Challenges in paediatric urology and nephrology
Friday 23rd February marked the next instalment in the 2017-18 RSM Urology Section calendar with a day devoted to ‘Challenges in paediatric urology and nephrology’. President, Mr Roland Morley, and his Honorary Secretary, Sri Sripasad, had prepared a day that included a wide range of speakers from across the UK and the United States of America. This diverse programme attracted enough adult urologists, paediatric urologists, paediatric surgeons and trainees from within these disciplines to fill up the lecture theatre – not counting the trainees in East of England, West Midlands, Wessex, Scotland and Northern Ireland!
The day commenced by examining “Common conditions that tax us!”. Chaired by Miss Pareeta Patel, Epsom and St Helier University Hospital NHS Trust, this topic opened the floor to discussion on issues frequently encountered within paediatric urology. Mr Feilim Murphy, of St George’s Hospital, began by describing the indications for circumcision in the twenty-first century, highlighting that in many cases what may at first have appeared to be a phimosis will retract in time with conservative management or six weeks of topical steroid therapy. He noted that the majority of circumcisions in boys should be for balanitis xerotica obliterans (BXO) rather than phimosis.
Mr Henrik Steinbrecher, of Southampton, presented on the medical and surgical management of urinary tract infections in children and the role of antibiotics. He emphasised that while asymptomatic bacteriuria was not an indication for the prescription of antimicrobial therapy in cases of bladder and bowel dysfunction, prophylactic antibiotics may reduce recurrence of infections thus reducing the likelihood of scarring with positive consequences for long-term renal function. He also reminded delegates of the importance of urine culture in confirming the presence of infection – nitrites are often negative in gram positive infections and would go un-diagnosed on dipstick testing alone. Culture to identify the pathogen and its sensitivities is also part of anti-microbial stewardship in modern medicine.
Mr Stephen Griffin, of Southampton Children’s hospital; and Mr Jonathan Glass, from Guy’s Hospital, London proceeded to discuss the management of urinary tract stones and considered the similarities and differences between treating children and adult patients. Ultrasound is the imaging modality of choice, with CT scans being the second line if uncertainty persists. It was noted that there has been an increase in the burden of stone disease in adolescent patients, which is likely as a consequence of rising rates of obesity and increased detection of stones than occurred in the past. This also explained the greater incidence of metabolic stones compared to stones of infective aetiology in younger patients.
Session two focussed on “Conditions that may affect fertility in adult life”. Chaired by guest speaker, Professor John Gearhart of Johns Hopkins Hospital, Baltimore, this concentrated on indications for treatment and appropriate management options in cases of undescended testis and adolescent varicocele. Mr Mark Woodward, of Bristol Royal Hospital for Children, presented on the former subject and explained the rationale for performing orchidopexy before boys reach twelve months of age, ideally between six and twelve months old. This provoked discussion concerning the feasibility in achieving such a target in the NHS at present. Many attendees explained that their practice rarely encountered cryptorchidism at such a young age (let alone had waiting lists short enough to facilitate surgery). Following debate over the ideal and the reality Mr Cervellione, of the Royal Manchester Children’s Hospital, spoke on varicocele in adolescent patients. He described the difference between this cohort of patients and adult patients, indicated that treatment be offered in cases of pain or asymmetry, and discussed the role of selective vein ligation in operative management.
Mr Mark Woodward chaired the third and final session of the morning on hypospadias. Guest speaker form Texas, USA, Dr Warren Snodgrass described his years of experience in the field and how his expertise had been refined through reflection on his surgical outcomes. He focussed on audit, defining success and improving his surgical technique in hypospadias repair to reduce the rate of fistulae, strictures and dehiscence, among other complications in his patients. He encouraged trainees and consultants alike to be motivated by the ‘three Ps’ of personal improvement, prospective analysis, periodic review and practice changing to improve results (Figure 1).
