Urological Survey Trauma, and Genital and Urethral Reconstruction Re: Ventral Oral Mucosal Onlay Graft Urethroplasty in Nontraumatic Bulbar Urethral Strictures: Surgical Technique and Multivariable Analysis of Results in 214 Patients G. Barbagli, F. Montorsi, G. Guazzoni, A. Larcher, N. Fossati, S. Sansalone, G. Romano, N. Buffi and M. Lazzeri Center for Reconstructive Urethral Surgery, Arezzo, Italy Eur Urol 2013; 64: 440e447.
Abstract available at http://jurology.com/ Editorial Comment: There is so much to say about this article! First, the good. This is a well written, detailed analysis from a center of excellence, and the contributions of this group through the years cannot be overstated. There is no disputing the efficacy of buccal mucosa graft urethroplasty, a technique that most of us use regularly. I am glad to see that Barbagli et al (who popularized the dorsal graft approach) now appear to be changing their tune with a preference for ventral grafting, acknowledging its technical simplicity. While dorsal grafting has proved to achieve comparable outcomes through the years, I could never see its big attraction given the efficiency of the ventral approachdjust open the scarred urethra and put the graft in; why bother to mobilize the whole urethra and place the graft on the back if the results are the same? One of the concerns I have had about grafting is in cases with a narrow urethral plate. I like the concept presented in this article to actually “miss” the mucosal margin with the needle on one side, sewing the graft to spongiosum instead to add a few more millimeters of circumference to the lumen. This strategy is artistically conveyed in the diagrams, and the statistical analysis appears to suggest that it works reasonably well. I have 3 main arguments with this article. First, the title suggests that nontraumatic strictures are clear cut and distinct from those of traumatic origin. While I would agree that traumatic strictures tend to have more severe spongiofibrosis (and, therefore, are not amenable to grafting), I have long been baffled by the number of patients who present with severe strictures and no known history of trauma. The authors themselves report that the etiology of strictures in this series was unknown in the majority of patients (163 of 214, 76.2%). Did they sustain unrecognized trauma during childhood? Did they suffer iatrogenic trauma from multiple dilations or endoscopic incisions? How can we ever really know? Another objection I have with this article is the success rate of “only” 85.5%. While this is perfectly acceptable for longer strictures (more than several centimeters), the literature strongly suggests that shorter strictures have a nearly 10% higher success rate from excision with primary anastomosis. This series includes many strictures in the range of 1 to 3 cm. Did the authors graft everyone? Have they abandoned anastomotic urethroplasty completely? In my experience of more than 1,000 urethroplasties roughly a tenth have been reoperative. The most common procedure performed initially was a graft procedure, and the most common solution was an anastomotic procedure—often involving complete excision of the grafted area with its surrounding recurrent stenosis. This finding suggests that these patients should have undergone excision with primary anastomosis in the first place. (Another advantage of the ventral graft approach is that during reoperation, if needed, it is easy to mobilize along the virgin planes along the dorsal wall of the urethra).
0022-5347/14/1913-0694/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
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www.jurology.com
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http://dx.doi.org/10.1016/j.juro.2013.11.046 Vol. 191, 694-696, March 2014 Printed in U.S.A.
MALE AND FEMALE SEXUAL FUNCTION AND DYSFUNCTION; ANDROLOGY
The last objection I would like to raise is patient preference. When we query our patients about their impressions and preferences after urethroplasty, most who have buccal grafts are bothered by the mouth harvesting more than the perineal dissection and uniformly would have preferred to have had the procedure performed without the oral surgery component. Likewise, those with intermediate length strictures are uniformly pleased when they wake up to find that we did not need a graft. I compliment the authors on their beautiful article and video, which includes many helpful surgical tips. Clearly ventral application of oral mucosa graft is a mainstay in the reconstructive armamentarium. However, as good as it is, we must avoid a “cookbook” approach and recognize the limitations of this method while offering our patients the procedure that gives the highest chance of success. Allen F. Morey, MD
Male and Female Sexual Function and Dysfunction; Andrology Re: Management and Outcomes of Penile Fracture: 10 Years’ Experience from a Tertiary Care Center € zel and A. Kos¸ar A. Ozorak, M. B. Hos¸can, T. Oksay, A. Gu € Department of Urology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey Int Urol Nephrol 2013; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: These data continue to support the concept of early intervention, ie surgical repair, for penile fracture. The 10-year followup data in this study demonstrate a lack of erectile dysfunction, penile curvature or pain following surgical repair. Thus, penile fractures should be treated aggressively and emergently. Allen D. Seftel, MD
Laparoscopy/New Technology Re: Increased Intra-Abdominal Fat Predicts Perioperative Complications Following Minimally Invasive Partial Nephrectomy M. A. Gorin, J. K. Mullins, P. M. Pierorazio, G. Jayram and M. E. Allaf James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland Urology 2013; 81: 1225e1230.
