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LETTERS TO THE EDITOR |
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| Year : 2021 | Volume
: 26
| Issue : 3 | Page : 210-212 |
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Insight into posterior urethral valve management: My two cents
Yogesh Kumar Sarin
Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India
| Date of Submission | 10-Mar-2021 |
| Date of Acceptance | 24-Mar-2021 |
| Date of Web Publication | 17-May-2021 |
Correspondence Address:
Prof. Yogesh Kumar Sarin
Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi - 110 001
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.JIAPS_38_21
How to cite this article:
Sarin YK. Insight into posterior urethral valve management: My two cents. J Indian Assoc Pediatr Surg 2021;26:210-2 |
Sir,
I read with interest the article published on insight into the posterior urethral valve (PUV) by Chatterjee et al.[1] and its criticism by Babu and Chandrasekharam.[2] Although I broadly agree with the criticism, especially the use of double J stent to overcome the vesicoureteral obstruction in patients, and difficulty of performing urodyanmic studies (UDS) on infants and using those findings for the management of subsequent bladder management. I also agree with Babu and Chandrasekharam[2] that higher incidence of end-stage renal disease in the cohorts treated by second and third authors could be a chance finding, as there could be multiple confounding factors and that Chatterjee should conduct a random controlled study with and without primary bladder neck incision (BNI) for PUV patients.
I liked the original paper for its novelty and originality and would like to filter out the thoughts, hypothesis, and results of only the first author – Chatterjee. The other two authors have mostly used the management of PUV on the lines which parallel the general consensus. In fact, the second author was a coauthor of a consensus statement that was published in JIAPS recently.[3]
Chatterjee tries to build a case of the role played by external urethral sphincter (referred to as to rhabdosphincter) in the management of PUVs and hypothesises the role of thermal dissipation, longer catheterization, and balloon pull of rhabdosphincter as the adjunct or hidden (unproved) mechanisms to take care of the overactive or unresponsive external urethral sphincter. He also then mentions the use of BNI for primary and secondary indications in [Table 2].[1] I am terrified on the very thought of patient of PUV having has both internal sphincter (bladder neck) and external sphincters incised/damaged; this boy would be rendered incontinent of life even if the bladder above behaves.
In spite of having statistically insignificant advantage of BNI in our pilot study,[4] I have continued to perform BNI as a primary adjunct along with the primary endoscopic visual incision (PEVI) of the PUV, because of the type of the clientele we deal with; they come from far, have poor compliance to intake of alpha-blockers and poor follow-ups as also seen by Chatterjee et al.[1] However, learning from the adult urology colleagues that the risk of injury to external sphincter lies more while working at 5'o and 7'o clock positions, have changed the policy of performing PEVI at 5'o, 7'o, and 12'o clock positions to a single incision at 12'o clock position, precisely to avoid the double whammy of damaging both the sphincters.
I also have reservations about excluding voiding cystourethrogram (VCUG) from the initial diagnostics. I understand that they are few authors who have done that previously and successfully using sickle-shaped cold knife.[5] The concept of different severity of PUV has been beautifully elucidated by Nakai et al.[5] They emphasize that, in case, the valves are not seen in the 5'o and 7'o clock positions, one should look for the more distally located thick anterior fusion. The use of Bugbee at 5'o and 7'o clock positions in such mild valves is asking for trouble. One could land up having thermal injury to the urethral mucosa and/or damage to the external sphincter.
I also detest the idea of performing Crede's maneuver to check the urinary flow after incising the valves; this shall push the infusion fluid present in the bladder up under pressure to the already compromised kidneys. So let us not propagate approximating the cusps of PUV by suprapubic pressure.
I concur with authors[1] that some of the patients of PUV would eventually need ureteral reimplantation, but this could be achieved only after a proper bladder management. VUJO in PUV patients is secondary to high detrusor pressures and seldom to intrinsic primary obstruction. Hence reimplantation should be reserved only in those patients where major grade symptomatic vesicoureteral reflux does not get resolved after proper bladder management.
Although I like and applaud the lateral thinking, I would look forward to hear more from Chatterjee regarding evidence-based research (beyond conjectures and hypothesis) on the role of external urethral sphincter in patients of PUV.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 Author’s Reply | |  |
Thank you so much for your scholastic curiosity toward our article published[1] as well as your appreciation (although selective) toward novelty and originality in our thoughts and hypothesis. We believe that our discourse would help readers a lot.
This article has shown our main concern on obstruction at various gateways of urine transport. We have shown our concern essentially on ureterovesical junction obstruction (UVJO), not on “yoyo vesicoureteric reflux (VUR).” We have already mentioned in previous letter that urinary tract infection (UTI) occurs due to “stasis of urine” and UVJO contributes to that. Combo of UTI and UVJO is further harmful than simple “yoyo VUR,” i.e., without stasis.
