children. Eur J Surg Oncol, 23: 538, 199713. Izarn, R., Lorthioir, J. M., Gakwandi, O., Baryama, A., Mugongo,

B. and Nibogora, D.: [An alternative to cesarean section: sym-physiotomy (Zarate’s operation).] Med Trop (Mars), 43: 83,1983

14. Bergstrom, S., Lublin, H. and Molin, A.: Value of symphysiotomyin obstructed labour management and follow-up of 31 cases.Gynecol Obstet Invest, 38: 31, 1994

15. Menticoglou, S. M.: Symphysiotomy for the trapped aftercomingparts of the breech: a review of the literature and a plea for itsuse. Aust N Z J Obstet Gynaecol, 30: 1, 1990

16. Verkuyl, D. A.: Symphysiotomies are important option in devel-oping world. BMJ, 323: 809, 2001

EDITORIAL COMMENT

These authors revisit a unique surgical adjunct to the difficultproblem of posterior urethroplasty after urethral distraction injury,namely symphysiotomy. Symphysiotomy for stricture was initiallypresented in the 1960s and 1970s but few reports have appeared inthe more recent literature. The procedure has its advocates. It seemsrobust when used in difficult incontinence cases, such as extensivesoft tissue tumors in childhood and urethroplasty in adulthood inolder reports. Symphysiotomy has been used extensively in develop-ing countries to assist childbirth in cases of cephalopelvic dispropor-tion with acceptably low orthopedic complications.

Symphysiotomy is likely to have limited use in adults but it may beuseful in children or after failed primary repairs, for which mostgroups advocate pubectomy and subsequent transpubic repair.These authors used the less invasive method of symphysiotomy in 2such cases, which perhaps may be how symphysiotomy would bemost used and useful. Transpubic urethroplasty may also be advo-cated in children. In contrast to the usual excellent results obtainedby perineal repair of posterior urethral stricture reported in adults,Flynn et al recently reported a dismal 50% failure rate in maleadolescents who underwent perineal posterior urethroplasty.1Podesta also noted a 26% lower success rate when he performedurethroplasty perineally instead of transpubically (abdominoperine-ally) in children (reference 8 in article). Perhaps transpubic repairsare more advisable in children than in adults and perhaps sym-physiotomy is the way to affect these repairs with the least trouble topatient and surgeon.

I and others may be tempted to use this approach in rare cases inwhich we still may use the transpubic approach for adult urethro-plasty. It is unknown whether this report of symphysiotomy inchildren predicts similar success in adults, although studies from the1970s suggest that it may. It may not even be possible in adults sincethe less pliable adult pelvis may not distract sufficiently in all casesto provide surgical access.

Situations that would cause hesitation in the use of symphysiot-omy would be an unstable pelvic fracture or a pelvic fracture thatwould become unstable if symphysiotomy was performed, as whenthere already exists a site of pelvic nonunion and the addition ofsymphysiotomy would create a freely floating pelvic segment. Manyurologists have a natural aversion to operating on the skeleton andperhaps we are right to use caution. Osteitis pubis and symphysealnonunion are potential orthopedic complications of this procedure.Nevertheless, with these cautions in mind these authors seem tohave resurrected a useful tool from the past.

Richard A. SantucciDepartment of UrologyDetroit Receiving HospitalWayne State University School of MedicineDetroit, Michigan

1. Flynn, B. J., Delvecchio, F. C. and Webster, G. D.: Perinealrepair of posterior urethral stricture and defect: experience in79 cases in the last 5-years. J Urol, suppl., 167: 15, abstract 60,2002

REPLY BY AUTHORS

As we mentioned, the more cephalad location of the pelvic visceramakes transpubic surgery seem particularly appealing for children.This assumption is supported by the significantly better resultsgained in treating pediatric urethral stricture via transpubic surgeryinstead of the classic perineal route (reference 8 in article and ref-erence 1 in editorial comment). Santucci is correct about the reluc-tance of most urologists to manipulate bone. This fact alone mayhave pushed symphysiotomy into the shadows such that few articleshave ever reported its use for urethral stricture in children. Based onnumerous reports available on pubic resection (reference 5 in arti-cle)1 and our own experience with pubectomy and symphysiotomy,we do not believe such fear of orthopedic complications to be justified.Most cases of osteitis pubis attributed to symphysiotomy have oc-curred when it was resorted to immediately in a less than optimal(frequently rural) setting in adults with obstructed labor. Peters et aland Hendren encountered no case of nonunion or osteitis in theirseries of symphysiotomy for nonstricture pathology (reference 4 inarticle). Even their 2 cases of simultaneous ileal osteotomy had astable pelvis after the intervention. In the manner described, sym-physiotomy reapposes the pelvic girdle ventrally with almost noinvasion of the bone, which would leave most pelvic fractures in thesame condition they were found.

1. Khan, A. U. and Furlow, W. L.: Transpubic urethroplasty.J Urol, 116: 447, 1976

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