Re: Predictors of Surgical Approach to Repair Pelvic Fracture Urethral Distraction Defects

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Re: Predictors of Surgical Approach to Repair Pelvic Fracture Urethral Distraction Defects
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  Re: Predictors of Surgical Approach to Repair Pelvic FractureUrethral Distraction Defects M. M. Koraitim J Urol 2009;   182:   1435–1439. To the Editor:   We read this article with interest. Koraitim retrospectively analyzed clinico-radiological parameters as predictors of the need for progression during urethroplasty, sothat the operation can be planned more objectively. The author devised a gapometry/ urethrometry (GU) index. An index of less than 0.35 indicated execution of urethroplasty bysimple perineal operation, whereas an index of greater than 0.35 was associated withurethroplasty by an involved perineal or transpubic procedure. Involved perineal andtranspubic procedures have different implications in terms of complexity and extent of surgery. The readers might wish to know which category of patients would require transpubicprocedures or otherwise. Therefore, it would have been more appropriate to subcategorizecases with a GU index of greater than 0.35 accordingly, to make the data more informa-tive.Conventional urethroplasty comprises serial progressive steps, such as mobilization of thebulbar urethra, division of the triangular ligament, crural separation, inferior pubectomy andsupracrural rerouting of the urethra. Approximately 2 cm length is bridged in each step. 1 Mobilization of the bulbar urethra gives a maximum length (a third of its length), as was alsodiscussed in this article.Inferior pubectomy or a transpubic approach is required in patients with more proximaldisplacement of the posterior urethra, lateral displacement with associated dense scarring and complex posterior urethral injuries. 2–4 The incidence of these procedures is increased inchildren because of higher proximal displacement, involvement of the bladder neck due tolack of prostatic development, confined perineum and shorter bulbar urethra. 5 Separation of the corpora cavernosa and division of the triangular ligament are simpleinitial steps of complex perineal urethroplasty, and can be performed by relatively lessexperienced surgeons without significantly increasing operative time or morbidity. 1 However,inferior pubectomy, rerouting and especially transpubic procedures are surgically morecomplex and time consuming, require special surgical experience and expertise, and areassociated with significant blood loss and untoward effects. 2–5 Therefore, analysis of factorspredicting the need for inferior pubectomy, rerouting or transpubic procedures would beclinically more relevant. Additionally a GU index that can determine the need for thesecomplex procedures would allow for better preparation of patients in terms of operativetimes, arrangement of blood transfusion, experience of surgeons and, above all, appropriatepatient counseling.Respectfully, Sananda Bag, Mayank M. Agarwal, Shrawan K. Singh and Arup K. Mandal Department of Urology Postgraduate Institute of Medical Education and ResearchChandigarh-160 012, India e-mail:  shrawanksingh2002@yahoo.com 1. Mundy AR: Transperineal bulbo-prostatic anastomotic urethroplasty.World J Urol 1998;  16:  164.2. Cooperberg MR, McAninch JW, Alsikafi NF et al: Urethral reconstruc-tion for traumatic posterior urethral disruption: outcomes of a 25-yearexperience. J Urol 2007;  178:  2006.3. Gupta NP, Mishra S, Dogra PN et al: Transpubic urethroplasty forcomplex posterior urethral strictures: a single center experience. UrolInt 2009;  83:  22.4. Pratap A, Agrawal CS, Tiwari A et al: Complex posterior urethraldisruptions: management by combined abdominal transpubic perinealurethroplasty. J Urol 2006;  175:  1751.5. Zhang J, Xu YM, Qiao Y et al: An evaluation of surgical approaches forposterior urethral distraction defects in boys. J Urol 2006;  176:  292. LETTERS TO THE EDITOR/ERRATA 1648
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