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Nephrology, Urology

A New Pathway for Prenatal Hydronephrosis

A model of the kidney (Stock photo)

A multidisciplinary team at Children’s of Alabama and the University of Alabama at Birmingham (UAB) has developed a standardized clinical pathway for newborns diagnosed prenatally with hydronephrosis, reducing variability in care, improving coordination among specialties, and helping families receive timely guidance without unnecessary testing or travel.

The pathway, developed by general pediatricians in the newborn nursery in collaboration with pediatric nephrology and pediatric urology, provides a risk-stratified approach to determining which infants require immediate evaluation, which can be safely monitored, and which need little to no intervention. The initiative has already prompted changes in workflow, increased access to telehealth services, and generated interest from providers outside Birmingham.

Prenatal hydronephrosis, or dilation of the kidney’s collecting system, is one of the most common abnormalities identified on prenatal ultrasound. While some cases resolve spontaneously, others may signal underlying conditions such as urinary tract obstruction, vesicoureteral reflux, urinary tract infection risk, or chronic kidney disease. Determining which infants need urgent intervention has historically been challenging.

“We found the existing guidelines confusing,” said Terry Wall, M.D., division director of the UAB Division of Academic General Pediatrics and attending physician in the newborn nursery. “Different specialties interpreted them differently, radiology reports varied in terminology, and there was a lot of inconsistency in how babies were evaluated and referred.”

Wall, who is also a medical informaticist, brought together leaders in pediatric nephrology and pediatric urology to create a single algorithm that could be used consistently by nursery physicians, specialists, radiologists, and obstetric providers.

The resulting pathway categorizes infants based on prenatal and postnatal imaging findings, including the degree of hydronephrosis, bladder abnormalities, and progression over time. Infants identified as high risk are evaluated by urology or nephrology before discharge, while lower-risk patients receive targeted education and follow-up recommendations.

David Askenazi, M.D., pediatric nephrologist and medical director of the Pediatric and Infant Center for Acute Nephrology at UAB, said the pathway was designed with two goals in mind: ensuring that babies with significant disease are identified early while avoiding unnecessary interventions for families whose infants are unlikely to require treatment.

“We don’t want to miss a child who needs to be seen right away, but we also don’t want to burden families when their baby has a mild finding that is likely to resolve,” Askenazi said.

For infants requiring specialty follow-up, the pathway introduced another innovation. Stacy Tanaka, M.D., chief of pediatric urology, established a telehealth model that allows families to meet with pediatric urologists approximately two weeks after discharge.

Previously, referrals often occurred through community pediatricians, and specialists frequently lacked access to postnatal imaging before the initial visit. Families would travel to Birmingham for an appointment, only to learn that additional studies were needed.

Now, newborn ultrasounds are obtained before discharge when indicated, and specialists can review imaging in advance of the telehealth visit. During these appointments, providers discuss results, explain whether additional testing is needed, determine if antibiotic prophylaxis is appropriate, and establish a plan for ongoing surveillance.

“It has helped our workflow tremendously,” Tanaka said. “It also allows us to set expectations for families much earlier. If they need another study, they know why. If the hydronephrosis is likely to resolve, they understand what we’re watching and what to expect.”

This approach is particularly beneficial for families traveling from rural communities or other regions of Alabama. Parents of newborns can participate in appointments from home rather than making repeated trips for visits that may not require in-person evaluation.

The pathway also has strengthened communication among departments. Discussions with radiology and obstetrics have focused on standardizing prenatal ultrasound reporting so nursery providers can more easily place patients into the appropriate risk category.

Although the initiative was implemented only recently, providers say it already has reduced confusion, improved consistency, and enhanced education for both families and primary care physicians.

The work ultimately may extend beyond Children’s. Tanaka has shared the algorithm with pediatric urologists in Mobile, Ala., and Askenazi plans to discuss the model with colleagues in the Neonatal Kidney Collaborative, an international network focused on improving kidney care for newborns. “We’ve worked out many of the details,” Wall said. “If other centers can use what we’ve learned to standardize care and improve outcomes for families, that’s a win for everyone.”

