Comments on: Comparison of three different endoscopic techniques in management of bladder calculi.

Sir,

I read with great interest the recently published article entitled “Comparison of three different endoscopic techniques in management of bladder calculi” by Singh KJ and Kaur J.[1] I would like to thank the authors for sharing their experience in managing bladder calculi using three different endoscopic techniques. Their study was very comprehensive on comparing various endoscopic methods for urinary bladder calculi treatment. The authors provide the result of significant advantages of transurethral stone removal through nephroscope over percutaneous removal with nephroscope. The data showed significantly less in operative time (32.1 + 8.5 minutes over 46 + 7.3 minutes) and operative stay (1.4 + 0.6 days over 2.1 + 0.15 days) as listed in [Table 1].[1] Both had P-value of 0.005.[1] This is contrast to other previous two studies by Aron M. et al.[23] On analyzing this article I noted that the authors combined both male and female patients in the sample size calculation with ratio of 3:1. It showed significant number of female patients were included in this study. It is well-known that transurethral surgery for male and female has marked difference due to anatomical variety. In female patient, naturally urethral length is short and almost similar to percutaneous tract which is an advantage in transurethral surgery. This is because of readily similar length of excess in transurethral stone removal without added procedure (excess creation). Thus, I predict that this study outcome may be in favour of percutaneous stone removal if the authors did sub-group analysis comparing only male patients in both groups, as what have been done in the previous two studies by Aron M. et al, where they found that percutaneous stone removal took less than half of the time required for transurethral stone removal.[23] Besides that, the authors also published the data of multiple perurethral entries during transurethral surgery compared to percutaneous procedure (3.2 + 0.6 vs 1.04 + 0.04). This will increase the risk of urethral stricture during managing large bladder stone especially in male patients.[23] Thus, it will give other added morbidity for transurethral stone removal. In conclusion, this article gives a big doubt for me, due to an indiscriminate combination of male and female patients while the procedures have marked difference in technical difficulty and morbidities between these two groups of patients. I believe that percutaneous route has more advantages than transurethral route in managing large bladder stone for male and pediatric patients in view of minimal handling of urethra during prolonged surgery.