Posting write up sent by Prof. S S Joshi Sir
Please read and respond
Dr. Gyanendra Sharma ' write up on CTT uploaded as a PDF file....
This is a Mail I sent to Gyanendra Sharma on 10-1-2018 addressing the discussion taking place. I would like to share that mail with all of you.
You I have been following you and your views since 2012. I had the privilege to read all the articles that you have brought out explaining your views.
I have travelled in Paediatric Urology for well over half a century with my interest in the field spanning from 1966 till today. I have travelled through the turmoil of time and changes in the advancements of our understanding of Paediatric Urology. I have changed my concepts in management of problems of Paediatric Urology almost every decade as advancements were made available.
Many of the younger generation of today feel that we who belonged to the older generation did not believe in Evidence and offered the knife liberally. We had evidences even then which prompted us to manage patients with utmost care. Let me place some views that may be of interest for you in the field of PUJO which you have rightly termed as ‘PUJ like Obstructions’, which probably explains the scenarios concerning PUJO’s.
JT Geraghty and WA Frontz (1918) wrote that ‘PUJ obstruction has challenged the ingenuity of surgeons and remains one of the most enigmatic clinical problems and may continue to be so as what is obstruction has not yet been proved to satisfaction (This is true even today). In General PUJ obstructions are described as minimal, moderate, or severe. Flow impairment at the PUJ, however, has defied useful quantitative analyses. This comment of the yore is still valid as we still do not know what obstruction is. It was Cambell Bregg (1946) who gave a possible explanation as why some of these larger pelvis’s (non-obstructive hydronephrosis) had delayed drainage. He considered the pelvis at various levels as spheres and larger the sphere, the cylinder at the PUJ level shortens as a consequence thereby imparting more resistance and this again increases the tonicity of the muscle at that region and prevents flow of urine down the ureter, though there are no anatomically documented obstruction.
Murnaghan (1958) published an article on ‘Physiology of Hydronephrosis’ summing up the knowledge we had understood then. In that he mentions all renal pelvic dilatation do not denote obstruction and to call ‘obstruction’ there should be calyceal alterations, however minimal it may be which indicates a higher pressure in the renal pelvis. Hence it is clear that even in those times not all renal pelvic dilatations were considered hydronephrotic. Prof HS Bhat (Doyen of Indian Urology) used to teach us that all dilatation of renal pelvis should not be considered obstructive though the concept of resolving of PUJ obstruction was not even under consideration. To presume that all renal pelvic dilatation, associated with non visualized ureter underwent surgical options was totally incorrect as is being presumed by us today. We did not have all the tests governing decisions of today, but still had the concept that not all Pelvic dilatations warranted surgery. Hence what has changed today from the concepts we adhered to in times of yore. We are now able to quantify function in much better way and have probably a better idea as which cases deserve intervention and which we did not. In the past we studied suspected cases of PUJO by taking prone films which delineated the PJU level better and also use what was then called as ‘Diuretic IVU’ which is a precursor for Diuretic Renography. An increase in pelvic dilatation by ~20% was considered obstructive in addition to calyceal changes as mentioned by Murnaghan.
In one of you articles you had aptly quoted Albert Einstein by stating that ‘A perfection of means but a confusion of conclusion seems to be our problem’. To this I would like to add a quote from Henry Miller wherein he stated that ‘Confusion is a word we invented for an order which is not understood’. Another Quote from Jonathan Adams is also worth remembering ‘People don't expect too much from literature. They just want to know they're not alone with being confused’.
It is true that our understanding as to what constitutes ‘obstruction’ is still in a confused state and we have no answer yet. With thinking Urologists like you, maybe we will begin to have an answer in near future.
I am providing the links of two articles on the subject other than what Gyanendra has provided and also adding another article by Ramesh Babu.
http://www.ijri.org/article.asp?issn=0971-3026;year=2016;volume=26;issue=1;spage=15;epage=21;aulast=Sharma (PDF available)
http://www.indianjurol.com/article.asp?issn=0970-1591;year=2010;volume=26;issue=4;spage=494;epage=496;aulast=Babu (PDF available)
With warm regards,