- Email: [email protected]
Reply by Allen
143
LETTERS TO THE EDITOR leakage. Doctor Leadbetter has raised some questions that deserve our consideration. He states that many of these patients had some leakage of urine preoperatively and that no mention was made in our paper of this fact. On the contrary, in paragraph 3 on page 1249 we stated clearly that "none of the patients had had incontinence before the internal urethrotomy". Doctor Leadbetter erroneously concludes that because we indicate that the resting urethral pressure profile by itself is not sufficient to characterize reliably the competency of the urethra to maintain continence at all times, such measurements are not accurate and speculation is necessary. The fundamental logic of deriving such a conclusion is flawed and is based on ignorance of the published text. In actual fact, our studies were repeated several times during the same session in every patient and the measurements were reproducible. Abnormally low urethral pressure profiles were observed in all patients when compared to our normal controls. The only speculation was whether when compared to our normal controls these patients might demonstrate urinary stress incontinence with increasing age, since it is well known that with aging the extrinsic mechanisms maintaining continence are less efficient. Furthermore, in our paper we not only overcame the said limitations inherent in urethral pressure profile measurements but we extended our urethral recordings to incorporate dynamic transmission measurements. These measurements best emulate the actual conditions contributing to incontinence. It is simplistic to presume that all urethral measurements are urethral pressure profiles. Indeed, such an interpretation demonstrates lack of critical reading of the evidence provided and is based on ad hominem interpretation of our data. Doctor Leadbetter also comments that the technique of urethrotomy used in these patients was technically wrong and overdone because 2 incisions were made in the urethra, the incisions were too deep (38 to 40F) and bleeders were fulgurated. He refers to his technique, 1 and states that the incision should be made at the 10 or 2 o'clock position, the incisions should be made only in the fibrous meatal or submeatal elastic ring and not the entire urethra, the blade must be dull and never sharpened, and bleeding must never be fulgurated. However, a review of that article indicates that the incisions were made at the 5 and 7 o'clock positions through the bladder neck and the entire urethra, and that no attention should be paid to the numbers on the urethrotome dial. No mention is made in the article cautioning one to use a dull blade and to avoid fulguration of bleeders. It should be appreciated that in 50 per cent of our patients fulguration was not mentioned in the operative report and, thus, it cannot account for the abnormal profile studies in these particular patients. It is interesting that Doctor Leadbetter believes that there still is a place for internal urethrotomy in girls with recurrent urinary tract infection. Multiple studies have shown that urethral obstruction has no role in girls with urinary tract infection. 2- 5 Kaplan and associates compared urethral dilation, urethrotomy and medication alone in such children, and found no difference in cure rates of urinary tract infection. 5 Thus, they were unable to confirm the work of Halverstadt and Leadbetter. 1 In summary, our paper verifies that these young girls who underwent internal urethrotomy potentially are rendered incontinent by disrupting the intrinsic urethral closure mechanism. We indicate further that current vestigial continence is maintained by the action of the extrinsic closure mechanism and conclude that these patients are likely to have an accelerated path to total incontinence with aging. 1. Halverstadt, D. B. and Leadbetter, G. W., Jr.: Internal urethrotomy and recurrent urinary tract infection in female children. I. Results in the management of infection. J. Urol., 100: 297, 1968. 2. Graham, J. B., King, L. R., Kropp, K. A. and Uehling, D. T.: The significance of distal urethral narrowing in young girls. J. Urol., 97: 1045, 1967. 3. Gillenwater, J. Y., Harrison, R. B. and Kunin, C. M.: Natural history of bacteriuria in schoolgirls. A long-term case-control study. New Engl. J. Med., 301: 396, 1979. 4. Fair, W. R., Govan, D. E., Friedland, G. W. and Filly, R. A.: Urinary tract infections in children. Part I. Young girls with non-refluxing ureters. West. J. Med., 121: 366, 1974. 5. Kaplan, G. W., Sammons, T. A. and King, L. R.: A blind comparison of dilatation, urethrotomy and medication alone in the treatment of urinary tract infections in girls. J. Urol., 109: 917, 1973.
