Transitional urologists face challenging and high-risk operative interventions [10], caring for patients who often have a history of numerous prior interventions. Preparation for and understanding of the potential challenges that may arise is key to a successful clinic, as Summers et al. reported 85% of patients with spina bifida reported a urologic problem at first visit at time of transition and 34% underwent a surgical procedure during clinic follow-up [11]. These findings were further corroborated by Duplisea et al., reporting urologic issues in 88.5% of patients with 81% of issues requiring intervention [12], highlighting the burden of symptomatology in this population. Dependent on the population served, the burden of surgical care may be even higher [13] and ranges from botox injection to augmentation or urinary diversion. Further, the surgical needs of these patients may shift over time, requiring a broad armamentarium of skills that bridge the gap between pediatric and adult urologists [14].

It is well established that successful transition is a hallmark of patient outcomes, with those that fail to appropriately transition having higher inpatient and emergency utilization [15]. This may yield a cycle of emergency visits without appropriate outpatient care, especially in patients with a history of multiple prior surgeries [16]. Therefore, to optimize transition and create an environment where the individual gains increased responsibility for care, the transition should occur during a time of surgical stability. Given the multitude of system, patient and provider barriers to transition [6,7,8,9], adding the need for complex surgical intervention during the handoff further impairs successful transition. While further research is warranted, best practice suggests that the handoff between urologic providers should occur only once the patient has reached a “steady state,” avoiding transition during active post-operative problems, impaired bladder dynamics requiring complex reconstruction, or severely impaired quality of life from incontinence.

Development of an optimized transitional urology clinic should therefore consider the surgical challenges one may face and focus on integrating processes and support systems that reduce barriers to optimal care. Establishing relationships amongst urology colleagues (adult reconstructive urologist, pediatric reconstructive urology), colorectal surgeons (bowel management, surgical expertise in lysis of adhesions), gynecologists (surgical and fertility considerations for female transitional urology patients) and neurosurgeons (ventriculoperitoneal shunt management, hydrocephalus management, cord tethering management) serves to address the many challenges one may face in the operative care of this population. Ultimately, careful consideration of pre-operative, peri-operative, and post-operative needs of transitional urology patients may lead to improved care in this population.

1. Pre-Operative Considerations1a. Surgical History, Current Anatomy and Clinical Considerations

The number of surgeries that patients with spina bifida [17, 18], bladder exstrophy [19, 20], and posterior urethral valves [21, 22] undergo can be substantial. This represents a unique challenge to the transitional urologist, requiring them to synthesize prior surgical history and current anatomy in order to anticipate subsequent surgical challenges and complexity.

The relationship between surgery, adhesion development, and surgical complexity is well described [23,24,25], therefore understanding and planning for increased surgical challenges and multi-disciplinary involvement where appropriate is necessary. While re-operative cases present one barrier, the associated anatomic complexity presents another. Transitional urologists must have a detailed understanding of patient anatomy, which may be challenging to compile dependent on prior location of operations, availability of notes, and patient understanding. We highlight several important considerations in the context of patient history and reconstruction needs in Table 1. Ultimately, the transitional urologist must review, synthesize, and understand the current anatomy in the context of patient needs to provide optimal care.

Table 1 Key considerations in the synthesis of surgical history, patient needs, and operative plans

If operative reports and patient history alone are not sufficient to obtain this, diagnostic imaging and / or procedures play an important role in pre-operative care. Cross-sectional imaging, diagnostic cystoscopy, fluoroscopy, and ureteroscopy (antegrade or retrograde) can define anatomy and characterize important factors such as anatomical relationships, location of neo-anastomoses, and drainage parameters. For patient-specific complaints, such as challenges with catheterization, recurrent urinary tract infections, or incontinence, these work-ups, including the use of video urodynamics where appropriate, can elucidate drivers of symptomatology (impaired bladder dynamics, stomal stenosis or false passages, stone burden, poor drainage from components of a reconstruction or upper tracts).