July 24, 2026 by
Urology

Treating Bathroom Issues Virtually

Children’s is using telehealth to answer parents’ questions about bathroom habits. (Stock photo)

For families of children with bladder and bowel dysfunction, the journey to care at Children’s of Alabama can involve a long drive, a crowded waiting room, and the worry that the problem was serious—only to be told that what their child needs most is better bathroom habits.

“We have a really wide catchment area,” said Children’s chief of pediatric urology Stacy Tanaka, M.D. “Sometimes we were seeing families coming in from the coast. They had driven three-and-a-half, four hours.” By the time they arrived, parked and waited, an entire day was lost and the advice they received was, well, less than earth-shattering.

“They get here, and you tell them, ‘Hey, you just need to urinate and poop a little bit better,’” she said. “It doesn’t go over that well sometimes.” In fact, it could have been handled by a phone call.

Today, that’s essentially how they handle it. Tanaka and nurse practitioner Kelsey Boswell Moore, CRNP, see more than 20 patients each week via telehealth.

The program launched in early 2025, partly out of necessity. “We were transitioning and were a bit understaffed,” Tanaka said. “We started it just as a ‘let’s try to get as many patients seen as possible.’”

What began as a staffing solution quickly became a new model of care.

One reason it works so well is that most children with bladder and bowel dysfunction improve just from counseling and conservative management on better bladder habits and better bowel habits. They don’t even require prescription medication. If any red flags pop up, such as a child who had back surgery or is having urinary tract infections with fever, the team brings them in for a face-to-face consultation. “Those are signals we need to see you sooner,” Tanaka said.

For most families, all it takes is talking and instructions.

“A lot of times they’ve never really paid attention to how often they’re going to the bathroom,” said Moore, who conducts most of the telehealth visits. “They’ll say they have urgency, or that they can’t hold it, but then you realize they’re waiting until the last minute every time.”

Telehealth makes it easier to explore those details.

“They’re sitting in their living room,” Tanaka said. “It’s a more relaxed environment. All the other distractions really go away. In that relaxed environment, it’s easier to talk about how often they’re going, when they’re going and what’s really happening,” she said.

“Sometimes they say they’ve done everything,” she said. “But the child is still drinking fluids late at night or didn’t actually go to the bathroom before bed.”

And for those who do need to be seen in person, the telehealth visit allows Moore and Tanaka to prepare for the appointment by ordering any necessary tests, which increases efficiency.

If families still want to be seen in the office or have the child undergo imaging, “We can absolutely do that,” Tanaka said. “We can rule out the scary things, and then it becomes easier to continue with telehealth knowing everything looks okay.”

“This only works if the patient and parent are engaged,” she added. “If they don’t feel right about the plan, it’s not going to work.”

And it does work. For instance, consider the 8-year-old boy with enuresis. The problem became obvious after a brief telehealth visit.

“When he woke up in the morning, he didn’t go to the restroom,” Tanaka said. “He would eat breakfast, get dressed, and the first time he went was at school.” The child had trained himself to ignore bladder signals.

The solution? A schedule. Go first thing in the morning and use the restroom at planned times during the day. Also, alert the teacher. Four weeks later, the problem was resolved.

“That family never had to step foot in the hospital,” Tanaka said.

Which, of course, is the goal.

February 17, 2026 by
Urology

In New Role, Hopson Working to Address Sexuality in Patients With Spina Bifida

Betsy Hopson, Ph.D., MSHA, recently moved into a new role within the Division of Pediatric Urology.

Betsy Hopson, Ph.D., MSHA, describes her philosophy in one word: listen.

“Early in my career, I adopted this principle that if I heard the same story from two or more patients then it was either a research question or a quality improvement opportunity,” she said.

That mindset has shaped nearly two decades of work at Children’s of Alabama and the University of Alabama at Birmingham (UAB) and now underpins her new role as an assistant professor and health scientist in the Division of Pediatric Urology. There, she will direct a clinic dedicated to helping children with congenital urologic conditions transition to the adult health care setting.

