde balloon cautery endopyelotomy. J Urol, 164: 128, 2000

in part explains the need for hospitalization due to pyelonephritis and the relative increase in postoperative serum creatinine in some patients. The loss of 25 to 33 cm. of the right colon and 10 to 15 cm. of distal ileum for the efferent limb in addition to the original conduit length substantially increases the risk for changes in bowel habits, which the authors observed were most obvious in neuropathic and previously irradiated cases. The indication for conversion in this study was preference in only 11 of 23 patients (47.8%), while indications for undiversion in elderly patients and those who had undergone radical cystectomy for bladder cancer may be seriously questioned. Considering the potential hazards of repeat major intra-abdominal surgery, the possible need for revision surgery and late complications, the indications for undiversion need to be redefined. Although urinary diversion and sexual dysfunction were the most common quality of life problems in such patients, the type of urinary diversion did not seem to be associated with a differential quality of life.1 We reported our experience with continent undiversion of the conduit diversion to a modified ureterosigmoidostomy in 5 male patients 14 to 21 years old (mean 17.8) born with bladder exstrophy.2 The indications for undiversion were exclusively patient preference and high motivation to be free of the skin stoma, which they had had for an average of 9.4 years. All patients declined continent catheterizable skin stoma. The original technique of the valved S shaped rectosigmoid pouch was described in 1993,3 and we introduced some modifications to incorporate the original conduit in the construction with the ureters reimplanted with a nonrefluxing technique. The functional and dynamic results in these patients were excellent at a mean followup of 19.8 months. Only 10 cm. of ileum were used in patients with previous colonic conduit, and no ileum was used in those with previous ileal conduit. Our experience confirms that continent undiversion contributes significantly to the maintenance of a favorable body image and improvement in the quality of life in these patients. Respectfully, Mostafa K. Mansi Division of Urology and Kidney Transplantation Department of Surgery MBC 1446 King Fahad National Guard Hospital P.O. Box 22490, Riyadh 11426 Saudi Arabia 1. Hart, S., Skinner, E. C., Mayerowitz, B. E. et al: Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, or cutaneous or urethral Kock pouch. J Urol, 162: 77, 1999. 2. Mansi, M.: Continent urinary undiversion to modified ureterosigmoidostomy in bladder extrophy patients. World J Surg, 23: 207, 1999. 3. Sundin, T. and Mansi, M. K.: The valved S-shaped rectosigmoid pouch for continent urinary diversion. J Urol, 150: 838, 1993.

RE: PRESERVATION OF THE THIN DISTAL URETHRA IN HYPOSPADIAS REPAIR S. S. D. Yang, Y. T. Chen, C. H. Hsieh

AND

S. C. Chen

J Urol, 164: 151–153, 2000 RE: SIMPLIFIED TECHNIQUE WITH SHORT AND LONGTERM FOLLOWUP OF CONVERSION OF AN ILEAL CONDUIT TO AN INDIANA POUCH T. E. Ahlering, G. Gholdoian, D. Skarecky, A. C. Weinberg and T. G. Wilson J Urol, 163: 1428 –1431, 2000 To the Editor. The authors report their experience with conversion of the cutaneous conduit urinary diversion to the Indiana pouch continent cutaneous diversion with preservation of the native ureteral anastomoses. Although it was not specifically noted in the article, one can assume that the ureters were originally implanted into the conduit via a refluxing technique. The conduit was incised along its antimesenteric border from the stoma down to approximately 2 cm. from the ureters, and the detubularized conduit was attached to the Indiana pouch. This method is not similar to the Studer neobladder in which a 15 to 20 cm. afferent ileal segment provides some protection against reflux from the neobladder, which is constructed from ileum. The pressure inside the Indiana pouch may be different from ileal neobladder and the risk of reflux may

To the Editor. The authors recommended preservation of the distal thin urethral segment adjacent to the hypospadiac orifice in neourethral reconstruction. The congenital or iatrogenic paper-like thin distal urethral segment in hypospadias is composed of a thin mucosal layer which is devoid of adequate blood supply and, thus, may be unsuitable for neourethra reconstruction as it is susceptible to ischemic changes.1, 2 In cases suitable for onlay urethroplasty the onlay flap should be anastomosed to a well vascularized urethral edge covered by healthy spongiosal tissue because the proximal anastomosis is usually a critical site for healing.3 Also, there may be a relative decrease in blood supply to the proximal and distal edges of the onlay flap (the most distant points from the axial vascular pedicle).4, 5 The direct proportional relationship between the complication rates and proximity of the hypospadiac orifice is a true clinical observation because more sophisticated techniques are used to repair more proximal hypospadias.3 Despite compromised blood supply, this finding does not imply that one must preserve the distal few mm. of an uncovered thin urethral mucosa. The authors report that the length of a thin distal urethral mucosa was 4 to 10 mm. (mean 6.5) in 15 of 18 patients, which may not deserve preservation in onlay

