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.