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Published by: api-221992709 on Jul 16, 2013
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Adolescent UrologyDan Wood, PhD, FRCS(Urol),
Consultant in Adolescent and Reconstructive Urology, University CollegeLondon Hospitals.
Declaration of conflicting interests:
None declared.
This article is designed to give a broad overview of the specialist elements of adolescent urology. It emphasises the need for multidisciplinary care of thosepatients born with congenital disorders and treated in childhood. Theimportance of ensuring long-term follow-up and minimising potential damageto the kidneys as well as other metabolic follow-up is discussed.
The definition of adolescent urology should be obvious – however, it is moredifficult than it would at first appear and there are a number of reasons for this. Since the creation of the specialty by Christopher Woodhouse, outcomesin paediatric urology have continued to improve. Whereas major congenitalanomalies, or indeed surgery to correct them, may have previously resulted indeath or major disability – good quality, long-term survival is now areasonable expectation for patients and parents. Interventions such as earlyself-catheterisation and an improved understanding of the need for multidisciplinary care have contributed to these advances . There are anumber of sequelae that result from this and which start to impact on our definition. Firstly, when does adolescence start and therefore when does itend – or in this context should it end at all? Secondly, how should a childmove from paediatric care to adult care? Additionally, what are the problemswith this and who should be involved in long-term care? What are the long-tem outcomes of either congenital disease or its treatment? What about newdisorders identified in adolescence? We do encounter these but they arelargely beyond the scope of this review. If more children need long-term carehow do we manage that? The list goes on – and this article will aim to discusssome of these concerns. No matter how we look at it though, paediatricpatients who have been well cared for in early life have a right to expectcontinued and expert care throughout their adult life. With increasing numbersof patients reaching adulthood new opportunities for clinicians wishing todevelop an interest in adolescent urology will arise and new challenges willbecome clear as part of this expansion.
What is adolescence?
The word comes from the latin –
– to grow, and addressing thebasic principles of adolescent urology is fundamentally important tounderstanding the potential problems. There is no fixed definition for theperiod of adolescence but most people understand it as a period of physical,psychological and emotional development that begins with the onset of puberty. We are all aware that this begins for different individuals at differenttimes. In designing care for these patients we need to recognise this. Themove from paediatric to adolescent or adult care is now widely considered tobe a transition. There is widespread understanding that this is not simply atransfer of care but is in fact about enabling the responsibility for decision-making to shift to the patient rather than the parent. The young person’sneeds and aspirations are central to care. It is not, therefore, a single eventbut a continuous process beginning in childhood and progressing through andinto adulthood. Its importance has been recognised by the Department of Health who have shown strong support for this(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083592).
Who should be involved in adolescent urological care?
With the above in mind there is little point in having a set age at which allpatients should be transferred from the paediatric team to the adult team.Instead there needs to be a window of time that allows the paediatric team tomake a judgment about the medical, physical and psychological readiness of a child (and their parents) before transfer to adolescent care. A patient can beseen jointly at first, in the paediatric centre and then move over to anadolescent clinic when all are agreed. Once they are under the care of theadolescent urology service they remain under the care of the so-calledadolescent team for life. In our view, there would be little point in patientsseeing one team for a short time and then moving on to someone else.The needs and aspirations of an adolescent patient are, generally, far better aligned to an adult than a paediatric service. Quite naturally adolescentpatients will want to consider higher education or employment issues,relationships – both emotional and physical – and may also have legitimatequestions or issues about long-term outcomes. A team working in the adultsphere will have some experience relating to these issues and can also adjustcare when concerns arise. A paediatric team may well be able to set realisticexpectations but are less likely to be able to manage problems in adulthoodwhen they arise – if for no other reason than many paediatric health facilitieswill not provide care for adult patients.We have identified a number of specific needs in adulthood and in some of these groups psychological support is a major concern . We know from our patients with bladder exstrophy that fertility is possible but conception may bedelayed. Without proper support through pregnancy and delivery, the risk tomother and baby increases. Prolapse can be a significant issue in 52% .Nephrological support is also vital for these patients and our team runs a jointnephrological clinic and multidisciplinary team that includes a consultantnephrologist and radiologist. This has allowed us to understand and predictthose patients likely to be at greater risk based on their renal status inadolescence and in some cases recognise new phenomena – such as
volume dependant renal deterioration that can be reversed by identifying acritical bladder volume and ensuring a patient maintains their bladder belowthat level . Clearly, this breadth of care is beyond the remit of any urologist or any single specialty and could only be provided with the involvement of other teams. The creation and function of a multidisciplinary team includingspecialist nurses, urologists, radiologists, nephrologists, gynaecologists,psychologists and endocrinologists is vital.It is also important to recognise that many of these patients have complexsurgical needs – having had multiple procedures before. This makes both thedecision-making and the surgery complex. Most individuals who havedeveloped this field as an interest have had reconstructive training and shouldhave undertaken some paediatric urology as part of that and this is vital tounderstanding both the underlying condition and its treatment. Havingunderstood this, it is equally important to recognise one’s limitations within therole – and the involvement of additional sub-specialist expertise from withinurology and also from other surgical specialties is important for the safe andeffective care of these patients.
The kidneys
In some conditions, such as bladder exstrophy, we know from our data thatrenal outcomes appear to be very good. We have recently examined a seriesof patients with at least 20 years of follow-up and found that none neededrenal replacement therapy (Gupta et al. - manuscript submitted for review).The same data showed abnormal appearances of the upper tracts in 33% of patients – thus expertise within a team is required in evaluating thesepatients. Some conditions have seen a dramatic improvement in renaloutcome as a result of aggressive early bladder management. Historical datashow that 50% of patients with myelomeningocele would not survive beyondthe age of 35 years – the majority due to end stage renal failure. As a result of early intermittent catheterisation and anticholinergics, outcomes appear tohave improved. The same cannot be said for all conditions. In patients bornwith posterior urethral valves the renal damage seems to occur in uterobecause long-term data suggest end stage renal failure will occur in one-thirdof these patients by the age of 30 years, and this happens regardless of earlyintervention .In adolescent practice it is important to recognise any form of renaldeterioration. When a reduction in renal function is identified, urologicalcauses including stones, urinary tract infections, obstruction or bladder dysfunction need to be excluded. In patients with a complex uronephrologicalbackground it is good practice to maintain regular follow-up that monitors for these conditions. All patients under our long-term follow-up are checked ateach visit for blood pressure and proteinuria – if this is detected aprotein:creatinine ratio is undertaken and an up to date chromiumethylenediamine tetraacetic acid (EDTA) glomerular filtration rate (GFR) issought. Once urological causes have been excluded for any detectabledeterioration we work jointly with our nephrological colleagues and patientswill be seen in our joint clinic. Angiotensin-converting-enzyme (ACE) inhibitorshave been shown to slow functional loss in renal deterioration and althoughthey will not prevent the progression to end stage renal failure they maysignificantly delay the need for renal replacement therapy. Those patients with

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