Hopson began her career at Children’s in 2006 as coordinator of the Spina Bifida Program in the Division of Pediatric Neurosurgery. Yet she spent nearly as much time interacting with urology, she said, which plays a central role in bladder management for patients with the disease.

Her early work focused on helping patients make the difficult transition from pediatric to adult care. After realizing that young adults with spina bifida were aging out of pediatric clinics without clear adult pathways, she returned to school to earn a master’s degree in health care administration and then built an internationally recognized transition model.

It was listening to her patients, however, that led to the next chapter in her life.

In one case, a 15-year-old adolescent asked her about her research. When she told him it was sexual and reproductive health, “He whispered, ‘Betsy, I can’t do that, can I?”’

“Can’t do what, buddy?” she asked. “Date or have sex,” he answered. “That’s not for me, is it?”

Or the newly engaged, college-educated young woman with spina bifida who burst into tears when Hopson started discussing birth control with her. “You mean I can get pregnant?” she said. “I had no idea.”

“If this young woman who is very educated had no idea,” Hopson said, “what is this like for the rest of the population?”

And a light bulb went off. “We’re telling them we want them to be independent, that we want them to take care of themselves, but we’re not giving them any carrot or showing them what’s possible and helping them paint that picture of what adult life could look like.”

Her “eureka” moment led her back to school to obtain her Ph.D. in Rehabilitation Science and a certificate in Mixed Methods Research. Her goal was to understand gaps in sexual health education for people with congenital diseases like spina bifida. What she uncovered was far more troubling.

“Because these patients are prescribed catheterization for bladder management early in life,” she said, “they’re taught the technical skills of catheterization but not taught about personal boundaries and appropriate touches.”

Her research found that 46% of adults with spina bifida reported a history of sexual abuse. For her dissertation, she validated a clinical screening tool to identify abuse risk and gaps in sexual health knowledge.

In her new role with the urology team, she sees her goal as twofold: “One is to help support normal development,” she said. “I want to normalize sexual and reproductive health conversations so patients can see what’s possible and give them space to imagine a full adult life.”

The other involves educating patients, parents and clinicians about the increased risks vulnerable patients face and developing tools for clinicians and families to identify and talk openly about those risks.

It’s important, she noted, to bring the parents into the discussion. “When you bring [sexuality] up in the clinical setting in front of their child, they might be initially hesitant.” Her solution is the same approach that has guided her career: listen first. That means holding focus groups with patients and parents to shape new curricula and ensure the content reflects lived experience rather than clinician assumptions.

“If there’s one thing my career has taught me,” she said, “it’s to never stop learning and never stop looking for ways to make a difference.”

February 12, 2026 by
Urology

A new protocol for kidney tests in spina bifida patients

A new study shows that ultrasound is not enough to monitor kidney health in children with spina bifida. (Stock photo)

For decades, doctors have relied heavily on ultrasound scans to monitor kidney health in children with spina bifida, the most common permanently disabling birth defect in the U.S. People with spina bifida tend to develop end-stage renal disease up to 20 years earlier than the general population, so keeping a close watch on kidney health from a young age is important, says Children’s of Alabama pediatric urologist Stacy Tanaka, M.D. “Then if there’s a concern, it can be acted upon early and not ignored.”

Current guidelines from the Spina Bifida Association (SBA) recommend annual screening with ultrasound to look for hydronephrosis—a condition in which the urine backs up into one or more kidneys—as a sign of kidney function, and blood tests like serum creatinine, to measure overall kidney health. But with kids, Tanaka says, “the practice pattern was that a lot of people were only doing renal ultrasound.”

Now a new study from Tanaka and her Children’s colleague David Joseph, M.D., as well as other kidney experts from around the country, shows that ultrasound alone is not enough to assess kidney health. “We basically use ultrasonography as a reflection of renal function,” Joseph said, but few, if any, studies assessed its accuracy in determining renal function.

Stacy Tanaka, M.D.

