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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.


With New Surgical Robot, Urology Team Can Better Serve Patients

Dr. Carmen Tong and the Children’s of Alabama urology team are preparing to start using the new Da Vinci surgical robot.

When Stacy Tanaka, M.D., arrived at Children’s of Alabama as the chief of pediatric urology, she resolved to bring in more technology. “I don’t want families of patients who need our services to go elsewhere because they think we can’t provide it,” she said at the time. That was in January 2022. By the end of her first year, one big piece of the puzzle was in place.

The da Vinci surgical robot arrived in December 2022, and according to Carmen Tong, D.O., director of pediatric robotic surgery, staff should be ready to use it within the next several months. “I’m so excited to offer this service for our children,” she said.

The surgical robot provides an alternative to laparoscopic surgery, in which instruments are inserted through two or three small incisions. Laparoscopic surgery is minimally invasive, but the technique is not ideal. “The instruments don’t articulate at the wrist, so they don’t mimic actual hands in the body,” Tong said. This makes certain maneuvers, such as internal suturing, quite challenging. “It’s as though you’re using chopsticks,” she said. There is also a steep learning curve.

The robot, however, “completely changed the landscape of minimally invasive surgery,” according to Tong. It provides a three-dimensional view with improved depth perception. In addition, the instruments enable much more refined movements—mimicking hands and fingers—and are gentler, which is particularly important when operating on babies, who have very delicate tissue. Overall, robotic surgery is less invasive, less disfiguring and results in quicker recovery than the traditional open technique. One small study also found it resulted in shorter surgeries and less suturing than using a laparoscopic approach for the same procedure.[i]

One major advantage is the three-dimensional, magnified view of the surgical field through the console, which isn’t available with the tiny cameras used in laparoscopic procedures. “It’s fabulous,” Tong said. “You’re able to see exactly what you’re picking up and what you’re cutting and stopping the bleeding on. From a safety standpoint, it’s a superior product.” One study found that robotic-assisted surgery could complement the motor skills of the surgeon’s nondominant hand, eliminating the innate difference in dexterity between hands and conveying ambidexterity.[ii]

Having the da Vinci robot also means Children’s no longer has to rely on access to the surgical robot at the University of Alabama at Birmingham (UAB), which is an adult hospital.

[i] Silay MS, Danacioglu O, Ozel K, Karaman MI, Caskurlu T. Laparoscopy versus robotic-assisted pyeloplasty in children: preliminary results of a pilot prospective randomized controlled trial. World J Urol. 2020;38(8):1841-1848. doi:10.1007/s00345-019-02910-8

[ii] Choussein S, Srouji SS, Farland LV, et al. Robotic Assistance Confers Ambidexterity to Laparoscopic Surgeons. J Minim Invasive Gynecol. 2018;25(1):76-83. doi:10.1016/j.jmig.2017.07.010


Children’s of Alabama Leads Practice-Changing Spina Bifida Study

Dr. David Joseph is a pediatric urologist at Children’s of Alabama.

Spina bifida, a condition in which the neural tube doesn’t completely close, is one of the most common congenital malformations, affecting approximately one out of every 2,700 births. While neurosurgeons provide immediate care, it isn’t long before urologists and nephrologists get involved. That’s because damage to the spinal cord and nerves may keep brain signals from reaching the bladder. If that happens, urine can back up into the kidneys, possibly causing kidney damage. “Yet nearly all newborns with spina bifida show normal kidney function at birth,” Children’s of Alabama pediatric urologist David Joseph, M.D., said. “But over time, at least half will deteriorate to some degree.”

Which begs the question: How do you manage these children? A 10-year, nine-center initiative at Children’s of Alabama has been trying to answer that question. Called Urologic Management to Preserve Initial Renal Function Protocol for Young Children with Spina Bifida (UMPIRE), the initiative is designed to provide an evidence-based protocol for testing and monitoring kids with spina bifida to identify early kidney injury. The Centers for Disease Control and Prevention (CDC) funds the study, which is now following more than 500 children with the most severe form of spinal bifida, myelomeningocele, in which a sac of fluid containing part of the spinal cord and nerves protrudes through an opening in the baby’s back.

Unlike most clinical trials, where the outcomes are evaluated at the end, the UMPIRE investigators review the data every quarter and tweak the protocol accordingly. “Obviously, this is not as clean as a randomized control trial,” Joseph said. “But it’s an effective way to manage a small population without a control group.”

This approach has led to some important revelations. For example, the team learned that bringing newborns in for imaging every three months for the first year as they’d been doing had no benefit at the nine-month visit. They also recognized that prophylactic antibiotics to prevent infection weren’t needed in newborns. Children’s chief of pediatric urology Stacy Tanaka, M.D., discovered that each center assessed urodynamics (lower urinary tract function) differently, which was a serious problem given the reliance on those tests to classify a patient’s level of damage and determine treatment.

Finding participants for the study hasn’t been a problem, Joseph said. “I don’t think we’ve had a family in the past seven years that has turned down the opportunity to be in the study,”—something he attributes to Betsy Hopson, MSHA, coordinator of the Children’s of Alabama Comprehensive Spina Bifida Program. The goal is to follow the children for at least 10 years or for as long as the CDC continues to fund the study.

“The urologic community looks to the UMPIRE program for the protocol in anticipation that it will help direct future management,” Joseph said.

Inside Pediatrics, Urology

New Chief of Urology Aims to Make Cutting-Edge Tech More Accessible to Alabama Families

Stacy Tanaka, MD, Chief of Pediatric Urology at Children’s of Alabama.

For pediatric urologist Stacy Tanaka, MD, it was an easy decision to accept the role of chief of pediatric urology at Children’s of Alabama. She already had relationships with several physicians here, including working on a spina bifida project with some of the pediatric neurosurgeons. 

She was also close with David Joseph, MD, who had been chief since 1986 but had decided to step down from the administrative role. “He’s so well respected in the pediatric urology community and urology community,” Tanaka said.

Coming to Children’s felt like a new but comfortable challenge. She started in January after 12 years at Vanderbilt Children’s Hospital in Nashville.

Tanaka’s vision for the department is to ensure that the children of Alabama rarely have to leave the state for pediatric urology services. And that means bringing in more technology. “I don’t want families of kids who need our services to go elsewhere because they think we can’t provide it.”

One area is robotic surgery. Laparoscopic surgery has revolutionized the field, but it’s challenging. “When you’re doing conventional laparoscopy, it’s a little bit like putting a fork through one hole and a knife through the other and trying to cut your steak,” she said. “With the surgical robot, there is more freedom of movement, making it closer to using your hands,” she said. 

Currently, the Children’s team can access a surgical robot at the University of Alabama at Birmingham, but UAB is not a children’s hospital. So, with Dr. Tanaka’s arrival, Children’s will soon have its own robot.  Having robotic surgery at Children’s would help keep families here, Tanaka said. “Your care is going to be as good or better than anywhere else you go, and you don’t have to travel.”