initial voiding cystourethrography, and the valves remained undiagnosed in 1 patient until 3 years of age.1 These findings indicate that the possibility of another valve or obstruction site should be considered when a patient does not respond well to the treatment. Oblique-view voiding cystourethrography with full urethral delineation and meticulous cystoscopy are invaluable diagnostic tools for the assessment of infravesical obstructions. Last but not the least, the authors managed to ablate the valves in a 6-day-old neonate using an 8.5-Fr cystoscope in the first patient.1 With rapid advances in pediatric urology instruments, cystoscopes as small as 4.5-Fr with working channels are now available. These new technologies enable physicians to treat the valves even in premature infants, highlighting the importance of a timely and accurate diagnosis. Sorena Keihani, M.D. Abdol-Mohammad Kajbafzadeh, M.D. Pediatric Urology Research Center Pediatric Center of Excellence Tehran University of Medical Sciences Tehran, Iran References 1. Tran CN, Reichard CA, McMahon D, et al. Anterior urethral valve associated with posterior urethral valves: report of 2 cases and review of the literature. Urology. 2014;84:469-471. 2. Paulhac P, Fourcade L, Lesaux N, et al. Anterior urethral valves and diverticula. BJU Int. 2003;92:506-509. 3. Ranawaka R, Dickson AP. Multiple urethral anomalies: anterior urethral diverticulum, posterior urethral valves, and distal hypospadias. J Pediatr Surg. 2013;48:e5-e8. 4. Carvell J, Mulik R. A case of hypospadias, anterior and posterior urethral valves. J Surg Case Rep. 2013;2013:e1-e3. 5. Narasimhan K, Chua J, Rai R, et al. Missed double urethral obstruction. BJU Int. Published online: 2012; Accessed October 2014; 6. Kumar A, Bajpai M, Gupta AK. Double urethral obstruction in a neonate—a case report. Eur J Pediatr Surg. 2005;15:449-451. 7. Kajbafzadeh AM, Jangouk P, Ahmadi Yazdi C. Anterior urethral valve associated with posterior urethral valves. J Pediatr Urol. 2005; 1:433-435. 8. Graham SD Jr, Krueger RP, Glenn JF. Anterior urethral diverticulum associated with posterior urethral valves. J Urol. 1982;128:376-378. 9. Zia-ul-Miraj M. Anterior urethral diverticulum and posterior urethral valves: a rare association. BJU Int. 2000;85:557-558. 10. Razi A, Zargoushi J, Mohammadi D. Anterior urethral valve associated with posterior urethral valve. Med J Islam Repub Iran. 1996; 10:257-258. 11. Ortiz C, Cleveland RH, Jaramillo D, et al. Urethral valves in Russell-Silver syndrome. J Pediatr. 1991;119:776-778.

Reply by the Authors We would like to thank Keihani et al1 for their comments regarding our article and for the opportunity to clarify our report regarding the number of cases of concomitant anterior urethral valves (AUV) and posterior urethral UROLOGY 85 (3), 2015

valves (PUV) in the literature. The authors state that “at least14 cases are reported in the English literature to have PUV in association with AUV and/or anterior urethral diverticulum (AUD).” The number of cases that we originally cited in our article reflects only that of PUV in association with AUV—and not with AUD. AUD and AUV are both rare obstructive lesions of the anterior urethra and were formerly considered to be part of the same clinical spectrum, with some authors combining all these anatomic anomalies under the term AUD or AUV.2,3 However, many authors have distinguished between AUV and AUD on the basis of the urethral morphology.3-5 Although AUD present with an acute angle between the proximal aspect of the diverticulum and the urethra, the angle is obtuse in AUV.6 Additionally, AUD are saccular diverticula that may become obstructive on micturition due to urine filling and distending the diverticular cavity and pressing the distal lip forward and up to create obstruction of the urethral lumen.3 In contrast, AUV present as mucosal folds that rise during micturition to cause obstruction. The distinction between these 2 entities helps to determine appropriate clinical management.3 As previously discussed, the treatment for obstructing AUV is generally straightforward and consists of endoscopic valve resection. In AUD, removal of the diverticulum is not always desirable; in many cases, removal of the obstructing lip alone may be sufficient to relieve urethral obstruction.3 Despite recent attempts to better classify these 2 entities, we acknowledge that there may remain ongoing debate regarding their anatomic distinction and propose that future work in this area clearly delineate what is considered to be an AUV or an AUD. Finally, although cystoscopes as small as 4.5-Fr are indeed available, the smallest resectoscope available remains 8.5 Fr. Christine N. Tran, M.D. Chad A. Reichard, M.D. Daniel McMahon, M.D. Audrey Rhee, M.D. Department of Urology The Glickman Urological and Kidney Institute Cleveland Clinic Foundation Cleveland, OH References 1. Keihani S, Kajbafzadeh AM. Re: Tran et al.: Anterior Urethral Valve Associated with Posterior Urethral Valves: Report of 2 Cases and Review of the Literature. Urology. 2015;85:710-711. 2. Firlit RS, Firlit CF, King LR. Obstructing anterior urethral valves in children. J Urol. 1978;119:819-821. 3. Paulhac P, Fourcade L, Lesaux N, et al. Anterior urethral valves and diverticula. BJU Int. 2003;92:506-509. 4. Brueziere J, Guerrieri M. [Congenital diverticula and valves of the anterior urethra]. Ann Urol (Paris). 1985;19:101-107. 5. Jehannin B. [Congenital obstructive valves and diverticula of the anterior urethra]. Chir Pediatr. 1990;31:173-180. 6. Ranawaka R, Dickson AP. Multiple urethral anomalies: anterior urethral diverticulum, posterior urethral valves, and distal hypospadias. J Pediatr Surg. 2013;48:e5-e8.


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