The study’s genesis came during a multidisciplinary meeting in 2003 of specialists who treat children with spina bifida. “The bottom line from all disciplines at that time was that nobody was really treating this population with evidence-based care,” Joseph said.

To change that, the Centers for Disease Control and Prevention and the SBA established the National Spinal Bifida Patient Registry (NSBPR), to which 20 spina bifida clinics submit data to help develop evidence-based care. In addition, nine clinics established a urologic protocol to manage and preserve initial renal function in young children with spina bifida (UMPIRE). The NSBPR and UMPIRE provided the data set Joseph and Tanaka used to determine the effectiveness of renal ultrasound vs. blood test to assess renal function.

The two registries included data on 2,500 children ages 1-18 with myelomeningocele, the most severe form of spina bifida. All had had an ultrasound and blood test within six months to determine estimated glomerular filtration rate (eGFR), a marker of kidney health.

The results were striking: ultrasound-based detection of hydronephrosis had only about a 25% sensitivity for identifying children with signs of chronic kidney disease in the UMPIRE study and 24% in the NSBPR cohort. That means kidney damage in three out of four children was going undetected. The poor sensitivity held even when researchers looked only at severe hydronephrosis, which had an even worse sensitivity rate–just 6% to 11%. “The renal ultrasound by itself wasn’t all that good,” Joseph said, “but that didn’t surprise us.”

David Joseph, M.D.

The findings challenge current practice and suggest that blood tests measuring kidney function should be routinely performed alongside ultrasound, not just when ultrasound results look concerning, as some clinicians practice. The team at Children’s prefers testing for cystatin C rather than creatinine because of the test’s improved and more accurate ability to obtain an eGFR.

One reason clinicians may eschew blood tests is that it involves needles, Tanaka said, which be traumatizing for children. Ultrasound, on the other hand, is noninvasive, easily available, and can be performed by technicians.

“The ultrasound is very helpful and important,” Joseph said, “but you need to recognize that it may not be telling you about renal function or injury to the kidney.” The findings have already changed practice at Children’s, where all kids with spina bifida now receive both tests during kidney health screening.

Ideally, the next study would randomize kids to either double testing or ultrasound alone, but that requires significant funding, particularly since the children would need to be followed for years.

This study was conducted with very little financial support, Tanaka said. “It represents a labor of love for everyone at all nine UMPRIE centers who have been involved in this project,” Joseph added.

July 25, 2025 by
Urology

Improving pediatric renal injury care

A urology collaborative seeks to standardize care for suspected renal trauma in children. (Stock photo)

Current guidelines for the evaluation and management of renal injury focus on adult patients, as these cases are relatively uncommon among children. In recognition of this gap, Carmen Tong, D.O., alongside a team of experts including David Kitchens, M.D., developed the Trauma Renal Injury Collaborative in Kids (TRICK). Consisting of five Level-1 tertiary pediatric trauma centers across the United States, this initiative aims to standardize both evaluation and management protocols for pediatric patients with high-grade renal trauma.

The importance of studying pediatric renal trauma

Anatomical differences impact children’s susceptibility to renal injury from blunt abdominal trauma. Children’s kidneys are smaller and typically less protected by surrounding anatomical structures, which increases their vulnerability to injury from impact. Children cannot be viewed as “little adults,” but current guidelines for renal trauma typically cater to adult patients, leaving health care providers without clear guidelines for children.

“There are currently no standardized protocols on how to image children with suspected renal trauma. This is partly due to the ‘as low as reasonably achievable’ (ALARA) principle and other efforts to reduce exposure to radiation in this population,” Tong said. “The key is to identify which patients might benefit from any radiation imaging such as CT while avoiding unnecessary repeated imaging in stable, asymptomatic patients.”

Clinicians typically manage renal injury in children with conservative interventions or with repeated imaging for symptomatic patients. “A good number of patients are transferred in from outside institutions with radiographic imaging already obtained,” Kitchens said. “Before our study, we would usually recommend repeating some of these studies as we did not feel they provided necessary information to guide treatment. But now we know that only a small number of these patients (those with gross hematuria or otherwise clinically unstable) will require repeat imaging upon presentation.”

