Global Goodness: Pediatric Urology Collaborative

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Urology Update

For more than 7 years, Aseem R. Shukla, MD, Director of the Minimally Invasive Surgery Program for The Children’s Hospital of Philadelphia’s Division of Urology, has led a pediatric urology collaborative that includes 3 major children’s hospitals in the U.S. — CHOP, Seattle Children’s Hospital, and Cincinnati Children’s Hospital — and Ahmedabad Civil Hospital in India.

Ahmedabad Civil Hospital is an 800-bed referral hospital with a catchment area of more than 60 million people, making it the second largest hospital in the second-most populous country in the world. Pediatric urological disease is widespread in India. Unfortunately, Ahmedabad Civil Hospital suffers from a lack of resources, particularly for conditions treated by pediatric urologists.

Pediatric urology is in its early infancy as an independently accredited specialty outside of the developed world. It is estimated that more than 90% of pediatric urologic disease in India is treated by pediatric general surgeons. There are few formally fellowship-trained pediatric urologists working exclusively for children in India today, and there are, as of yet, no centrally certified pediatric urology fellowships or training programs in Southeast Asia.

However, the need for competency in pediatric urology is intense. The population of 1.2 billion (1/6 th of the global population) in India is compounded each year by a birth rate of 22 million (compared to 4.2 million births per year in the U.S.). At the same time, the infant mortality rate has greatly decreased with improved perinatal care. The result is an ever increasing burden of pediatric urological birth defects and associated disease. Extrapolating by the birth rate calculations presented, the incidence of bladder exstrophy/epispadias, posterior urethral valves, and hypospadias is 600, 1500 and 72 000 per year, respectively.

Given this massive volume of congenital disease and limitations of access to highly trained pediatric urologists, a preponderance of children with significant urogenital pathology fail to access adequate surgical care. Thankfully, after 7 years, word of this collaborative has spread in the region, and children and their families are finding their way to access the care they desperately need.

The collaborative is a dynamic relationship based on multiple interactions by the team throughout the course of the year, culminating in a 2-week trip to Ahmedabad, usually in late January. During the trip, surgeons and surgical fellows provide much-needed urologic care, including evaluation, management, and direct mentoring of staff physicians, as well as complete complex reconstructive surgical procedures. The team also spends time sharing clinical and research updates with surgeons in India through didactic lectures and surgical presentations.

The collaboration offers myriad benefits. During the 2-week trip, the American team gains exposure to an immense volume of complex urologic disease often seen sparingly in the U.S., performing complex cases that include proximal hypospadias repair, primary exstrophy/epispadias repairs, salvage exstrophy closures, epispadias repairs, and cystectomy with ureterosigmoidostomy using a Mainz II pouch.

As Dr. Shukla notes, “It would take our program 3 or 4 years to see what we see during the 2 weeks we spend in India. The breadth of our collective experience in dealing with serious pediatric urological disease is significantly augmented by this collaboration.”

At the same time, Civil Hospital clinicians gain valuable exposure to the latest surgical approaches, and afflicted children receive quality care from surgeons with foundational experience gained through an academically rigorous fellowship training program. The exposure to an American academic infrastructure allows emergent evidence-based studies to be completed in the Indian context, enriching the surgical experience abroad. This year, thanks in part to support from the collaboration, the surgical chief of the Civil Hospital will travel to the U.S. to observe surgical care in this country, further cementing the relationship.

“It’s a true collaboration in that regard,” says Shukla. “Our partners in India are so overwhelmed by such a diversity of disease pathology; they never have a chance to focus on specific disease processes. This collaboration allows the team in India to have this unique opportunity. During the designated 2 weeks, the hospital turns into a pediatric urology center, allowing all medical and surgical teams to focus on learning about and hewing their expertise in pediatric urology. This has now become an annual academic exercise for the staff in India.”

The experience of administering surgical care in a relatively austere context also adds a critical awareness and an incredible, comprehensive learning opportunity for the U.S. participants. “It’s an overall transformative experience for surgeons and fellows alike,” notes Shukla. “We have come to appreciate the immense challenges other countries face and how they tackle them, and seeing how these teams operate with few resources to tackle those challenges improves our own practice. We are reinvigorated by that essential sense of what it is to be a surgeon in that environment.”

Shukla’s goal is to outfit the Civil Hospital with the infrastructure, training, and equipment necessary to deliver CHOP-level care in their resource-deprived area. “CHOP is an established, recognized center of excellence for the treatment of congenital urologic disease,” he says. “That leadership is something we want to share.”