No. 4

When Christi Everingham had her children seven years apart, she thought the age gap would avoid all the sibling drama, but Jacob and Faith tease, scare and antagonize each other in the way that only brothers and sisters lovingly can.

 

While Jacob, 17, is looking at colleges to attend next fall, Faith, 10, is also gaining a level of independence thanks to the Division of Pediatric Urology at the Monroe Carell Jr. Children’s Hospital at Vanderbilt.

The division was recently recognized as one of the nation’s best programs by U.S. News & World Report. The magazine’s annual Best Children’s Hospitals rankings placed the division at No. 4, its highest-ever spot and the highest for any specialty at Vanderbilt.

“We’re one of the busiest pediatric urology programs in the country, and we’re a triple threat department with expertise in research, education and clinical care,” said John W. Brock III, M.D., director of Pediatric Urology, surgeon-in-chief of Children’s Hospital and Monroe Carell Jr. Professor.

“I’m proud that we are again given this distinguished acknowledgement and placed among the top programs in the country. It is outward recognition of the teamwork, dedication and comprehensive care we give to patients like Faith every day.”

Faith, now a fifth grader in White House, Tenn., was born with spina bifida, a congenital condition in which the layers of tissue and bone that normally cover the spinal cord fail to close during development, leaving the delicate nerves exposed. Faith spent two months in the neonatal intensive care unit having multiple surgeries for her spinal defect, severely clubbed feet, hydrocephalus, and jejunal atresia (an abnormality in her small intestine).

Children with spina bifida often have lifelong bowel and bladder problems. Last summer Faith was still in diapers and her parents knew it was time to do something.

“As she was getting older, it was getting hard to find a place to lay her down and get her pants off to do the catheter. And there’s no privacy because changing tables are out in the open. She was getting aware of her body and wanting more privacy,” Everingham said.

John Thomas, M.D., associate professor of Urologic Surgery, had followed Faith in the multidisciplinary spina bifida clinic since birth. He opted for an extensive surgery that would give Faith’s parents more control over her bladder and bowel function and eventually allow her to do it herself as she got older.

The Mitrofanoff procedure uses a piece of her intestine to build a channel from her bladder to her belly button to catheterize through. The MACE (Malone antegrade continence enema) creates another channel with her appendix that facilitates bowel movements using enemas.

“Faith had two surgeries in one,” Thomas explained. “She can now catheterize through the belly button to stay dry and through the MACE to control her bowels.”

The surgery took over nine hours and Faith spent 11 days in the hospital recovering. The surgery also irritated her jejunal atresia, and Walter Morgan, M.D., assistant professor of Surgery and Pediatrics, performed another surgery to resect that part of her intestine and reconnect the healthy ends. Faith spent another 21 days in the hospital.

“Through all of that, even with the surgery aggravating her issues and causing another surgery, I would still go through with it. It’s been the best thing for her and for our family,” Everingham said.

“It got her out of diapers. Now she can stay seated in her wheelchair when we cath through her belly button. And we flush her bowels once a day and control when that happens, versus having no control before.”

After the surgeries, Faith bounced back quickly to her sassy, spunky self.

“Faith’s outlook is great,” Thomas said. “She continues to become more independent. She’s smart as a whip and can do anything she wants in life.”

As Faith gets older, the goal is for her to catheterize herself to have more independence and privacy. She will continue to be seen at the spina bifida clinic every six months and has more orthopaedic surgeries in her future, but the family is enjoying this period of newfound freedom and credits Pediatric Urology for the great outcome.

“I’m not surprised by the high ranking,” Everingham said. “Dr. Thomas is especially wonderful and very down to earth and never makes us feel rushed. He took time to build a relationship with Faith. We couldn’t imagine being anywhere else. We’re very lucky to have such a great hospital with great doctors 30 minutes down the road.”

Built From Scratch

Urology is the medical specialty that cares for the urinary and genital systems, which includes kidney and bladder function. Nonsurgical care includes urinary incontinence, urinary tract infections and voiding dysfunction. Surgery ranges from circumcision and kidney stones to bladder exstrophy (part of the bladder is outside the body) and hypospadias (abnormally placed urethra opening).

