Rania Habib, MD, DDS (Host): About one in 5,000 children are born with defects in their bowel or pelvis that prevent them from stooling easily or at all. This can cause pain and lead to serious health problems. Children's Health is one of the few pediatric hospitals in the U.S. with a multidisciplinary center to care for these kids.

This is Pediatric Insights: Advances and Innovation with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Rania Habib. Joining me today is Dr. Charles Hong, a pediatric surgeon at Children's Health and an Assistant Professor at UT Southwestern; And Dr. Irina Stanasel, a pediatric urologist at Children's Health and Assistant Professor at UT Southwestern. They are here to share information about the Colorectal and Pelvic Center, and how multiple disciplines come together to treat complex colorectal and pelvic defects. Welcome, Dr. Hong and Dr. Stanasel. Thank you for being with us here today.

Charles Hong, MD: Thank you so much, Dr. Habib. Very happy to be here.

Irina Stanasel, MD: Thank you so much for having us. Really looking forward to this conversation.

Host: Well, we are so excited to discuss this multidisciplinary center. Dr. Hong, let's first talk about the Colorectal and Pelvic Center at Children's Health. What is it? What services does it provide and how long has it been serving North Texas families?

Charles Hong, MD: The Colorectal and Pelvic Center, which we call CPC at Children's, started in 2021 by Dr. Eric Hansen. It is a multidisciplinary clinic that specializes in the care of children with a history of congenital colorectal and pelvic conditions. So, for example, like anorectal malformations, along with any associated urologic anomalies, Hirschsprung's disease, and any other complex pelvic malformations that can impact GI and urinary function.

We provide both surgical and non-surgical care for these kids and incorporate perspective from different disciplines to make sure that we provide comprehensive care that appropriately addresses each child and family's unique needs. So, this can include surgeries to address the malformation, and that can be staged surgeries or just an initial definitive repair; long-term monitoring of bowel, urinary, and/or gynecologic function; motility evaluations, bowel management, which can involve surgery, and also non-surgical management with the goal of helping them achieve continence; nutritional management, psychological counseling, child-life specialists to help kids cope with these sometimes difficult diagnoses, and also social work support.

Host: Wow. This sounds like a phenomenal center that you guys developed. Dr. Hong, what disciplines and specialists are involved at this center? What does it take to provide coordinated care under one roof?

Charles Hong, MD: So, our center includes pediatric surgeons, like myself, urologists like Dr. Stanasel, also gastroenterologists, gynecologists. We have a nurse practitioner, a program manager who's also a nurse, we have a psychologist, a child-life specialist, and also a social worker. So, it really takes a village to provide coordinated multidisciplinary care, and good communication is very important. We run a monthly multidisciplinary clinic where all the specialties discuss the care of each patient and we see them together in the same visit. And outside of our monthly CPC Clinic, there's still frequent communication amongst ourselves with the referring providers and with the families. Michelle Phelan, our program manager, really makes it happen very smoothly, and she really gets to know the families very well.

Host: That is fantastic. It's really important that you guys are all meeting to discuss these patients live. And then, you said you're staying in touch so that you can really make sure that you guys are providing the best care in all of these aspects given the amount of specialists that you have. It's wonderful.

Charles Hong, MD: Right, yeah. And it takes a lot more than just, you know, once a month clinic, so the work is always ongoing.

Host: Absolutely. Dr. Stanasel, why is this center important? And how has it benefited patients with colorectal and pelvic defects?

Irina Stanasel, MD: Sure. The center, really, the most special part about it to me is that it brings multiple specialists together to help these children with complex pelvic floor conditions, and we can do so in a collaborative and seamless manner. It allows us to discuss the different aspects of the patient's condition, each from our point of view, the point of view of our own specialty, but ultimately to develop a plan that best serves the patient holistically. It really ultimately allows us to treat the patient in not just one aspect of their condition.

The patients in our center have differing needs. And together, we can work to identify comprehensive surgical and medical plans to allow us to treat the patients acutely as well as to develop these long-term treatment plans for them. Working together also allows the families to be informed and engaged. It really is care that happens in the hospital, in the clinic, and at home for these children. And it's wonderful to have the families very engaged and have the opportunity to ask us questions together as a team in the clinic setting.

Host: That is wonderful.