Yes, “multiple confounding factors:” Similar phrases are very common, popular, and consoling adage and pop up in the management of posterior urethral valve (PUV), particularly to offset wearisome outcome. This index study was done to find those factors responsible and disguised as so-called “multiple confounding factors!” Incidence of end-stage renal failure in the cohorts treated by the second and third authors is 9% and 5%, respectively, much lower compared (25%–50%) to other literature.[2]
“Terrified on… thought…:” Yes, you are absolutely exact, it looks so at the outset. At inception, some novel concepts/techniques/procedures, with high innovative threshold that does not parallel to or validates convention, might have been terrifying, e.g., gastrocystostomy (horrifying collection of hydrochloric acid in the cyst), clean intermittent catheterization (horrifying UTI), Frayer's enucleation of the prostate (terrifying blind procedure), transurethral resection of the prostate (TURP) (terrified thermal damages of continence; setback for decades), lap-cholecystectomy (innovator was behind the bars), and buried strip concept (hypothesis of regeneration; difficult to digest even after 70 years), and some were highly unbelievable at initiation, e.g., Ramstead's and Heller's myotomy. However, those shocks and suspicions gradually got diluted through pragmatic discourse. We have not done or used horrific phrase such as “external sphincter incision” or we have not “damaged external sphincter.” Rather, we have used tolerable phraseology, e.g., “dissipation of thermal energy to neutralize/alleviate the spasm” as a mechanistic explanation for relief of obstruction following fulguration of PUV.
Bladder neck incision (BNI) is made on the neck which is “pathophysiologically overkill and causes obstruction,” not a normal neck (akin to cholecystectomy done on cholecystitis; not on normal gallbladder)! Although “horrifying”…. We have to incise full thickness of the bladder neck muscle for BNI to get significant changes in UDS. Incision only on the mucosa would not be sufficient.
Adult urologists use cutting loop which is equivalent to 30–40 dots of Bugbee tip and power of cutting current in TURP is ~6–7 times compared to PUV fulguration. Nevertheless, they resect the portion of adenoma at 5'O, 7'O clock, near verumontanum, called apical lobe; bearing the closeness of rhabdosphincter in mind. That is why thermal injury, damage of external sphincter and incontinence following TURP is extremely rare. We have not yet found urethral incontinence, urethral stricture following PUV fulguration.
Thank you for your “reservations about excluding voiding cystourethrography…” it is a personal preference and an option, but not a recommendation.
You might have “detest” for Crede's maneuver; however, we have no “detest” in doing Crede's maneuver only during fulguration of PUV, unlike routine advice in neurogenic bladder for regular evacuations. Few impulses during the procedure are causing further renal functional damage… Difficult to stomach! Otherwise, coughing and sneezing in those patients with VUR would have deteriorated renal function.
Yes, we agree regarding reimplantation. However, we have mentioned in our index article that we might do reimplantation in UVJO, not for “yoyo VUR,” to preserve renal function. Even in high-grade “yoyo VUR,” we manage conservatively and do follow up with creatinine clearance and/or DTPA renogram.
To exclude UVJO, we recommend a delayed film in all micturating cystourethrogram, to check residual contrast in ureters following evacuation of contrast from the bladder with the same catheters. There is no other investigation to diagnose horrific association of UVJO with VUR, and for the same, combo of UVJO and VUR is not yet identified in the global literature.
Conjectures and hypotheses are the base foundation for social and scientific progress, and progress is landmarked by outcome in “evidence-based research.” We are also doing further research on rhabdosphincter spasm and expecting research from all interested readers.
Thank you again for your appreciation and applaud for our “lateral thinking” reproduced in index article.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
Chatterjee US, Basu AK, Mitra D. Insight into posterior urethral valve from our experience: Paradigm appended to abate renal failure. J Indian Assoc Pediatr Surg 2020;25:297-305.
Sharma S, Joshi M, Gupta DK, Abraham M, Mathur P, Mahajan JK, et al. Consensus on the management of posterior urethral valves from antenatal period to puberty. J Indian Assoc Pediatr Surg 2019;24:4-14.
| References | | |
| 1. | Chatterjee US, Basu AK, Mitra D. Insight into posterior urethral valve from our experience: Paradigm appended to abate renal failure. J Indian Assoc Pediatr Surg 2020;25:297-305.  [Full text] |
| 2. | Babu R, Chandrasekharam VV. Insight into posterior urethral valve management. J Indian Assoc Pediatr Surg 2021;26:137-8. [Full text] |
| 3. | Sharma S, Joshi M, Gupta DK, Abraham M, Mathur P, Mahajan JK, et al. Consensus on the management of posterior urethral valves from antenatal period to puberty. J Indian Assoc Pediatr Surg 2019;24:4-14. [ PUBMED] [Full text] |
| 4. | Sarin YK, Sinha S. Efficacy of bladder neck incision on urodynamic abnormalities in patients with posterior urethral valves. Pediatr Surg Int 2013;29:387-92. |
| 5. | Nakai H, Hyuga T, Kawai S, Kubo T, Nakamura S. Aggressive diagnosis and treatment for posterior urethral valve as an etiology for vesicoureteral reflux or urge incontinence in children. Investig Clin Urol 2017;58:S46-53. |
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