VUR – a Discharge Summary - 47 Yrs old

• 24 Jun 2021 11:41:36 AM
• |Pediatic Urology

Dear All,

It was much to my surprise that Padmaraj Hegde (Prof of Urology, KMC, Manipal) provided me with this Discharge Summary (Attached) of a Patient whom I had operated in 1974 for Bilateral reflux. It is now 2021 and obviously he has survived from my onslaughts on him for 47 Years. I thought it would be nice to share this with all.  

You will notice that several aspects provided in the discharge Summary are no longer in use.

The Child Presented with Bilateral Palpable Kidneys, a finding not often seen in the present day.

He was Poorly nourished weighing a mere 9KGs at one and half Years.

In spite of this, the Renal functional status was fairly within the normal range. The Child underwent IVU which according to the Discharge Summary was performed as an emergency (which is seldom performed of late). The IVU findings are mentioned.

In view of these findings a Rt Nephrostomy was performed (PCN was not popular then and what we did was open Nephrostomy).

On recovery, a VCUG was performed and it revealed Bilateral High Grade Reflux (one should remember that Int Grading for VUR was introduced only in 1985 and we at that time divided VUR as Low Grade (type1) and High grade (type 2).

He underwent Bilateral Paquin’s Intra and Extravesical Reimplantation of Both Ureters. We did not possess Ureteric Stents as we have now and Ureters were Splinted post surgically.

A Repeat IVU showed Improvement in Findings and Details are available and he was eventually discharged in a stable condition though he has prolonged hospital stay.

As mentioned, seeing this discharge summary sent by the patient to Padmaraj after 47 Years, by itself was astonishing. What is more astonishing is the way the Discharge Summary has been preserved.

I thought, having travelled in Paediatric Urology for over half a decade, I will provide some historical aspects that I have seen and practiced during this period. One may think how primitive were we but the same thought will be there in future that how the present treated VUR.

With warm regards,

Venu

Comments(5)

• 

  Dr G G Laxman Prabhu

  24 Jun 2021 01:22:58 PM

  It was such a joy to see a typewritten discharge summary generated in the department where I had my training and I would thank Dr Padmaraj Hegde, KMC, Manipal for sharing it with Professor P Venugopal. It is also a matter of satisfaction that the patient is keeping good health.  

  I would particularly draw the attention of readers to the biopsy findings- namely hypertrophied ureteric muscle. This is invariably seen in both types of megaureters-obstructive as well as refluxing. In obstructive megaureters, a logical mind would easily follow this, as the ureters overwork to surmount the obstruction leading to the hypertrophy of muscles. It should be pointed out that reflux is a functional obstruction on its own count. The dilated ureters have to handle larger volumes of urine. Whenever reflux occurs, the ureters attempt to propel down a larger volume of water across the vesico-ureteric junction. This will result in hypertrophy of ureteric muscle.  

  Over a period of time, inflammation induced injury would result in replacement fibrosis. Ureters which are severely scarred ( microscopic) tend to fare poorly after surgical intervention.

  In this case, the ureter had not shown much replacement fibrosis. This could be one of the factors which lead to a better outcome.

  Histological study of ureteral segments excised before uretero-neocystostomy provide valuable prognostic information, albeit, the outcomes depend on many other factors, notable amongst these being the degree and extent of co-existing renal dysplasia.

  Patients who value and preserve their documents are rarely seen these days as reliance on digital preservation has made most lazy and careless.

  Professor has commented on the older terminology which is interesting and he himself had given up the term megaureters for easily understandable large ureters.

  
  

  GG L Prabhu 

• 

  Dr. Anil Takvani

  24 Jun 2021 06:41:28 PM

  Dear Sir,

  Many thanks for this post...

  Excellent discharge summary,  equally excellent presentation on records by patient's care takers.

  
  

  Most important is management; not changed only some of investigations related to upper tract function are changed.

  I have presented and talked about temporary diversion in cases of bilateral high grade VUR with in severely ill child. 

  Child was rightly offered diversion of choice of surgeon and that worked very much as kidneys were not dysplatic.

  Child improved post diversion and successful reimplantation was performed again technique was of a choice of urologist worked extremely well.

  This case inforce my understanding and experience which I presented multiple times in national and international conferences and published that proper surgical management of in patients of VUR with febrile UTI gives life free of recurrent febrile episodes,  preserved kidneys and better overall bodily health. 

  That is why, I always insist senior urologist to share his experience along with literature as for many pediatric urology conditions evidences are on either side. For me their truely shared experiences though not published are much more useful in practice and better treatment of similar cases. We know many times published works are also cooked according to persons wish...

  This case also speaks about need of longterm follow up of pedantic and oncourological conditions before we arrive to any conclusions. 

  Thank you very much to department of urology KMC Manipal to share discharge record to professor.  

  Venu Sir " teacher of teachers " , we know you have hundreds of cases treated extremely well and they are enjoying quality of life...

  Thanks 

• 

  Dr. Roy Chally

  24 Jun 2021 09:40:30 PM

  I have nothing further to add. Importance of maintaining records in hospitals for such long periods are very unusual. This case brings out the importance of this practice to add knowledge. In this case the result of surgery was good. But we should be aware that good results with bilateral ureteric reimplantation of dilated ureters in one stage is technically challenging. 

• 

  Chandra Singh J

  26 Jun 2021 10:44:43 PM

  Thank you sir, for posting the valuable document of the Discharge Summary that was so carefully preserved. Amazing! From the documentation of the chronology, it is quite evident how much attention was paid to details of clinical profile and course in the hospital. Unfortunately, most of all this is taken for granted now a days. The clinical acumen and surgical expertise required in those years is not emphasized. It is partly made up by newer imaging modalities, advances in OR lights, sutures, other instruments etc. But if we continue to strive towards perfection in all these aspects, that will certainly have a positive impact on the surgical outcomes. I feel we should discuss in a separate post the difference in surgical practice then and now, what modifications we have done to reduce morbidity and expedite recovery.

  
  

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  Ravindra Sabnis

  01 Jul 2021 10:25:56 PM

  SO much to learn from this case. It is not only important to write good discharge summery but what is still more important is preservation of this summery. - Initially by parents & then by himself. How many of our patients preserver summery especially when he is doing well. Patients preserve reports, notes when they have recurrent problem. but when he perfectly healthy, to preserve everything is to be appreciated. 

  learning from the case is never blame the lack of facilities, lack of investigations - even in so called primitive conditions (although they may be best at that time)- results are much more than ideal. 

  Thank you sir for posting this case.