E U R O P E A N U R O L O G Y 6 4 ( 2 0 1 3 ) e 6 – e 7

avai lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Letter to the Editor

Re: Katja Kero, Jaana Rautava, Kari Syrjanen,

Seija Grenman, Stina Syrjanen. Oral Mucosa as a Reservoir

of Human Papillomavirus: Point Prevalence, Genotype

Distribution, and Incident Infections Among Males in a

7-year Prospective Study. Eur Urol 2012;62:1063–70

Should men sample the urethra after buccal mucosa repair?

We read the article by Kero and co-workers [1], along with

the subsequent discussion, with interest. The authors found

a fluctuation of oral human papillomavirus (HPV) from

15.1% to 31.1% during the 7-yr follow-up of 131 young men.

Worldwide, the incidence of oropharyngeal HPV-related

cancers has increased significantly, from 41% (in 2000) to

72% (after 2004); this finding suggests that today, HPV,

instead of tobacco and alcohol, is the most important cause

of oropharyngeal squamous cell carcinoma [2]. However,

the relationship between HPV and oral cavity cancers is not

established yet.

The first use of buccal mucosa for urethral repair was in

1992 [3]. Since then, buccal mucosa has been widely used

for urethral repairs. Should we be afraid that these patients

are at risk for developing urethral cancer? First, the

incidence of urethral cancer is low: 1%–2% of all urologic

cancers, with a female-to-male ratio of 4 to 1. Its

relationship to HPV is unknown. Second, reports on urethral

HPV screening lead to conflicting results. Giovannelli et al.

[4] found that a sampling combination of penile shaft and

urethra was most effective in finding genital HPV (100%),

with the urethral brushing being HPV positive in 50.0%. In

contrast, Giuliano et al. [5] found the lowest detection of

HPV in the urethra (10.1%). Third, the sampling brush will

not always reach the place of transplantation, and it will

screen only the more distal part of the urethra.

According to the most relevant HPV-related diseases,

screening programs have been organized for the cervix and

the anus (both genders, in high-risk groups). Self-sampling

kits have been developed to increase participation in

screening programs.

Would urethral self-sampling in men be feasible?

We asked 10 heterosexual, healthy males to perform a

urethral self-sampling with an interval of 1 wk, once with a

cotton-tipped swab and once with an EndoCervex-Brush-S

DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.06.045.

0302-2838/$ – see back matter # 2013 European Association of Urology. Phttp://dx.doi.org/10.1016/j.eururo.2013.04.003

(Rovers Medical Devices, The Netherlands). Adequacy of

samples was obtained in 100% and 70%, respectively. None

of the samples was HPV positive. All men rated the sampling

as painful; two men would refuse another urethral

sampling.

Should we screen or self-screen every man after a buccal

mucosa urethral repair? HPV infections mostly occur in a

transient way. A detected HPV might be innocent, and a

brush might miss the actual HPV infection. Urethral

sampling or self-sampling is feasible, but screening means

sampling on a regular basis, which would be hampered by

the painfulness of the examination.

At this moment, there is no link between HPV and urethral

cancer. If the current increase in oral HPV is found to be

related to an increase in urethral cancer, it will be elucidated

only in 20–40 yr. One could wonder if this revolutionary

operative technique, which has proved its usefulness many

times, should be abandoned at this stage. In light of the

findings of Kero et al., however, it might be useful to monitor

all patients with a buccal urethroplasty on an annual basis so

that urethral tumors may be detected at an early stage.

Conflicts of interest: The authors have nothing to disclose.

References

[1] Kero K, Rautava J, Syrjanen K, Grenman S, Syrjanen S. Oral mucosa

as a reservoir of human papillomavirus: point prevalence, genotype

distribution, and incident infections among males in a 7-year

prospective study. Eur Urol 2012;62:1063–70.

[2] Mehanna H, Beech T, Nicholson T, et al. Prevalence of human

papillomavirus in oropharyngeal and nonoropharyngeal head

and neck cancer — systematic review and meta-analysis of trends

by time and region. Head Neck 2013;35:747–55.

[3] Burger RA, Muller SC, el-Damanhoury H, Tschakaloff A, Riedmiller H,

Hohenfellner R. The buccal mucosal graft for urethral reconstruction:

a preliminary report. J Urol 1992;147:662–4.

[4] Giovannelli L, Migliore MC, Capra G, et al. Penile, urethral, and

seminal sampling for diagnosis of human papillomavirus speci-

mens in men. J Clin Microbiol 2007;45:248–51.

[5] Giuliano AR, Nielson CM, Flores R, et al. The optimal anatomic sites

for sampling heterosexual men for human papillomavirus (HPV)

detection: the HPV Detection in Men Study. J Infect Dis 2007;196:

1146–52.

ublished by Elsevier B.V. All rights reserved.

E U R O P E A N U R O L O G Y 6 4 ( 2 0 1 3 ) e 6 – e 7 e7

Kathleen D’Hauwersa,*

Gunter De Winb

Wiebren Tjalmac

aDepartment of Urology, Radboud University Nijmegen, Medical Centre,

Nijmegen, The NetherlandsbDepartment of Urology, University Hospital Antwerp, Antwerp, Belgium

cUniversity Multidisciplinary Breast Clinic Antwerpen,

University Hospital Antwerp, Antwerp, Belgium

*Corresponding author. Department of Urology, Radboud University

Nijmegen, Medical Centre, Geert Grooteplein Zuid 10–Internal

Route 659, 6525 GA Nijmegen, The Netherlands.

Tel. +31 24 361 37 35; Fax: +31 24 354 10 31.

E-mail address: k.dhauwers@uro.umcn.nl (K. D’Hauwers).

April 3, 2013

Published online on April 11, 2013