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Transitional urology 1
1. TRANSITIONAL
UROLOGY
D E P T O F U R O L O G Y
G O V T R O YA P E T TA H H O S P I TA L
K I L PA U K M E D I C A L C O L L E G E
C H E N N A I
2. MODERATORS:
Professors:
โข Prof. Dr. G. Sivasankar, M.S., M.Ch.,
โข Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
โข Dr. J. Sivabalan, M.S., M.Ch.,
โข Dr. R. Bhargavi, M.S., M.Ch.,
โข Dr. S. Raju, M.S., M.Ch.,
โข Dr. K. Muthurathinam, M.S., M.Ch.,
โข Dr. D.Tamilselvan, M.S., M.Ch.,
โข Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
4. GOAL
To provide uninterrupted, high quality,
developmentally appropriate transfer of
medical care to an adult care model as
a patient moves from adolescence to
adulthood
Transition from pediatric, parent-
supervised health care to more
independent, patient-centered adult
health care
4
Dept of Urology, GRH and KMC, Chennai.
5. ASPECTS IN
TRANSITION
โข Managing medication, physicians,
knowledge of medical condition,
hospitals, medical resources
โข Independent Living
โข Education
โข Vocation
โข Insurance Coverage
โข Community Inclusion
โข Sexuality
Improved quality of life
Survival
5
Dept of Urology, GRH and KMC, Chennai.
7. SIX CORE ELEMENTS INTRANSITIONAL CARE
US Department of Health and Human Services
7
Dept of Urology, GRH and KMC, Chennai.
8. PRINCIPLES IN HEALTH CARE TRANSITION
Importance of youth- and/or young adultโcentered
Emphasis on self-determination, self-management, and family and/or caregiver engagement
Acknowledgment of individual differences and complexities
Recognition of vulnerabilities and need for a distinct population health approach for youth and young
adults
Need for early and ongoing preparation, including the integration into an adult model of care
Effective communication, and care coordination between pediatric and adult clinicians and systems of
care;
Recognition of the influences of cultural beliefs and attitudes as well as socioeconomic status
Need for parents and caregivers to support youth and young adults in building knowledge regarding
their own health and skills in making health decisions and using health care. 8
Dept of Urology, GRH and KMC, Chennai.
9. BACKGROUND
Transition > 18 million Adolescents 18-21 yrs
4.5 million (20%) have special needs/chronic conditions
>85% Report Lack of Access to Providers
Only seek Healthcare Emergently
Highest ER visit rate patients <75 yrs
Care Systems are not prepared for TRANSITION
Prior et al. Pediatrics 2014
9
Dept of Urology, GRH and KMC, Chennai.
10. NEED FOR TRANSITIONAL
UROLOGY
โข Genitourinary system โ most frequently affected by
congenital defects
โข As long-term survival with complex congenital and
pediatric diseases has improved, more patients with
congenital genitourinary conditions are living into
adulthood.
โข These patients can continue to face lifelong issues
related to their conditions, including
โ urinary incontinence
โ recurrent urinary tract infections
โ chronic kidney disease
โ difficulties with sexual health and function
10
Dept of Urology, GRH and KMC, Chennai.
11. CANDIDATES FOR TRANSITIONAL
CARE IN UROLOGY
โข Isolated โ Hypospadias
โข Multiple organ involvement โ Spinal bifida
โข Small subset of this group e.g. Exstrophy, urologist is often the most
knowledgeable care provider about their condition, anatomy and long term
medical risks associated with the disorder
Congenital urological defects
Survivors of pediatric and pelvic cancers
Pediatric Renal transplant recipients
11
Dept of Urology, GRH and KMC, Chennai.
12. TRANSITIONAL UROLOGY
Field of urologic
congenitalism
combines the
speciality skillset
of pediatric and
adult urology
12
Dept of Urology, GRH and KMC, Chennai.
14. ASSESSMENT
Defining patientsโs baseline
Understanding patientโs goals, resource constraints, executive and
cognitive assets and deficits and social constraints
Characterizing new or worsening complaint
Determining appropriate diagnostic tests to define the problem
Developing a menu of treatments that will address the concern
and delineating the associated personal costs or risks of each.
14
Dept of Urology, GRH and KMC, Chennai.
15. DEFINING
BASELINE
โข Baseline assessment of urological
function
โข Renal function
โข Continence status / use of protective
garments
โข Urinary infections
โข Sexual function and activity
โข Fertility (past and present)
โข Prior urological medical and surgical
treatments Key components of initial evaluation of an adult with
congenital urological needs
15
Dept of Urology, GRH and KMC, Chennai.