Key findings and implications

At the 2023 Societies for Pediatric Urology meeting in Houston, Tong and Kitchens presented groundbreaking findings from TRICK’s research. One pivotal discovery revealed that children with gross hematuria (visible blood in urine) following trauma benefit from more extensive radiologic evaluation, similar to adult patients. This novel discovery challenges the prevailing assumption that pediatric and adult renal trauma require vastly different diagnostic approaches.

This finding also helps clinicians better recognize pediatric patients at increased risk for surgical intervention who would, by turn, benefit from a more thorough radiographic evaluation. By identifying these children early, healthcare providers can prioritize further radiographic testing. However, for stable, asymptomatic patients, repeat imaging can often be avoided, reducing both patient risk resulting from radiation and overall health care costs.

Advances in diagnosis and treatment

In recent years, the management of pediatric renal trauma has shifted toward conservative approaches, with most injuries resolving without surgical intervention. In many cases, this is thanks to emerging diagnostic tools, such as contrast-enhanced ultrasound. For the 12% of patients requiring surgery in TRICK’s cohort, clinicians used minimally invasive techniques to treat kidney injuries, reflecting advancements in pediatric urology.

Broader implications for trauma care

By collecting data from diverse geographic regions, the TRICK consortium generates robust evidence that single institutions might struggle to achieve independently. This approach not only improves outcomes for pediatric renal trauma but also sets a precedent for addressing other pediatric conditions requiring specialized care.

For parents and guardians, TRICK’s work highlights the importance of vigilance following blunt abdominal trauma. Visible blood in a child’s urine or significant trauma to the side of the body — common in sports injuries or falls — warrants a rapid medical evaluation to rule out renal injury. Educating families about these warning signs promotes early intervention and better outcomes.

The path forward

TRICK’s ongoing efforts aim to standardize imaging protocols, particularly for children with gross hematuria, as a predictor of surgical intervention. Tong predicts that future studies will likely explore additional predictors and refine management strategies, further enhancing pediatric trauma care. Through collaboration and innovation, TRICK continues to make strides in ensuring that children with renal trauma receive the best possible care, tailored to their unique needs.

January 9, 2025 by
Urology

A new model for testicular torsion detection

Residents practicing testicular torsion detection using a new model created by the Children’s Pediatric Simulation Center

Testicular torsion is a serious medical emergency that requires immediate surgical intervention. It occurs when the spermatic cord twists, cutting off blood flow to the testicle. If not treated promptly, the condition can lead to permanent damage or loss of the affected testicle.

“Time is testicle,” said Carmen Tong, D.O., a pediatric urologist at Children’s of Alabama. “Pretty much every minute counts when it comes to testicular torsion.” Indeed, the so-called “golden window” to salvage testicular function after symptom onset is between four and eight hours. Any longer not only affects long-term testicular function but increases the risk of orchiectomy, or the removal of one or both testicles. “That can be devastating,” Tong added.

So prompt diagnosis is crucial. Yet the condition may present with vague symptoms such as abdominal pain and nausea. To improve diagnosis, Tong turned to pediatric intensivist Nick Rockwell, M.D., and advanced nurse educator Autumn Layton, MSN, RN, in the hospital’s Pediatric Simulation Center. Together, they created a testicular torsion model that provides hands-on training for residents.

The initiative came about after a teenaged boy’s torsion was missed. That begged the question: “Is there a way we can work with our trainees to give them a better understanding of something that’s a rare event, but when it happens, is a high-stakes situation,” Rockwell said.

From left: Carmen Tong, D.O.; Nick Rockwell, M.D.; Autumn Layton, MSN, RN

Rockwell, Layton and their team used Play-Doh-covered Styrofoam balls to simulate a torsed testicle, while a stress ball represents a normal testicle. These are enclosed in balloons to mimic scrotal skin and attached to a mannequin. Residents can then practice palpating the model to distinguish between normal and torsed testicles, providing a “full, immersive experience,” Rockwell said.