Reply by Allen. It is well that Doctor Leadbetter has clarified the technique used in internal urethrotomy, since it is clear that what he has described in his letter is different from what generally has been
done around the country.Unfortunately, it also is not what was described by Halverstadt and Leadbetter in their article in 1968 (reference 1 in Reply by Kessler and Constantinou). For example in their article they stated that they ". . . adopted a technique of cold cutting of the entire urethra with the Otis urethrotome similar to that described by Keitzer and Benavent". The article by Keitzer and Benavent, however, describes the technique as follows: "In the female child, make full length incisions in the three upper quadrants and only at the neck of the bladder at the lower quadrant. The usual procedure is to insert the instrument at 12 o'clock, open to feel of resistance (30F), and cut full length; turn to 3 o'clock and open to resistance (38F) and cut full length; turn to 9 o'clock, open to 45F and cut full length. At 6 o'clock open to 45F and holding handle up to 45', cut only at the bladder neck for 1 cm. 1 In his letter Doctor Leadbetter indicates that a single incision through only the submeatal fibrous ring is made with the blade at the 10 or 2 o'clock position and with the instrument expanded to 20 to 24F. However, in his article the description is as follows: "The Otis urethrotome is placed per urethram with the knife at 5 and 7 o'clock .... The urethrotome is opened until snug in the urethra". (No measured calibration is given.) "A longitudinal incision is made through the bladder neck and entire urethra by pulling the knife '..along its track toward the observer." With such discrepancies, inconsistencies and frank contradictions surrounding the technical aspects of the procedure, it is little wonder that so much confusion exists regarding it. However, I stand upon my convictions that there is little evidence of the benefit of such an undertaking and too much evidence of the risks that can result from it. I will continue to discourage the operation to anyone who will listen. 1. Keitzer, W. A. and Benavent, C.: Bladder neck obstruction in children. J. Urol., 89: 384, 1963.
Note by Editor. The controversy generated by this article and Editorial gives no indication of subsiding. Doctor Leadbetter recently wrote a further response, stating in part, "I read the responses sent to me. There is no question in my mind that the 11 girls tested have difficulties with continence. However, the main purpose of my Letter to the Editor was to point out that urethrotomy should not be condemned because of complications resulting from the totally wrong technique. The proper technique was described in Glenn's Urologic Surgery, 1975. As authors, we should all write early retracting statements when changes in indications or techniques occur, as they did in this instance." If further factual information is available on this topic it should be presented formally. RE: A NEW, ONE-STAGE PEDICLED SCROTAL SKIN GRAFT URETHROPLASTY
D. Yachia J. Urol., 136: 589-592, 1986
To the Editor. Since 1972 we had been using the new procedure described by the author 1 but, subsequently, we prefer the use of free skin grafts. 2• 3 The primary reason that we changed techniques is that the preputial skin or skin of other parts of the body is thinner and softer than scrotal skin and it is hairless. When scrotal skin must be used it is important to perform frequent electrocoagulation of the hair follicles, otherwise the growth of hair in the reconstructed urethra causes many problems. To avoid the occurrence of a diverticulum the free skin patch must be supported ventrally by the corpus spongiosum in the bulbous tract2 • 4 or dorsally by the corpora in the penile tract. 4 The pedicle of the scrotal skin island does not provide this support and the bulbocavernous muscles cannot be used as support because their presence is limited to the proximal bulbous urethra. The dartos and cremasteric muscles are not sufficient to support the graft area. Finally, the illustrations presented by the author show a circular end-to-end urethral anastomosis. This type of anastomosis narrows the urethra and may cause recurrent stricture. The end-to-end anastomosis in the urethra must always be an overlap type as many authors emphasize. 1- 5 Respectfully, R. Lenzi and G. Barbagli Department of Urology University of Florence Viale Pieraccini 18 50139 Florence, Italy