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urethroplasty. In 3 patients the length of the distal thin mucosa was 15 to 20 mm. (table 1 in article) which appeared to be iatrgenic (fig. 1 in the article) and, thus, the spongiosal tissue could be easily repositioned to cover the distal urethral mucosa. On the other hand, when the repair is performed by tubularization of the urethral plate with or without midline incision, meticulous dissection and mobilization of a divergent corpus spongiosum is the optimal choice to cover a thin and nearly avascular distal urethral mucosa.6 Respectfully, Adel Elbakry Department of Urology Suez Canal University P.O. Box 76 Mansoura, Egypt 35511 1. Keating, M. A. and Caldamone, A. A.: Current concepts in the management of hypospadias. In: Clinical Urologic Practice. Edited by B. S. Stein, A. A. Caldamone and J. A. Smith, Jr. New York: Norton, chapt. 51, pp. 1461–1505, 1995 2. Duckett, J. W. and Baskin, L. S.: Hypospadias. In: Adult and Pediatric Urology, 3rd ed., Edited by J. Y. Gillenwater, J. T. Grayhack, S. Howard et al. St. Louis: Mosby, chapt. 55, pp. 2549 –2589, 1996 3. Duckett, J. W.: Hypospadias. AUA Update Series, vol. XII, lesson 17, p. 130, 1993 4. Wacksman, J.: Use of the Hodgson XX (modified Asopa) procedure to correct hypospadias with chordee: surgical technique and results. J Urol, 136: 1264, 1986 5. Walker, R. D. and Graham, B.: Measurement of blood flow in hypospadias flaps with subvisual doses of fluoresein. J Urol, 136: 266, 1986 6. Yerkes, E. B., Adams, M. C., Miller, D. A. et al: Y-to-I wrap: use of the distal spongiosum for hypospadias repair. J Urol, 163: 1536, 2000

Reply by Authors. The thin distal urethra in patients with hyposapadias is a well recognized phenomenon (references 1 and 2 in letter). The thin distal urethra shown in figure 1 of the article was recognized before treatment and, similar to that in figure 2, A, was not made iatrogenically. Before circumcision and degloving of the penile skin, the thin distal urethra and its covering skin, which may be nourished by diffusion from the adjacent tissues, appeared healthy. We agree that the thin distal urethra is relatively ischemic compared to the normal urethra but it is healthy. However, the blood supply to the free skin graft, buccal mucosal graft and possibly the distal edge of the onlay flap are severely compromised, and all grafts could be used for urethroplasty with a reasonable success rate. Thus, it is reasonable to preserve the healthy “in situ free graft,” that is the thin distal urethra, in hypospadias repair. To reduce the possibility of fistula, it is important to cover a de-epithelialized flap or mobilized divergent spongiosal tissue on the thin distal urethra and neourethra. We proved that even a 15 to 20 mm. segment of thin distal urethra could be successfully preserved and incorporated into the neourethra formation. Whether the shorter segments should be preserved depends on surgeon preference. Although a short segment of thin distal urethra may be not critical in hypospadias repair, 6 to 10 mm. is a long segment in younger boys in whom the penis is about 30 mm. long.

RE: CONCENTRATION OF OFLOXACIN IN CANINE PROSTATE TISSUE AND PROSTATE FLUID AFTER INTRAPROSTATIC INJECTION OF BIODEGRADABLE SUSTAINED-RELEASING MICROSPHERES CONTAINING OFLOXACIN J. Y. Bahk, J. S. Hyun, J. Y. Lee, J. Kim, Y. H. Cho, J. H. Lee, J. S. Park AND M. O. Kim J Urol, 163: 1560 –1564, 2000 To the Editor. The unclearly defined prostatic barrier is believed to limit antibiotic infiltration into the prostate.1 Intraprostatic injection of antibiotics in chronic prostatitis as reported by the authors aims to overcome this barrier. Since the early 1980s I have used a different approach to treat chronic prostatitis which also achieves high drug concentrations in the prostatic tissue.2 Taking advantage of venous communications consisting of 2 to 6 sizeable veins, which unidirectionally transmit blood from the hemorrhoidal to the vesicoprostatic plexus,3 drugs can be administered to the pelvic organs, including the

