- Email: [email protected]
Re: Urethral Stricture is Now an Open Surgical Disease
LETTERS TO THE EDITOR/ERRATA
2535
with similar BMIs, stone locations and stone compositions operated by a single surgeon is required. Respectfully, H. I. Cimen, E. C. Serefoglu and M. D. Balbay Department of Urology Ataturk Training and Research Hospital Ankara, Turkey 1. Skolarikos A, Alivizatos G and de la Rosette JJ: Percutaneous nephrolithotomy and its legacy. Eur Urol 2005; 47: 22. 2. Rassweiler J, Gumpinger R, Bub P et al: Wolf Piezolith 2200 versus the modified Dornier HM3. Efficacy and range of indications. Eur Urol 1989; 16: 1. 3. Pareek G, Hedican SP, Lee FT Jr et al: Shock wave lithotripsy success determined by skin-to-stone distance on computed tomography. Urology 2005; 66: 941.
4. Psihramis KE, Jewett MA, Bombardier C et al: Lithostar extracorporeal shock wave lithotripsy: the first 1,000 patients. J Urol 1992; 147: 1006. 5. Lingeman JE, Coury TA, Newman DM et al: Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol 1987; 138: 485.
Re: Urethral Stricture is Now an Open Surgical Disease A. Morey and H. Wessells J Urol 2009; 181: 953--955.
To the Editor: We would like to respond jointly to the opposing views expressed by Morey and Wessells, with a rational view regarding the place of internal urethrotomy and urethral dilation as modalities in the modern management of urethral strictures. We refrain from joining Morey in decimating the roles of internal urethrotomy and urethral dilation in the overall management of urethral stricture disease. We accept that the hype of the late 1980s surrounding internal urethrotomy as a panacea has now settled down, positioning the procedure in its rightful place.1 In our practice we still find internal urethrotomy invaluable as first line treatment in well localized, short segment, partial strictures. Although reported long-term cure rates with internal urethrotomy remain at 25%,2 the salvage value of urethrotomy for initial urethroplasty failures averts many repeat urethroplasties and cannot be disputed. As for urethral dilation, current common sense precludes discussion of blind, metal, traumatic and morbid dilations. We still find a place for atraumatic urethral stretch done with soft polytetrafluoroethylene dilators under endoscopic control as an ambulatory procedure, with the interval between 2 procedures not less than 6 months. This approach is a cost-effective modality for a highly selected group of patients who may shy away from urethroplasty or in whom a complex urethroplasty is likely to yield adverse outcomes. A small fraction of our patients are stable and satisfied for several years with this modality, and we find no reason to foist urethroplasty on their stable status.3,4 Morey makes a case for early liberal application of anastomotic urethroplasty. There may be a justification to recommend this approach for strictures of traumatic origin. However, this approach may prove disastrous for the localized appearance of a systemic inflammatory disease of the urethra. In this situation the surgeon would be joining an obvious or subtly inflamed urethra with a high potential of subsequent scarring despite surgical dexterity and technical satisfaction. Respectfully, Arun Sivanandam, Siddharth Siva and Mahendra Bhandari Vattikuti Urology Institute Henry Ford Hospital 2799 W. Grand Blvd. Detroit, Michigan 48202 e-mail: [email protected]
2536
LETTERS TO THE EDITOR/ERRATA
1. Naude AM and Heyns CF: What is the place of internal urethrotomy in the treatment of urethral stricture disease? Nat Clin Pract Urol 2005; 2: 538.
3. Bhandari M, Palaniswamy R, Achrekar KL et al: Strictures of the penile urethra. Br J Urol 1983; 55: 235.
2. Boccon-Gibod L and Le Portz B: Endoscopic urethrotomy: does it live up to its promises? J Urol 1982; 127: 433.
4. Bhandari M and Palaniswamy R: Management of complicated strictures of the urethra in men. Br J Urol 1984; 56: 410.
Reply by A. Morey: I agree that urethral dilation is far superior to inexpert urethroplasty. But just how atraumatic is endoscopic dilation? I have long observed that most men with irregular strictures have a history of multiple endoscopic procedures and vice versa. I am certain that many of these strictures have become more complex along the way as a result of urological instrumentation, whereas those cases that have a more direct path to urethroplasty tend to require less elaborate repairs. I am not sure what the authors mean by their novel term “localized systemic inflammatory” urethral disease. Perhaps that is what you call it when localized strictures become systemic and inflammatory after atraumatic dilation.