The surgical and clinical history of the patient further influences readiness for surgical intervention. Transitional urology patients may present with macro or micronutrient deficiencies dependent on disease-specific state and prior surgeries. Patients with spina bifida demonstrate high rates of vitamin D deficiency [26] and obesity [27, 28], patients with posterior urethral valves often present with the associated metabolic derangements and sequelae of chronic kidney disease [29, 30], and those with cloacal or bladder exstrophy face long-term growth failure [31, 32]. Patients with intestinal ileal augmentation are at risk for vitamin B12 deficiency, with substantial increase in risk after 5 years [33]. Husmann emphasized the importance of long-term evaluation of metabolic derangements in patients who have undergone augmentation, including acid-base disturbances and metabolic syndrome from obesity [34]. Not only do these factors impact the long-term prognosis of patients, but peri-operative outcomes as well [35, 36]. Prior to surgical intervention, patients should therefore undergo standard laboratory analysis of blood chemistry and blood counts, with specific testing (Vitamin D, Vitamin B12) reserved for patients with independent risk factors.

1b. Functional Status

A cornerstone in the management of neurogenic bladder (and neurogenic bowel for some) includes catheterization and subsequent reliance on appropriate manual dexterity. For these patients, the transition from child to adolescent often includes development of self-management skills, with the adolescent to adult transition requiring even greater independence in managing their care. The safe and independent process of catheterization, whether per urethra or per stoma, is directly influenced by dexterity. Therefore, the considerations for surgical options in a transitional urology clinic must take into account manual dexterity and handedness [37]. This may influence location of a stoma for catheterizable channels or the decision to pursue incontinent diversion when challenges in catheterization from dexterity or loss of social support in young adulthood risk upper tract deterioration. The transitional urologist must take these factors into account for surgical planning as well as closely monitor for deterioration in dexterity or treatment compliance to avoid renal deterioration and adverse outcomes [38].

While the cosmesis may favor an umbilical stoma, one must consider the individual patient when choosing a site. Although attempts to develop questionnaires have been studied to predict catheterization ability [39], no validated process exists to appropriately select patient and site for catheterizable channels. There is emerging evidence that the incorporation of occupational therapy in the pre-operative assessment of a patient’s ability to catheterize can lead to improvements in independence. Therefore, a multi-disciplinary team, especially one with rehabilitation specialists and occupational therapists, should assist with determining the site, favoring a location where a patient with appropriate dexterity may catheterize with the dominant hand in typical position (accounting for ambulatory status, wheelchair use, and social conditions for catheterization) [40, 41].

1c. Bowel Preparation

High rates of concomitant neurogenic bowel exist in patients with neurogenic bladder which forms a significant proportion of those seen in transitional urology clinics [42]. The appropriate management of these patients requires an in-depth knowledge of clinical and surgical characteristics as well as psychosocial parameters. This is especially critical given the profound impact bowel-related incontinence has on health-related quality of life in this population [43].

Optimization of bowel function for patients with neurogenic bowel is important for both post-operative convalescence and intra-operative technical difficulty. For those not optimized on oral medications, consideration of transanal irrigation may optimize neurogenic bowel status [44]. The decision for pre-operative bowel preparation relies on surgical and patient-specific factors. Standard mechanical preparations may be inadequate in patients with neurogenic bowel [45], therefore augmentation with oral antibiotics may be considered [46]. Notably, these considerations are extrapolated from the colorectal literature, and the decision should be individualized based on pre-operative factors and surgical plan, as the benefit of bowel preparation in pediatric patients undergoing urinary system reconstruction has not been demonstrated [47]. Care should be taken to avoid overly aggressive regimens that risk hypovolemia.

1d. Choice of Surgical Approach - Minimally Invasive vs. Open Surgical Intervention

While the safety of robotic assisted surgery for pediatric lower urinary tract reconstruction has been demonstrated [48, 49], the decision for operative approach in transitional urology clinics depends on numerous factors, including prior surgical history, presence and location of a ventriculoperitoneal shunt (VP), body habitus, including body mass index (BMI), contractures and positioning, and surgeon comfort. Although benefits to robotic surgery in reconstructive urology has been demonstrated [50], tradeoffs of longer operative duration should be considered. Comparative studies in transitional urology population are lacking and longer-term, larger population-based data is necessary to support superiority of one technique over another [51].