The students are told the mannequin is a 15-year-old boy admitted the night before for abdominal pain that is getting worse. Rockwell “plays” the patient, responding to questions. He can also adjust the mannequin’s vital signs, such as increasing heart rate if the trainees do something painful during the exam.

Next up for the training is a series of mannequins: one is normal while three others depict the disease at different stages. This helps learners distinguish which testicle is torsed, or if the testicle is inflamed (epididymitis). Through this exercise, trainees learn the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, which identifies children at risk of testicular torsion. The higher the score, the more urgent the need for immediate treatment.

The response to the training been overwhelmingly positive, Tong said. In addition, “what’s super impressive about this model is that it’s easily replicable. So once we publish this, other institutions can take what we did and create the same model. It doesn’t cost thousands of dollars.”

August 6, 2024 by
Urology

Improving the transition of care

Urologist Timothy Boswell, M.D., speaks with a patient at Children’s of Alabama.

For children who grow up coping with congenital urologic conditions, there’s no standard process guiding their transition to an adult urology program—meaning these patients can feel adrift at a critical point in their care. But Children’s of Alabama pediatric urologist Timothy Boswell, M.D., is setting out to change that in hopes of smoothing their path forward.

Boswell recently received a University of Alabama at Birmingham (UAB) faculty development grant to examine how to improve care for patients with congenital urology problems, who face a lifelong need for follow-up. He plans to use the funds to tap into the wealth of knowledge these patients can share, reimbursing them for their time being interviewed or filling out surveys asking them about their experiences as they age through care.

“There’s no set way of doing this around the country—every hospital has its own way,” explained Boswell, who’s also an assistant professor of pediatric urology at UAB. “We want to figure out what’s going to work best for our system, but we also want to catalog this scientifically to help others down the road. It has become more evident that these young adult patients with congenital anomalies can fall through the cracks.”

Urologic problems in children that persist through adulthood aren’t common, but those that do can have pervasive and often treatable effects on quality of life, Boswell says. “That brings the challenge of having enough patients to learn from, but it also makes it more feasible to manage the whole population of them,” he said. “That’s our goal. Since we’re the main pediatric offering in the region, we have many of these patients, so we’re poised to learn from them.”

The most prevalent congenital urologic condition persisting through adulthood is spina bifida, Boswell notes, followed by conditions such as posterior urethral valves or major urologic reconstruction after cancer or for another reason. Standing on the shoulders of a well-structured pediatric spina bifida clinic, UAB and Children’s providers recently established an adult spina bifida clinic that is paving the way in serving these specific pediatric urologic patients as they transition to adult care.

Research on spina bifida patients in the general population indicates they often don’t establish regular adult care after leaving a pediatric setting. “They end up coming into the ER with urinary tract infections, kidney stones or bladder stones, and the assumption is that this is because they haven’t gotten good enough regular outpatient care,” Boswell said. “But those types of analyses haven’t been done as much in patients with other urologic diagnoses to know what problems or challenges those patients have.”

“The progress the UAB adult spina bifida clinic is making for spina bifida patients serves as a good representation of the improvement that can be made in this patient population with a focused effort to improve their transition,” he added. “I’ll be interviewing some patients with spina bifida to learn what they’re experiencing and compare and contrast that with other groups of congenital urology patients who don’t have a structured transition process.” As part of his research, Boswell hopes to also reach out to patients with congenital urologic problems who aren’t receiving regular care, giving Children’s the opportunity “to potentially plug them back in and prevent complications,” he said. “The project has fluidity to it in trying to determine what the major issues are, and my strategy is to adjust as we go with the goal of improving their care, and all those to follow them.”

August 2, 2024 by
Urology

Improving Kidney Stone Intervention Follow-up Care

Many patients skip follow-up visits after kidney stone surgery. A QI project aims to change that.

