LAUSR

In their recent article, Zumstein et al. describe the operative technique and report outcomes from the largest series of patients who underwent single stage dorsal inlay buccal mucosal graft urethroplasty (BMGU) for isolated meatal stenosis and fossa navicularis strictures) [1]. Based on their results, they have advocated inlay BMGU as a valid and efficient last-resort single-stage technique. Since its initial description of usage of oral mucosal graft to augment stricture urethra by the Russian surgeon Saphezko in 1894, substitution urethroplasty with buccal mucosa has become the standard of care for most anterior urethral strictures ranging in length from short segment to pan anterior urethral strictures [2]. Here, the authors have described their short-term outcomes with BMGU for a specific location of strictures namely, the meatus and the fossa navicularis. As the authors have rightly pointed out, when it comes to the fossa navicularis strictures there have been close to 20 procedures described ranging from the simplest meatotomy to flap urethroplasty to substitution urethroplasty and we congratulate the authors for their successful outcomes with their BMG inlay technique [3]. However, some methodological issues need to be discussed. The authors have described their patient group as a “homogenous” group which is far from true. We noted with interest that of the 32 patients included in the study nearly 50% are post-hypospadias strictures. For long this has been the bane of papers describing specific procedures on the urethra, where post hypospadias “strictures” have been included as part of the cohort. It is a known fact that these narrowing of the neourethra cannot be considered as actual strictures as unlike normal urethra they do not have actual spongiosal covering. Further unique issues in theses so called “strictures” include poor vascularity due to previous hypospadias repairs and abnormalities in the ventral dartos which may be a developmental defect or due to the previous surgical intervention [4–8]. Though the authors have shown reasonably good results with their technique, as they say the end should not justify the means and we believe that these posthypospadias strictures should be considered as a separate entity and not be part of cohort of anterior urethral strictures. Another point of potential criticism has to do with the fact that the authors have not defined their failures properly with regards to etiology. It would be of great importance to the readers in knowing the distribution of etiology among the ten patients who had recurrence. We all know that lichen sclerosis-induced strictures have poor results was that the case here also? [9]. Lastly, as the authors have themselves pointed out, we observe that most of the small studies on urethroplasties including the present one have focused on short term outcomes only [10]. We believe long term outcomes are the need of the hour as we need to know whether these grafts stand the test of time and whether the procedure gives durable long-term results. We hope the authors will come up with their long-term results too to benefit the scientific community at large. Nevertheless, the authors need to be congratulated for coming out with their successful outcomes with substitution urethroplasty as most of the urologists tend to take the easy way out by doing a meatotomy or a meatoplasty which though easier to do is cosmetically unappealing to the patient. This can also lead to future research activities such as designing a randomized clinical trial that will further improve the quality of the available evidence. This comment refers to the article available online at https ://doi. org/10.1007/s0034 5-019-03035 -8.