Despite limited data, the potential benefits of robotic surgery regarding expedited convalescence in this population cannot be understated. While spina bifida represents a subset of transitional urology patients, Loftus et al. reported > 40% rates of Clavien-Dindo grade 3 or higher complications after laparotomy for a urologic indication [10]. These rates may partially arise from the substantial burden of surgery these patients face (as noted above). These factors add to the complexity of robotic intervention, where access may be challenging due to adhesive disease and prior surgery (or ventriculoperitoneal shunts as below). If a robotic approach is chosen, careful review of operative reports and a physical exam help to determine the optimal point of access and insufflation. Open access (Hasson technique), coupled with initial lysis of adhesions, is often necessary to visualize the operative field in minimally invasive approaches.

1e. Body Morphology and BMI

Regardless of approach, patient positioning can be limited by contractures and body morphology. For young adults with spina bifida, conventional BMI measurements may be inadequate [52], where high rates of truncal obesity offer challenges to either approach [27]. The presence of neuromuscular scoliosis and / or history of spinal fusions may impact the ability for a patient to lie supine. Limitations in lower extremity mobility, including contractures, impact the position of the legs in either supine or dorsal lithotomy positioning. Transitional surgeons must account for the patient specific morphology, especially in overweight and obese patients given the higher rates of wound infection, venous thromboembolism and renal complications seen with obesity [53].

While not an all-encompassing list, attention to the important pre-operative details above plays an important role in optimizing surgical outcomes in this population. An example of a pre-operative checklist to systematically navigate these principles is provided in Fig. 1.

Fig. 1

Example of a pre-operative checklist for complex reconstructive surgery planning in transitional urology

2. Peri- and Intra-Operative Considerations2a. Considerations in Patients with a Ventriculoperitoneal Shunt

VP shunts play an important role in the neurologic management of many patients seen in transitional urology clinics. Intra-abdominal surgery with co-existing VP shunts risks shunt infection, obstruction and cerebrospinal fluid pseudocyst formation, although the overall risk is low [54] despite early literature reports [55, 56]. Strategies to reduce complications include adequate sterilization of the urine and early removal of operative drains [57,58,59]; however, no rigorous comparative studies exist regarding optimal strategies. There is no rigorous data to guide post-operative antibiotic management in patients with VP shunts; therefore, antibiotic prophylaxis should be guided by pre-operative culture data and operative plans [60] with post-operative prophylaxis guided by clinician judgement and patient or surgical factors.

Several approaches to intra-operative shunt management have been described, including shunt isolation in situ (most common), temporary externalization (rare and reserved for cases with purulent intra-abdominal spillage), and placement in an Endopouch during laparoscopic surgery [61]. Specific to laparoscopic surgery is the associated risk of increased intra-cranial pressure with insufflation [62], although numerous studies have demonstrated appropriate safety profiles [63, 64]. Pre-operative assessment of shunt location for access, confirmation of cerebrospinal fluid flow from the shunt tip intra-operatively, and careful anesthetic monitoring all play an important role in management for laparoscopic and robotic cases in patients with VP shunts [63]. All cares should be made to avoid the potential devastating consequence of a VP shunt infection [65, 66], though most patients do not require externalization if appropriate antibiotic therapy and intra-operative care is undertaken. Regardless of peri-operative approach, these patients require careful monitoring for stigmata of shunt failure (headache, altered mental status, vomiting) [67] in the immediate and extended post-operative setting, given the risk of shunt malfunction.

2b. Fluid Management

Intra-operative fluid management plays a critical role in the peri-operative period. Pertinent to transitional urology patients are high rates of renal dysfunction with susceptibility to hemodynamic shifts and volume changes. Avoidance of hypervolemia may reduce post-operative ileus [68], though one must ensure those with pre-operative bowel preparation with associated risk of hypovolemia are appropriately resuscitated [46].

2c. Alvimopan and Venous Thromboprophylaxis

Enhanced Recovery after Surgery (ERAS) pathways incorporate several important medications in the peri-operative period, including multi-modality pain regimens that seek to reduce opioid requirements. Reduction in opioid use seeks to reduce the impact of opioids on gastrointestinal motility via its impact on µ-opioid receptors [69]. For opioid naïve patients undergoing bowel resection as part of surgical reconstruction, alvimopan is associated with a lower risk of post-operative ileus and shorter length of stay [70]. These findings have been demonstrated in benign urinary tract reconstruction as well [71]. Therefore, the use of alvimopan with opioid-sparing regimens may play important roles in the peri-operative care of transitional urology patients undergoing major open reconstruction; however, there is minimal data specifically in this population and integration into surgical programs should acknowledge this limitation.