Irina Stanasel, MD: I think it is also our best chance to plan procedures in a way that limits the number of anesthetics for children. We can work together to plan surgeries in a way that we are minimizing the number of times they're going to the operating room. And certainly, it provides the families with the convenience of going to one doctor's visit rather than visiting offices of various specialists. So, that part is a huge benefit.

Host: Oh, it's huge. And the fact that you guys are all in one spot. And like you said, holistic care is really the best care for these children, and you're involving the parents, so it's really a wonderful approach that you guys are taking to these very complex conditions. Can you both share about the roles that each of you play at this center, specifically in regard to General Surgery and Urology? Dr. Hong, let's start with you.

Charles Hong, MD: Yeah. From a general surgery standpoint, we perform surgical repairs of these malformations as it pertains to the GI tract, so the colon and the anus primarily. So for example, anorectalplasties for imperforated anus are pull-throughs for children with Hirschsprung's disease. And also, in collaboration with our GI colleagues, we are also heavily involved in bowel management to help with both preventing constipation and helping kids achieve stool continence.

And with bowel management, again, it's also a big part of that long-term care we provide to these kids. With bowel management, it can range from starting laxatives, or doing enema therapy, or sometimes performing surgical procedures for antegrade enemas. And Sharon Kluger is our nurse practitioner who is an expert in bowel management and really runs our bowel management program. We've had quite a lot of success and and lots of happy families too.

Host: Dr. Stanasel, what about Urology?

Irina Stanasel, MD: Sure. So, as urologists, and actually there are several of us urologists who participate in the center, which we're very proud of because that allows us the flexibility to make sure that somebody is always available to be there for these children. Our job is to watch out for the well-being of the urinary tract, which includes the kidneys, the bladder, and the urethra. Sometimes, this really involves some very basic testing while the majority of their care is really provided more by Pediatric Surgery. So, we can do things like renal bladder ultrasounds to ensure the health of the urinary tract, as well as give some basic instructions like instructing the children to void regularly urinating and encourage them to follow up with the gastroenterologist and pediatric surgeon and make sure their bowels are well-managed.

Other times, we work closely with Pediatric Surgery to perform surgeries such as complex cloacal anomalies. And of course, our focus is reconstruction of the genitourinary tract. So, something like urethral reconstruction, creation of a catheterizable channel for drainage of the bladder and addressing vaginal abnormalities that can be associated with these pelvic floor anomalies. And most importantly, we provide long-term care to these kids. It's really a lifelong process to protect the health of the urinary tract. And kidney function is very important, so doing things to minimize the risk of kidney deterioration, to minimize the risk of urinary tract infections, to make sure that we are doing our best to provide the children with social continence so they can be dry and comfortable at school. These are all things that we do in an ongoing fashion throughout their childhood.

Host: You guys play such important roles in the care of these children with these very difficult diseases to treat, and I love the holistic approach. Could you each share an inspiring success story of a patient who has been treated at the Colorectal and Pelvic Center, and specifically address how did this center help them? Dr. Stanasel, let's start with you.

Irina Stanasel, MD: So in Urology, I think of success in two different buckets from two different aspects. One is from the medical side and that is to ensure that the children have a low risk of urinary tract infection or staying healthy or staying out of the hospital as much as possible and that we're protecting their renal function. And working together with our Pediatric Surgery colleagues certainly offers us the best chance to do that. And seeing the children as regularly and in a comprehensive manner, like in the CPC Center, has really allowed me to be able to catch things and address things sooner in a timely fashion, in a coordinated fashion to really feel like I am providing the best medical care to these children. And there are several children that come to mind where I can think of. We work together to identify signs of tether cord, for example, and to order MRI studies that identify a need for a neurosurgical intervention and make sure that we're doing everything that we can to keep their bladder and, thus, their kidneys healthy.

So, that is really important from the medical side. But to the children, probably what they care about acutely, more than anything, is their social continence. They come to us a lot of times and they are wet, they are incontinent, they are in a pull-up or a diaper when they are school-aged, and sometimes this is hard for them. And there are things that we can do to help them achieve their continence goals, things like medication, catheterization, or surgeries. And again, several children come to mind where I have worked to do things as simple as making sure they're on a good timed voiding program, and that really significantly improves their risk of accidents at school, as well as surgery that has involved catheterization programs and medication that have allowed them to achieve continence, or surgery to create a catheterizable channel to allow them for catheterization, and again for continence. And these are the things that really just have a huge quality of life effect on the children.

