Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

You hear me? Yes, you, we can hear you. Yes, we can hear you. All right. Ok, good afternoon everyone. I Doctor Julie, I'm a pediatric registrar at uh in a Wu in East London Complex. Uh Today I'm going to be talking about uh the posterior U valves. So, um these are the subheadings that I'm going to cover the pathophysiology, clinical presentation investigation, initial management and endoscopic management. We won't go further to uh further surgical management and management of the complications in this discussion. So you will need to just go a little bit close to your mic and talk a little bit slowly and, and loudly. Thank you. All right. Ok, thanks. Perfect. Ok. All right. Um So, uh this um these posterior ureteric valves which um thought to be a congenital malformation in uh in males. So this is just a schematic representation of um a male. Um um urinary, lower urinary um system which shows uh a bladder. Then you have a AAA bladder neck there, then the prostate and it shows um the valves, uh the posterior valves on the posterior urethra as just um thick um membranous leaflets that tend to meet in the midline, just below the urethral, um just above the urethral um sphincter. So, um as I mentioned that there are congenital male um malformation of uh hypertrophic variant of um inferior urethra. They are thought to be the remnant of um mesonephric um duct. So, it's this leaflet that come to fuse in the midline and they cause obstruction in that way, just proximal to the external um sphincter. So this is a representation of the types that were first described by young and as type one, type two and type three, when um looking at um what you saw in, in type one, basically the two leaflets that when they fuse, they sort of form like um a dome shape, type of form of um uh obstruction. So as the urine is coming from the bladder, tracking down, it kind of get caught in these um uh leaflets that are divided by these uh fibrous tissues where they um where they meet. And actually type two is formed in an opposite way that actually the the leaflets are actually facing down where they meet. And it's actually non obs obstructive uh type two because of the way that um the leaflets of the valves um are fused. And type three is thought to be just um circumferential um membrane which forms like a diaphragm that has got a central um opening and also it does um cause it and also this type type three is also um an obstructive type. So there's actually a lot of different um anatomical variation in this obstructive um type that they actually have been grouped as um called uh coal, which is a congenital obstructive posterior valve um membrane. And this excludes type two since it is not um obstructive. So, um uh PV are the commonest cause of congenital obstruction on the lower urinary tract and they compromise a, they comprise about 10% of uh antenatally diagnosed um neuropathy. And the incident, I estimated to be about one in between 5000 to 8000 male birth. But it is thought to be more in a more common for um the for fetal death. So, if you do um autopsies on those um fetal that died with no apparent reason, or it can be discovered that some of them, they might have had um a, a poster valves, the severity, it varies from mild to very severe and it can be lethal as well. Um They can be diagnosed antenatally and about a third of this patient, they will grow up and they will develop um and renal um endstage renal disease and they might need um a renal transplant at a later stage. So this is just looking at the pathophysiology of um the condition. So, in utero, if there is a significant uh obstruction, that result in a significant reduction of the amniotic fluid and with a significant uh um um oligo hydros, you may end up with lung hyperplasia. That is um, that you can see on this uh x-ray as well as in severe cases. They can have porter uh syndrome. But on the urinary tract um system itself, you get um injuries from uh lower down to, up to the upper uh urinary tract um system. So you get this um, thickened wall, um bladder that is trabeculated and you get uh with the backflow of the um of the pressure, you get um hydroureters and that also extend into um hydronephrosis um A as well with the pressure. So this is also just another representation of um the of, of, of, of, of posterior valves shows that there is an obstruction which is caused, can be caused by cum any of uh the component of uh cum and with, without any urinary drainage, you get dilated, posterior, uh urethra dilated, I mean um hypertrophic um bladder and then with the back and the blood blood pressure, you get hydronephrosis and hydroureter which also affect the functions of the kidneys. So, um clinical presentation. So it can present at any time. You can present antenatally as neonates, infants, toddler and school age or even in the adults. Um uh posterior valves have been um uh diagnosed in utero. It's usually by form of ultrasound where if you pick up uh hydro with hydronephrosis or you might be able to see also some bladder and um some bladder changes also on the ultrasound that also can be uh diagnostic. So how do neonates uh different ages present? So, neonates, they