Mike Smith, MD (Host): Welcome to MDCast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content and a valuable learning tool for world-class healthcare. I'm Dr. Mike. And with me today is Dr. Michael Ost from Tampa General Hospital, and we're going to be talking about common pediatric urology diagnoses and treatments. Dr. Ost, welcome to the show.

Michael Ost, MD: Thank you for having me.

Host: So, what are some of the common conditions you see and treat?

Michael Ost, MD: So, there are obviously many pediatric urologic conditions, but some of the more common conditions that I see and treat include undescended testicles, urinary tract infections and vesicoureteral reflux, and various congenital obstructions of the ureter.

Host: Give us an idea of, you know, how many patients do you see a day in your specialty?

Michael Ost, MD: So if we were to take a typical day, a clinic usually houses about 30 to 35 children.

Host: That's a little bit more than I thought it was going to be, Dr. Ost, to be honest with you. That's a lot actually.

Michael Ost, MD: It's a fair amount. But luckily, a lot of the problems that we see and some that I mentioned thankfully have relatively straightforward quick fixes.

Host: Yeah. And so, what made you decide to go into the field?

Michael Ost, MD: What I really enjoyed when I was a resident in urology was pediatric surgery in addition to pediatric urology. I think I just always was drawn to anatomical variation, which is common with congenital abnormalities in kids, and I was always fascinated by the surgeries that are there to fix them.

Host: I'm assuming most of the patients you see are referred to you. Is that correct?

Michael Ost, MD: That is correct. The large majority are referrals, usually from pediatricians or pediatric specialists. There are often some families who do call directly for appointments. But yes, the majority are referrals.

Host: Now, looking, you know, at some of the conditions that you stated, and there's so much more that you actually treat obviously. How do these issues impact the patients' the family's everyday life?

Michael Ost, MD: Sure. So, many of them can be extremely stressful for parents because there is a problem or an abnormality per se. And because of that, their children can become sick, and that results in not only stress but missed days of school, missed days of work. So, for example, we see a lot of kids who have recurrent febrile urinary tract infections, and it's a very common cause of fever in young children. And it can be a source of fever in about 10% of kids. Of those 10%, in a more formal urologic workup, up to 30% may get a condition called vesicoureteral reflux. And that's a condition where urine is not only urinated outward, but it wrongly goes retrograde or upstream back into the kidneys. And the problem with that is it can cause more infections or infections in the kidneys, such as pyelonephritis. And also, it could lead to renal scarring.

To just circle back directly with your question, this morbidity associated with it is a big source of stress. And for a child, it could lead to long-term problems with kidney function. So, we always want to make sure that when we see someone with a UTI, we're working it up appropriately so that we are avoiding problems going forward in the future.

Host: Well, I think this is a great example to kind of, you know, move into the next question. Here you have a child, let's say, with fever. At what point should the parent, should the pediatrician think of sending this to a specialist like yourself? How do they make that decision?

Michael Ost, MD: Sure. So, pediatricians are really a jack-of-all-trades, and they know hundreds of sources of fever in children. But what we can all agree on is that if a child has an especially high fever, greater than 102 degrees, for example, greater than 48 hours, there should be a higher suspicion of a UTI. And usually, what they do is look into that by testing the urine for infection and subsequently sending it out for a urine culture. And if indeed it's positive, they're treated with appropriate antibiotics. But a next step is investigating further if there could be an anatomical problem. And that would prompt a referral to a pediatric urologist who often at least obtains a renal bladder ultrasound to check for any obvious abnormalities. And then, sometimes we order a VCUG, which stands for a voiding cystourethrogram, and that's a fluoroscopic test that basically tests or rules out vesicoureteral reflux.

Host: What are some additional signs and symptoms that we shouldn't ignore, that should prompt us to reach out to the specialists like yourself?

Michael Ost, MD: Sure. So, just getting back to what I may have initially said, that a very common diagnosis that we see in pediatric urologic practice are children whose genitals or testicles are not descended in the right position. That can be picked up by a pediatrician, and it can also be picked up with a parent.

The statistics are that about 5% of boys will have at least one undescended testis. And if you were to add that up with a world population, that's a lot of young little guys. But what's important is that it's brought to the attention of a pediatric urologist for two main reasons. That, firstly, we can confirm if that's the case, and secondly, of course, we could put it back in the right position surgically. And we do that because we know it can preserve fertility in that testicle. And also, we want that testicle readily accessible for self-examination to screen for testis cancer, because testicular cancer is actually increased in terms of risk in undescended testes.

Host: If there is undescended testes, is there a number you can give to that? Is there a percent risk of cancer?

Michael Ost, MD: It's an excellent question, and there have been numerous studies. But in general, an undescended testicle will have at least a fourfold increased cancer risk compared to a fully descended testis.

Host: What do you think is going on there? Is it just the inflammation, oxidative stress? Like what's underlying that, do you think, that risk?

Michael Ost, MD: There's nothing that has really been proven as a one-to-one correlation. But most likely, it has to do with the association of undescended testicles with some element of aberrant formation or incorrect formation of the testicle itself.

Host: That's a statistic that's surprising to me. So, let's talk a little bit about treatment. What are some of the minimally invasive treatments that you use to treat a lot of these conditions?

