1
162 LETTERS TO THE EDITOR to achieve rectal continence with a program of regular bowel evacu- ation. Any acceleration of intestinal transit is detrimental to rectal control.'-4 After reading this report, I continue to stand by my recommendation to avoid the use of the ileocecal segment in myelo- meningocele patients. Respectfully, Ricardo Gonzalez Department of Urologic Surgery Section of Pediatric Urology University of Minnesota Medical School Box 45 Mayo Memorial Building 420 Delaware Street, S.E. Minneapolis, Minnesota 55455 1. Gonzalez, R., Sidi, A. A. and Zhang, G.: Urinary undiversion: indications, techniques and results in 50 cases. J. Urol., 136: 13,1986. 2. Gonzalez, R. and Cabral, B. H. P.: Rectal continence &r en- terocystoplasty. Dial. Ped. Urol., 10: 4, December 1987. 3. Gonzalez, R. and Sidi, A. A: The use of bowel in the reconstruc- tion of the urinary tract in children. In: Modem Technics in Surgery. Edited by R. Ehrlieh. Mount Kisko, New York: Fu- tura Publishing Co., pp. 42.1-42.21, 1988. 4. Gonzalez, R.: Bladder augmentation with sigmoid or descending colon. In: Reconstructive Urology. Edited by G. Webster, R. Kirby, L. King and B. Goldwasser. Oxford Blackwell Scien- tific, vol. 1, chapt. 30, p. 433,1993. Reply by Authors. Only patients 4,9 and 11 of t h e 12 patients mentioned in our article had myelomeningocele and, in contrast to the comment of Doctor Gonzalez, stool frequency did not increase in any of these patients. To date, we have reconstructed the ileocecal valve during conti- nent urinary diversion in 10 patients with myelomeningocele. Four patients have identical bowel habits &r urinary diversion and ileocecal reconstruction, and stool frequency has even normalized in 4 suffering from diarrhea preoperatively. Only 2 of these 10 patients have irregular defecations: 1 underwent diversion only 7 weeks ago and 1 has constipation and diarrhea, although preoperatively he had diarrhea 3 to 4 times a day! The implementation of alternative forms of urinary diversion as suggested by Gonzalez whereby the reservoir is constructed from ileum does not decrease the risk of diarrhea in myelomeningocele patients, since a substantial amount of small bowel must be resected during these procedures. We are currently undertaking experiments to determine intestinal transit time preoperatively, and after continent urinary diversion and ileocecal valve reconstruction. Nonetheless, with experience with 40 myelomeningocele patients in our entire series of more than 400 Mainz pouch I operations, ileocecal valve reconstruction pro- duces the most beneficial clinical results in myelomeningocele pa- tients. RE: VESICAL LITHIASIS: OPEN SURGERY VERSUS CYSTOLITHOTRIPSY VERSUS EXTRACORPOREAL SHOCK WAVE THERAPY V. Bhatia and C. S. Biyani J . Urol., 151: 660-662,1994 To the Editor. I do not believe that extracorporeal shock wave lithotripsy (ESWL*) has any role in the treatment of bladder stones. There is no substitute for lithotripsy done under direct vision. ESWL will not completely fragment stones in all cases and, therefore, cystoscopy may be required. With the advent of laser lithotripsy and more refined electrohydraulic lithotripsy techniques, I do not believe there is any excuse for performing ESWL on a patient with bladder stones. Perhaps in Kuwait City this is an option that patients will accept. However, in Columbus, Ohio I doubt if most of our patients * Dornier Medical Systems, Inc., Marietta, Georgia. would accept 45 minutes of ESWL therapy to the genital region. I know I would not. Respectfully, William J. Somers Division of Urology Ohio State University Medical Center 456 West 10th Avenue Columbus, Ohio 43210-1228 Reply by Authors. We certainly have electrohydraulic lithotripsy, ultrasound and laser lithotripsy in our department and a compara- tive study with ESWL for vesical stones is under consideration for publication. We do not consider ESWL to be a panacea for vesical stones but continue to be convinced about its simplicity, safety and low complication rate over transurethral endoscopic techniques.' We also perform strictly outpatient ESWL for bladder stones in select patients insisting on noninvasive therapy.2 We believe that the salient advantages of ESWL are avoidance of anesthesia, shortest catheterization time and minimal hospital stay. We, of course, do not recommend it as an absolute substitute for direct vision lithotripsy but do include it in our therapeutic options for vesical stones. 1. Bhatia, V. and Biyani, C. S.: A comparative analysis of cysto- lithotripsy and ESWL for bladder stones. Int. Urol. Nephrol., in press. 2. Bhatia, V. and Biyani, C. S.: Outpatient ESWL therapy for vesical lithiasis. Jap. J. Endourol. ESWL, in press. RE: PERIURETHRAL INJECTION OF AUTOLOGOUS FAT FOR THE TREATMENT OF SPHINCTERIC INCONTINENCE R. P. Santarosa and J. G. Blaiuas J. Urol., 151: 607-611,1994 To the Editor. The authors presented their early experience with periurethral injection of autologous fat in treating sphincteric incon- tinence. Their conclusions, however, seem to be excessively optimis- tic. The injection of autologous fat is not a new idea. The method was actually tested 100 years ago' and subsequently abandoned because of discouraging long-term results? As stated by the authors, the ultimate fate of the injected fat is the subject of controversy. In our opinion, the answer depends on the nature of aspirated material, which is approximately 25% blood3 and the remainder consists of fragments with destroyed fat cells at the periphery. It seems difficult to suppose that fat cells removed by strong aspiration can tolerate the trauma of harvesting and transplantation without undergoing cellular lysis. Moreover, the injection of broken cell pieces and fat causes mainly a foreign body reaction that, at best, could result in total resorption of the injected material in the long term.4 The implant of fat tissue has a rationale if unimpaired adipose lobules are used and all artifacts due to fragmentation during har- vest are avoided. McFarland postulated that reimplanted fat derives nutrients osmotically from surrounding extracellular fluid before vascularization by host blood vessel^.^ Nevertheless, a good perfu- sion supposes the existence of favorable volume-to-surfaceratio as in small adipose tissue fragment reimplantation. In the proposed tech- nique fat fragments are pressed together so that the theoretical advantages of a favorable volume-to-surface ratio is lost. It is also noteworthy that the fragments have no anatomical relationship, so that revascularization of 1 fragment does not affect adjacent frag- ments, since there is no vascular connection between them. This results in extensive necrosis in the adipose tissue graft. The report released in 1987 by the Ad Hoc Committee on New Procedures of the American Society of Plastic and Reconstructive Surgeons concluded that only 30% of injected fat can be expected to survive for 1 year.6 A preliminary report by Weber indicated only a 10% survival rate of fat graft^.^ Presently, it appears that little, if any, of the injected autologous fat survives at the new site for 1 year.' The long-term persistence of oil cysts makes it obvious why failure of the graft may not be fully apparent until months after implanta- tion. This finding also helps to explain the good short-term and discouraging long-term results of autologous fat injections reported in the literature. The report by the authors of an 84% overall success rate at 1 year seems even more impressive because the results are different from

