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Adolescent and Transitional Urology
Christopher R.J. Woodhouse
Questions
1.Adolescent urology is defined as the care of patients:
a.from 10 to 19 years old.
b.from puberty until death.
c.from 14 to 25 years old for males and from 12 to 21 years old for females.
d.from puberty to 25 years old.
e.from puberty until maturity as a young adult.
2.Effective transition requires:
a.establishment of a care plan for the patient in late childhood.
b.identification of a destination adolescent clinic.
c.four or five consults in a transition clinic.
d.management decisions by an adolescent urology team toward the end of transition.
e.all of the above.
3.Adolescent urology training requires:
a.board certification (or equivalent) in urology.
b.board certification (or equivalent) in pediatric urology.
c.board certification (or equivalent) in adolescent medicine.
d.1 year of training in psychology.
e.all of the above.
4.In adolescents with congenital abnormalities of the kidneys and urinary tract (CAKUT):
a.end-stage renal failure within 16 years is unlikely with a glomerular filtration rate (GFR) of 40 mL/min/1.75 m2.
b.end-stage renal failure can be prevented with early prescription of
angiotensin-converting enzyme inhibitors.
c.once renal functional deterioration begins, it will usually progress at more than 3 mL/min/yr.
d.ablation of posterior urethral valves in the first week of life prevents end-stage renal failure in adulthood.
e.if proteinuria exceeds 50 mg/mmol creatinine (0.5 g/d), renal functional deterioration is inevitable.
5.In which of the following situations should elective cesarean section be performed for urological indications.
a.Women with spina bifida
b.Women with intestinal neobladders
c.Women with a GFR below 40 mL/min/m2
d.Women with exstrophy
e.Women with simple (nonsalt-wasting) congenital adrenal hyperplasia
6.What percentage of adults of working age, born with one of the major congenital urological anomalies (including spina bifida), are likely to be engaged in a profession or administrative occupation
a.10% to 19%
b.20% to 29%
c.30% to 39%
d.40% to 49%
e.50% to 59%
Answers
1.b. From puberty until death. Clearly, the conventional definition of “adolescent” would be the period of growing from childhood to adulthood. That would probably mean from puberty until approximately 20 or 21 years old. When referring to the long-term care of children with congenital genitourinary (GU) anomalies, the term “adolescent urology” has been accepted, for want of a better name. There are no subspecialists of urology to which the children could be sent. Whichever physician them on at puberty is responsbile for their care forever.
2.e. All of the above. This answer is really self-explanatory. Parents get very anxious about long-term care for their children while the end of childhood (approximately 9 years old) approaches. They need to be involved in a comprehensive plan that will take them through the several steps to
adolescent (adult) urology. This takes time.
3.a. Board certification (or equivalent) in urology. In practice, an adolescent urologist will require the skills that are taught in a urology program and will, therefore, be board certified in that specialty. Some training in pediatric urology is needed to understand the nature of the conditions with which the children were born, but not to board level. Adolescent medicine and psychology are required but could be learned through specific courses or online teaching modules.
4.e. If proteinuria exceeds 50 mg/mmol creatinine (0.5 g/d), renal functional deterioration is inevitable. A patient who enters in adolescence with a GFR of 40 is likely to go into end-stage renal failure within 16 years. Progression to end-stage renal disease is much slower than in patients with medical renal disease such as glomerular nephritis. Because much of the renal damage occurs before birth in babies with posterior urethral valves (and other conditions), ablating the valve stops further obstruction and allows improvement in GFR, but it does not alter the long-term outcome in most cases. Proteinuria is an ominous sign in all patients with renal disease and, in those with CAKUT, heralds the onset of the final stage.
5.b. Women with intestinal neobladders. A reconstructed bladder lies immediately in front of the lower segment of the uterus and is very easy to damage in pelvic surgery. The greatest disasters occur if a cesarean section has to be performed as an emergency. It can take an hour or more to find the uterus. Although many women with reconstructed bladders can and do deliver vaginally, the safe advice is to do an elective cesarean section with an adolescent urologist present to expose the uterus and repair any “urological” damage. In the other conditions, the decision on the mode of delivery should be made jointly by the obstetrician and the adolescent urologist. If there is any doubt, do an elective cesarean section, not a trial of labor.
6.d. 40% to 49%. A most important concept of adolescent urology is that successful surgery is not an end in itself. The greater objective is to prepare patients for a normal adult life.
Chapter review
1.The majority of patients in a transitional care clinic will have a diagnosis of either posterior urethral valves or spina bifida.
2.Patients with disorders of sexual development should be seen in a
separate clinic.
3.Patients who have had successful hypospadias repairs not infrequently have quality-of-life issues.
4.Ketamine abuse may result in papillary necrosis, retroperitoneal fibrosis, and a shrunken, painful bladder.
5.Adolescents with a GFR greater than 60 mL/min are unlikely to develop end-stage renal disease.
6.Patients who have been reconstructed for significant abnormalities of their bladder or kidneys should be followed up for proteinuria, which is a harbinger of end-stage renal disease.
7.The urine of patients with intestinal diversions may be positive for human chorionic gonadotropin pregnancy test, giving a false-positive result.
8.A reconstructed bladder lies immediately in front of the lower segment of the uterus and is very easy to damage in pelvic surgery. In the pregnant patient, a cesarean section can be difficult, especially if it must be performed as an emergency. It can take an hour or more to find the uterus. Although many women with reconstructed bladders can and do deliver vaginally, the safe advice is to do an elective cesarean section with a urologist knowledgeable about the anatomy.