- Email: [email protected]
Reply by the authors
REFERENCES 1. Lawrentschuk N, Lee D, Marriott P, et al: Suprapubic stab cystostomy: a safer technique. Urology 62: 932–934, 2003. 2. Alagiri M, and Seidmon EJ: Percutaneous endoscopic cystostomy for bladder localization and exact placement of a suprapubic tube. J Urol 159: 963–964, 1998.
Andrea Gregori Alchiede Simonato Franco Gaboardi Department of Urology “Luigi Sacco” Hospital Milan, Italy doi:10.1016/j.urology.2004.01.036
sented in our institution with a local recurrence after primary treatment elsewhere. Up to now, we are aware of only one further local recurrence in the low-grade subgroup (found more than 6 years after the initial treatment). These favorable results should, however, only cautiously be compared to a series of high-risk leiomyosarcomas of the urinary bladder since most of our patients had easily accessible low-grade sarcomas of the inguino-scrotal region. REFERENCES 1. Rosser CJ, Slaton JW, Izawa JI, et al: Clinical presentation and outcome of high-grade urinary bladder leiomyosarcoma in adults. Urology 61: 1151–1155, 2003. 2. Froehner M, Lossnitzer A, Manseck A, et al: Favorable long-term outcome in adult genitourinary low-grade sarcoma. Urology 56: 373–377, 2000.
Michael Froehner, M.D. REPLY BY THE AUTHORS Thank you for highlighting the previous paper by Alagiri and Seidmon,1 which we readily acknowledge as the first paper describing percutaneous endoscopic cystostomy. We agree there is ambiguity in the statement that ours was the first paper to describe the use of flexible cystoscopy for suprapubic catheter insertion and that the title should be qualified with the word ultrasound, which was the objective of describing the technique in our recent article.2 It is also reassuring that other centers are using ultrasound in combination with flexible cystoscopy for difficult cases of suprapubic catheter insertion. REFERENCES 1. Alagiri M, and Seidmon EJ: Percutaneous endoscopic cystostomy for bladder localization and exact placement of a suprapubic tube. J Urol 159: 963–964, 1998. 2. Lawrentschuk N, Lee D, Marriott P, et al: Suprapubic stab cystostomy: a safer technique. Urology 62: 932–934, 2003.
Nathan Lawrentschuk, M.B.B.S. John Russell, F.A.C.S., F.R.A.C.S. Department of Surgery Division of Urology University of Melbourne Austin and Repatriation Medical Centre Heidelberg, Victoria, Australia doi:10.1016/j.urology.2004.01.037
High-Grade Urinary Bladder Leiomyosarcoma in Adults TO THE EDITOR:
I read with great interest the article by Rosser and coworkers1 presenting a very large study of bladder leiomyosarcomas. I appreciate that the authors cited our relatively small series of genitourinary sarcomas published in this journal 3 years earlier.2 Nevertheless, the erroneously mentioned recurrence rate (42% in patients with low-grade disease1) requires a comment. Up to the time of writing (see Table I in our article2), we observed only one recurrence among 12 patients with low-grade genitourinary sarcoma (8%). This patient pre188
Department of Urology University Hospital “Carl Gustav Carus” Technical University of Dresden Dresden, Germany doi:10.1016/j.urology.2003.08.050
Fascia Lata Graft for Urethral Fistula Repair TO THE EDITOR:
We read with interest the article by Kargi et al.1 on the use of fascia lata in the management of urethral fistulas after failed hypospadias. This preliminary experience is very encouraging and the fascia lata might be a promising tissue in urethral reconstructive surgery. However, I would point out some considerations. The authors suggested additional studies to confirm their results by using the fascia lata graft. We recently reported the first preclinical work on the assessment of autologous fascia lata as a graft for urethral repair in a rabbit model.2 In this study 10 animals underwent urethroplasty after creating a defect on the ventral aspect of the urethra. The urethra was then repaired by suturing a graft of fascia lata in an onlay fashion, and the results were evaluated at 2, 4, and 12 weeks after surgery with urethrography and histology. A new line of normal urothelium covering the graft was detectable in the second postoperative week, and the success rate was 80% after 3 months (considering the mean survival of the rabbit, this represents the average follow-up). An important point, omitted by Kargi et al., is the definition of polarity of the fascial graft during surgery. In the experimental set the anatomic study of the fascia lata showed a laminar structure of three different layers: the upper as vascular plane, the middle containing collagen fiber bundles, and the inner as areolar layer in contact with the epimysium. On the basis of these anatomic findings, the correct position of the fascia lata graft is maintaining the vascular plane in contact with tonaca dartos and opposite the urethral lumen. This approach is suitable either for the placing of the fascia lata graft to protect the urethra closed below, as depicted by the authors, or when the urethral edges are shorter—also after a plate incision—and a patch closure could preferably be perUROLOGY 64 (1), 2004
Andrea Gregori Alchiede Simonato Franco Gaboardi Department of Urology “Luigi Sacco” Hospital Milan, Italy doi:10.1016/j.urology.2004.01.036
sented in our institution with a local recurrence after primary treatment elsewhere. Up to now, we are aware of only one further local recurrence in the low-grade subgroup (found more than 6 years after the initial treatment). These favorable results should, however, only cautiously be compared to a series of high-risk leiomyosarcomas of the urinary bladder since most of our patients had easily accessible low-grade sarcomas of the inguino-scrotal region. REFERENCES 1. Rosser CJ, Slaton JW, Izawa JI, et al: Clinical presentation and outcome of high-grade urinary bladder leiomyosarcoma in adults. Urology 61: 1151–1155, 2003. 2. Froehner M, Lossnitzer A, Manseck A, et al: Favorable long-term outcome in adult genitourinary low-grade sarcoma. Urology 56: 373–377, 2000.
