EDITORIAL COMMENT The authors1 should be congratulated for accumulating this series of >460 patients with long urethral strictures from 8 institutions over a 30-year period. Their analysis has identified several important points. Overall success rate was >75% with an average follow-up of 20 months (range, 12-344 months). Dorsal onlay buccal mucosal graft was the most common procedure (47.9%) with a success rate of 82.5% suggesting this maybe the surgical option of choice when feasible. Second-stage Johanson urethroplasty repairs had a recurrence rate of 35.7%, and fasciocutaneous flaps carried a 32% complication rate compared with 14% when no flap was used. Of significance, prior urethral dilation and urethrotomy confers a higher chance of recurrence, whereas prior urethroplasty did not increase this risk. It is plausible that prior internal urethrotomy and/or dilations may extend the inflammatory process further than suspected and hence increase the risk of recurrence.2 Others have noted that tobacco use as well as diabetes increases the risk of recurrence, but this was not addressed in the present study. Previous studies have also confirmed that prior urethroplasty does not increase the risk of recurrence as compared with that in naïve patients.3 In addition, having an abnormal voiding cystourethrogram or a prior procedure involving a skin graft also increased the chance of stricture recurrence. The authors1 reported that 57% of patients having failed a prior urethroplasty underwent a definitive first-stage Johanson or perineal urethrostomy with a >75% success rate. For those patients who are poor surgical candidates or comfortable with voiding in a seated position, this remains a viable option with improved quality of life. Recent data from the Veterans Affairs centers have identified an increase in the use of open urethroplasty.4 Clearly, with recent events involving servicemen in Operation Iraqi Freedom and Operation Enduring Freedom, the number of injuries involving the genitalia arising from improvised explosive devices has increased dramatically, which may account for some of the reported increased usage of urethroplasty. These authors have suggested this may be related to the number of reconstructive fellowships in the United States associated with academic medical centers and Veterans Affairs facilities. The same authors have suggested that younger certified surgeons maybe

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more comfortable with urethroplasty compared with other urologic surgeons given this experience in recent years. There are a number of laboratories conducting critical research in the development of tissue engineered materials for utilization in urethral reconstruction.5,6 When this technology becomes approved for human usage, the urologic surgeon’s choices will be vastly improved. Urethroplasty may very well become the treatment of choice, especially for long strictures. I suspect this will drive patients to centers of excellence where surgeons with such experience in both urethral reconstruction and tissue engineered materials have high rates of success. The role of internal urethrotomy and repeat urethral dilation for long urethral strictures is clearly limited as evidenced by the high success as reported in this series. Mitchell H. Bamberger, M.D., M.B.A., F.A.C.S., Department of Urology, University of Massachusetts Medical School, Worcester, MA

References 1. Warner JN, Malkawi I, Dhradkeh M, et al. A multi-institutional evaluation of the management and outcomes of long-segment urethral strictures. Urology. 2015;85:1483-1488. 2. Breyer BN, McAninch JW, Whitson JM, et al. Multivariate analysis of risk factors for long-term urethroplasy outcome. J Urol. 2010;183: 613-617. 3. Levine MA, Kinnaird AS, Rourke KF. Revision urethroplasty success is comparable to primary urethroplasty: a comparative analysis. Urology. 2014;84:928-933. 4. Lacy JM, Cavallini M, Bylund JR, et al. Trends in the management of male urethral stricture disease in the veteran population. Urology. 2014;84:1506-1510. 5. Osman NI, Hillary C, Bullock AJ, et al. Tissue engineered buccal mucosal for urethroplasty: progress and future directions. Adv Drug Deliv Rev. 2014;82-83:69-76. 6. Huang JW, Xie MK, Zhang Y, et al. Reconstruction of penile urethra with the 3-dimensional porous bladder acellular matrix in a rabbit model. Urology. 2014;84:1499-1505.

http://dx.doi.org/10.1016/j.urology.2015.01.042 UROLOGY 85: 1488, 2015. Published by Elsevier Inc.

UROLOGY 85 (6), 2015