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Re: Welk et al.: The Augmented Nontransected Anastomotic Urethroplasty for the Treatment of Bulbar Urethral Stricture (Urology 2012;79:917-921)
Finally, we did not conclude that “preoperative positive urine culture is associated with more noninfectious complications of intraoperative bleeding” either in the abstract or the main report. Our conclusion was “Factors affecting the incidence of residual stones after PCNL are complete staghorn stones and the presence of secondary caliceal stones. Complications are significantly high if PCNL is not performed by an experienced endourologist or if the preoperative urine culture results are positive.” Ahmed R. EL-Nahas, M.D. Ibrahim Eraky, M.D. Ahmed A. Shokeir, M.D., PhD Ahmed M. Shoma, M.D. Ahmed M. El-Assmy, M.D. Nasr A. El-Tabey, M.D. Shady Soliman, M.D. Ahmed Elshal, M.D. Hamdy A. El-Kappany, M.D. Mahmoud R. El-Kenawy, M.D. Department of Urology Urology and Nephrology Center Mansoura University Mansoura, Egypt
The authors have not mentioned the length of stricture in both groups (treated with either ANTA or DOBG); however, they do mention the length of buccal grafts used in both groups (mean 4.5 and 5 cm). We feel that the length of stricture would be almost equivalent to the length of graft used. That means the authors have excised a mean urethral length of 4.5 cm and then bridged that gap at least on one surface (ventrally) by the anastomotic method. This step would seem tricky because most authors believe that bridging a gap of more than 2 cm is difficult.1 Apul Goel, M.S., M.Ch., D.N.B., M.N.A.M.S. Department of Urology, Chhatrapati Shahuji Maharaj Medical University Lucknow, India Anuj Goel, M.B.B.S., M.Sc. Wellcome Trust for Genetics, Oxford University Oxford, UK Reference 1. Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol. 2008;54:1031-1041.
References 1. El-Nahas AR, Eraky I, Shokeir AA, et al. Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Urology. 2012;79:1236-1241. 2. Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179:1379-1390. 3. Korets R, Graversen JA, Kates M, et al. Post-percutaneous nephrolithotomy systemic inflammatory response: a prospective analysis of preoperative urine, renal pelvic urine and stone cultures. J Urol. 2011;186:1899-1903. 4. Mariappan P, Smith G, Bariol SV, et al. Stone and pelvic urine culture and sensitivity are better than, bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study. J Urol. 2005;173:1610-1614. 5. El-Nahas AR, Shokeir AA, El-Assmy AM, et al. Post-percutaneous nephrolithotomy extensive hemorrhage: a study of risk factors. J Urol. 2007;177:576-579.
Re: Welk et al.: The Augmented Nontransected Anastomotic Urethroplasty for the Treatment of Bulbar Urethral Stricture (Urology 2012;79:917-921) TO THE EDITOR:
We read with interest this article in which the authors describe a large series of patients with bulbar urethral stricture managed by augmented nontransected anastomotic urethroplasty (ANTA) and dorsal onlay buccal grafting (DOBG). Because ANTA is a relatively less described procedure, we would like to know the indications of ANTA in greater detail. UROLOGY 80 (4), 2012
Reply by the Authors TO THE EDITOR:
The purpose of our report was to describe the technique of augmented nontransected anastomotic (ANTA) urethroplasty and to compare it with traditional dorsal onlay buccal graft. In cases in which we performed ANTA urethroplasty, the total stricture length (as suggested by the length of the buccal graft) was greater than the length of the partial thickness urethral resection. As shown in Figure 1,1 only the narrowest portion of the urethral stricture was excised. Next, the urethral mucosa was reapproximated and the remaining defect patched with a dorsal buccal graft. In all of our cases, ⬍2 cm of urethral mucosa was resected. With urethral mobilization, this mucosa defect can be closed in a tension-free manner, just as it is possible to do with a primary end-to-end anastomotic urethroplasty. As outlined in our conclusion, we believe the ANTA procedure is appropriate for strictures that are both too long to allow a primary anastomotic repair and contain a short segment of significant narrowing or obliteration. The ANTA procedure avoids complete urethral transection, such as would be necessary for augmented anastomotic urethroplasty.2 Blayne Welk, M.D., F.R.C.S.C., M.Sc. Division of Urology Western University St. Joseph’s Health Care London, Ontario, Canada 959
The authors have not mentioned the length of stricture in both groups (treated with either ANTA or DOBG); however, they do mention the length of buccal grafts used in both groups (mean 4.5 and 5 cm). We feel that the length of stricture would be almost equivalent to the length of graft used. That means the authors have excised a mean urethral length of 4.5 cm and then bridged that gap at least on one surface (ventrally) by the anastomotic method. This step would seem tricky because most authors believe that bridging a gap of more than 2 cm is difficult.1 Apul Goel, M.S., M.Ch., D.N.B., M.N.A.M.S. Department of Urology, Chhatrapati Shahuji Maharaj Medical University Lucknow, India Anuj Goel, M.B.B.S., M.Sc. Wellcome Trust for Genetics, Oxford University Oxford, UK Reference 1. Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol. 2008;54:1031-1041.
References 1. El-Nahas AR, Eraky I, Shokeir AA, et al. Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Urology. 2012;79:1236-1241. 2. Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179:1379-1390. 3. Korets R, Graversen JA, Kates M, et al. Post-percutaneous nephrolithotomy systemic inflammatory response: a prospective analysis of preoperative urine, renal pelvic urine and stone cultures. J Urol. 2011;186:1899-1903. 4. Mariappan P, Smith G, Bariol SV, et al. Stone and pelvic urine culture and sensitivity are better than, bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study. J Urol. 2005;173:1610-1614. 5. El-Nahas AR, Shokeir AA, El-Assmy AM, et al. Post-percutaneous nephrolithotomy extensive hemorrhage: a study of risk factors. J Urol. 2007;177:576-579.
Re: Welk et al.: The Augmented Nontransected Anastomotic Urethroplasty for the Treatment of Bulbar Urethral Stricture (Urology 2012;79:917-921) TO THE EDITOR:
We read with interest this article in which the authors describe a large series of patients with bulbar urethral stricture managed by augmented nontransected anastomotic urethroplasty (ANTA) and dorsal onlay buccal grafting (DOBG). Because ANTA is a relatively less described procedure, we would like to know the indications of ANTA in greater detail. UROLOGY 80 (4), 2012
Reply by the Authors TO THE EDITOR:
The purpose of our report was to describe the technique of augmented nontransected anastomotic (ANTA) urethroplasty and to compare it with traditional dorsal onlay buccal graft. In cases in which we performed ANTA urethroplasty, the total stricture length (as suggested by the length of the buccal graft) was greater than the length of the partial thickness urethral resection. As shown in Figure 1,1 only the narrowest portion of the urethral stricture was excised. Next, the urethral mucosa was reapproximated and the remaining defect patched with a dorsal buccal graft. In all of our cases, ⬍2 cm of urethral mucosa was resected. With urethral mobilization, this mucosa defect can be closed in a tension-free manner, just as it is possible to do with a primary end-to-end anastomotic urethroplasty. As outlined in our conclusion, we believe the ANTA procedure is appropriate for strictures that are both too long to allow a primary anastomotic repair and contain a short segment of significant narrowing or obliteration. The ANTA procedure avoids complete urethral transection, such as would be necessary for augmented anastomotic urethroplasty.2 Blayne Welk, M.D., F.R.C.S.C., M.Sc. Division of Urology Western University St. Joseph’s Health Care London, Ontario, Canada 959