Abstract available at http://jurology.com/ Editorial Comment: Unlike open partial nephrectomy, where the perinephric fat can be removed to improve exposure and enlarge the working space, in laparoscopic and robotic partial nephrectomy this is not a reasonable option. As such, in patients who have a lot of perinephric fat several steps of the procedure are more difficult, including hilar exposure, kidney manipulation, tumor resection and
695
Abstract available at http://jurology.com/ Editorial Comment: There is so much to say about this article! First, the good. This is a well written, detailed analysis from a center of excellence, and the contributions of this group through the years cannot be overstated. There is no disputing the efficacy of buccal mucosa graft urethroplasty, a technique that most of us use regularly. I am glad to see that Barbagli et al (who popularized the dorsal graft approach) now appear to be changing their tune with a preference for ventral grafting, acknowledging its technical simplicity. While dorsal grafting has proved to achieve comparable outcomes through the years, I could never see its big attraction given the efficiency of the ventral approachdjust open the scarred urethra and put the graft in; why bother to mobilize the whole urethra and place the graft on the back if the results are the same? One of the concerns I have had about grafting is in cases with a narrow urethral plate. I like the concept presented in this article to actually “miss” the mucosal margin with the needle on one side, sewing the graft to spongiosum instead to add a few more millimeters of circumference to the lumen. This strategy is artistically conveyed in the diagrams, and the statistical analysis appears to suggest that it works reasonably well. I have 3 main arguments with this article. First, the title suggests that nontraumatic strictures are clear cut and distinct from those of traumatic origin. While I would agree that traumatic strictures tend to have more severe spongiofibrosis (and, therefore, are not amenable to grafting), I have long been baffled by the number of patients who present with severe strictures and no known history of trauma. The authors themselves report that the etiology of strictures in this series was unknown in the majority of patients (163 of 214, 76.2%). Did they sustain unrecognized trauma during childhood? Did they suffer iatrogenic trauma from multiple dilations or endoscopic incisions? How can we ever really know? Another objection I have with this article is the success rate of “only” 85.5%. While this is perfectly acceptable for longer strictures (more than several centimeters), the literature strongly suggests that shorter strictures have a nearly 10% higher success rate from excision with primary anastomosis. This series includes many strictures in the range of 1 to 3 cm. Did the authors graft everyone? Have they abandoned anastomotic urethroplasty completely? In my experience of more than 1,000 urethroplasties roughly a tenth have been reoperative. The most common procedure performed initially was a graft procedure, and the most common solution was an anastomotic procedure—often involving complete excision of the grafted area with its surrounding recurrent stenosis. This finding suggests that these patients should have undergone excision with primary anastomosis in the first place. (Another advantage of the ventral graft approach is that during reoperation, if needed, it is easy to mobilize along the virgin planes along the dorsal wall of the urethra).
0022-5347/14/1913-0694/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
694
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2013.11.046 Vol. 191, 694-696, March 2014 Printed in U.S.A.
MALE AND FEMALE SEXUAL FUNCTION AND DYSFUNCTION; ANDROLOGY
The last objection I would like to raise is patient preference. When we query our patients about their impressions and preferences after urethroplasty, most who have buccal grafts are bothered by the mouth harvesting more than the perineal dissection and uniformly would have preferred to have had the procedure performed without the oral surgery component. Likewise, those with intermediate length strictures are uniformly pleased when they wake up to find that we did not need a graft. I compliment the authors on their beautiful article and video, which includes many helpful surgical tips. Clearly ventral application of oral mucosa graft is a mainstay in the reconstructive armamentarium. However, as good as it is, we must avoid a “cookbook” approach and recognize the limitations of this method while offering our patients the procedure that gives the highest chance of success. Allen F. Morey, MD
Male and Female Sexual Function and Dysfunction; Andrology Re: Management and Outcomes of Penile Fracture: 10 Years’ Experience from a Tertiary Care Center € zel and A. Kos¸ar A. Ozorak, M. B. Hos¸can, T. Oksay, A. Gu € Department of Urology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey Int Urol Nephrol 2013; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: These data continue to support the concept of early intervention, ie surgical repair, for penile fracture. The 10-year followup data in this study demonstrate a lack of erectile dysfunction, penile curvature or pain following surgical repair. Thus, penile fractures should be treated aggressively and emergently. Allen D. Seftel, MD
Laparoscopy/New Technology Re: Increased Intra-Abdominal Fat Predicts Perioperative Complications Following Minimally Invasive Partial Nephrectomy M. A. Gorin, J. K. Mullins, P. M. Pierorazio, G. Jayram and M. E. Allaf James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland Urology 2013; 81: 1225e1230.
Abstract available at http://jurology.com/ Editorial Comment: Unlike open partial nephrectomy, where the perinephric fat can be removed to improve exposure and enlarge the working space, in laparoscopic and robotic partial nephrectomy this is not a reasonable option. As such, in patients who have a lot of perinephric fat several steps of the procedure are more difficult, including hilar exposure, kidney manipulation, tumor resection and
695
