LETTERS TO THE EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 137-138
Insight into posterior urethral valve management
Ramesh Babu1, VV S. Chandrasekharam2
1 Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Department of Pediatric Minimally Invasive Surgery, Ankura Childrens Hospital, Hyderabad, Telangana, India
|Date of Submission||17-Sep-2020|
|Date of Decision||22-Sep-2020|
|Date of Acceptance||29-Sep-2020|
|Date of Web Publication||04-Mar-2021|
Dr. Ramesh Babu
Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Babu R, S. Chandrasekharam V V. Insight into posterior urethral valve management. J Indian Assoc Pediatr Surg 2021;26:137-8
We read with interest the article published on insight into the posterior urethral valve (PUV) by Chatterjee et al. There are several concepts that need clarification for junior colleagues.
| Role of Voiding Cystourethrogram|| |
The guidelines on the evaluation of bilateral antenatal hydronephrosis involve a voiding cystourethrogram (VCUG) in all male neonates to rule out PUV. VCUG gives a clear idea on the extent of posterior urethra (PU) dilatation, bladder, and reflux status [Figure 1]. Conventionally, pediatric surgeons do not omit a VCUG unless the child is preterm or too sick. A pre-procedure VCUG is also useful in assessing resolution by comparing parameters post fulguration.
|Figure 1: Prefulguration voiding cystourethrogram helps to understand anatomy and acts as a baseline to compare outcomes postprocedure. Classical posterior urethral valve (left image) shows increase in posterior urethra width and posterior urethra length compared to anterior urethra width|
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| Primary Bladder Neck Incision along with Posterior Urethral Valve Fulguration|| |
Primary bladder neck incision (BNI) was performed in select patients with high glistening bladder neck and severe trabeculations of the bladder. While the papers describe the technique and indications of BNI, the authors do not describe in the results whether those who had primary BNI performed better. It would have been beneficial to the readers if the patients were divided into two groups with or without primary BNI and the benefit proven in results. Sarin and Sinha did not find any benefit of BNI in children with PUV. Alpha-blockers have been reported to result in better bladder emptying. So we believe that a trial of medical management should be given before going for BNI.
| Urodynamic Study in Posterior Urethral Valve|| |
While urodynamic study (UDS) is very useful in older children with PUV, in infants with poorly developed voiding refluxes, it may often be inconclusive. The first author has particularly relied on UDS parameters for selecting patients for secondary BNI. Patients with persistent hydroureteronephrosis post-PUV fulguration are usually empirically treated with anticholinergics/alpha-blockers during infancy without UDS.
| Rhabdosphincter Spasm|| |
The article extensively discusses on the theories of rhabdosphincter (RS) and even describes five neonates where they could not find PUV. Although RS lies distal to the level of PUV, the author claims, it is at the same level and describes several RS managements (thermal dissipation, longer catheterization, balloon pull of RS) in those with PU trabeculation. We do not agree with these views and we feel that RS should not be damaged during PUV fulguration.
| Secondary Vesico Ureteric Reflux and Obstruction|| |
Proper bladder management often results in the improvement of secondary effects. The author attempts the insertion of DJ stent in these cases. This may introduce infection into the dilated system and also transfer the high bladder pressures to upper tracts. We do not support the role of DJ stenting in children with PUV.
Down staging of chronic kidney disease (CKD) was 4/91, 2/68, and 4/77 for three authors with no significant difference (Chi-square P = 0.79). The article concludes that the upstaging of CKD in the series of second and third authors could be due to not performing BNI or RS management. This could be a pure chance association (more dysplastic kidneys to start), and there is no solid statistical evidence provided in results to support BNI/RS management in PUV.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Chatterjee U, Basu A, Mitra D. Insight into posterior urethral valve from our experience: Paradigm appended to abate renal failure. J Indian Assoc Pediatr Surg 2020;25:297. [Full text]
Sinha A, Bagga A, Krishna A, Bajpai M, Srinivas M, Uppal R, et al
. Revised guidelines on management of antenatal hydronephrosis. Indian Pediatr 2013;50:215-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23474928
Babu R, Hariharasudhan S, Ramesh C. Posterior urethra: Anterior urethra ratio in the evaluation of success following PUV ablation. J Pediatr Urol 2016;12:385.e1-5.
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.
Abraham MK, Nasir AR, Sudarsanan B, Puzhankara R, Kedari PM, Unnithan GR, et al
. Role of alpha adrenergic blocker in the management of posterior urethral valves. Pediatr Surg Int 2009;25:1113-5.
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