2535
with similar BMIs, stone locations and stone compositions operated by a single surgeon is required. Respectfully, H. I. Cimen, E. C. Serefoglu and M. D. Balbay Department of Urology Ataturk Training and Research Hospital Ankara, Turkey 1. Skolarikos A, Alivizatos G and de la Rosette JJ: Percutaneous nephrolithotomy and its legacy. Eur Urol 2005; 47: 22. 2. Rassweiler J, Gumpinger R, Bub P et al: Wolf Piezolith 2200 versus the modified Dornier HM3. Efficacy and range of indications. Eur Urol 1989; 16: 1. 3. Pareek G, Hedican SP, Lee FT Jr et al: Shock wave lithotripsy success determined by skin-to-stone distance on computed tomography. Urology 2005; 66: 941.
4. Psihramis KE, Jewett MA, Bombardier C et al: Lithostar extracorporeal shock wave lithotripsy: the first 1,000 patients. J Urol 1992; 147: 1006. 5. Lingeman JE, Coury TA, Newman DM et al: Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol 1987; 138: 485.
Re: Urethral Stricture is Now an Open Surgical Disease A. Morey and H. Wessells J Urol 2009; 181: 953--955.
To the Editor: We would like to respond jointly to the opposing views expressed by Morey and Wessells, with a rational view regarding the place of internal urethrotomy and urethral dilation as modalities in the modern management of urethral strictures. We refrain from joining Morey in decimating the roles of internal urethrotomy and urethral dilation in the overall management of urethral stricture disease. We accept that the hype of the late 1980s surrounding internal urethrotomy as a panacea has now settled down, positioning the procedure in its rightful place.1 In our practice we still find internal urethrotomy invaluable as first line treatment in well localized, short segment, partial strictures. Although reported long-term cure rates with internal urethrotomy remain at 25%,2 the salvage value of urethrotomy for initial urethroplasty failures averts many repeat urethroplasties and cannot be disputed. As for urethral dilation, current common sense precludes discussion of blind, metal, traumatic and morbid dilations. We still find a place for atraumatic urethral stretch done with soft polytetrafluoroethylene dilators under endoscopic control as an ambulatory procedure, with the interval between 2 procedures not less than 6 months. This approach is a cost-effective modality for a highly selected group of patients who may shy away from urethroplasty or in whom a complex urethroplasty is likely to yield adverse outcomes. A small fraction of our patients are stable and satisfied for several years with this modality, and we find no reason to foist urethroplasty on their stable status.3,4 Morey makes a case for early liberal application of anastomotic urethroplasty. There may be a justification to recommend this approach for strictures of traumatic origin. However, this approach may prove disastrous for the localized appearance of a systemic inflammatory disease of the urethra. In this situation the surgeon would be joining an obvious or subtly inflamed urethra with a high potential of subsequent scarring despite surgical dexterity and technical satisfaction. Respectfully, Arun Sivanandam, Siddharth Siva and Mahendra Bhandari Vattikuti Urology Institute Henry Ford Hospital 2799 W. Grand Blvd. Detroit, Michigan 48202 e-mail: [email protected]
2536
LETTERS TO THE EDITOR/ERRATA
1. Naude AM and Heyns CF: What is the place of internal urethrotomy in the treatment of urethral stricture disease? Nat Clin Pract Urol 2005; 2: 538.
3. Bhandari M, Palaniswamy R, Achrekar KL et al: Strictures of the penile urethra. Br J Urol 1983; 55: 235.
2. Boccon-Gibod L and Le Portz B: Endoscopic urethrotomy: does it live up to its promises? J Urol 1982; 127: 433.
4. Bhandari M and Palaniswamy R: Management of complicated strictures of the urethra in men. Br J Urol 1984; 56: 410.
Reply by A. Morey: I agree that urethral dilation is far superior to inexpert urethroplasty. But just how atraumatic is endoscopic dilation? I have long observed that most men with irregular strictures have a history of multiple endoscopic procedures and vice versa. I am certain that many of these strictures have become more complex along the way as a result of urological instrumentation, whereas those cases that have a more direct path to urethroplasty tend to require less elaborate repairs. I am not sure what the authors mean by their novel term “localized systemic inflammatory” urethral disease. Perhaps that is what you call it when localized strictures become systemic and inflammatory after atraumatic dilation.