Nurse practitioner Lisa Lachenmyer said urology is a rewarding field.

“You know you’re helping medically but also socially with self-esteem and staying dry. It has a huge impact on the whole child, not just their medical issue.”

 

In 1991, Brock started the Pediatric Urology program from scratch and soon added Mark Adams, M.D., and John Pope IV, M.D., to the faculty. Adams helped carry the clinical load while Pope started a research program. A fellowship program began in 2003. The division has outreach clinics in nearby Franklin, Tenn., Jackson and Chattanooga and counts many “firsts” for Tennessee: first pediatric robotic surgery, first sacral neuromodulation and first pelvic floor biofeedback therapy program.

“I never dreamed that the division would be this big or this prominent. It’s a meteoric rise to be on the map worldwide in this small amount of time,” Brock said.

The division has been consistently ranked in the top 10 since U.S. News & World Report began ranking the pediatric urology specialty in 2009.

“As a fellow I could feel that momentum,” Thomas said. “It was like catching onto a rollercoaster. I knew I wanted to jump on because it was clearly going somewhere.”

The secret ingredient to the division’s success is teamwork, they say.

“Everybody has the same vision and same priorities. So many places it’s all about the individuals and everybody is doing their own thing. Here, everybody just pitches in to get the work done. We just all take care of each other,” Pope said.

The physicians constantly collaborate and often consult each other at a difficult case conference to get ideas on the best approach for a patient.

“We’re bouncing ideas off each other and having conversations in the hallway about a patient. There’s just a lot of professional interaction,” said Stacy Tanaka, M.D., assistant professor of Urologic Surgery.

Underlying that teamwork is a core commitment to the absolute best patient care.

“It all goes back to the quality of care we provide to patients. If it wasn’t for that, none of the rest of it would exist,” Adams said. “It’s seeing patients promptly, taking good care of them, communicating well with their families and pediatricians, and providing good service. If it wasn’t for that, No. 4 wouldn’t be possible.”

Clinical Strengths

Robotic Surgery

In 2011, Children’s Hospital became one of the first freestanding children’s hospitals with a robotic surgery device.

“The pelvis is such a confined space. It’s bounded on most all sides by either bone or other organs. It’s a tight, narrow place to work and the robot facilitates a lot of delicate operations,” said Douglass Clayton, M.D., assistant professor of Urologic Surgery, who performs the division’s robotic surgeries along with Thomas.

The da Vinci Surgical System, manufactured by Intuitive Surgical, combines the benefits of minimally invasive laparoscopic surgery with the ease of traditional open surgery. Though the da Vinci has been used in 60 pediatric urology surgeries, it is primarily used for pyelopasties (surgery to clear blockages in the kidneys or ureters).

Laparoscopic surgery is often described as operating with chopsticks, but the da Vinci offers remarkable dexterity and delicacy of movements.

“I’m controlling everything at a console, and it allows me to take fine motor skills we have as surgeons and translate those into laparoscopic instruments with all the degrees of freedom of motion I have in my hands,” Thomas said. “Suturing techniques become so much easier. We can make smaller incisions, and there is potentially less pain.”

“We don’t have hard data to prove it, but children do seem to recover well after the operations, especially the older adolescents,” Clayton said. “It facilitates our ability to do more complex reconstruction procedures and surgeries that need a lot of suturing.”

Interstim

For children with daytime urinary incontinence who have failed all other medicine and behavioral therapies, Children’s Hospital offers an innovative treatment, and is only one of a few places in the United States offering this last-resort therapy to children.

The therapy involves a device called Interstim, a sacral nerve stimulator that helps with bladder control. The device, used in adults for years, is implanted under the skin near the lower back and controls the nerves associated with the bladder to keep children from leaking or having urinary frequency.

“In the past, there really haven’t been a lot of alternatives for treating those children if they failed to respond to behavioral and medical treatments,” Pope said.