Host: Oh, absolutely. Especially those poor school-aged children when they're having those incontinence issues, it really hurts their confidence at school.

Irina Stanasel, MD: Yes, that's a tough age. And providing some care for those children that allows them to feel more comfortable and confident in themselves and in their body at school, that allows them to participate in activities they want to participate in. I mean, that's just tremendously rewarding.

Host: Absolutely. And Dr. Hong, same question to you. Could you please share an inspiring success story of one of your patients?

Charles Hong, MD: Sure. So, from a colorectal and bowel management standpoint, we've seen some families refer to us where, for example, the child had a prior anorectalplasty for an anorectal malformation and they've been struggling with lots of fecal soiling. And oftentimes, there's a lot more to the story than just, "Oh, it's a potty training problem." And sometimes, these families, they may not have gotten the appropriate counseling. And they think that maybe this is just what's to expect, that my child's just going to have stool accidents and we just have to deal with it. But in fact, there's a lot of workup that needs to be done and a lot of potential interventions that we can implement. So, as Dr. Stanasel mentioned, you know, there has been times where when we screen for a tethered cord, and it turns out, oh, this child did have a tethered cord, which is a known association with anorectal malformations. Or sometimes, we check for a stricture, and there's a stricture, that may be a problem that's affecting their fecal accontinence.

And then, finally, with a personalized bowel management program, we have had lots of success in getting kids clean of stool accidents and out of diapers. For example, sometimes, we would start with laxatives first. And if that doesn't work, there's still always other options. And so, for example, trying enemas and I found that it really has had an enormous impact on the kids' confidence and overall quality of life for the family, because some of these parents are spending hours of the day doing laundry or just making sure that their child makes it to the bathroom. But with a personalized structured bowel management program, we've been able to really help them in a lot of those aspects.

Host: That's fantastic. And again, it goes back to that holistic approach where you really have a bunch of different options at your center from least invasive to more invasive surgical options. So, I really appreciate you each showing that unique perspective. Dr. Hong, for physicians considering referrals, what criteria should guide them in sending patients to this center? How do they get in touch? And what is the number that they can call?

Charles Hong, MD: If a child has a history of an anorectal malformation, or Hirschsprung's disease, or any other congenital pelvic malformation, and they're having issues with bowel or bladder control, or they just need long-term follow-up and monitoring in this multidisciplinary setting, they should come to see us. There is an email, it's colorectal@childrens.com, and also a phone number, and that phone number is 214-456-8546. There's also an EPIC order if they are in the Children's EPIC system where you can put in a referral for Colorectal Surgery.

Host: That's awesome. Anything you'd like to add about the criteria, Dr. Stanasel?

Irina Stanasel, MD: I think that covers it very nicely. I think from a urological standpoint, my point would be that even if they seemingly don't have bladder control issues that are obvious, it is still important to have a urologist involved just to make sure that from a medical standpoint, the children are safe and that their kidneys look good on ultrasound, that we don't have hidden signs of a urinary abnormality that may prove to be a problem later. So, I'm always happy to see those children in our CPC Center along with Pediatric Surgery, even if they just seemingly have only bowel control issues.

Host: That's a great reminder. So, we really want to harness that multidisciplinary approach that you guys have at this center. If there is one thing you'd like physicians to know about the center, what would that be? Dr. Stanasel, let's start with you.

Irina Stanasel, MD: I think from my standpoint, if we were talking about kind of general physicians, general practitioners, pediatricians, it would be to keep in mind the potential for long-term medical implications of these underlying conditions. So, sometimes, like I said, even if kids seem to be doing well and their bladder control is fairly reasonable and they might have some constipation, but they don't have a lot of fecal soiling, but we know that they have this history of these complex pelvic floor abnormalities, you just may not realize exactly what is going on there. And there may be more to their underlying condition than meets the eye. So, a thorough multidisciplinary evaluation and ongoing care, I think, is still in the children's best interest, even if they seem to be doing rather well, just to make sure we're really doing everything we can possibly be doing for these kids.

Host: Absolutely. And Dr. Hong, same question to you. If there's one thing you'd like physicians to know about the center, what would that be?