can present as just urinary retention or they tell you that the patient hasn't passed urine um for a whole day after birth and has a bit of unhappy irritable. You know, they can have um respiratory distress if they have lung hyperplasia or in worse cases, they can have also ascitis as well, which will be your urine. Uh ascitis infants, they will present with urosepsis, which is also is just irritable kids with um high fevers. They might also have feeding intolerance during that time. Uh You might pick up that they have failure to drive some electrolytes, um imbalances as well as well as um dehydration toddlers. They tend to present more with um urinary tract infection. They can have incontinence or uh just um voiding dys dysfunction. They can have dribble dribbling after um voiding or not completely uh voiding of, of, of, of the bladder. The older Children, they present also with um recurrent uti and they can have nocturnal enuresis also with abdominal distension which would be associated with um a complication like um hydronephrosis as well. So, in these cases, there aren't too many um differential but um diseases like prone Bailey syndrome, urethral a um atresia and bilateral high grade um vaso um reflux as well. They can sort of give you uh this presentation. Um um looking at our investigative um measures. So the gold standard is the MCU G, which is a maturating cystourethrogram. And we have ultrasound as well. Cystoscopy can be diagnostic and therapeutic as well. And we also need to check the electrolytes and we have um nuclear medicine fetal. Uh MRI also has been described um for difficult cases in. So this is a representation of an MCU gene which was done for a child with a posterior valve which shows um a full bladder with a hypertrophic um bladder neck and dis dilated posterior um um urethra. And just below that, you can just um imagine that the point of, of, of obstruction where the valves are. In other cases, you are able to appreciate um the sharp well-defined um lucency around this area of um obstruction. And this description and can be described also as a key um a keyhole uh sign with this uh a noom representation of the bladder and um dilated posterior um uh urethra. So, as part of um the disease, you can get um hydro nephrosis and hydroureters, you can see here there is quite um is quite impressive um hydroureter which you can see on the side, it goes on to, to the kidney and you have your um uh hydronephrosis as well. Whereas on the left side, you, it's not as bad as A Y Yy you can appreciate on the right. So this um the ultrasound and investigation. So you will be able to appreciate the abnormal echogenicity and cortical cysts which um signify that uh that there is the severity of, of, of, of, of the condition and the lack of cortical and medullary um differentiation as well. It's also a sign of um um a severe form of o of the disease hydronephrosis. Also, you can pick it up on ultrasound hydroureters. You can still also be able to see posterior urethra if um you look um for it as well in utero. The there is ultrasound representation here also which show um keyhole sign in an ultrasound. This is a uh ultrasound that was done in utero. You can see a dilated um urinary bladder with a dilated and elongated um posterior um urethra as well. And then on this side, you can see this is a dilated um the bladder full of urine and on the left side, it's a left ureter which is also dilated cause you shouldn't be able to see a ureter uh like this in the um on, on, on the ultrasound. So, um further uh investigations. So um the fetal MRI which is useful in the antenatal um cases, but it's not uh something that is is is done often and you have to do the electrolytes because these kids, they present with metabolic acidosis, they have hypo uh calcemia as well as a hyperkalaemia. Your nuclear medicine scans are good for assessing differential um in function. And they can also look at the anatomical kind of the o oo of the the actual renal tissue uh as well. Cystoscopy. As I mentioned, it could be, it can be diagnostic and as well as uh therapeutics because you are able to actually visualize um the the the the valves and you can do some uh uh some procedures um through the cystoscopy to treat these um posterior valves. So um looking at the initial management, so initial management, it will involve managing the respiration if there is a respiratory uh distress and maybe secondary to pulmonary hyperplasia. And if they require ventilation, then they will need to be ventilated. But the mainstay is also to drain the urine. Um whichever way um possible you can pass in a catheter, a urine um catheter for the drainage. And if that isn't um happening, then you can look at the alternative uh ways of uh draining the urine because the main thing is you have to open the drainage of the urine and you have to rehydrate um the baby and correct the electrolytes, monitor the creatinine and treat uh sepsis with um antibiotics. If ascites are present, they will also need uh to be drained. So, uh surgical uh management, the primary treatment will be ablation of um of the valve, but um sometimes that's not possible and then you will have to do a uh cutaneous uh vasostomy or in other