Pelvic Floor Rehabilitation

A video game that guides a dolphin through the hoop with the use of a young patient’s pelvic floor muscles is part of a new biofeedback therapy system that helps children with urinary incontinence.

The pelvic floor muscles have two functions—to tighten and hold urine in the bladder while it is filling up, and then to relax and let urine out at the right time. In some children, these muscle movements become uncoordinated, often due to infections or previous accidents.

“It’s a learned muscle memory, and it’s hard to break that habit and get back to the right muscle coordination,” said Lachenmyer.

Using EMG stickers connected to their muscles, the patients can see that when they tighten their muscles, the dolphin moves to the top of the screen and it moves back down when they loosen.

“There are so many different games we can play. We can make it harder or easier depending on the child or focus on different muscles. It’s very individualized,” said Jenni Anderson, R.N., M.S.N.

The therapy is an innovative option for children who have failed medication or families who want to try an alternative to medication.

“We’ve had kids who have been on medicine for four to five years or have been in and out of the hospital with these horrible urinary tract infections, and then within a month or two of the therapy they’re emptying their bladder great,” Lachenmyer said.

Interdisciplinary Clinics

With so much emphasis on teamwork, it’s no surprise that Pediatric Urology is involved in many interdisciplinary clinics.

“It’s this approach that makes us special,” Brock said. “If you have a problem, you see all the experts that could solve the problem, and you do it in a fast and convenient way.”

The stone disease clinic brings together urologists to remove the kidney stone and nephrologists to determine how it happened and prevent a recurrence. The spina bifida clinic involves neurosurgery, orthopaedics, urology, physical and occupational therapy, social work and nutrition. Gastrointestinal and developmental pediatricians are on call as needed.

For patients who need lifelong Urologic care, the transition clinic helps them move smoothly from pediatrics to adult providers.

Pediatric Urology interdisciplinary clinics include:

• Stone disease

• Spina bifida

• Complex reconstruction

• Pediatric transition

• Maternal/fetal urology

• Bladder wellness

• Disorders of sexual development

Research Innovations

MOMS Trial

Brock was principal investigator for a landmark seven-year clinical trial comparing two methods of treatment for babies with spina bifida: fetal surgery before birth and surgical closure after birth. The results of the seven-year Management of Myelomeningocele Study (MOMS) prove that surgery before birth improves the health of children with spina bifida.

The positive outcomes include a decreased risk of death or need for shunt placement in the brain by the age of 12 months, plus improved mental and motor function.

“This fetal surgery was pioneered at Vanderbilt and we fully believed in the benefits, but we had to take a step back, do a randomized controlled study and prove that the surgery was safe and effective,” Brock said.

The study’s 183 participants continue to be followed to assess if other side effects, like bladder and bowel control, and intellectual/learning disorders are impacted by fetal surgery.

Vanderbilt University Medical Center is one of only three centers in the U.S. that participated in the National Institutes of Health (NIH)- funded research, which was published in the New England Journal of Medicine.

Bladder Fibrosis

Pope, who joined the Pediatric Urology faculty in 1997, was charged with developing the division’s research program. He focused on bladder fibrosis, a scarring of the tissue that occurs with urethra obstruction, one of the most common congenital defects.

“Our whole philosophy was that everyone else was into tissue engineering and replacing diseased bladder, but we looked at what we could do to prevent the bladder from becoming diseased. How can we prevent, reverse or treat dysfunction or disease?” explained Pope, who is one of the few pediatric urologists in the nation to receive a prestigious R01 research grant from the NIH.

Using mouse models with artificial obstructions, Pope and his team found some genetic markers and enzymes that could potentially be altered to reduce bladder fibrosis.

“We’re not quite to a therapy yet, but we have learned a lot about fibrosis—where it happens, when it happens and some about why it happens,” Pope said.

Fibrosis Biomarker

Clayton has picked up Pope’s research in bladder fibrosis, focusing more on specific cellular changes that occur with obstruction and looking for a biomarker that could provide a noninvasive way to monitor bladder health.

“Especially with spina bifida, a lot of bladder deterioration doesn’t become evident until the very end stage. We need something early on to understand how the problems are progressing. You can’t get a biopsy from everyone who walks in the clinic, but urine is very readily obtained,” Clayton said.

