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Clinical Focus

Clinical Case Vignette Series: Integrating Recent Data into Practice to Improve Outcomes in Advanced Prostate Cancer

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

This episode's guest is Julia Beth Finkelstein, MD, MPH, CPPS. She discusses the recent 

 study “Telemedicine for Pediatric Urological Postoperative Care is Safe, Convenient and Economical,” for which she served as a study author. Finkelstein is assistant professor of urology at Columbia University Medical Center in New York.

A HIFU expert discusses his treatment criteria

Dr. Angela Smith discusses Jelmyto for low-grade UTUC

What patients undergoing HIFU should expect postoperatively

In this episode, Julia Beth Finkelstein, MD, MPH, CPPS, discusses what she and her co-authors learned from a recent study evaluating the use of telemedicine for pediatric post-op visits.

Speaking of Urology: Dr. Finkelstein discusses telemedicine for pediatric post-op visits

"We've been working with families and other providers to learn the diagnostic criteria for what makes a urinary tract infection and to avoid treating when it's unnecessary," says Briony K. Varda, MD, MPH. 

ER utilization and overtreatment for UTI in pediatric patients with spina bifida

"Robotic surgery has some major advantages. One that rises to the top is that your magnification is anywhere from 10x-15x higher," according to Laurence S. Baskin, MD.

Dr. Laurence Baskin discusses robotic pediatric urological surgery at UCSF

Join Urology Times and Contemporary Pediatrics for a discussion about controversies over circumcision and its implications.

Medical professionals to discuss circumcision on Twitter

A new national survey shows severe physician shortages among certain pediatric specialties, and pediatric urologists top the list of those registering long wait times for pediatric surgical care.

Pediatric urologists top list of those with long wait times

Stone disease and minimally invasive treatment approaches are once again leading issues in the pediatric urology section of the 2012 AUA annual meeting.

Pediatric urolithiasis, vesicoureteral reflux evaluation under close scrutiny

Dr. Briony K. Varda highlights findings on UTI treatment among pediatric patients with spina bifida

Study finds overtreatment of presumed UTI in pediatric patients with spina bifida

, highlights the background and key findings from the study, “Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida,” for which she served as the lead author. Varda is a pediatric urologist, the co-director of the spina bifida program, and the director of clinical research at Children’s National Hospital in Washington, DC.

We wanted to know for our spina bifida patients that presented to the emergency room, how many of them were treated for a urinary tract infection when they didn't meet diagnostic criteria for a urinary tract infection. This is based on the idea that there are different criteria for a UTI in patients who self-catheterize. Specifically, these patients need to have 2 or more urologic symptoms, they need to have more than 10 white blood cells in their urinalysis, and they need to have a urine culture that grows greater than 100,000 of a single bacteria. In many instances, our patients were being treated, and not meeting all 3 criteria. So, we looked at the rate of that occurrence.

In short, 80% of our patients who received antibiotics were overtreated. What we found was that pyuria, or the incidence of white blood cells in the urinalysis, was a big driver for treating patients with antibiotics. But many of those patients would end up having negative cultures later, or they wouldn't have symptoms and were treated simply for the white blood cells in the urine. So, that was an important finding. Then the second aspect of this is that we found that patients who were non-White were more likely to be overtreated, which made us concerned about the thoroughness of symptom elicitation, and just relying on testing rather than connecting with the patient and understanding their concerns. We also found that headache was not associated with a UTI, which I think in some patient populations, such as spinal cord population, it can be associated. But it's important to note that our spina bifida patients are different and headache wasn't a predictor of a true UTI. So, overall, our patients were overtreated at a very high rate, and certain patients were overtreated in comparison to others.

This transcription has been edited for clarity.

Videos

“What we found was that pyuria, or the incidence of white blood cells in the urinalysis, was a big driver for treating patients with antibiotics,” says Briony K. Varda, MD, MPH. 

Miriam Harel, MD, discusses current key topics in pediatric urology.

Dr. Harel on hot topics in pediatric urology

 discusses current key topics in pediatric urology. Harel is an assistant professor of urology at Albert Einstein College of Medicine, Bronx, New York.

What are some current key topics in pediatric urology?

I think probably the area getting the most attention nowadays is advances in robotic and minimally invasive surgery. That's really been a big push in recent years, to try to keep up with the advances that are happening in adult surgery. I think also, there's been a big focus on transitional care. A lot of conditions that we treat in pediatrics, these children get older, and they become adults. There's more of a need to really make sure that we have people well trained in taking care of these adults who started out with congenital abnormalities. One other area that I find particularly fascinating is a lot of work is being done to try to improve options for fertility preservation in boys. This has obviously been around for a long time in adults, and there is a particular challenge in children who might be undergoing chemotherapy or some treatments that will affect their eventual fertility. The particular challenge is that they are unfortunately being treated with these toxic agents at an age where they don't yet have mature sperm. It's much simpler in postpubertal patients where they can maybe just bank sperm for the future. But in younger children, that's not possible. There are many centers trying to advance the options in preserving prepubertal testicular tissue and then trying to work out ways to then use that tissue in the future. There's still a lot more work that needs to be done for us to know what to do with that tissue later, but I think it's very exciting to be able to at least offer those families some hope.

