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‘Late show with David Letterman’ comes back … how to manage asymptomatic ureteropelvic junction obstruction?

2019; Elsevier BV; Volume: 15; Issue: 5 Linguagem: Inglês

10.1016/j.jpurol.2019.07.014

1873-4898

Salvatore Arena, Ugo Calabrese, E. Antonelli, Carmelo Romeo,

Fetal and Pediatric Neurological Disorders

We read the interesting article written by Vemulakonda et al. [ [1] Vemulakonda V.M. Hamer M.K. Kempe A. Morris M.A. Surgical decision-making in infants with suspected UPJ obstruction: stakeholder perspectives. J Pediatr Urol. 2019 May 30; https://doi.org/10.1016/j.jpurol.2019.05.027 Google Scholar ] ‘Surgical decision-making in infants with suspected UPJ obstruction: stakeholder perspectives’ that encourages more than one reflection. With the advent of routinary neonatal or antenatal ultrasonography during the early 1980s, a fervent debate about the most appropriate management in asymptomatic ureteropelvic junction obstruction (UPJO) started. Considering the common clinical scenario of spontaneous improvement of hydronephrosis in children affected by UPJO [ [2] Cutroneo G. Arena S. Anastasi G. Cervellione R.M. Grimaldi S. Di Mauro D. et al. Altered cytoskeletal structure of smooth muscle cells in ureteropelvic junction obstruction. J Urol. 2011; 185: 2314-2319https://doi.org/10.1016/j.juro.2011.02.045 Crossref PubMed Scopus (17) Google Scholar ], after about forty years, the boundary line between a ‘watchful waiting’ management and surgery is still unclear. Just like the famous talk show conducted by David Letterman, which debuted in 1982 with the name ‘Late Night with David Letterman’ and later continued as ‘Late show with David Letterman’ until 2015, highly qualified scientific journals have become a platform of many experts reporting their experience and opinion about the management of asymptomatic UPJO. Although it is worldwide accepted that the goal of treatment of UPJO is the preservation of the renal function, there are no clearly defined criteria for surgery in asymptomatic patients. Some physicians primarily recommend surgery after initial ultrasound findings or changes on serial ultrasounds, and others in case of impairment of renal function or of abnormal half-time radiotracer clearance [ [3] Arena S. Chimenz R. Antonelli E. Peri F.M. Romeo P. Impellizzeri P. et al. A long-term follow-up in conservative management of unilateral ureteropelvic junction obstruction with poor drainage and good renal function. Eur J Pediatr. 2018; 177: 1761-1765https://doi.org/10.1007/s00431-018-3239-2 Google Scholar ]. In this ‘potpourri’, although the physicians try to build an open and transparent dialogue with parents, the latter often appear not satisfied and confident of this physician-parent relationship and so request a second opinion from other experts or, even, try to find a solution on ‘Google’ [ [1] Vemulakonda V.M. Hamer M.K. Kempe A. Morris M.A. Surgical decision-making in infants with suspected UPJ obstruction: stakeholder perspectives. J Pediatr Urol. 2019 May 30; https://doi.org/10.1016/j.jpurol.2019.05.027 Google Scholar ]. For this gap of knowledge, the decision-making is based on the reliance of parents on physician expertise, which makes the decision based on their personal experience and training.