17. CURRENT STATUS
Health care Transition is an unfulfilled promise
Current literature is in Consensus Statements,
Recommendations, and suggested Transitional
Process Elements
NO Data, NO Research
Outcomes conducted through Surveys and small
samples from a few sub-specialty clinics and hospital
programs
17
Dept of Urology, GRH and KMC, Chennai.
18. BARRIERS
โข Medical Education Gaps at every level
โข HCT implies Smooth transition but typically Abrupt
โข Lack of Communication, Coordination between Pediatric-
Adult Care Providers
โข Practice Differences between peds supportive family
centered to Adult Independence
โข Access Restrictions (Too Old,Too Complex)
โข Patients psychosocial fears, new team, complexity
โข Financial
18
Dept of Urology, GRH and KMC, Chennai.
19. MEDICAL EDUCATION
IN TRANSITION
โข Training in chronic disease and Transition is
not adequately addressed during residency
โข At Subspecialty level NEED for enhanced
training in Transition care for Fellowships
โข Transition training for physicians and all
allied health care providers ( nurses, NP, PA,
pyschologist, social workers)
19
Dept of Urology, GRH and KMC, Chennai.
20. CONSENSUS PANEL
-CONGENITALISM
โข 2015 Recommendations AUA
Working Group
โข Coined Term โCongenitalismโ
โข Lack of Data, Management
Complex
โข Need more, Consensus
discussions and
recommendations throughout
the life of these patients
20
Dept of Urology, GRH and KMC, Chennai.
21. OVERLAP CLINICS
Structured overlap in care during adolescence
Sees both their pediatric and future adult providers at the
same time or in the same clinic space before cessation of
pediatric care.
Several joint visits over one or more years before
transitioning fully to the adult urology practice.
Afford patients exposure to a new provider in a safe context,
building trust and allowing patients and their families to
ensure that all parties invested in their health develop aligned
goals as their care moves into a new clinical setting. 21
Dept of Urology, GRH and KMC, Chennai.
23. MYELODYSPLASIA / SPINA BIFIDAS
Survival into adulthood โ 85%
Goal โ preservation of renal function
Transitional Care
โข Formal exchange of medical records โ catheterisation schedules, need for anticholinergics,
attention to upper urinary tract, prior surgeries and surgical reconstruction
โข Screening for urologic cancers
โข Untreated neuropathic bladders โ UTIs, incontinence, deterioration of upper urinary tract
with loss of renal function
โข Follow up โ physical examination, usg, serum creatinine, UDS if new symptoms (urinary
incontinence, increased leakage between catheterisation and recurrent UTIs)
โข Attention to bladder function and continence, CIC, Recurrent UTIs
โข Attention to sexual function and pregnancy
23
Dept of Urology, GRH and KMC, Chennai.
24. MYELODYSPLASIA โ POST SURGICAL
CONSIDERATIONS
Chronic bacteriuria
Mucus production
Formation of bladder calculi
Metabolic abnormalities from exposure of bowel to urine
Bladder perforation
Potential risk of bladder or bowel malignancy
24
Dept of Urology, GRH and KMC, Chennai.
25. BLADDER
EXSTROPHY
EPISPADIAS
COMPLEX
Childhood - multiple reconstructive
operations with the goal of achieving
urinary continence, adequate sexual
function, and acceptable cosmesis.
Adult life - It is important to assess the
integrity of the reconstruction,
functional outcomes (urinary, sexual,
psychological), and cosmesis in adult life.
Transitional Care Primary Goals - to
preserve renal function, establish
urinary continence, and functional
genitalia
25
Dept of Urology, GRH and KMC, Chennai.
26. TRANSITIONAL CARE IN BEEC
โข renal ultrasound, serum creatinine, or GFR measurements
Renal function
โข frequency of UTIs, hematuria, bladder pain, transplant status, and other risk
factors.
Bladder cancer risk assessment
โข method of bladder emptying; changes in urinary continence since prior visit,
satisfaction with continence
Urinary continence status
โข desire, erectile/ejaculatory function (men), dyspareunia/ anorgasmia (women),
satisfaction with sexual function, and fertility considerations/ concerns
Sexual function
โข Serum chemistry, vitamin B12 levels if appropriate
Nutrition
โข counseling if appropriate or if desired
Psychological health
Adult patients with BEEC should be evaluated annually with a complete physical
exam, including pelvic exam for women and assessment for the following
26
Dept of Urology, GRH and KMC, Chennai.
27. ADULT
HYPOSPADIAS
Goals - straight penis, neourethra of adequate caliber, meatus
at or near the tip of the glans penis, and normal voiding and
good penile cosmesis with minimal complications.
