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Response to commentary to “27 years of experience with the comprehensive surgical management of prune belly syndrome”
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MODEL
Journal of Pediatric Urology (2015) xx, 1
Letter to the Editor
Response to commentary to “27 years of experience with the comprehensive surgical management of prune belly syndrome”
“Two roads diverged in a yellow wood, And sorry I could not travel both (.) Two roads diverged in a wood, and Id I took the one less traveled by, And that has made all the difference.” From “The Road not Taken”, by Robert Frost
First of all, we thank the very honest comments on our work. We accept the criticism regarding our 11% rate of ureteral obstruction requiring surgical revision. However, it is important to note that prune-belly syndrome (PBS) patients usually have bilateral massive pyelo-ureteral dilatations, much more than in cases of primary vesico-ureteral reflux or megaureters. Although such complications were observed, early diagnosis and treatment prevented loss of renal function in all cases. As a matter of fact, our long-term results in regards to reno-ureteral anatomy and function, bladder function, infection, testicular size, and location, as well as abdominal aspect and tonus, testify that comprehensive surgery is an adequate method of management in PBS patients. In the mentioned article, Seidel et al. [1] performed ureteral, bladder, and abdominal procedures in less than 50% of their patients, but on the long-term follow-up, 45% of them required upper or lower urinary tract diversion, which evidently impaired their quality of life. In addition, 39% of the patients ended with chronic renal failure and 17.4% were submitted to renal transplantation while only five of our 46 patients (10.8%) developed chronic renal failure and only three (6.5%) were submitted to renal transplantation. Often in our country adequate medical follow-up is problematic. Clinical observation
of significantly dilated and tortuous ureters associated to recurring urinary tract infections, requiring continuous antibacterial prophylaxis and frequent imaging and laboratory controls is not practicable, and there is a parental desire to solve all the problems associated to PBS as soon as possible, preferably in one procedure. Therefore, we believe that this treatment is safer and more suitable that conservative management in most cases. We do agree that an answer to the question of which patients would benefit most from extensive surgery should be answered by a randomized multicentric study. Unfortunately, PBS has a variable spectral presentation and the quality of care varies widely in different countries, therefore it will be a struggling effort to answer this question properly. Finally, we sincerely hope that with the data presented in our work and in others, termination of pregnancy will no longer be ethically accepted as a form of management in PBS.
Reference [1] Seidel NE, Arlen AM, Smith EA, Kirsch AJ. Clinical manifestations and management of prune-belly syndrome in a large contemporary pediatric population. Urology 2015;85:211e5.
Francisco Tibor De ´nes* Roberto Iglesias Lopes Uropediatric Unit, Division of Urology, University of Sa˜o Paulo Medical School, Brazil *Correspondence to: F.T. De ´nes, Uropediatric Unit, Division of Urology, University of Sa ˜o ´neas de Paulo Medical School, Rua Dr E Carvalho Aguiar 455-7 andar Sa ˜o Paulo, Sa ˜o Paulo 11273-9, Brazil E-mail address: [email protected] (F.T. De ´nes) 10 June 2015 Available online xxx
DOIs of original article: http://dx.doi.org/10.1016/j.jpurol.2015.05.031, http://dx.doi.org/10.1016/j.jpurol.2015.05.018. http://dx.doi.org/10.1016/j.jpurol.2015.06.012 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: De ´nes FT, Lopes RI, Response to 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.2015.06.012
MODEL
Journal of Pediatric Urology (2015) xx, 1
Letter to the Editor
Response to commentary to “27 years of experience with the comprehensive surgical management of prune belly syndrome”
“Two roads diverged in a yellow wood, And sorry I could not travel both (.) Two roads diverged in a wood, and Id I took the one less traveled by, And that has made all the difference.” From “The Road not Taken”, by Robert Frost
First of all, we thank the very honest comments on our work. We accept the criticism regarding our 11% rate of ureteral obstruction requiring surgical revision. However, it is important to note that prune-belly syndrome (PBS) patients usually have bilateral massive pyelo-ureteral dilatations, much more than in cases of primary vesico-ureteral reflux or megaureters. Although such complications were observed, early diagnosis and treatment prevented loss of renal function in all cases. As a matter of fact, our long-term results in regards to reno-ureteral anatomy and function, bladder function, infection, testicular size, and location, as well as abdominal aspect and tonus, testify that comprehensive surgery is an adequate method of management in PBS patients. In the mentioned article, Seidel et al. [1] performed ureteral, bladder, and abdominal procedures in less than 50% of their patients, but on the long-term follow-up, 45% of them required upper or lower urinary tract diversion, which evidently impaired their quality of life. In addition, 39% of the patients ended with chronic renal failure and 17.4% were submitted to renal transplantation while only five of our 46 patients (10.8%) developed chronic renal failure and only three (6.5%) were submitted to renal transplantation. Often in our country adequate medical follow-up is problematic. Clinical observation
of significantly dilated and tortuous ureters associated to recurring urinary tract infections, requiring continuous antibacterial prophylaxis and frequent imaging and laboratory controls is not practicable, and there is a parental desire to solve all the problems associated to PBS as soon as possible, preferably in one procedure. Therefore, we believe that this treatment is safer and more suitable that conservative management in most cases. We do agree that an answer to the question of which patients would benefit most from extensive surgery should be answered by a randomized multicentric study. Unfortunately, PBS has a variable spectral presentation and the quality of care varies widely in different countries, therefore it will be a struggling effort to answer this question properly. Finally, we sincerely hope that with the data presented in our work and in others, termination of pregnancy will no longer be ethically accepted as a form of management in PBS.
Reference [1] Seidel NE, Arlen AM, Smith EA, Kirsch AJ. Clinical manifestations and management of prune-belly syndrome in a large contemporary pediatric population. Urology 2015;85:211e5.
Francisco Tibor De ´nes* Roberto Iglesias Lopes Uropediatric Unit, Division of Urology, University of Sa˜o Paulo Medical School, Brazil *Correspondence to: F.T. De ´nes, Uropediatric Unit, Division of Urology, University of Sa ˜o ´neas de Paulo Medical School, Rua Dr E Carvalho Aguiar 455-7 andar Sa ˜o Paulo, Sa ˜o Paulo 11273-9, Brazil E-mail address: [email protected] (F.T. De ´nes) 10 June 2015 Available online xxx
DOIs of original article: http://dx.doi.org/10.1016/j.jpurol.2015.05.031, http://dx.doi.org/10.1016/j.jpurol.2015.05.018. http://dx.doi.org/10.1016/j.jpurol.2015.06.012 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: De ´nes FT, Lopes RI, Response to 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.2015.06.012