Michael Ost, MD: Sure. So, we can use the example of vesicoureteral reflux and ureteral obstructions to answer your question. The standard of care for a very long period of time, for over 30 years, is an open surgical repair, such as a re-implant of the ureter into the bladder so it doesn't reflux. In addition, other common diagnoses such as a ureteral-pelvic junction obstruction, which is an obstruction in the ureter due to a narrowed segment can be fixed by an open procedure as well. These have very high success rates, 95% to 100% success rates.

But in the more modern era, there are laparoscopic and robotic techniques that have shown almost equivalent outcomes in ureteral abnormalities. So, we luckily have that technology, and we are able to provide that service to the children and the parents with not only a great result, but also less of a hospital stay, less pain, and less scarring.

Host: With the robotic surgery, do you—I mean obviously, Dr. Ost, it's going to continue to increase with innovation and all that kind of stuff. But, like, where do you see that going in the future? What are you most excited about there?

Michael Ost, MD: I think what I'm really most excited about is not only the robotic technology with regards to just fixing something in a minimally invasive fashion, but there's a lot of fusion of imaging studies as maps, tactile feedback. These are all being integrated into robotic platforms to really be even more precise and more exact in not only how you fix a problem, but get to it quicker during an operation.

In addition, the instruments continue to get smaller and smaller, but yet can function just as well as its predecessors. So there'll be a point in time where the incisions are probably almost not visible

Host: That's pretty amazing, right? That's like—

Michael Ost, MD: It's amazing.

Host: Yeah. That's awesome to hear. I want to talk to you a little bit about how do you decide in non-obstructive cases, reflux, maybe hydronephrosis, how do you decide between the watchful waiting versus actually intervening right away?

Michael Ost, MD: Sure. So, there are many different diagnoses that come under hydronephrosis, which in general means a dilation in the urogenital tract, specifically the ureters, the tubes that connect the kidneys to the bladder. And the workups usually include ultrasounds, VCUGs, or even what we call a renal scan, which is something that can prove an obstruction.

But the important thing that people need to know is that the majority of hydronephrosis in kids that have it, and that's about 5% of all births worldwide, the majority of them will resolve over time, and we know that because we watch them with serial ultrasounds. But if there isn't resolution in that small percentage of that 5%, which usually is about 5% to 10% of the 5%, we know that they need a surgical procedure.

Host: So, you gave us the statistics and how you use that data to drive your decision of whether I wait and watch or intervene. But how do you explain that to the parents?

Michael Ost, MD: So, anytime we see a newborn with hydronephrosis or any child for that matter, we always first take a very minimal approach with regards to intervention. And we explain that in watching them with ultrasounds, there isn't going to be any "problem" or damage going forward in the future because we're keeping a close eye on it. If we note changes in the serial ultrasounds or in imaging, and of course symptomatology, we have outstanding operations that have extraordinarily high success rates in addressing it. So just to reiterate, if someone is found to have a UPJ obstruction, it's 95% to 100% successful with an operation.

Similarly, if reflux, which is watched over time to see if it resolves, because the large majority do resolve over time, but for those that don't, the operation to correct it is 95% to 100% successful. And I think parents just take comfort in two things. Firstly, that there's usually not an urgency to the operation. And secondly, there is, of course, a very high success rate.

Host: Yeah, yeah. If you have to go down that route, it's effective and safe at the end of the day. And that's what they want to know.

Michael Ost, MD: Sure. That's what they want to know. And we're lucky in pediatric urology that the bulk of our operations have such high success rates.

Host: I want to go back to this question because I find it really interesting. You know, we touched upon, like some of the robotic stuff in the future. Anything else in imaging technology that you think is really going to change how you practice?

Michael Ost, MD: For sure. I think another very exciting and interesting field is the whole field of intrauterine interventions, meaning how is someone with a congenital abnormality, not only diagnosed, but also actually an intervention can be addressed before birth. And that is a big, big area of discovery and excitement because if you could fix something that you know potentially is going to be a problem in utero, it's fixed immediately. And essentially, an intervention in some conditions can actually be very, very helpful in preserving kidney function.

Host: Yeah, fascinating. You know, what's going to be out there in the future for us, how we practice medicine, and ultimately for the patient and the families, right? I mean, it's exciting to see what's going to—and I think we're at a place where we're going to see a lot of this stuff quicker than we thought.

Michael Ost, MD: I think for sure. I mean, I've been doing it now for 20 years, and I can see already how quickly the most cutting-edge sophisticated operations cannot really sustain themselves in terms of being the best option. And things are always changing, and that's why we have a whole generation of medical students, residents, and new attendings who are learning this stuff so that they can continue to offer these outstanding treatments

Host: Dr. Ost, any last words that you would like to share with the audience about pediatric urology?

Michael Ost, MD: Sure. Just that in the scope of problems in the genitourinary tract involving the kidney, the ureter, the bladder, the genitals, is that it's extremely common. And, the large majority of pediatric urologists are equipped to really address most of the problems very successfully. And even if there is highly complicated problems, the cohort of pediatric urologists like myself are happy to help you with that.

Host: Fantastic. Dr. Ost, I want to thank you for coming on the show today. For more information, you can go to tgh.org/definingmedicine. If you enjoyed this podcast, please share it and check out the entire library of topics of interest to you. This is MD Cast by Tampa General. I'm Dr. Mike. Thanks for listening.