cases where you gonna have to do your supra uh vesicle um diversions which could be either your ute ureterostomy. Um There's also a nephrostomy can be done and there's also the procedure described sober and t uh uterostomy, which also is described that can be used, which doesn't uh totally disrupt the flow of urine into the bladder. On, on, on, on that side, it sort of create like a venting um um stoma for, for the urine drainage as well. So with the surgical management at a later stage, the patient might need a bladder augmentation as a management of their complications. So, um the procedure for ablation of um the procedure valves, you need um periodic um cystoscopy. The idea is that the valve has to be disrupted in three identified area at um at, at five o'clock, seven o'clock and at 12 o'clock. And these are the instrument that you can use, you can use it at the hook or a cold um knife. The idea is just to pass through the, to pass through the opening and you just cut on, you try to cut on at 11 at um five o'clock, seven o'clock and 12 o'clock. And hopefully, that will relieve uh the obstruction. But there's also uh other options of um laser operations that have been described, which are actually can be done even with the smaller um scopes. So, um this procedure of um before you take the child for valve ablation, you have to make sure that it's well um resuscitated child and then you're gonna need a cystoscopy, then you're gonna uh have to incise, as I mentioned, uh at five o'clock, seven o'clock and at uh 12 o'clock. And once that is done, you can even check the urine stream by pressing on the suprapubic of, um, and pressing the bladder to see if after ablation, your, the stream of urine um improves. But, um, the main thing of seeing if you have done it enough is it would be an MCU G that um some people say it can vary. You can do it between any time between 2 to 4 weeks um after ablation to see if there was a complete um excision of, of, of the world complications associated with the procedure. You can have incomplete uh valve and incision and you can also cause urethral uh stricture especially with using of uh the di thing or if you are over with your own cutting. So, um cutaneous um vasostomy. So this uh is more appropriate in small or premature uh neonate when the scope size that you have cannot um be used uh in, in, in, in that uh neon because of uh the small caliber of their urethra. So um doing a vasostomy, we can buy you time and to, to drain the urine while um making um sure that they grow uh until you are able to, to do the ablation of, of the valves. But uh cutaneous vasostomy also offers an option of retrograde um ablation. So which the scope can be passed through the vesicostomy um to ablate the, the valves and it is also reversible. Once the ablation has done, uh it can be reversed and it does allow adequate um urine um drainage in most cases. So I'm looking at the prognostic uh factors of this um condition. So you have favorable and unfavorable features. So, Children that um have low serum creatinine after ablation or diversion of, of the urine. Uh that's a good uh feature. They actually have good uh prognosis or those that you can visualize uh good uh cortico um differentiation. Or if they don't develop uh vaso um valves, unfavorable um features involve bilateral um vasic urethro um reflux and renal cyst or poor cortical medullary differentiation. Or if they fail to achieve diurnal um continent uh by the time that they old age and um the follow up for these patients follow up is very important for these uh patients. You can follow them up with an MC EG just to assess um the condition if it's deteriorating or getting better because doing the primary procedure doesn't um guarantee that um the patient is cured. The patient can still develop, go into endstage renal um disease with adequate um primary uh management. So they need a very close followup with M CE ultrasound. You check for their renal function and electrolytes and their BP as well because it can be the sign of auto um renal um failure. These kids, they also have a problem of um growth. So you have to monitor them if uh their growth uh throughout the years, if they are keeping up with their normal um growth. So, um in summary, um post urethral valves, they are common uh obstructive uropathy in boys and they can be diagnosed in uh in and the in utero fetal intervention is available but um with a questionable um success weighing the risk and, and the benefits as well. Uh the symptoms, they range from marked to severe or can be fatal as as well. So, as we mentioned, a third of these patients will develop endstage renal disease and may require them renal um transplant, which is also the renal transplant gets complicated by the fact that they usually don't have healthy bladders. So um long life uh follow up is um advise for this patient. Yeah, it's going to be the end of my presentation. These are my um references. Thank you. Uh So that was a really excellent presentation. You stick to the time 25 minutes and you just showed very nice uh understanding and you put it very nicely and simply um um I just welcome Professor John Lazarus. Unfortunately, uh he couldn't join us from the beginning. Um