Transitional urology patients undergoing major reconstruction are often at moderate to high risk [72] of VTE due to several factors, including BMI, prolonged surgical times [73], abdominopelvic surgery, baseline immobility and subsequent impaired post-operative mobility. There is a paucity of literature regarding VTE risk in pediatric and adult spina bifida patients after urinary system reconstruction [74, 75]; however, reported rates of 3.3 to 3.6% are consistent with moderate to high-risk categorization, although the small numbers must be considered in interpretation of the data. Therefore, consideration for pre-operative risk stratification with validated scoring systems (Caprini risk assessment model) [76] and post-operative mechanical and venous thromboprophylaxis for appropriate patients [77]. Consideration of extended prophylaxis has gained traction in urologic oncology with the use of prolonged enoxaparin in the reduction of VTE for patients undergoing radical cystectomy [78]. However, despite some correlates to benign reconstruction in high-risk patients, further data is necessary to provide stronger recommendations.

3. Post-Operative Considerations

Complication rates for adults with spina bifida undergoing laparotomy are as high as 91.5%, with ileus, not surprisingly, being one of the most common complications [10]. The high rates of complications, with resultant prolonged length of stay [75], represent a unique challenge to transitional urologists. To address the challenges, ERAS protocols and special attention to individual mobility are key to a successful transitional surgical program.

3a. Enhanced Recovery after Surgery Pathways

ERAS pathways have shifted peri-operative care to a multi-modal and multi-specialty focused endeavor, demonstrating improvement in key outcomes, including length of stay, complications and readmission [79]. Integration of ERAS into complex pediatric lower urinary system reconstruction has led to similar improvements [80,81,82], with a meta-analysis of 10 studies by Cassaro et al. reporting a reduction in major and minor complications as well as length of stay [83]. These studies may be extrapolated to transitional urology patients, a majority of whom undergo complex, challenging reconstructive surgery and represent a high-risk sub-group for which ERAS protocols may have the most benefit.

Despite successful implementation of ERAS at multiple centers, the Pediatric Urology Recovery After Surgery Endeavor (PURSUE) group highlighted barriers that exist at the administrative and team level [84, 85]. Stone et al. provided a framework for implementing enhanced recovery pathways, providing both facilitating factors and highlighting barriers [86]. Integrating an ERAS protocol within a transitional urology clinic may be leveraged by existing programs; however, those without programs may tie development with the building of the clinic by obtaining buy in from the front-line surgical team as well as hospital leadership for the co-creation of an ERAS protocol with the clinic. This embeds the protocol with the global management of these patients, an important component of protocol sustainability [87]. Aligning with the need to adapt programs to local contexts [86], transitional urology patients are at high risk for complications and prolonged length of stay and ERAS protocols may serve to improve the overall outcomes of this population.

3b. Mobility Considerations and Risk of Pressure Ulcers

Skin-related disorders, including pressure ulcers, are highly prevalent and have significant impact on patients with spina bifida [88,89,90]. The associated risk of skin breakdown increases with age [91], thus for patients with impaired mobility, careful skin assessments pre-operatively are paramount. Pressure injury risk assessment tools, such as the Braden Scale, have not been validated in transitional urology populations [88] and the majority of patients will score as high risk. Therefore, combining these tools with clinical judgement may optimally risk stratify patients. For example, high risk patients with spina bifida include those with higher lesion level, wheelchair use, urinary incontinence, a shunt, male sex, obesity, above-the-knee orthopedic surgery, and recent surgery [92, 93].

Management spans both surgical and post-operative settings. Surgical reconstruction in transitional urology may be prolonged, correlating with an increased risk of iatrogenic pressure injury [94]. Alternatives to the standard surgical operating room bed may therefore be considered, including viscoelastic polymer pads, gel overlays, and micropulsating air overlays [95,96,97]. In the post-operative setting, the Integument Guidelines should be incorporated into the care of these high-risk patients, with pressure-relief maneuvers, frequent repositioning and moisture management as key components [