I find I keep remembering how important it is to tell these parents that it's not in their child's control. I think a lot of parents, without any ill will, think that there's a component of laziness or lack of motivation or lack of interest. But overnight, while these children are sleeping, it's completely out of their control. And it's important for both parents and child to know that.

This transcription was edited for clarity.

"I think probably the area getting the most attention nowadays is advances in robotic and minimally invasive surgery," says Miriam Harel, MD. 

Miriam Harel, MD, shares management strategies for nocturnal enuresis. 

Pediatric urologist shares management strategies for nocturnal enuresis

 shares management strategies for nocturnal enuresis. Harel is an assistant professor of urology at Albert Einstein College of Medicine, Bronx, New York.

What are some management strategies for nocturnal enuresis?

I like to tell my patients, one of the first kind of treatments is actually reassurance - reassuring parents that this is, again, usually normal and will go away, also reassuring the children that there's nothing wrong and there's no reason to be embarrassed. If we don't find any underlying causes, then oftentimes the management might just be observation. If parents and children are comfortable with that, I tell a lot of families that bedwetting is usually not dangerous. The most potential danger is if it affects children's self esteem and lifestyle. If they're young enough where that's not a concern, then sometimes we'll just observe conservatively. If they are more interested in active treatment, one of the first things is, again, focusing on their daytime habits and setting them up for success at night. Some of the most important recommendations are what we call "timed voiding," which means that children should not wait too long to go to the bathroom during the day. For younger children, we usually recommend voiding every 2 hours, even if they don't feel the urge to void. Management of constipation is a huge factor in treating bedwetting; we actually find in about 20% of children who have constipation, their bedwetting may resolve with just management of constipation alone. Those are helpful conservative strategies to start with. If that's not sufficient and the children or parents are bothered by it, then there are some medications that we can add. The most common medication we use for bedwetting is called desmopressin. It's something that children would take 1 or 2 hours before bedtime, and it basically works to help limit urine production overnight. It's very safe if parents know to restrict their child's fluid intake at night, so that we don't affect the concentration of their electrolytes. But this can be effective in keeping children dry until they grow out of bedwetting. I always tell patients, most of us believe that this is not really a cure, but it's kind of like a band aid to help keep them dry while they're waiting to outgrow it. Many families are very happy just having that kind of temporary crutch. What I believe is the most effective treatment is using enuresis alarms. There are many different types of bedwetting alarms that specifically wake the child up when they start to urinate. It's important for parents to know that this is very different than just waking up their children randomly. A lot of parents try that, and it doesn't work and it kind of just makes everybody exhausted. The alarms are different because they are triggered by the actual wetness, and so over time, if the child gets up to then go to the bathroom, it teaches their brain and their bladder to communicate better and helps them grow out of the bedwetting faster. I believe that is a better long-term solution than medications; however, it does come along with much more effort not just for the child, but often for the parents who might have to wake their child up. Because again, part of this problem is that a lot of these children won't hear the alarm while they're sleeping.

"I like to tell my patients, one of the first kind of treatments is actually reassurance," says Miriam Harel, MD.

Miriam Harel, MD, discusses causes of nocturnal enuresis. 

Dr. Harel on potential causes of nocturnal enuresis

 discusses causes of nocturnal enuresis. Harel is an assistant professor of urology at Albert Einstein College of Medicine, Bronx, New York.

Could you describe your clinical practice?

I think our whole department here provides a pretty comprehensive spectrum of pediatric urologic care. For me personally, I would say my particular interests are in reconstructive surgery, complex hypospadias repair, management of neurogenic and non-neurogenic voiding dysfunction, prenatal hydronephrosis, and I'm also very interested in posterior urethral valves.

What are some potential causes of nocturnal enuresis?

This is a very common condition that we treat and I think it's important to differentiate primary nocturnal enuresis, which means that the children have always had bedwetting and never grew out of it. Another important distinction is whether they have isolated nocturnal enuresis or if they have daytime incontinence as well. Probably the most common scenario that we get a lot of parental concerns about are the patients that only have bedwetting, and it just never went away. And in that particular group, it's first important to reassure parents that in most cases, it's actually normal. There are some genetic factors involved, meaning that some people are just more prone to having this prolonged bedwetting, but for most children, they will just outgrow it over time. That's a very common scenario. Other factors that might come to play are their bladder capacity being small, potentially urine overproduction at night. Some other things that we are always focusing on are any potential daytime habits related to their voiding or bowel movements that can affect them at night. And then another possible source is related to sleep patterns. Arousal can be an issue, most of these children sleep very deeply, andthat can also come into play where as they get older, and their sleep patterns change, they may be more likely to grow out of bedwetting.

"Probably the most common scenario that we get a lot of parental concerns about are the patients that only have bedwetting, and it just never went away," says Miriam Harel, MD.

Pediatrics

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