uh John Delay. Yes. Yes. No, le leave your leave your presentation on, don't, don't take it off, just leave it on, on uh on, on the screen. Yeah. And uh and um so um most of us know Professor John Lazarus, just to just for those who do not know him, he is the professor and head of entire division of Urology at uh University of Cape Town, which includes Hospital and Red Cross Children's Hospital. And obviously his special interest is periodic urology. And uh he is the current secretary of the College of uh Urologist of South Africa as well. So what I will do is um if I may request Doctor um Majola to make some comments first and then we will invite uh Professor John Lazarus to give his his uh uh advice about posterior urethral valves in general and what he does and yeah, what, what uh points of, of practical importance he can tell us. So, Doctor Majola, hm. Hi everyone. Um Oh, am I loud enough? Yes. Yes, very good. Thank you. Ok. Uh good presentation MZ. So basically uh Postero valve is one of those conditions that are also uh sort of agent or emergent in uh getting on top of uh as MZ had stated and we have moved away from the term postero urethral valves and we've moved more towards uh the term coal, which is congenital obstructive postera urethral membrane. Uh which yeah, was why you made uh you reference a valve somewhere in that term which is not there anymore. Um So basically you need to get on top of it. As I said, it's, it's, it's an urgent or emergency per se cause these kids, if you don't sort out the obstruction, they're gonna have uh, detrimental outcomes when it comes to kidney injury. And basically the child themselves, the only issue is that as well with these kids already having this problem in UTR, you don't really know how much damage has been, uh, has occurred onto those onto the kidneys. And hence, even with good management of these kids, a third of them will, will end up having endstage renal disease and might need um a transplant. So it's important to drain the urine. As MSA said, uh with the uh some form of catheter, transurethral catheter, if you don't have a, a small enough size, use a, a feeding tube, drain the urine resuscitate the child. Well, and then sort out the, the issue at, at hand. Firstly, diagnosis with an MCU G as I stated, that's the gold standard. And then if means and if you have the means, then you can scope them and ablate the valves if you can't. And because of the, you don't have a small enough scope or you don't have the tools to do it, then have a SST toy in the interim to make sure that the child is draining urine adequately so that they don't suffer from uh severe uh adverse events of obstruction and also getting uh urosepsis and then sorting out the problem. That will be my comments. Th Thank you. That was uh a very nice uh uh summary of the advice. I just like to just mention one or two very mi small minor things. One is uh just remember in addition to back pressure changes, uh this urinary system is dysplastic right from the beginning because things didn't start, right. So, so uh the entire urinary system is dysplastic. And that's the reason why they have uh many of them have such bilateral, severe vaso ureteric reflux part of it could be vaso ureter junction obstruction because of thick wall hypertrophic bladder. But uh uh many of them, it would be just the dysplastic kidneys and, and uh the the ureters which are laterally displaced or the opening. And uh so overall dysplasia and the prognosis actually depends amount uh uh on, on the amount of dysplasia or the degree of dysplasia. And obviously, as uh Doctor Majola also mentioned, uh the length for which the obstruction persists and obviously also on the severity of obstruction because one you, you uh clarified it nicely that uh each and every child may not have severe obstruction. So it's a spectrum of disorders. Some Children may present only quite late and some of them may just be born dead. Uh So, so that's, that's that. And just for any junior doctor, don't think that catheterizing a newborn baby with posterior urethral valves is an easy uh exercise quite often, the posterior urethra is so dilated. Um and, and elongated that it's not easy to catheterize the bladder of the Children. So most important thing is plenty of lubrication and, and be as gentle as possible, do not force the catheter through the urethra of a baby boy because if you are forcing you are more likely to do damage than actual good. So if you can't do it, get you a senior and and let the senior try with with more expertise. So I think that's, that's really all I would like to say at this stage. And I would then invite uh Professor John Lazarus. Uh So John, I know you missed more than half the presentation, but we would really like to know your uh your sort of current strategy. What do you do? Um And yeah, your overall advice about uh mm mm posterior urethral valves in Children. Thank you John uh Professor Chits. Uh Thank you very much for the warm invitation and apologies to Doctor Juli for missing a little bit of the talk. Um I can perhaps add most value by discussing some of the surgical techniques because I think there is a, a little bit of a learning curve in terms of doing the