ilizing the urine with selective perioperative antibiotics canavoid previously reported infectious complications.10 Properpatient positioning is also of paramount importance becauselithotomy related complications can occur in the pediatricpopulation.10 We believe that the potential for position re-lated problems may be elicited during an office evaluation byplacing the patient in the exaggerated lithotomy position andquestioning about back pain or paresthesias of the lowerextremities.

CONCLUSIONS

Open urethral reconstruction of adolescent and pediatricurethral strictures is associated with excellent long-term re-sults with minimal patient morbidity. Tension-freeepithelium-to-epithelium repair can be accomplished in 1stage via a perineal incision. Due to the importance of repairdurability in the pediatric population open urethral recon-struction should be strongly considered primary treatmentfor pediatric urethral stricture disease. Endoscopic proce-dures should be reserved for patients with short bulbar ure-thral strictures that are associated with minimal spongiofi-brosis.

REFERENCES

1. Leadbetter, G. W., Jr. and Leadbetter, W. F.: Urethral stricturesin male children. J Urol, 87: 409, 1962

2. Harshman, M. W., Cromie, W. J., Wein, A. J. and Duckett, J. W.:Urethral stricture disease in children. J Urol, 126: 650, 1981

3. Noe, H. N.: Long-term followup of endoscopic management ofurethral strictures in children. J Urol, 137: 951, 1987

4. Scherz, H. C. and Kaplan, G. W.: Etiology, diagnosis, and man-agement of urethral strictures in children. Urol Clin NorthAm, 17: 389, 1990

5. Frank, J. D., Pocock, R. D. and Stower, M. J.: Urethral stricturesin childhood. Br J Urol, 62: 590, 1988

6. Madgar, I., Hertz, M., Goldwasser, B., Ora, H. B., Mani, M. andJonas, P.: Urethral strictures in boys. Urology, 30: 46, 1987

7. Gibbons, M. D., Koontz, W. W., Jr. and Smith, M. J. V.: Urethralstrictures in boys. J Urol, 121: 217, 1979

8. Devereux, M. H. and Burfield, G. D.: Prolonged follow-up ofurethral strictures treated by intermittent dilation. Br J Urol,42: 321, 1970

9. Hayden, L. J. and Koff, S. A.: One-stage membranous urethro-plasty in childhood. J Urol, 132: 311, 1984

10. Pritchett, T. R., Shapiro, R. A. and Hardy, B. E.: Surgical man-agement of traumatic posterior urethral strictures in children.Urology, 42: 59, 1993

11. Senocak, M. E., Ciftci, A. O., Buyukpamukcu, N. and Hicsonmez,A: Transpubic urethroplasty in children: report of 10 caseswith review of the literature. J Pediatr Surg, 30: 1319, 1995

12. Waterhouse, K., Abrahams, J. I., Caponegro, P., Hackett, R. E.,Patil, U. B. and Peng, B. K.: The transpubic repair of mem-branous urethral strictures. J Urol, 111: 188, 1974

13. Jordan, G. H.: Penile reconstruction, phallic construction, andurethral reconstruction. Urol Clin North Am, 26: 1, 1999

14. Quartey, J. K. M.: One-stage penile/preputial cutaneous islandflap urethroplasty for urethral stricture: a preliminary report.J Urol, 129: 284, 1983

15. Andrich, D. E. and Mundy, A. R.: Substitution urethroplastywith buccal mucosal-free grafts. J Urol, 165: 1131, 2001

16. Webster, G. D.: Perineal repair of membranous urethral stric-ture. Urol Clin North Am, 16: 303, 1989

17. Chapple, C. R., Goonesinghe, S. K., Nicholson, T. and DeNunzio,C.: The importance of endoscopic surveillance in the follow upof patients with urethral stricture disease. J Urol., suppl., 167:16, abstract 64, 2002

18. Pansadoro, V. and Emiliozzi P.: Internal urethrotomy in themanagement of anterior urethral strictures: long-term fol-lowup. J Urol, 156: 73, 1996

19. Rosen, M. A., Nash, P. A., Bruce, J. E. and McAninch, J. W.: Theactuarial success rate of surgical treatment of urethral stric-tures. J Urol, suppl., 151: 360A, abstract 529, 1994

20. Albers, P., Fichtner, J., Bruhl, P. and Muller, S. C.: Long-termresults of internal urethrotomy. J Urol, 156: 1611, 1996

21. Heyns, C. F., Steenkamp, J. W., de Kock, M. L. S. and Whitaker,P.: Treatment of male urethral strictures: is repeated dilationor internal urethrotomy useful? J Urol, 160: 356, 1998

22. Koraitim, M. M.: Posttraumatic posterior urethral strictures inchildren: a 20-year experience. J Urol, 157: 641, 1997

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EDITORIAL COMMENT

The authors report a series of children with urethral stricturetreated with urethroplasty with excellent results. When one com-pares this series with our report of 20 years previously,1 there areseveral striking differences. The most important difference is themarked decrease in the incidence of iatrogenic strictures. Of 37nonhypospadias strictures in our series 14 were iatrogenic, whereasonly 3 of their 17 were iatrogenic. In addition, they treated noinflammatory strictures, whereas we treated 4 secondary to urethri-tis produced by catheters that were placed atraumatically. Presum-ably an improvement in catheters has resulted in this change sincewe also no longer observe such strictures. The patients in our studywere younger. Median age in our series was 9 years, whereas meanage in their study was 13.4 years.

Classifying stricture etiology remains an area in which there isstill a lack of agreement. Because stricture treatment varies some-what depending on the etiology, classification is of more than aca-demic interest. Congenital strictures occur in children, as did (do?)inflammatory strictures. Iatrogenic strictures are a subtype of trau-matic strictures. Although in the past we have classified stricturesthat develop in the course of idiopathic urethrorrhagia2 as iatrogenic,it is not clear that they are not inflammatory in etiology. Further-more, it is probably best to retain an idiopathic category for cases inwhich there is no clear-cut etiology.

Treatment of stricture in children has changed since our report. Atthat time we were just emerging from the use of repeat dilation,followed by staged repair to the era of 1-stage repair. Dilation as amodality in children has been virtually abandoned. In addition, thereis no question, as the authors state, that repeat direct vision internalurethrotomy has no place in management and even initial directvision internal urethrotomy has only a limited role for short stric-tures. We continue to believe that the transpubic approach has aplace in the management of posterior urethral stricture in smallchildren, in whom the perineal approach is difficult because of anarrow perineum. It may be that the younger age in our series andperhaps also in our current experience has influenced our thinking.

George W. KaplanPediatric Urological AssociatesSan Diego, California

1. Kaplan, G. W. and Brock, W. A.: Urethral strictures in children.J Urol, 129: 1200, 1983

2. Kaplan, G. W. and Brock, W. A.: Idiopathic urethrorrhagia in-boys. J Urol, 128: 1001, 1982

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