Transitional urology 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

MODERATORS:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D.Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

TRANSITION
HEALTH CARE
DEFINITION
“Purposeful planned
movement of adolescents and
young adults with chronic
conditions from child-centered
to adult-centered care”
3
Dept of Urology, GRH and KMC, Chennai.

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

ASPECTS IN
TRANSITION
• Managing medication, physicians,
knowledge of medical condition,
hospitals, medical resources
• Independent Living
• Education
• Vocation
• Insurance Coverage
• Community Inclusion
• Sexuality
Improved quality of life
Survival
5

TRANSITIONAL
CHANGES
6

SIX CORE ELEMENTS INTRANSITIONAL CARE
US Department of Health and Human Services
7

PRINCIPLES IN HEALTH CARE TRANSITION
Importance of youth- and/or young adult–centered
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

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

NEED FOR TRANSITIONAL
UROLOGY
• Genitourinary system – most frequently affected by
congenital defects
• As long-term survival with complex congenital and
pediatric diseases has improved, more patients with
congenital genitourinary conditions are living into
adulthood.
• These patients can continue to face lifelong issues
related to their conditions, including
– urinary incontinence
– recurrent urinary tract infections
– chronic kidney disease
– difficulties with sexual health and function
10

CANDIDATES FOR TRANSITIONAL
CARE IN UROLOGY
• Isolated – Hypospadias
• Multiple organ involvement – Spinal bifida
• 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

TRANSITIONAL UROLOGY
Field of urologic
congenitalism
combines the
speciality skillset
of pediatric and
adult urology
12

ISSUES TO
BE
ADDRESSED
Sexuality
Post-pubertal
genital
appearance
and function
Renal
Function
Urinary and
fecal
incontinence
Fertility and
pregnancy
Typical age
related problems
complicated by
coexisting
anomalies and
prior surgeries
13

ASSESSMENT
Defining patients’s baseline
Understanding patient’s 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

DEFINING
BASELINE
• Baseline assessment of urological
function
• Renal function
• Continence status / use of protective
garments
• Urinary infections
• Sexual function and activity
• Fertility (past and present)
• Prior urological medical and surgical
treatments Key components of initial evaluation of an adult with
congenital urological needs
15

TRANSITIONAL
UROLOGY
CURRENT STATUS
& FUTURE
16

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

BARRIERS
• Medical Education Gaps at every level
• HCT implies Smooth transition but typically Abrupt
• Lack of Communication, Coordination between Pediatric-
Adult Care Providers
• Practice Differences between peds supportive family
centered to Adult Independence
• Access Restrictions (Too Old,Too Complex)
• Patients psychosocial fears, new team, complexity
• Financial
18

MEDICAL EDUCATION
IN TRANSITION
• Training in chronic disease and Transition is
not adequately addressed during residency
• At Subspecialty level NEED for enhanced
training in Transition care for Fellowships
• Transition training for physicians and all
allied health care providers ( nurses, NP, PA,
pyschologist, social workers)
19

CONSENSUS PANEL
-CONGENITALISM
• 2015 Recommendations AUA
Working Group
• Coined Term “Congenitalism”
• Lack of Data, Management
Complex
• Need more, Consensus
discussions and
recommendations throughout
the life of these patients
20

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

SPECIFIC
UROLOGIC
CONDITIONS
22

MYELODYSPLASIA / SPINA BIFIDAS
Survival into adulthood – 85%
Goal – preservation of renal function
Transitional Care
• Formal exchange of medical records – catheterisation schedules, need for anticholinergics,
attention to upper urinary tract, prior surgeries and surgical reconstruction
• Screening for urologic cancers
• Untreated neuropathic bladders → UTIs, incontinence, deterioration of upper urinary tract
with loss of renal function
• Follow up – physical examination, usg, serum creatinine, UDS if new symptoms (urinary
incontinence, increased leakage between catheterisation and recurrent UTIs)
• Attention to bladder function and continence, CIC, Recurrent UTIs
• Attention to sexual function and pregnancy
23

MYELODYSPLASIA – 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

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

TRANSITIONAL CARE IN BEEC
• renal ultrasound, serum creatinine, or GFR measurements
Renal function
• frequency of UTIs, hematuria, bladder pain, transplant status, and other risk
factors.
Bladder cancer risk assessment
• method of bladder emptying; changes in urinary continence since prior visit,
satisfaction with continence
Urinary continence status
• desire, erectile/ejaculatory function (men), dyspareunia/ anorgasmia (women),
satisfaction with sexual function, and fertility considerations/ concerns
Sexual function
• Serum chemistry, vitamin B12 levels if appropriate
Nutrition
• 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

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
• 9 % for distal hypospadias repair
• 32 % for proximal hypospadias repairs
Problems encountered in post-pubertal life include:
• Urinary—spray, deviated stream, weak stream, dribbling
• Sexual—erectile dysfunction, ejaculatory dysfunction
• Infertility
• Cosmesis—scarring, persistent chordee
• Psychosocial—sexual inhibition, dissatisfaction with appearance, overall
decreased QoL
27