Figure 1. MDT discussion on hypospadias
This self-reflection was followed by Professor Peter Cuckow, of Great Ormond Street Hospital, London and Aarhus University, Denmark who considered the UK perspective on hypospadias repair. Contrasts with Dr Snodgrass’s presentation included the relative merits and drawbacks of one-stage versus two-stage repair in hypospadias. There was great debate on the subject and no consensus was reached though it was apparent that different healthcare systems on each side of the Atlantic Ocean face different pressures. This, combined with the training individual surgeons receive, contributes to the type of surgery offered to patients. Professor Cuckow also explained the role of a posterior auricular skin graft in repair, analysing the outcomes his patients had had following the procedure. A discussion was subsequently held in the style of a multi-disciplinary meeting with clinicians bringing cases to the floor for discussion and sharing of approaches and ideas (Figure 2). This stimulated discussion and the sharing of ideas for when to operate, which approach to utilise and when to offer conservative management. Finally, Professor Ramnath Subramaniam, of Leeds Teaching Hospital, engaged the audience by providing an overview of the role of robot-assisted surgery in paediatrics with videos of his experiences and techniques.
Figure 2. Engagement from trainees in Dr Sondgrass’s reflections
The afternoon consisted of a “urological pot pourri” – chaired by Professor Tim Terry and Mr Roland Morley (Figure 3). This began with Mr Andrew Robb, also of Birmingham Children’s Hospital, discussing the management, follow-up and outcomes in children with posterior urethral valves. His overview of the natural history, suggested investigations and subsequent management explored the risk of bladder outlet obstruction causing decompensation and end-stage renal failure in later life, with the role of desmopressin when the kidney produces urine of reduced osmolality.
Mr Yazab Rawashdeh from Denmark presented on trauma in the paediatric urinary tract. Cycling accidents are greatest contributer to such cases in Denmark, which is converse to the idea that gunshot wounds are the greatest risk. Mr Rawashdeh emphasised the importance of exploring the shattered kidney, explaining the grading system and to follow up with the aim of avoiding secondary haemorrhage post-operatively by advising that patients abstain from sport for two to three months – and have DMSA at twelve weeks post-operatively in severe cases to determine the remaining renal function. Dr Stephen Marks provided a nephrologist’s perspective on haematuria from his experiences at University College London and Great Ormond Street Hospital. Take home messages included that asymptomatic haematuria is frequently inconsequential but there is a necessity to follow up proteinuria in children as a renal cause is most likely with a high likelihood of underlying immunological disease. To close the ‘pot pourri’, Mr Andrew Baird, of Alder Hay’s Children’s Hospital, and Mr Dan Wood, of University College London Hospital, debated the role of bladder neck closure versus artificial urinary sphincter insertion in the incontinent, neuropathic adolescent. Mr Baird defended bladder neck closure and advised the reconstruction of the augment postpartum in female patients while examining the risk of infection, erosion and failure of artificial sphincters. Mr Wood, conversely, defended the insertion of artificial urinary sphincters.
Figure 3. Urological pot pourri
Finally, the meeting concluded with a state of the art lecture from Professor John Gearhart on bladder exstrophy, and an interactive masterclass with himself and Dr Snodgrass educating trainees on surgical approaches, dilemmas and management strategies. Professor Gearhart spoke on primary versus delayed closure in exstrophy, the need for osteotomy and examined molecular markers as predictors of success when delaying surgery to facilitate the growth of a bladder template (Figure 4). He was a strong advocate for the centralisation of care in such niche surgery and explained his role in educating other centres via the ‘International Co-Surgeon’ model of training. The afternoon culminated in a discussion between panel members and the audience on the subject of training the next generation of paediatric urologists and urologists with an interest in paediatrics, while addressing the pressures on healthcare systems and the need to address gaps in service provision.
Figure 4. Professor Gearhart on bladder exstrophy
Huge thanks to Mr Morley and Sripasad for another stimulating programme in this year’s RSM Urology Section calendar, to all speakers for their presentations and openness to discussion and finally to attendees for engaging in the talks throughout the day.