Michael Froehner, M.D. REPLY BY THE AUTHORS Thank you for highlighting the previous paper by Alagiri and Seidmon,1 which we readily acknowledge as the first paper describing percutaneous endoscopic cystostomy. We agree there is ambiguity in the statement that ours was the first paper to describe the use of flexible cystoscopy for suprapubic catheter insertion and that the title should be qualified with the word ultrasound, which was the objective of describing the technique in our recent article.2 It is also reassuring that other centers are using ultrasound in combination with flexible cystoscopy for difficult cases of suprapubic catheter insertion. REFERENCES 1. Alagiri M, and Seidmon EJ: Percutaneous endoscopic cystostomy for bladder localization and exact placement of a suprapubic tube. J Urol 159: 963–964, 1998. 2. Lawrentschuk N, Lee D, Marriott P, et al: Suprapubic stab cystostomy: a safer technique. Urology 62: 932–934, 2003.
Nathan Lawrentschuk, M.B.B.S. John Russell, F.A.C.S., F.R.A.C.S. Department of Surgery Division of Urology University of Melbourne Austin and Repatriation Medical Centre Heidelberg, Victoria, Australia doi:10.1016/j.urology.2004.01.037
High-Grade Urinary Bladder Leiomyosarcoma in Adults TO THE EDITOR:
I read with great interest the article by Rosser and coworkers1 presenting a very large study of bladder leiomyosarcomas. I appreciate that the authors cited our relatively small series of genitourinary sarcomas published in this journal 3 years earlier.2 Nevertheless, the erroneously mentioned recurrence rate (42% in patients with low-grade disease1) requires a comment. Up to the time of writing (see Table I in our article2), we observed only one recurrence among 12 patients with low-grade genitourinary sarcoma (8%). This patient pre188
Department of Urology University Hospital “Carl Gustav Carus” Technical University of Dresden Dresden, Germany doi:10.1016/j.urology.2003.08.050
Fascia Lata Graft for Urethral Fistula Repair TO THE EDITOR:
We read with interest the article by Kargi et al.1 on the use of fascia lata in the management of urethral fistulas after failed hypospadias. This preliminary experience is very encouraging and the fascia lata might be a promising tissue in urethral reconstructive surgery. However, I would point out some considerations. The authors suggested additional studies to confirm their results by using the fascia lata graft. We recently reported the first preclinical work on the assessment of autologous fascia lata as a graft for urethral repair in a rabbit model.2 In this study 10 animals underwent urethroplasty after creating a defect on the ventral aspect of the urethra. The urethra was then repaired by suturing a graft of fascia lata in an onlay fashion, and the results were evaluated at 2, 4, and 12 weeks after surgery with urethrography and histology. A new line of normal urothelium covering the graft was detectable in the second postoperative week, and the success rate was 80% after 3 months (considering the mean survival of the rabbit, this represents the average follow-up). An important point, omitted by Kargi et al., is the definition of polarity of the fascial graft during surgery. In the experimental set the anatomic study of the fascia lata showed a laminar structure of three different layers: the upper as vascular plane, the middle containing collagen fiber bundles, and the inner as areolar layer in contact with the epimysium. On the basis of these anatomic findings, the correct position of the fascia lata graft is maintaining the vascular plane in contact with tonaca dartos and opposite the urethral lumen. This approach is suitable either for the placing of the fascia lata graft to protect the urethra closed below, as depicted by the authors, or when the urethral edges are shorter—also after a plate incision—and a patch closure could preferably be perUROLOGY 64 (1), 2004