Insight into Posterior Urethral Valve Management: My Two Cents.

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.

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Nil.

Conflicts of interest

There are no conflicts of interest.