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This is despite the fact that it is likely that living with a urethral stricture is more detrimental to quality of life than having small cosmetic imperfections in the appearance of the penis. I used hypospadias as an example of one of the most frequent anomalies treated by pediatric urologists but similar dilemmas exist in other types of genital reconstruction as well as in many other diseases. Prospective studies, ideally with control groups and randomization are the backbone of evidence based medicine.
Unfortunately, precious few such studies exist to back up management protocols in our specialty.
Frontiers in Pediatric Urology – Specialty Grand Challenge
The obstacles to performing such studies are great; nevertheless to move beyond where we are in the treatment of pediatric genitourinary diseases they are sorely needed. This is one of the greatest challenges for pediatric urologists. Given that in Western countries the numbers of cases is often too small to run such studies, two possible options to solve this problem come to mind.
One is the conduction of multicenter studies and the other is setting up protocols for studies in countries with large populations treated at high volume centers. It is our job to set these options in motion.
We should strive to make all treatment indications based on evidence. It is our responsibility to conduct research to provide such evidence. Basic research conducted by scientists working in close collaboration with surgeons is the basic for significant progress in any surgical specialty. The ideal of the surgeon—scientist which was instilled in me at the onset of my training is probably unrealistic in most settings given the heavy clinical workloads dictated by third party payers. More realistic is to develop a close cooperation between surgeons providing the clinical perspective and full time laboratory researchers.
The areas of bioengineering, genetics, mechanisms of disease are at the forefront of current research in pediatric urology. Academic surgeons should continue to lead the way for innovations and new understanding of diseases they treat. Whether or not this is an effective approach to stimulate young surgeons to pursue an academic and research career is open to question given time limitation and relative shortness of mentors More effective is probably to provide interested faculty members adequate protected time to conduct research.
Advances have been made in many countries formalizing the training requirements for future specialists.
Different approaches have been taken in the US, Canada, and in Europe. In the US and Canada, opportunities for specialized training are limited to those who have completed training in general urology. A more encompassing approach in Europe allows both urologist and pediatric surgeons to pursue advanced training in pediatric urology increasing the number and spectrum of potential trainees.
The decades ahead will reveal if one approach is superior to the other. One of the challenges of training surgeons to treat rare anomalies is the relatively small number of complex cases at most institutions. This is particularly problematic in the Western world with large number of centers, low birth rates, and decreasing incidence of major malformations. Setting up training collaborations with large volume centers in countries with large populations and greater incidence of birth defects may be a solution to the problem.
How to obtain funding and accredit such programs are obstacles to overcome. Training and providing expert care for rare malformations are closely related. Another approach to provide training and expert care to children with rare congenital malformations is the creation of regional centers of expertise to which patients are referred, thus creating teams of expert surgeon—teachers in one particular malformation.
This approach is being used in the United Kingdom for the treatment of bladder exstrophy, and could be expanded to other parts of the world and other diseases. Keeping in mind the wellbeing of children, we should be able to overcome the first two obstacles in a relatively short time.
This leads me to the discussion of the last topic of this article. In some countries, pediatric surgeons and urologists taking care of children with genitourinary malformations and diseases work separate from each other, even in the same institution. Progress in our field could be accelerated by having better integration and cooperation between specialists with common interests regardless of their training background.
The creation of Pediatric Urology units at major institutions would allow such integration. Geographical differences also determine who is better qualified to care for children with genitourinary disorders. In the US, rotations in pediatric urology are mandatory in the course of training in urology so that a few individuals become interested in pursuing further training.
In contrast in Europe, many trainees in urology have minimal or no exposure to pediatric urology whereas many pediatric surgery training programs include rotations in urology Also greater cooperation between developed and developing countries would be beneficial. Although the efforts of groups and individuals traveling from the developed world to needy regions to operate on children is beneficial to individuals, greater benefit could be gained by using experienced surgeons to train local teams to care for their children on more permanent basis.
Isolated examples of this model exist in places like Eritrea 12 and Pakistan Sultan S, personal communication. Another related issue that needs emphasis is that pediatric urology cannot exist in a vacuum. Good cooperation with pediatric nephrologists, endocrinologists, pediatric imaging specialists, psychologists, neonatologists, and other pediatric specialties is essential to provide state of the art care. The role of the pediatric urologist in the pediatric health care system has evolved differently in various environments.
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For example, earlier on in the USA, most pediatric urologists were attached to academic medical centers and involved in complex surgical reconstructive procedures.