Pediatric exstrophy is one of the most complicated conditions managed by pediatric urologists. The condition is rare, occurring in about two to four of every 100,000 live births. Prompt and effective closure of the bladder during the newborn period is critical to ensure good outcomes and functional results.
During Sunday morning’s Next Frontier plenary session, two experts will debate whether treatment of these complex cases should be centralized. The 20-minute point-counterpoint debate, titled Complex Surgical Cases Should be Centralized, will begin at 8:30 am in Hall E at Moscone North.
“The title of this session should probably read, Complex Surgical Cases Should be Centralized, or Should They?” said session moderator David Joseph, MD, FACS, FAAP, professor of Urology at the University of Alabama at Birmingham and Chief of Pediatric Urology/Beverly P. Head Chair in Pediatric Urology at Children’s of Alabama.
Studies evaluating pediatric bladder exstrophy have defined high volume centers as those with five cases a year to as few as 1.7 cases a year. However, very few centers in the U.S. meet either of those thresholds, Dr. Joseph said.
“It’s difficult to argue the fact that there are likely improved patient outcomes associated with increased surgical experience,” Dr. Joseph said. “If things were centralized, individuals at a center that does five cases a year would now be doing 30 cases.”
Increased volume would likely reduce practice variants and allow surgeons to develop their own best practices, Dr. Joseph said. However, there are also practical issues associated with centralization to consider, he added.
There are currently several centers of excellence for pediatric exstrophy cases, and Dr. Joseph noted that families with the foresight to investigate the condition, the economic resources and the support system can choose to go to these centers. By contrast, centralized care would require everyone to go to a few high volume centers.
“We do not have the economic environment, with multiple payers, to support that,” Dr. Joseph said. “We would need a single payer system in order to financially support everyone being able to go to the centers of excellence.”
Centralization has worked well for other medical disciplines such as trauma, he noted. Trauma patients are treated at a centralized location and then referred back locally for rehabilitation and recovery.
“When treating these complex congenital cases, the surgical treatment is just the start,” Dr. Joseph said. “Patients have to followup on the potential risks and complications, which I would say are almost equally, if not more difficult and challenging to care for. If we state that a local institution or pediatric urologist does not have the expertise to care for the condition primarily, what will the family think when we tell them to go back to that individual for followup?”
The session’s debaters are Aseem Shukla, MD, associate professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania, who will make the case for centralization; and Jacob Ben-Chaim, of Tel Aviv University in Israel, who will present the counter argument.
By the end of the debate, Dr. Joseph said attendees will better understand the appeal of centralization for pediatric bladder exstrophy as well as the limitations and challenges.
“I would like to see people understand that we would need to change the way we support health socially and financially in order for centralization to be possible,” Dr. Joseph said.