Re: Vesical Lithiasis: Open Surgery Versus Cystolithotripsy Versus Extracorporeal Shock Wave Therapy

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Page 1: Re: Vesical Lithiasis: Open Surgery Versus Cystolithotripsy Versus Extracorporeal Shock Wave Therapy

162 LETTERS TO THE EDITOR

to achieve rectal continence with a program of regular bowel evacu- ation. Any acceleration of intestinal transit is detrimental to rectal control.'-4 After reading this report, I continue to stand by my recommendation to avoid the use of the ileocecal segment in myelo- meningocele patients.

Respectfully, Ricardo Gonzalez Department of Urologic Surgery Section of Pediatric Urology University of Minnesota Medical School Box 45 Mayo Memorial Building 420 Delaware Street, S.E. Minneapolis, Minnesota 55455

1. Gonzalez, R., Sidi, A. A. and Zhang, G.: Urinary undiversion: indications, techniques and results in 50 cases. J. Urol., 136: 13, 1986.

2. Gonzalez, R. and Cabral, B. H. P.: Rectal continence &r en- terocystoplasty. Dial. Ped. Urol., 10: 4, December 1987.

3. Gonzalez, R. and Sidi, A. A: The use of bowel in the reconstruc- tion of the urinary tract in children. In: Modem Technics in Surgery. Edited by R. Ehrlieh. Mount Kisko, New York: Fu- tura Publishing Co., pp. 42.1-42.21, 1988.

4. Gonzalez, R.: Bladder augmentation with sigmoid or descending colon. In: Reconstructive Urology. Edited by G. Webster, R. Kirby, L. King and B. Goldwasser. Oxford Blackwell Scien- tific, vol. 1, chapt. 30, p. 433, 1993.

Reply by Authors. Only patients 4, 9 and 11 of the 12 patients mentioned in our article had myelomeningocele and, in contrast to the comment of Doctor Gonzalez, stool frequency did not increase in any of these patients.

To date, we have reconstructed the ileocecal valve during conti- nent urinary diversion in 10 patients with myelomeningocele. Four patients have identical bowel habits &r urinary diversion and ileocecal reconstruction, and stool frequency has even normalized in 4 suffering from diarrhea preoperatively. Only 2 of these 10 patients have irregular defecations: 1 underwent diversion only 7 weeks ago and 1 has constipation and diarrhea, although preoperatively he had diarrhea 3 to 4 times a day!

The implementation of alternative forms of urinary diversion as suggested by Gonzalez whereby the reservoir is constructed from ileum does not decrease the risk of diarrhea in myelomeningocele patients, since a substantial amount of small bowel must be resected during these procedures.