prostate, bladder, cervix and rectum.2, 4 –7 The appropriate therapeutic agent is injected in the anal submucosa above the pectinate line, which is a painless area. Drug concentrations in the pelvic organs when administered by the submucosal anal route reached levels 5 to 10 times higher than those attained orally or parenterally.2, 4 –10 On the other hand, drug concentrations in the serum are significantly lower after anal injection than after oral or parenteral administration. High tissue concentrations of the drug with low serum levels gives a satisfactory therapeutic result with negligible systemic adverse effects.2, 4 –10 To treat chronic prostatitis that has not responded to prolonged treatment with antibiotics, I administer gentamicin by the submucosal anal route, and the results are satisfactory.2 The authors investigated the intraprostatic injection of microspheres containing ofloxacin. However, I have some concerns about this study. Direct injection of material to the prostate, especially when administered in microspheres, may injure prostatic tissue and lead to necrosis. Also, the volume and concentration of the injected antibiotic may irritate prostatic tissue. I believe that a drug reaching the prostate smoothly by the local pelvic circulation may be less traumatic and irritating to the prostatic tissue than that injected intraprostatically. Respectfully, Ahmed Shafik Department of Surgery and Experimental Research Faculty of Medicine Cairo University Cairo, Egypt 1. McGuire, E. J. and Lytton, B.: Bacterial prostatitis: treatment with trimethoprim-sulfamethoxazole. Urology, 7: 499, 1976 2. Shafik, A.: Anal submucosal injection: a new route for drug administration. VI. Chronic prostatitis: a new modality of treatment with report of eleven cases. Urology, 37: 61, 1991 3. Shafik, A.: A concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Dis Colon Rectum, 30: 970, 1987 4. Shafik, A.: Anal submucosal injection: a new route for drug administration. V. Advanced prostatic cancer: results of methotrexate treatment using anal route—preliminary study. Eur Urol, 18: 132, 1990 5. Shafik, A., Haddad, S., Elwan, F. et al: Anal submucosal injection: a new route for drug administration in pelvic malignancies. II. Methotrexate anal injection in the treatment of advanced bladder cancer. Preliminary study. J Urol, 140: 501, 1988 6. Shafik, A.: Anal submucosal injection: a new route for drug administration in pelvic malignancies. IV. Submucosal anal injection in treatment of cancer of uterine cervix—preliminary study. Am J Obstet Gynecol, 161: 69, 1989 7. Shafik, A., El-Metnawy, W. and El-Sibai, O.: Anal submucosal injection: a novel modality for the treatment of advanced rectal cancer. Eur J Surg Oncol, 25: 76, 1999 8. Shafik, A., El-Merzabani, M. M., El-Aaser, A. A. et al: Anal submucosal injection: a new route for drug administration in pelvic malignancies. Part I. Experimental study of misonidazole distribution in serum and tissues, with special reference to urinary bladder. Preliminary report. Invest Radiol, 21: 278, 1986 9. Shafik, A., El-Desouki, G.: Anal submucosal injection: a new route for drug administration in pelvic malignancies. III. Misonidazole distribution in serum, uterus and vagina: an experimental study. Gynecol Obstet Invest, 23: 219, 1990 10. Shafik, A., El-Dawi, M. and El-Metnawi, W.: Anal submucosal injection: methotrexate concentration in rectal tumor tissue and serum after anal compared to parenteral injection. Anticancer Drugs, 5: 650, 1994

Reply by Author. In a preclinical study using dogs it is difficult to evaluate trauma to the prostate after open surgical direct injection of microspheres containing ofloxacin. When we used only 1 ml. microsphere suspension which contained 12 mg. ofloxacin there was no prostatic tissue injury, such as necrosis. In a preliminary study we used up to 5 ml. microsphere solution but did not note necrosis, although only 5 dogs were used. Although we are currently performing other studies, from before this article was written we have studied several antibiotics as control and experimental agents at a preliminary level. Unfortunately, we cannot report the results at this point but we found 2 agents which caused prostatic tissue injury, including necrosis of the prostatic parenchyma as mentioned by Shafik. However, the reproducibility was not high and the degree of necrosis was not constant. We are performing further studies on the effects of these 2 drugs on prostatic tissue injury. That our methods