LETTERS TO THE EDITOR leakage. Doctor Leadbetter has raised some questions that deserve our consideration. He states that many of these patients had some leakage of urine preoperatively and that no mention was made in our paper of this fact. On the contrary, in paragraph 3 on page 1249 we stated clearly that "none of the patients had had incontinence before the internal urethrotomy". Doctor Leadbetter erroneously concludes that because we indicate that the resting urethral pressure profile by itself is not sufficient to characterize reliably the competency of the urethra to maintain continence at all times, such measurements are not accurate and speculation is necessary. The fundamental logic of deriving such a conclusion is flawed and is based on ignorance of the published text. In actual fact, our studies were repeated several times during the same session in every patient and the measurements were reproducible. Abnormally low urethral pressure profiles were observed in all patients when compared to our normal controls. The only speculation was whether when compared to our normal controls these patients might demonstrate urinary stress incontinence with increasing age, since it is well known that with aging the extrinsic mechanisms maintaining continence are less efficient. Furthermore, in our paper we not only overcame the said limitations inherent in urethral pressure profile measurements but we extended our urethral recordings to incorporate dynamic transmission measurements. These measurements best emulate the actual conditions contributing to incontinence. It is simplistic to presume that all urethral measurements are urethral pressure profiles. Indeed, such an interpretation demonstrates lack of critical reading of the evidence provided and is based on ad hominem interpretation of our data. Doctor Leadbetter also comments that the technique of urethrotomy used in these patients was technically wrong and overdone because 2 incisions were made in the urethra, the incisions were too deep (38 to 40F) and bleeders were fulgurated. He refers to his technique, 1 and states that the incision should be made at the 10 or 2 o'clock position, the incisions should be made only in the fibrous meatal or submeatal elastic ring and not the entire urethra, the blade must be dull and never sharpened, and bleeding must never be fulgurated. However, a review of that article indicates that the incisions were made at the 5 and 7 o'clock positions through the bladder neck and the entire urethra, and that no attention should be paid to the numbers on the urethrotome dial. No mention is made in the article cautioning one to use a dull blade and to avoid fulguration of bleeders. It should be appreciated that in 50 per cent of our patients fulguration was not mentioned in the operative report and, thus, it cannot account for the abnormal profile studies in these particular patients. It is interesting that Doctor Leadbetter believes that there still is a place for internal urethrotomy in girls with recurrent urinary tract infection. Multiple studies have shown that urethral obstruction has no role in girls with urinary tract infection. 2- 5 Kaplan and associates compared urethral dilation, urethrotomy and medication alone in such children, and found no difference in cure rates of urinary tract infection. 5 Thus, they were unable to confirm the work of Halverstadt and Leadbetter. 1 In summary, our paper verifies that these young girls who underwent internal urethrotomy potentially are rendered incontinent by disrupting the intrinsic urethral closure mechanism. We indicate further that current vestigial continence is maintained by the action of the extrinsic closure mechanism and conclude that these patients are likely to have an accelerated path to total incontinence with aging. 1. Halverstadt, D. B. and Leadbetter, G. W., Jr.: Internal urethrotomy and recurrent urinary tract infection in female children. I. Results in the management of infection. J. Urol., 100: 297, 1968. 2. Graham, J. B., King, L. R., Kropp, K. A. and Uehling, D. T.: The significance of distal urethral narrowing in young girls. J. Urol., 97: 1045, 1967. 3. Gillenwater, J. Y., Harrison, R. B. and Kunin, C. M.: Natural history of bacteriuria in schoolgirls. A long-term case-control study. New Engl. J. Med., 301: 396, 1979. 4. Fair, W. R., Govan, D. E., Friedland, G. W. and Filly, R. A.: Urinary tract infections in children. Part I. Young girls with non-refluxing ureters. West. J. Med., 121: 366, 1974. 5. Kaplan, G. W., Sammons, T. A. and King, L. R.: A blind comparison of dilatation, urethrotomy and medication alone in the treatment of urinary tract infections in girls. J. Urol., 109: 917, 1973.