The incidence and prevalence of pediatric kidney stones have been rising rapidly in the United States, particularly in the South. A Children’s of Alabama study found an increase of 84.4% over 15 years, with an average increase of 16.1% every three years.1 Recurrence rates are also high, with about half of children experiencing a recurrence within five years.2

The economic costs are significant, noted Children’s of Alabama pediatric urologist Carmen Tong, D.O. One study found overall costs for 8,498 patients of $117.1 million.3 Medical costs, however, don’t take into consideration the intangible human capital loss such as lost workdays for caregivers and extra childcare costs, Tong said.

Carmen Tong, D.O.

Some of this cost is due to high recurrence rates, she said, but also to issues relating to pain and infections after intervention.

Current guidelines call for follow-up imaging four to six weeks after surgery to confirm all stones are gone and discuss preventive measures. However, Tong’s review of 130 patient charts found that nearly half didn’t return for that follow-up visit. Those findings echo other studies in larger populations.4

That prompted a new quality improvement project to identify socioeconomic factors that could predict adherence with postoperative follow-up, she said. “We’ve noted that parents come back with their patients because of pain, poor pain control or issues with infection,” but not for routine follow-up if the child is doing well, Tong said.

The project will examine barriers and boost resources and education for families. “Enhanced communication can hopefully limit complications like inadequate pain control and infections, which currently prompt some visits,” Tong said. Her team will partner with Nationwide Children’s Hospital in Columbus, Ohio, to examine the influence of a multi-institutional, incentivized study on follow-up adherence versus no incentive.

“We want to improve our communication and education to this population so they’re better equipped to provide the follow-up care their child needs,” she said.

  1. [1] Zhang SY, Collingwood JD, Fujihashi A, He K, Oliver LA, Dangle P. Incidence of Emergency Department Presentations of Symptomatic Stone Disease in Pediatric Patients: A Southeastern Study. Cureus. 2022;14(11):e30979. Published 2022 Nov 1. doi:10.7759/cureus.30979 ↩︎
  2. [1] Tasian GE, Kabarriti AE, Kalmus A, Furth SL. Kidney Stone Recurrence among Children and Adolescents. J Urol. 2017;197(1):246-252 ↩︎
  3. [1] Sturgis MR, Becerra AZ, Khusid JA, et al. The monetary costs of pediatric upper urinary tract stone disease: Analysis in a contemporary United States cohort. J Pediatr Urol. 2022;18(3):311.e1-311.e8. doi:https://doi.org/10.1016/j.jpurol.2022.02.019 [1] Ellison JS, Merguerian PA, Fu BC, et al. Postoperative Imaging Patterns of Pediatric Nephrolithiasis: Opportunities for Improvement. J Urol. 2019;201(4):794-801. doi:10.1016/j.juro.2018.10.002 ↩︎
  4. Ellison JS, Merguerian PA, Fu BC, et al. Postoperative Imaging Patterns of Pediatric Nephrolithiasis: Opportunities for Improvement. J Urol. 2019;201(4):794-801. doi:10.1016/j.juro.2018.10.002 ↩︎
January 25, 2024 by
Urology

How Games Help With Surgical Robot Training

Children’s of Alabama residents practice using the urology team’s surgical robot by playing games like Hasbro’s Perfection.

When the Children’s of Alabama urology department acquired its first Da Vinci surgical robot in January 2023, Carmen Tong, D.O., pediatric urologist at Children’s of Alabama, developed a training curriculum that brings in classic children’s games to help residents develop their skills with the new technology.
 
“There’s a movement in urology to ‘gamify’ the robot,” Tong said. “Such training is vital to the safety of our patients.”
 
Surgeons are very competitive, she said. “Gamification taps into our competitive side and allows us to push and encourage each other to improve. It helps with camaraderie.”
 
Indeed, studies show that gamification, whether with actual games like Tong is using or embedding competitions and rewards into skill development, enhances resident engagement.[i]
 
The curriculum is not, however, all fun and games. Residents and any interested ancillary medical staff learn the robot from the inside out. “The surgeon who’s using that technology should be the most knowledgeable person of that technology,” Tong said. “We have to be prepared to troubleshoot to figure out what’s happening if the components of the robot are not responding the way we want.”
 
