Single-stage preputial skin flap urethroplasty for long-segment urethral stricture: evaluation and determinants of success
Sir,
We read the article by Mathur et al. [1] with interest, in which the authors advocate the use of preputial flap urethroplasty for long-segment urethral stricture. Some points in this article need clarification. The authors mention that the strictures were complex in nature; however, they fail to mention the criteria used for this classification. The sites of stricture also need explanation. How many strictures were extending into the membranous region and what was their aetiology?
Also, it is not clear from the manuscript if urethral ultrasonography was performed only at 3 months or even later. The authors mention that the postoperative median diameter of the urethral lumen on ultrasonography was 4.8 mm. As urethral ultrasonography is not routinely performed, it would have been useful if the authors had highlighted how the urethral lumen size was calculated. Were the lumen diameters calculated at several points and then a mean value obtained in each patient? What is the normal lumen size on ultrasonography?
In the discussion, the authors have highlighted the role of gutka and mention that its use is fairly common in their state; however, they have not highlighted the role of gutka use in their results. The authors found that smoking adversely affected the results of urethroplasty in their study. Could the use of gutka also affect the outcome?
Apul Goel and Manmeet Singh
Department of Urology, King George Medical University, Lucknow, India
Reference
- Mathur RK, Nagar M, Mathur R, Khan F, Deshmukh C, Guru N. Single-stage preputial skin flap urethroplasty for long-segment urethral stricture: evaluation and determinants of success. BJU Int, doi:10.1111/bju.12361.
Sir,
We read the comments and arguments raised by Dr. Apul Goel and Dr. Manmeet Singh regarding our paper [1] and are pleased to respond to their comments.
A complex urethral stricture by definition includes a stricture more than 2.5 cm in length or stricture with failed previous procedures, including urethral dilatation, DVIU or previous urethroplasty [2]. In our project, we used the same criteria to classify the strictures.
Sixteen strictures extended into the membranous region; of these nine had traumatic aetiology, three idiopathic, two were due to infection and two due to catheterisation.
Urethral diameter is non uniform apart from the penile portion where it is mostly uniform, measuring about 6 mm in diameter. In our patients we mentioned the urethral diameter only at the stricture site preoperatively and post-operatively. In case of multiple site strictures we measured the stricture size at various points and then the mean was calculated for each patient. As the follow-up gradually decreased over the period of time to only 63.79%, the median diameter mentioned in the article denotes urethral diameter at 3 months, whereas in all the patients with complications or complaints the procedure was subsequently performed on reporting.
One of our current projects is “tobacco and urethroplasty”; the results of which will be reported later. Currently we can say that it definitely renders the buccal mucosa unsuitable to be used as a substitute for urethra due to dyskeratotic changes [3-4].
Dr. Milesh Nagar
On behalf of the authors
MGM Medical College & M Y Hospital, Indore, India
References