Rates of secondary surgery for hypospadias
โข 9 % for distal hypospadias repair
โข 32 % for proximal hypospadias repairs
Problems encountered in post-pubertal life include:
โข Urinaryโspray, deviated stream, weak stream, dribbling
โข Sexualโerectile dysfunction, ejaculatory dysfunction
โข Infertility
โข Cosmesisโscarring, persistent chordee
โข Psychosocialโsexual inhibition, dissatisfaction with appearance, overall
decreased QoL
27
Dept of Urology, GRH and KMC, Chennai.
28. POSTERIOR URETHRAL VALVE
Approximately 1/3 of patients develop ESRD by young adulthood, with renal deterioration often
seen during and shortly after adolescence.
Despite active treatment progressing to transplant in 15.8 % of children
Detrusor dysfunction in PUV โ 75% - detrusor overactivity, poor compliance, and myogenic
failure
Decreased sexual function and fertility โ due to CRF, abnormal prostatic urethra, crypto-
orchidism, leukospermia, and recurrent epididymo- orchitis
28
Dept of Urology, GRH and KMC, Chennai.
29. PUV โ
TRANSITIONAL
CARE
Renal function assessment - urea and
electrolytes, blood pressure and USS to assess
the upper tracts.
Periodic urodynamic monitoring, particularly
when new voiding problems (retention, UTI,
stones) appear or imaging and serum Cr
suggest worsening renal function, is necessary
Ensure compliance with e.g. medications
(anticholinergics, antibiotics), voiding strategies,
intermittent self catheterization/bladder
washouts, and attendance at follow- up clinics.
29
Dept of Urology, GRH and KMC, Chennai.
30. VUR AND ADULTS
โข Even when corrected, certain patients are at
risk for noteworthy sequelae ofVUR.
โข VUR is heritable, which makes family
counseling an important aspect of patient
management.
โข VUR may remain undetected until adulthood
and serve as an unrecognized source of
patient morbidity.
30
Dept of Urology, GRH and KMC, Chennai.
31. PEDIATRIC
GU CANCER
SURVIVORS
โข Late events described inWilms tumor survivors
include tissue hypoplasia, secondary malignancies,
nephrologic, endocrinologic,urologic, orthopedic,
cardiovascular, and pulmonary events.
โข Late pelvic effects are more substantial in this
population, including:
โ Infertility
โ Bladder dysfunction
โ Sexual dysfunction
โ Rectal/fecal dysfunction
31
Dept of Urology, GRH and KMC, Chennai.
33. UTI IN NEUROGENIC /
RECONSTRUCTED BLADDER
Symptoms nonspecific &
Confirmatory cultures are useful
Asymptomatic bacteriuria is common.
UTIs should only be treated in this population if they are symptomatic
CIC is associated with lower risk of UTI
Factors that can lead to new or
worsening UTI
Urolithiasis, VUR, poor bladder compliance, anatomic problems leading to
compromised drainage of the ureters or bladder, and noncompliance with
catheterization.
Preventative strategies for
recurrent UTIs
irrigation (NS, water, or antibiotics)
CIC
Optimization of bowel function
Prophylactic antibiotics, D -mannose, cranberry, and bacterial interference
33
Dept of Urology, GRH and KMC, Chennai.
34. TROUBLESHOOTING CONTINENT
CATHETERIZABLE CHANNELS
Obstruction
Incontinence
Most of the complications related to continent catheterizable channels can be resolved by
minimally invasive interventions that can be performed by adult general urologists.
Few patients need surgery to revise or replace the channel, and referral to a specialist
trained in reconstructive urology would be appropriate in such instances.
Conversion to an incontinent urinary diversion should only be considered as a last resort.
34
Dept of Urology, GRH and KMC, Chennai.
35. AUGMENTATION
CYSTOPLASTY:
RISKS FOR
MALIGNANCY
Neuropathic bladder with or without augmentation
โ 4- 6 fold increase in bladder cancer risk
Lethality of cancers seen in neurogenic bladder is
worse than the general population
โข 80 % demonstrating locally invasive (T2 or higher) and/or
metastatic disease at the time of presentation.
โข Median survival from diagnosis is 1.5 years.
Risk of malignancy in augmentation cystoplasty:
โข Gastric cystoplasty 2.8 % per decade
โข Colon or ileal cystoplasty 1.5 % per decade.
โข Renal transplantation with history of viral cystitis represents a
very high risk group (sixfold to tenfold increase).
35
Dept of Urology, GRH and KMC, Chennai.
36. AUGMENTATION CYSTOPLASTY: SUGGESTIONS
FOR FOLLOW-UP EVALUATIONS
โข Recommended annual
surveillance:
โ Interval medical history
focused on determining
whether baseline
urological symptoms have
changed
โ Serum chemistries
โ Radiographic screening
(ultrasound, KUB, or CT
when indicated)
โ Abnormalities seen on
annual surveillance should
prompt further diagnostic
testing as appropriate 36
Dept of Urology, GRH and KMC, Chennai.
