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Journal of Indian Association of Pediatric Surgeons, Vol. 10, No. 3, July-September, 2005, pp. 163 Editorial Comment Editorial comments Gupta DK Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India- 110029 Code Number: ip05040 Related article: ip05039 The author of this review article is a senior paediatric urologist in Sheffield. He has visited many paediatric surgical centres in India and hence has the first hand information not only on volume of the problem but also the difficulties that the surgeons and the parents face while managing such cases. In developing countries, the problem is much different and so the management plan may vary accordingly. The patients with PUV may present at any age depending on the degree of obstruction, severity of symptoms and the facilities available for medical treatment within the reach of the parents. In developing countries, these are the newborns, who suffer the most. The disease is usually severe (may be with inherent dysplasias, unilateral or bilateral, partial or complete) with the upper tracts severely dilated and tortuous and incapable of propelling the urine effectively. Sepsis is very common due to stagnant urine in the ureters coupled with the small, thick walled and inflamed bladders with poor detrussor function. The low-birth weight in developing countries precludes the use of the smallest available neonatal scope in the newborn period. Moreover, the neonatal scopes and the required expertise may not be easily available in peripheral centres. Under such circumstances, a vesicostomy is still safe and fully justified in developing countries to avoid any trauma to the small urethra and relieve the urinary obstruction in neonates who can not manage to travel long distances to reach the referral centres. The management in the Institutions is more or so on the same lines as has been outlined by the author. However, in the presence of the dilated upper tracts, persistent deranged renal biochemistry, unrelenting sepsis (even pyo-ureters) and small bladders with multiple diverticula, it is not uncommon in our set up to seriously consider high diversion to provide direct drainage to the urine or pus, remove obstruction in the tortuous ureters and prevent stasis in the ureteral folds. With this life saving approach, the condition of the baby should improve if the renal functions are good. Failure to improve in renal biochemistry and sepsis would indicate poor outcome. Approximately, more than 20% newborns and >10% children would require high diversion at tertiary care level centres in India. Regarding the choice of the diversion, it should be high, and able to by-pass the obstruction. Pyelostomy is not preferred if the dilated ureters are available for diversion. In our experience, a loop ureterostomy is quite simple, easy, and quick to perform in an emergency situation. An end to side ureterostomy (Sober′s), though considered better to retain the bladder function, is only occasionally performed in our practice. Henceforth, the management of patients with posterior urethral valve (PUV) has to be individualized depending on the facilities and the expertise available when these are needed most, especially in a newborn in an emergency situation. An over enthusiastic approach with improper instrumentation would be more harmful than doing good.I am sure the readers would enjoy this masterly manuscript written by the expert on the role of high diversion in PUV, outlining the clinical indications so well. Copyright 2005 - Journal of Indian Association of Pediatric Surgeons |
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