We are currently undertaking experiments to determine intestinal transit time preoperatively, and after continent urinary diversion and ileocecal valve reconstruction. Nonetheless, with experience with 40 myelomeningocele patients in our entire series of more than 400 Mainz pouch I operations, ileocecal valve reconstruction pro- duces the most beneficial clinical results in myelomeningocele pa- tients.

RE: VESICAL LITHIASIS: OPEN SURGERY VERSUS CYSTOLITHOTRIPSY VERSUS EXTRACORPOREAL SHOCK

WAVE THERAPY

V. Bhatia and C. S. Biyani

J . Urol., 151: 660-662, 1994

To the Editor. I do not believe that extracorporeal shock wave lithotripsy (ESWL*) has any role in the treatment of bladder stones. There is no substitute for lithotripsy done under direct vision. ESWL will not completely fragment stones in all cases and, therefore, cystoscopy may be required. With the advent of laser lithotripsy and more refined electrohydraulic lithotripsy techniques, I do not believe there is any excuse for performing ESWL on a patient with bladder stones. Perhaps in Kuwait City this is an option that patients will accept. However, in Columbus, Ohio I doubt if most of our patients

* Dornier Medical Systems, Inc., Marietta, Georgia.

would accept 45 minutes of ESWL therapy to the genital region. I know I would not.

Respectfully, William J. Somers Division of Urology Ohio State University Medical Center 456 West 10th Avenue Columbus, Ohio 43210-1228

Reply by Authors. We certainly have electrohydraulic lithotripsy, ultrasound and laser lithotripsy in our department and a compara- tive study with ESWL for vesical stones is under consideration for publication. We do not consider ESWL to be a panacea for vesical stones but continue to be convinced about its simplicity, safety and low complication rate over transurethral endoscopic techniques.' We also perform strictly outpatient ESWL for bladder stones in select patients insisting on noninvasive therapy.2 We believe tha t the salient advantages of ESWL are avoidance of anesthesia, shortest catheterization time and minimal hospital stay. We, of course, do not recommend it as an absolute substitute for direct vision lithotripsy but do include it in our therapeutic options for vesical stones.

1. Bhatia, V. and Biyani, C. S.: A comparative analysis of cysto- lithotripsy and ESWL for bladder stones. Int. Urol. Nephrol., in press.

2. Bhatia, V. and Biyani, C. S.: Outpatient ESWL therapy for vesical lithiasis. Jap. J. Endourol. ESWL, in press.

RE: PERIURETHRAL INJECTION OF AUTOLOGOUS FAT FOR THE TREATMENT OF SPHINCTERIC INCONTINENCE

R. P. Santarosa and J. G. Blaiuas

J. Urol., 151: 607-611, 1994

To the Editor. The authors presented their early experience with periurethral injection of autologous fat in treating sphincteric incon- tinence. Their conclusions, however, seem to be excessively optimis- tic. The injection of autologous fat is not a new idea. The method was actually tested 100 years ago' and subsequently abandoned because of discouraging long-term results? As stated by the authors, the ultimate fate of the injected fat is the subject of controversy. In our opinion, the answer depends on the nature of aspirated material, which is approximately 25% blood3 and the remainder consists of fragments with destroyed fat cells at the periphery. It seems difficult to suppose that fat cells removed by strong aspiration can tolerate the trauma of harvesting and transplantation without undergoing cellular lysis. Moreover, the injection of broken cell pieces and fat causes mainly a foreign body reaction that, at best, could result in total resorption of the injected material in the long term.4

The implant of fat tissue has a rationale if unimpaired adipose lobules are used and all artifacts due to fragmentation during har- vest are avoided. McFarland postulated that reimplanted fat derives nutrients osmotically from surrounding extracellular fluid before vascularization by host blood vessel^.^ Nevertheless, a good perfu- sion supposes the existence of favorable volume-to-surface ratio as in small adipose tissue fragment reimplantation. In the proposed tech- nique fat fragments are pressed together so that the theoretical advantages of a favorable volume-to-surface ratio is lost. It is also noteworthy that the fragments have no anatomical relationship, so that revascularization of 1 fragment does not affect adjacent frag- ments, since there is no vascular connection between them. This results in extensive necrosis in the adipose tissue graft.

The report released in 1987 by the Ad Hoc Committee on New Procedures of the American Society of Plastic and Reconstructive Surgeons concluded that only 30% of injected fat can be expected to survive for 1 year.6 A preliminary report by Weber indicated only a 10% survival rate of fat graft^.^ Presently, it appears that little, if any, of the injected autologous fat survives a t the new site for 1 year.'

The long-term persistence of oil cysts makes it obvious why failure of the graft may not be fully apparent until months after implanta- tion. This finding also helps to explain the good short-term and discouraging long-term results of autologous fat injections reported in the literature.

The report by the authors of an 84% overall success rate a t 1 year seems even more impressive because the results are different from