37. BPH AND PELVIC ORGAN PROLAPSE IN
PATIENTS WITH NEUROGENIC BLADDER
In patients performing CIC, initial indication - difficulty with catheterization
In patients with neurogenic bladder who void byValsalva maneuvers - feeling of
incomplete emptying, a weaker stream than usual, or the complete inability to void.
Unique to patients with neurogenic bladder who develop POP, the initial presentation
maybe incontinence between catheterizations, the feeling of a full bladder sooner after
performing catheterization, or the need to catheterize more frequently.
37
Dept of Urology, GRH and KMC, Chennai.
38. RECOMMENDATIONS
Urinalysis, creatinine ,renal ultrasound, and consideration of urodynamic testing.
If concern for a stricture exists, cystoscopy should be considered
Initial management for patients with neurogenic bladder who develop BPH should be with
medical therapy, consisting of an alpha blocker alone or in combination with a 5-
alphaeductase inhibitor.
In patients for whom medical therapy is contraindicated or fails - indwelling suprapubic
catheter, formation of a catheterizable channel (Mitrofanoff)
Management in patients with neurogenic bladder who develop POP should be based on
patient preferences, and may include measures such as anti-incontinence pads, placement
of a pessary, or repair of the prolapse. 38
Dept of Urology, GRH and KMC, Chennai.
39. CALCULI IN NEUROPATHIC /
AUGMENTED BLADDER
RISK FACTORS:
โข Urinary tract infection
โข Bladder dysfunctionโurine
retention
โข Lower urinary tract reconstruction
โข Urinary diversion
โข Chronic indwelling catheter
โข Immobilization Hypercalciuria
โข Acidosis of urine
โข Vesicoureteral reflux
โข Presentation may include recurrent/ escalating UTIs or new
incontinence
โข Should have low threshold for axial imaging in patients with
risk factors
โข Bladder irrigation with or without antibiotic solution should be
encouraged in recurrent bladder stone formers.
โข Surgical treatment will likely be multimodal with patients often
requiring more than one procedure for stone clearance.
Surgical planning should include consideration of:
โข โ Prior surgical interventions/ reconstructions
โข โ Body habitus (obesity, lower extremity contractures)
โข โ Respiratory status
โข โ Stone size and density 39
Dept of Urology, GRH and KMC, Chennai.
40. ACID BASE DISTURBANCES
โข Ileal / colonic segments โ hyperchloremic
metabolic acidosis
โข Gastric segment โ Hypochloremic
hypokalemic metabolic alkalosis
โข Jejunum โ hyponatremic, hypochloremic,
hyperkalemic, acidosis with azotemia
โข Ileal conduit โ mild acidosis
โข Chronic acidosis โ decreased bone mineral
density โ osteomalacia / osteoporosis
โข Calcium,Vitamin D supplementation
40
Dept of Urology, GRH and KMC, Chennai.
41. IN PREGNANCY
Vaginal delivery should be considered contraindicated in:
โข Patients with a narrow bony pelvis
โข Patients with artificial sphincters or bladder neck reconstructions
โข Patients with contracted hips
Vaginal delivery should be performed with caution:
โข Patients with ureterosigmoidostomy
โข Fetal malpresentation
โข Patients with uterine rolapse
Concerns for cesarean section in :
โข Patients with intraperitonealVP shunts
โข Patients with diversion pouches, enterocystoplasty, or neobladder
โข Technical considerations with cesarean section include
โข performing the procedure via a high midline incision to avoid
damage to the reservoir
โข Catheterization of channels in the immediate preoperative period
may assist with either avoidance or recognition of injury induced by
the dissection.
41
Dept of Urology, GRH and KMC, Chennai.
42. TRANSITIONAL
CARE -
FERTILITY
โข Actively engage adolescent and adult patients in
discussions regarding sexual activity, contraception, and
fertility
โข Engage multidisciplinary team for preconception
counseling
โข Advocate high-dose folic acid use (4 mg/day)
โข Monitor renal function, preferably with non-creatinine-
based evaluation
โข Caution with use of urine pregnancy tests with bladder
augmentation patients
โข Individualize risk management and mode of delivery to
patient goals
42
Dept of Urology, GRH and KMC, Chennai.
43. SUMMARY
โข Transitional urology - Urologic congenitalism - Involves group of medical specialists,
care givers & rehabilitation specialists
โข To date most studies are observational & Current practices are based on Review
of literature
โข Variable important components and potential barriers to the ideal process
โข A good model transition / transfer of care remains elusive
โข Provide uninterrupted, developmentally appropriate transfer of medical care to an
adult care model
โข Need for more research studies to develop an ideal transitional model in
Urological care
43
Dept of Urology, GRH and KMC, Chennai.