valve ablation. Uh So if you're happy for me to talk a little bit about that at the start. No, please. No, that that would be excellent. Thank you. Good. So, so do you have any power point John or you would just stop? I'll just talk. Uh You can see me. OK. No, we can see you. We can hear you. Thank you. Oh, good. Um So I think the first thing is that I it's important not to take a child to theater without an MC. Uh that's the hallmark of the diagnosis. And, you know, sometimes people don't like doing M CS in babies, but it's an essential part of the diagnosis. Uh To my mind, they once showed in a, in a study, various posterior urethra to experience pediatric urologists. And many of them were fooled into thinking these are post urethral valves. So don't call it on cystoscope. You must rely on MC to help make the diagnosis. Um The technique uh that I would encourage you to do is first of all, make sure you got the right equipment. We shouldn't in this day and age, be doing basics because we haven't got the right equipment and um forgive me if we're using the name storts, but they are the ones that we have access to. And uh we use the 11 French uh receptors cope. And we've also got access to a 10 French optical. You'll find the smaller babies. You're not going to be able to get the 11 in and you're going to rely on the cold knife of the 10 French optical in smaller babies. So, ideally, you would like to have both of those bits of equipment available. The second thing is that you're going to want to have good visualization in order to do that you're gonna have a good flow. And what I do is put a gel co into the baby's bladder that optimizes drainage out of the bladder. The second thing is that uh Doctor Julie, you mentioned that you would always ablate the valve and then bring the child back uh for an MC. And if MC looks good, you'd be happy, we've stopped doing that. It's not a bad thing to do. In fact, it's often quite encouraging because you can see how plastic the bladder is. It looks terrible. Uh In a Christmas tree circulated, trabeculated small capacity bladder with reflux and you ablate the valve and it looks much better. But we've learned from Patty Dean and uh mentioned um cum uh Paddy Derwin from Melbourne and Australia is the person who defined that term. It's probably a better term by a long straw. And uh he has also recommended doing a redo valve ablation. So he would, what we do now is after six weeks after the ablation, we take the child back because invariably, perhaps there's been a bit of beating and you haven't appreciated the valve entirely. And you often find that your second relook is actually still some tissue left. So we mandate these kids to go at least twice to theater uh to satisfactorily, assure ourselves that we've ablated the valve sufficiently. On the second look, I would also contemplate doing a bladder neck incision. There's a very good paper from Iran which has randomized kids, either having a bladder neck incision or just having the valve ablation. And you'll know from looking at M CS that there's often bladder neck hypertrophy, which can be involved in causing bladder outlet obstruction. And they were able to show that they improved urodynamic features. If you ablated the bladder neck as well, I don't do it in all kids. But if I found the ultrasound looking bad at the second re look, I would contemplate doing a bladder neck incision. The other thing to mention is that once I've done the ablation, I would take the scope out and I push on the baby's bladder and try and convince myself that the pressure is improved from when I pressed on it at the beginning before I started. And I find that quite helpful, a creed maneuver just to see you got good, nice low pressure flow out of the bladder. Um What else can I tell you? The other thing is that we often think in, in surgery that uh less is often more, but I want to encourage you to be quite aggressive in your bladder in your ablation of the really got to work hard to open up a nice channel. And it's one place that I've discovered that more is more, in fact, uh and I'd encourage you to try and be quite aggressive in ablating the valve to the best of your ability and proving with the creed that you've got a, a good uh flow at the end of it. So those are the bits of techniques that I find quite helpful. Um II can perhaps stop there and take any questions or see if people disagree or agree. Um John, thank you. Uh Just so so very interesting because um uh this is exactly what uh we had learned from Larry G. And I'm sure uh Professor Colin Lazarus had also learned this from Larry G when uh he was training at Red Cross. So we always use uh used and still use uh MCU as the gold standard for diagnosis. And I will fully concur with you because uh few times we have convinced ourselves on cystoscopy for a child to have valves. But uh uh if we went back and did the MC, then there was obviously a absolutely no obstruction. So I think that is a very important advice and um we have been doing copy about six weeks after uh the initial uh ablation. And uh and um uh yeah, I think uh more is more um uh I something new I've learned today from you, which is, which is very important. But I think for occasional