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 – 75% - detrusor overactivity, poor compliance, and myogenic
failure
Decreased sexual function and fertility – due to CRF, abnormal prostatic urethra, crypto-
orchidism, leukospermia, and recurrent epididymo- orchitis
28

PUV –
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

VUR AND ADULTS
• Even when corrected, certain patients are at
risk for noteworthy sequelae ofVUR.
• VUR is heritable, which makes family
counseling an important aspect of patient
management.
• VUR may remain undetected until adulthood
and serve as an unrecognized source of
patient morbidity.
30

PEDIATRIC
GU CANCER
SURVIVORS
• Late events described inWilms tumor survivors
include tissue hypoplasia, secondary malignancies,
nephrologic, endocrinologic,urologic, orthopedic,
cardiovascular, and pulmonary events.
• Late pelvic effects are more substantial in this
population, including:
– Infertility
– Bladder dysfunction
– Sexual dysfunction
– Rectal/fecal dysfunction
31

SPECIFIC ISSUES
IN TRANSITIONAL
UROLOGY
32

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

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

AUGMENTATION
CYSTOPLASTY:
RISKS FOR
MALIGNANCY
Neuropathic bladder with or without augmentation
– 4- 6 fold increase in bladder cancer risk
Lethality of cancers seen in neurogenic bladder is
worse than the general population
• 80 % demonstrating locally invasive (T2 or higher) and/or
metastatic disease at the time of presentation.
• Median survival from diagnosis is 1.5 years.
Risk of malignancy in augmentation cystoplasty:
• Gastric cystoplasty 2.8 % per decade
• Colon or ileal cystoplasty 1.5 % per decade.
• Renal transplantation with history of viral cystitis represents a
very high risk group (sixfold to tenfold increase).
35

AUGMENTATION CYSTOPLASTY: SUGGESTIONS
FOR FOLLOW-UP EVALUATIONS
• Recommended annual
surveillance:
– Interval medical history
focused on determining
whether baseline
urological symptoms have
changed
– Serum chemistries
– Radiographic screening
(ultrasound, KUB, or CT
when indicated)
– Abnormalities seen on
annual surveillance should
prompt further diagnostic
testing as appropriate 36

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

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

CALCULI IN NEUROPATHIC /
AUGMENTED BLADDER
RISK FACTORS:
• Urinary tract infection
• Bladder dysfunction—urine
retention
• Lower urinary tract reconstruction
• Urinary diversion
• Chronic indwelling catheter
• Immobilization Hypercalciuria
• Acidosis of urine
• Vesicoureteral reflux
• Presentation may include recurrent/ escalating UTIs or new
incontinence
• Should have low threshold for axial imaging in patients with
risk factors
• Bladder irrigation with or without antibiotic solution should be
encouraged in recurrent bladder stone formers.
• Surgical treatment will likely be multimodal with patients often
requiring more than one procedure for stone clearance.
Surgical planning should include consideration of:
• – Prior surgical interventions/ reconstructions
• – Body habitus (obesity, lower extremity contractures)
• – Respiratory status
• – Stone size and density 39

ACID BASE DISTURBANCES
• Ileal / colonic segments – hyperchloremic
metabolic acidosis
• Gastric segment – Hypochloremic
hypokalemic metabolic alkalosis
• Jejunum – hyponatremic, hypochloremic,
hyperkalemic, acidosis with azotemia
• Ileal conduit – mild acidosis
• Chronic acidosis → decreased bone mineral
density → osteomalacia / osteoporosis
• Calcium,Vitamin D supplementation
40

IN PREGNANCY
Vaginal delivery should be considered contraindicated in:
• Patients with a narrow bony pelvis
• Patients with artificial sphincters or bladder neck reconstructions
• Patients with contracted hips
Vaginal delivery should be performed with caution:
• Patients with ureterosigmoidostomy
• Fetal malpresentation
• Patients with uterine rolapse
Concerns for cesarean section in :
• Patients with intraperitonealVP shunts
• Patients with diversion pouches, enterocystoplasty, or neobladder
• Technical considerations with cesarean section include
• performing the procedure via a high midline incision to avoid
damage to the reservoir
• Catheterization of channels in the immediate preoperative period
may assist with either avoidance or recognition of injury induced by
the dissection.
41

TRANSITIONAL
CARE -
FERTILITY
• Actively engage adolescent and adult patients in
discussions regarding sexual activity, contraception, and
fertility
• Engage multidisciplinary team for preconception
counseling
• Advocate high-dose folic acid use (4 mg/day)
• Monitor renal function, preferably with non-creatinine-
based evaluation
• Caution with use of urine pregnancy tests with bladder
augmentation patients
• Individualize risk management and mode of delivery to
patient goals
42

SUMMARY
• Transitional urology - Urologic congenitalism - Involves group of medical specialists,
care givers & rehabilitation specialists
• To date most studies are observational & Current practices are based on Review
of literature
• Variable important components and potential barriers to the ideal process
• A good model transition / transfer of care remains elusive
• Provide uninterrupted, developmentally appropriate transfer of medical care to an
adult care model
• Need for more research studies to develop an ideal transitional model in
Urological care
43

THANK YOU
44

Transitional urology 1

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