The residents complete online modules and practice surgeries via a video game-type simulator. Then, every two months, Tong brings in the actual games, and the residents compete against each other using the robotic arm in place of their own hands. For instance, they used the Hasbro Perfection game, designed for kids ages 5 and up, to work on wrist articulation. The fast-paced puzzle involves fitting shapes into their matching holes before time is up and the pieces pop out.
 
“We’re sitting at the robot using real instruments,” Tong said. “They may have perfected those simulator games. But when you’re actually holding the needle with the robotic instrument, it’s very different.” Ultimately, she said, “when they’re ready to perform those skills on an actual patient, it’s not their first time.”
 
Even though the gaming sessions aren’t mandatory, “almost all residents participate.” That, she said, “says a lot about the program’s success.”
 
The residents aren’t the only ones playing with ‘Tater Bot,’ which the surgical robot was named following a hospital-wide naming contest. Two patients, who underwent surgery with the device, have also had a chance to play the games. Tong brought in some hospital administrators to play with the new equipment, as well.
 
The two most challenging skills to learn are spatial awareness and manipulating tissue so it doesn’t tear. “One of the harder things to grasp with the robot is tactile feedback,” Tong said. “You just don’t know how hard you’re pulling because it isn’t the same as having your hand in there. But with practice, you learn how to be gentler. But that takes a really long time to master.”
 
Most residents won’t complete their first robotic surgery on a real patient until the end of the five-year program. “They have to prove that they understand the advantages and the shortcomings of the robot in order to be a safe and competent surgeon,” Tong said. “It’s essentially practice, practice, practice.”

[i] Nakamoto K, Jones DB, Adra SW. Gamification of robotic simulation to train general surgery residents. Surg Endosc. 2023 Apr;37(4):3136-3144. doi: 10.1007/s00464-022-09520-3. Epub 2022 Aug 10. PMID: 35947198.
 

January 25, 2024 by
Urology

Study Aims to Standardize Kidney Stone Treatment

Cases of kidney stones are on the rise among children.

As the incidence of pediatric kidney stones rises, Children’s of Alabama is joining forces with the Pediatric KIDney Stone Care Improvement Network (PKIDS) to gain knowledge on patient-centered outcomes and comparative effectiveness data on kidney stone treatment and surgery to improve outcomes that are most important to patients.

PKIDS is a collaborative community of patients, caregivers, clinicians and researchers from 26 pediatric health care systems in the U.S. Through a prospective cohort study, the network is comparing stone clearance, re-treatment and unplanned health care encounters in children who receive surgical interventions as part of their clinical care. The goal is to enroll 1,300 patients throughout the country. “This is by far the largest pediatric stone study that’s been published to date,” Children’s pediatric urologist Carmen Tong, D.O., said.

Children’s is particularly well suited to participate in this study given that Alabama sits in what’s known as the “stone belt” for its higher incidence and prevalence of kidney stones. “It’s a pretty big economic and public health burden,” Tong said.

“There have not been any good studies looking at care for children with kidney stones, including patient and parent experiences with children needing kidney stone surgery,” Tong said. “Then there are issues with access to care, compliance with follow-up care and prevention of kidney stones. While these issues have been well studied in adults, our understanding in children is limited.” In fact, current guidelines for managing pediatric kidney stones are minimal and dated, she said. “This study is supposed to help change the paradigm and come up with a uniform, standardized algorithm on treatment of kidney stones.”

It’s not clear what’s driving the increased prevalence of stones in children, Tong said. Causes could be dietary (e.g., sugary drinks, high sodium) and/or hereditary, but climate change could also be a culprit, she said. “There are studies looking at weather-related causes. In the summer, when it’s hotter and children drink less water, the incidence rises.” Certain medications, like antibiotics, also increase the risk. Children are 50% more likely than adults to have recurrence within three years.

Families in the study complete a series of surveys about their and their child’s experiences with kidney stones and surgery. “We want to get from the parent and patient standpoint how they’re dealing with their kidney stones,” Tong said. On the clinical side, investigators will get a comprehensive view of how stones are treated around the country, including which surgical interventions were used and when.

August 25, 2023 by