Editorial comment on interim outcomes of dorsal skin graft bulbar urethroplasty

J Urol 2005; 174: 397-398.
In his Editorial Comment, Dr. Mundy tries to address some of the main issues about the reconstructive urethral surgery which need further researches and controlled studies. Mundy’s concerns confirm his wide experience in this field of pathology and his high critical analysis of the manuscript. Mundy reminds us that our study enrolled a “relatively small number of patients” and that it could limit the validity of results. We feel to disagree with Mundy’s comment. The rationale of patients’ selection was based on 556 patients with a bulbar stricture who underwent to surgery by 8 different techniques. 57 underwent dorsal onlay graft and 45 over these 57 were selected for the study not “for the likelihood of a more successful outcome” but according specific criteria which are reported throughout the text. Our choice provided a very homogeneous group: the same stricture etiology and location, the same surgeon (GB) and the same graft material (skin). The term “urethral stricture” refers to different pathologies with regard anatomy, etiology and surgery, and the urologists usually include into the urethral stricture category, pathologies such as Lichen sclerosus, failed hypospadias repair or pelvic trauma. So, the honest and skilled reporter prefers to have a “small sample”, but homogeneous group of patients, instead of an huge, non-homogeneous group of patients with different anatomical, etiological and pathological strictures, treated by different techniques, or by different surgeons. For all these reasons we are convinced that the sample size is sufficient to draw the right conclusions. Other two Mundy’s concerns regard the methodology and the duration of follow-up. We introduced the ultrasound as a routine since 1998, for follow-up, considering it a non-invasive techniques and more diagnostic acceptable tool for patients who underwent urethroplasty. We think that ultrasonography could be considered “adiuvant” to the traditional cystourethrography, especially in the bulbar urethra, but the specific role of ultrasonography in detecting the development of the disease at the level of proximal urethra have to be defined. We agree with Dr Mundy when he states that the criteria for success or failure remains imprecise. All the surgeons involved in the urethral reconstruction should do an effort to understand the role of radiological, endoscopic, functional and clinical studies before to provide a definitive judgment on the outcome. So, in order to avoid that follow-up methodology was imprecise, in our series we used all these criteria: radiological, endoscopic, functional and clinical. We consider our criteria very selective and not “imprecise”. With regard the concern about whether a previous failed urethrotomy is a risk factor for recurrence of stricture after a subsequent urethrorplasty we already discussed this question in an other paper (references n. 11 of the manuscript). We disagree when Mundy reports that the role of ischemia is often vague and imprecise. There is a lot of experimental and clinical data that suggest the importance of “ischemic noxa” in the pathogenesis of urethral stricture. We agree that the follow-up in this single study could be short and we aware that any future study would need to have a longer flow-up. Finally, We believe that a “Consensus Conference on urethral stricture diseases”, involving all the urologists engaged in urethral reconstruction, could help to perform a standardization of diagnostic criteria, surgical techniques and outcome parameters.