One compound found in urine is F2 isoprostane, which is a biomarker of oxidative stress.

“Our theory is that bladder function deteriorates because of these repetitive stressful events in the bladder, just like poor heart function over time would be repetitive stressful events for the heart. By measuring the isoprostanes, we can see how much stress the bladder is under.”

The end goal of the research is to find a drug that will improve bladder function or a way to scientifically measure the state of the bladder.

Clinical Databases

Tanaka is capitalizing on the large number of patients with a variety of diagnoses who come for treatment at Children’s Hospital to build clinical databases that can be mined for information in scientific studies.

The spina bifida population is a major focus because their frequent follow-up visits allow for easy tracking.

“We’re trying to collect all the Urology specific information right now, like how often they’re catheterizing, the results of their imaging studies, and also some of the neurosurgical information like do they have shunts and how does that affect their urologic issues, and we’ll be tracking the procedures they’re having.”

Collecting this data on the front end, called a prospective study, can eliminate scientific bias.

Adams also spearheaded data tracking on certain surgical procedures as a way to measure quality and outcomes. The division tracks common procedures like bladder augmentation, hypospadias, pyeloplasty, MACE and Mitrofanoff.

International Outreach

Members of the Division of Pediatric Urology have traveled more than 2,000 miles to take their surgical expertise to children in Guatemala.

Urology initiated the medical mission partnership with the Shalom Foundation in February 2006 and has performed three separate trips and nearly 100 surgeries in Guatemala City. The mission has since been adopted by other Children’s Hospital divisions to impact more than 450 children and their families.

In 2011, the division celebrated the grand opening of the Moore Pediatric Surgery Center, providing 12,000 square feet of well-equipped space for consultation, surgery, intensive care and recovery.

Caroline Berberich, MBA, clinical business coordinator for perioperative services, has been on two trips to Guatemala, and says the impact is incredible.

“It’s a different world of health care access. It’s very rewarding and overpowering,” Berberich said.

The most common surgical procedures include hernia repair, orchiopexy (fixing undescended testicles) and hypospadias (fixing abnormally placed urethra openings).

Lori Graves, B.S.N., R.N., C.N.O.R., pediatric operating room manager, said staff enjoy the opportunity to work in another country and provide this medical care.

“Oftentimes we take our ability to visit the doctor and receive health care for granted, people in Third World countries do not have this luxury and are extremely grateful for the assistance that we offer to their children,” Graves said.

Education

This year, Pediatric Urology’s fellowship program celebrated its 10th anniversary. The Pediatric Urology fellowship is one year of protected research time after residency followed by one year honing clinical skills.

“There aren’t many programs that have protected the [fellowship research] time as vigorously as we have. A lot of places have time but if the clinic gets busy, you get pulled out to help. But that was our plan and we’ve stuck to it,” Adams said.

Three former fellows—Tanaka, Thomas and Clayton—have joined the Vanderbilt faculty while the others are in private and academic practice around the country.

Siam Oottamasathien, M.D., a fellow from 2005-2007, now at Primary Children’s Medical Center at the University of Utah, said it was career altering.

“My No. 1 concern was to become an excellent clinician, both in the office and in the operating room. The training was outstanding and I came out extremely well equipped. The bonus was to be exposed to basic research. I never thought that would become my career, but now I direct the basic science mission with my group and devote 60-70 percent of my time to research. All of that started at Vanderbilt.”

Oottamasathien said many things initially attracted him to Vanderbilt: “The leadership, the vision, the drive for education, the breadth of both the science and clinical care and dedication to those missions,” he said.

“I pride myself on my Vanderbilt fellowship. That’s what built me, and I wouldn’t be who I am without Dr. Brock and his crew.”

To celebrate the 10th anniversary, the division invited all 10 fellows for a two-day symposium to give presentations on their research and clinical work.

“It was amazing to see what the group is accomplishing. We’re populating the country with academic prowess, which is what I envisioned,” Brock said.

– by Leslie Hill