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: [email protected] (K. D’Hauwers).
April 3, 2013
Published online on April 11, 2013
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