pediatric urologist like myself, we were always a bit scared to uh ablate more and cause damage to the urethra and cause a potential stricture. So I can just give example of doctor Sang, who was our long term colleague here in East London and the two of us quite often did these things together and uh we would do as much as we would think, safe at the first sitting. But six weeks later, we needed to do little more um in, in quite a few of the Children. And um we were forced to do vesicostomy for quite a while because we did not have uh small enough uh instruments, the scopes. But we are blessed that uh quite recently, uh our trust sponsored uh the, the smallest uh resectoscope and especially it was, it was uh motivated by Doctor Majola after he came back uh from fellowship uh with you. And uh so um II don't think we have needed to send any patient to you or we have needed to do a vesicostomy in, in the recent time and just coming back to the incidence uh Zilei uh it's, it's important that it is, it is not that uncommon. It is uh one in 5 to 8000 boys. So, so if we say boys and girls about 5050. So in all Children, it's about just uh half the uh incidence of of anorectal malformation. But many of them obviously are, are undiagnosed. Uh As you correctly said, some of the fetuses just are born dead and uh uh uh a lot of Children just die uh undiagnosed. So I think that is important for us to teach our pediatric colleagues and also general practitioners and doctors at peripheral hospital about these varied presentations of posterior urethral valves. Uh So, so those are my comments. And um then I would just encourage uh John de la to ask questions to either Doctor Moola or to prof John. Um and others also to ask questions or make comments, please, John de la uh good evening pros and thanks for your advice. Um I will just just want to ask um the question about the bladder neck um incision um because I also have find out that it does also increases the chances of um incontinence. And as you mentioned that you don't do in all the patient and you assess and pick um the patients that are best um for the bladder neck um incision. So in terms of the percentage of the patients that you do, how often do you have to do a bladder neck incision and how often do deal with the complication of having incised uh the bladder neck? Yes. Um I would say in about a third of cases and you are correct that I have seen incontinence following that, but you never know is that incontinence due to what you've done or is it due to the fact that the child now has a valve bladder syndrome, which I'm sure you you spoke about. I didn't hear that, but that's important concept of this being a lifelong disease in many ways and, and they all end up with some degree of bowel bladder syndrome, which may make them incontinent for other reasons. So, uh I think the data is pretty compelling. Uh Our pediatric surgery colleagues in, in, um Iran have put together a well conducted uh trial and they were able to show better urodynamic features. I'll be happy to, to send the paper uh to look it out. But um I think the point is that yes, maybe incontinence might be increased. But you've also got to think you're dealing with very high risk situation here. If you fail to just obstruct this child, they're gonna go into endstage renal disease and they're probably not gonna be lucky enough to receive a transplant. Um We've looked at our valve cases. We had, I think close to 100 and we noted that if they made a creatinine, the lowest creatinine that they got to in the first year was more than 80 they were going to end up in, in the end stage renal disease. So the stakes are pretty high here. And that's why I think you've got to work quite hard to, to know whether your very minor surgical input is going to be effective enough to optimize this child's uh chance of nice low pressure uh bladder to protect the kidneys. Yes. Uh uh Thank you, John. I think uh w whenever you get a chance, no rush, if you can just forward that uh Iranian paper to me, I will share it with uh all, all our, our colleagues here in East London. And, um, before I invite Doctor Majola once again, uh, we, uh, Doctor Jua has, uh, studied, uh, the, uh, the, the problem, the issue of gallbladder. Um, he has actually a couple of slides. So, uh, can you share that those, uh, two slides of gallbladder and talk about it briefly, please? So, like I actually have taken them out on this presentation, those two slides. Oh, you have taken them out. You didn't leave them in? Ok. Ok. No, that, that's fine. That that's ok. That's no problem. Uh So, so I just then invite Doctor Majola again, Doctor Majola. Any any more comments after pro John's advice? Um I just wanna ask John the on a practical note when you do the blader neck incision. Uh where about do you actually make the incision? And how deep do you go if that's a measurable um incision per se? Yes. Um I think you read in the books that they described doing it at uh 85 and 12 o'clock. You will be able to identify the valve. This is key by not only seeing the sheet of tissue because you can get confused with the sphincter, but by seeing what are called the clear collicular. In other words, you got the veri Montanum