Reply by Allen. It is well that Doctor Leadbetter has clarified the technique used in internal urethrotomy, since it is clear that what he has described in his letter is different from what generally has been
done around the country.Unfortunately, it also is not what was described by Halverstadt and Leadbetter in their article in 1968 (reference 1 in Reply by Kessler and Constantinou). For example in their article they stated that they ". . . adopted a technique of cold cutting of the entire urethra with the Otis urethrotome similar to that described by Keitzer and Benavent". The article by Keitzer and Benavent, however, describes the technique as follows: "In the female child, make full length incisions in the three upper quadrants and only at the neck of the bladder at the lower quadrant. The usual procedure is to insert the instrument at 12 o'clock, open to feel of resistance (30F), and cut full length; turn to 3 o'clock and open to resistance (38F) and cut full length; turn to 9 o'clock, open to 45F and cut full length. At 6 o'clock open to 45F and holding handle up to 45', cut only at the bladder neck for 1 cm. 1 In his letter Doctor Leadbetter indicates that a single incision through only the submeatal fibrous ring is made with the blade at the 10 or 2 o'clock position and with the instrument expanded to 20 to 24F. However, in his article the description is as follows: "The Otis urethrotome is placed per urethram with the knife at 5 and 7 o'clock .... The urethrotome is opened until snug in the urethra". (No measured calibration is given.) "A longitudinal incision is made through the bladder neck and entire urethra by pulling the knife '..along its track toward the observer." With such discrepancies, inconsistencies and frank contradictions surrounding the technical aspects of the procedure, it is little wonder that so much confusion exists regarding it. However, I stand upon my convictions that there is little evidence of the benefit of such an undertaking and too much evidence of the risks that can result from it. I will continue to discourage the operation to anyone who will listen. 1. Keitzer, W. A. and Benavent, C.: Bladder neck obstruction in children. J. Urol., 89: 384, 1963.
Note by Editor. The controversy generated by this article and Editorial gives no indication of subsiding. Doctor Leadbetter recently wrote a further response, stating in part, "I read the responses sent to me. There is no question in my mind that the 11 girls tested have difficulties with continence. However, the main purpose of my Letter to the Editor was to point out that urethrotomy should not be condemned because of complications resulting from the totally wrong technique. The proper technique was described in Glenn's Urologic Surgery, 1975. As authors, we should all write early retracting statements when changes in indications or techniques occur, as they did in this instance." If further factual information is available on this topic it should be presented formally. RE: A NEW, ONE-STAGE PEDICLED SCROTAL SKIN GRAFT URETHROPLASTY
D. Yachia J. Urol., 136: 589-592, 1986
To the Editor. Since 1972 we had been using the new procedure described by the author 1 but, subsequently, we prefer the use of free skin grafts. 2• 3 The primary reason that we changed techniques is that the preputial skin or skin of other parts of the body is thinner and softer than scrotal skin and it is hairless. When scrotal skin must be used it is important to perform frequent electrocoagulation of the hair follicles, otherwise the growth of hair in the reconstructed urethra causes many problems. To avoid the occurrence of a diverticulum the free skin patch must be supported ventrally by the corpus spongiosum in the bulbous tract2 • 4 or dorsally by the corpora in the penile tract. 4 The pedicle of the scrotal skin island does not provide this support and the bulbocavernous muscles cannot be used as support because their presence is limited to the proximal bulbous urethra. The dartos and cremasteric muscles are not sufficient to support the graft area. Finally, the illustrations presented by the author show a circular end-to-end urethral anastomosis. This type of anastomosis narrows the urethra and may cause recurrent stricture. The end-to-end anastomosis in the urethra must always be an overlap type as many authors emphasize. 1- 5 Respectfully, R. Lenzi and G. Barbagli Department of Urology University of Florence Viale Pieraccini 18 50139 Florence, Italy