Charles Hong, MD: I would mirror Dr. Stanasel's answer and also add that I think it's important for everyone who cares for these kids that care for them extends beyond just the surgical repair that happens during infancy. Because we may do the most perfect surgery and make the anatomy as close to normal as possible, but that doesn't necessarily guarantee that the function will be normal. There's a lot of things that we just can't predict and these conditions have long-term implications, and it's important that we continue to watch these kids and make sure they thrive.

Host: Thank you. That's a beautiful answer. Now, this is obviously a one-of-a-kind center that's really doing wonderful things for North Texas. What is your hope for the future of this center? Dr. Hong, let's start with you.

Charles Hong, MD: So, my hope is that we continue to grow and that we are able to help more and more patients with congenital colorectal and pelvic conditions. It really is a joy to be able to watch these kids grow up and be able to longitudinally guide families through managing their child's complex medical conditions.

And as we follow more and more children long-term, I also hope that we are able to learn more about what are things that we can do better, because there's still quite a bit of unknown in terms of longer term outcomes for many of these conditions. Like, what exactly is the right thing to do? Sometimes, we learn more with more experience.

Host: Wonderful. Thank you. And Dr. Stanasel, same question to you. What is your hope for the future of this center?

Irina Stanasel, MD: Sure. My hope is maybe along the same lines. As we continue to grow and maybe have more patients in the clinic and more support, I would like to be able to offer care in a way that's even more tailored to the patient's needs and have some more flexibility, like continuing to add clinic days and support staff just to allow the families as much flexibility as possible for being seen in our clinic.

Host: Dr. Stanasel, is there anything else you'd like to share with our audience as the final question of our podcast?

Irina Stanasel, MD: Yes. I think what I would like to share is just as I've been involved with this clinic from the beginning how proud I am of this center. The people that are a part of the center, our conversations, our meetings, every time I'm a part of them, I am just so proud to be surrounded by such a dedicated group who is willing to tackle the most complex of conditions and just be there for the children in the best way that we possibly can be. It's just really a tremendous group of surgeons and physicians who just really show up for the children in every way that we possibly can. So, it's really just a joy to be a part of the center.

Host: You can tell that you're very proud of this center. Dr. Hong, same question for you. What is your final message for our audience today?

Charles Hong, MD: Yeah. I do love how everyone in the center is very dedicated and cares so much for their families, and we're very proud to be part of this amazing clinic. The one thing I would like to add is it is very easy to get in touch with us if you think a patient would benefit from being seen in the CPC, just take an email or a phone call or an EPIC call. And then, once we have information, that physician will review the patient's medical history and reach out to the family. Sometimes, it can take a little bit of time to get them into the multidisciplinary clinic because it's just once a month, but we still try to set them up ahead of time to get needed studies beforehand. And if they do need to be seen sooner and we can't fit them into the monthly CPC Clinic, we can also schedule for them to see one of the individual providers who is part of the center to get them connected with us sooner.

Irina Stanasel, MD: And we are, of course, still available outside of the clinic times. These are clinic times when we are all together to see the children in a multidisciplinary fashion. But individually, we're there every day available to take care of the children, and we make sure that we certainly can do whatever is needed at any time for the children.

Host: Well, you both bring such a wonderful service to the Children's Hospital and we really appreciate you sharing all this wonderful information about the Colorectal and Pelvic Center. Thank you, Dr. Hong and Dr. Stanasel, for joining us today and for sharing all this wonderful information.

Charles Hong, MD: Thank you so much, Dr. Habib. Thanks for having us and for letting us share our center with everyone.

Irina Stanasel, MD: Thank you so much. This has been a total joy to be able to talk about our CPC Clinic with you today.

Host: Once again, that was Dr. Charles Hong, a Pediatric Surgeon at Children's Health and Assistant Professor at UT Southwestern, and Dr. Irina Stanasel, a Pediatric Urologist at Children's Health and Assistant Professor at UT Southwestern. It's been great talking to you. I'm your host, Dr. Rania Habib, wishing you well.

Thank you to our audience for listening to Pediatric Insights: Advances in Innovation with Children's Health, where we explore the latest in pediatric care and research. You can learn more about the Colorectal and Pelvic Center at childrens.com. And if you found this podcast helpful, please rate and review or share the episode and please follow Children's Health on all of your social channels.