and coming out towards you from the very Montanum are these two folds that then become the valve. So that's the classic uh type one valve. You Hampton Young described all those years ago and I find your best bang for buck is in fact to turn the scope upside down and then you're looking out from underneath and your loop, maybe I can, my video might be on it. And if you can see if you're effectively, then you're, you're looking out from below and the cutting uh quarter is at the top. And then you get a lot of um ability to quite nicely ablate the valve at 12 o'clock. And often these valves are not a thin sheet of tissue. It's often quite a thick tissue. The other thing to say is that you're safe going at 12 o'clock, there's nothing you can damage. Even if you go outside of the bladder neck area there, you can't do any major damage. It's gonna heal nicely. Ok? I would want to add to that, that you can run into a bit of trouble with the bladder neck incision because that uh you can in fact undermine the bladder neck trigo and area. So you got to be a little bit cautious when you go deep there, but I would encourage you to feel safe going at 12 o'clock. And yes, you can go at five and eight. But I must say mostly if you go at 12, you're going to uh effectively divide the valve in two and it's going to be flapping in the wind and you'll have done a good job. Ok. Thank you. Uh John. It's, it's so very interesting because the, these are the things which Larry G uh has taught. He has, I'm sure written about those things and this is almost like word to word uh description. What you are describing is that you turn the scope upside down and then in inside the valve and, and uh they are not uh very thin and flimsy, they actually are, are, are a bit of tissue and it needs efforts to, to either ablate them or to cut them. So, so that, that's, that's very good delay if I can ask you uh to just uh sort of clarify 22 concepts. The first concept is about urinary ascitis. How will you manage urinary ascitis uh in a newborn? That's number one. And secondly, just give us a little more information about Potter's Syndrome. Uh I know because of shortage of time. You didn't uh didn't elaborate, but you can start with what do you mean by Poer syndrome? So like sure, eyes on delay. Yes, I know. Yes. Did you hear my question? Yeah. Yes, I had a question about uh Poer syndrome and um and the urinary ascitis, urinary, a arthritis. Ok. So just talk for about Porter syndrome for about a minute and then talk about urinary management of urinary ascitis in a newborn, obviously associated with posterior urethral valves for one minute. Yeah. Ok. Um So it, it, it's a Porter's um syndrome is caused by hydras as II have uh mentioned and things to talk, you know. Sorry. So we are losing you. So I did tell you to talk, you know, it, so it stop, you know. Hi. I, the I shave legs. Hi is on delay. So is he still on? I think he's probably got disconnected. Um, just give him another second talk to the one, you know, now 100 and 33,000. Hi. So we have lost you. Ok. Ok. Ok. No problem. Ok. Ok. Ok. So for example to talk to your, ok, like you said, mom, you know this. Yeah. Um should this place? So no, it, it looks like he's having trouble reconnecting. Um uh I don't think we need to uh keep waiting and especially keep uh John waiting. Uh So I think uh John um uh last few words from you before we close the meeting. Oh, I see him yet. Yes, sir, Meland. Uh just once again. Thank you very much for the invitation. Um I would like to encourage the juniors to going to choose one topic to start their reading with uh pediatric urology. I'd encourage them to read about vowels because it has all the things that you find in other chapters such as reflux, it's akin to the neuropathic bladder, uh voiding dysfunction. So it's a good place to start your, your reading and um a fascinating illness and these patients are often with you for a long period of time. So getting it right from the first go is is important. Uh Thank you very much. Yes, thank you John. And uh just so so interesting that uh you know, Patty de uh much more than we do. But I have also um I've met him and I've seen him operating live in Bloemfontein. Uh So it's always so nice uh uh to see that somebody who is so prominent in in the field of pediatric urology, we know that person, we have met that person, we have learned firsthand from that person. So John, thank you very much for, for your um contribution and we will involve you again sometime next year. Absolute pleasure. Thank you, Melan. OK. Uh Thank you everybody. Um So delay uh If you could please uh email me your presentation, then I will put it uh put it on the Zoom Group and uh Mia if you can just hang on for a few minutes, I just want to check if I can um I can transfer the w the hosting rights to you, Heimia. I think the Yeah, yeah, the rest uh of, of uh the attendees uh can, can disconnect or leave the meeting. Thank you very much for your attendance. Thank you to Doctor Jola for, for uh excellent presentation and to Doctor Moola for guiding him and for uh rest of the staff members to attend and I am recording. So I will, I will share the link uh uh as soon as Uh, I, I've recorded the meeting.