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MODEL
Journal of Pediatric Urology (2015) xx, 1
Commentary to ‘27 years of experience with the comprehensive surgical management of prune belly syndrome’ Grahame H.H. Smith Sydney Childrens Hospital Network, Australia [email protected] (G.H.H. Smith)
27 May 2015 Accepted 29 May 2015 Available online xxx
The authors describe aggressive surgical management in a series of 46 patients with prune belly syndrome treated over the period 1987 to 2014. Management included orchidopexy, abdominoplasty, ureteral reimplantation with reduction ureteroplasty, cystoplasty, and on six occasions Mitrofanoff creation. I do not question the need for orchidopexy in all patients or for Mitrofanoff catheterisable conduits in selected patients, as failure of bladder emptying is a common problem in this syndrome. However, I do question the indication for aggressive upper and lower urinary tract management including aggressive use of abdominoplasty. The indication given for ureteric reimplantation with reduction ureteroplasty was stasis plus or minus urinary tract infections. It has been my experience that the major abnormality in this condition is failure to empty the bladder. That is often the cause of recurrent urinary tract infections. I don’t think bladder emptying with a Crede maneuver or Valsalva maneuver is a good long-term solution [1], but if the failure to empty can be addressed with a vesicostomy, by double voiding or by clean intermittent catheterization, then the infections cease to be a problem. Vesicoureteric reflux and “upper tract stasis” often do not need to be separately treated. I note that 7 of 62 renal units became obstructed after operation and required revision, an 11% obstruction rate. As the benefits of upper urinary tract reconstruction are debatable, I’m not sure that is an acceptable complication rate. In a similar fashion, abdominal wall laxity does improve with time and does not neces-
sarily require an abdominoplasty. I note this was undertaken in 44 patients and three developed later intestinal obstruction, presumably secondary to adhesions. This is a 7% complication rate for an operation that is also controversial. The orchidopexy results are impressive and in particular the low number of patients that required division of the testicular vessels when a laparotomy approach was used. I think a higher percentage of gonadal vessels are divided when a laparoscopic approach is utilized. Perhaps we need to be more conservative in dividing the gonadal vessels in this condition and more aggressive about utilizing a laparotomy approach? The authors attempt to justify their aggressive surgical approach with the statement that follow-up is problematic. However, operating on these kids doesn’t mean that they don’t need follow-up. Further, just because an operation is undertaken that doesn’t mean the operation was needed or that the fact the patient did well was the result of the operation. I would like to congratulate the authors for the honest reporting of their complications, the length of follow-up, and the impressive results in this series.
Reference [1] Chang SM, Hou CL, Dong DQ, Zhang H. Urologic status of 74 spinal cord injury patients from the 1976 Tangshan earthquake, and managed for over 20 years using the Crede maneuver. Spinal Cord 2000;38(9):552e4.
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2015.05.018. http://dx.doi.org/10.1016/j.jpurol.2015.05.023 1477-5131/Crown Copyright ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company. All rights reserved.
Please cite this article in press as: Smith GHH, Commentary to ‘27 years of experience with the comprehensive surgical management of prune belly syndrome’, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.023
MODEL
Journal of Pediatric Urology (2015) xx, 1
Commentary to ‘27 years of experience with the comprehensive surgical management of prune belly syndrome’ Grahame H.H. Smith Sydney Childrens Hospital Network, Australia [email protected] (G.H.H. Smith)
27 May 2015 Accepted 29 May 2015 Available online xxx
The authors describe aggressive surgical management in a series of 46 patients with prune belly syndrome treated over the period 1987 to 2014. Management included orchidopexy, abdominoplasty, ureteral reimplantation with reduction ureteroplasty, cystoplasty, and on six occasions Mitrofanoff creation. I do not question the need for orchidopexy in all patients or for Mitrofanoff catheterisable conduits in selected patients, as failure of bladder emptying is a common problem in this syndrome. However, I do question the indication for aggressive upper and lower urinary tract management including aggressive use of abdominoplasty. The indication given for ureteric reimplantation with reduction ureteroplasty was stasis plus or minus urinary tract infections. It has been my experience that the major abnormality in this condition is failure to empty the bladder. That is often the cause of recurrent urinary tract infections. I don’t think bladder emptying with a Crede maneuver or Valsalva maneuver is a good long-term solution [1], but if the failure to empty can be addressed with a vesicostomy, by double voiding or by clean intermittent catheterization, then the infections cease to be a problem. Vesicoureteric reflux and “upper tract stasis” often do not need to be separately treated. I note that 7 of 62 renal units became obstructed after operation and required revision, an 11% obstruction rate. As the benefits of upper urinary tract reconstruction are debatable, I’m not sure that is an acceptable complication rate. In a similar fashion, abdominal wall laxity does improve with time and does not neces-
sarily require an abdominoplasty. I note this was undertaken in 44 patients and three developed later intestinal obstruction, presumably secondary to adhesions. This is a 7% complication rate for an operation that is also controversial. The orchidopexy results are impressive and in particular the low number of patients that required division of the testicular vessels when a laparotomy approach was used. I think a higher percentage of gonadal vessels are divided when a laparoscopic approach is utilized. Perhaps we need to be more conservative in dividing the gonadal vessels in this condition and more aggressive about utilizing a laparotomy approach? The authors attempt to justify their aggressive surgical approach with the statement that follow-up is problematic. However, operating on these kids doesn’t mean that they don’t need follow-up. Further, just because an operation is undertaken that doesn’t mean the operation was needed or that the fact the patient did well was the result of the operation. I would like to congratulate the authors for the honest reporting of their complications, the length of follow-up, and the impressive results in this series.
Reference [1] Chang SM, Hou CL, Dong DQ, Zhang H. Urologic status of 74 spinal cord injury patients from the 1976 Tangshan earthquake, and managed for over 20 years using the Crede maneuver. Spinal Cord 2000;38(9):552e4.
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2015.05.018. http://dx.doi.org/10.1016/j.jpurol.2015.05.023 1477-5131/Crown Copyright ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company. All rights reserved.
Please cite this article in press as: Smith GHH, Commentary to ‘27 years of experience with the comprehensive surgical management of prune belly syndrome’, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.023
