Pediatric Urology in India Has Come of Age.

Sir,

Pediatric Urology in India is now at a crossroads, from where it needs to advance in the right direction. This is a historic moment for pediatric surgeons of India as they have been the custodians of pediatric urology in India. As we know, both pediatric surgeons and adult urologists claim their right to pediatric urology. However, it is well known that in most teaching institutes in India, pediatric surgery departments handle the bulk of pediatric urology cases. While pediatric urology typically accounts for 40%–50% of a pediatric surgeon's workload, it is hardly 5% of work of an adult urologist. We have nothing against any other specialty, but how many adult urologists are ready to dedicate at least 60% of their practice to pediatric urology? This is because adult urology is easier to practice and financially more lucrative than pediatric urology. Further, the bulk of adult urology consists of endoscopic and ablative surgery; in contrast, pediatric urology, like pediatric surgery consists of mostly delicate reconstructive operations in infants and young children. Such procedures require delicate tissue handling which is the hallmark of pediatric surgeons. Thus, complex reconstructions such as hypospadias repair or repair of exstrophy-epispadias complex have been in the exclusive domain of pediatric surgeons. Finally, it is noteworthy that currently, while at least seven pediatric surgical departments offer fellowship in pediatric urology in India, only 1 adult urology department offers such fellowship.

On the academic front, pediatric surgeons of India have been at the forefront of advancing pediatric urology. The authors reviewed the Indian contributions in the Journal of Pediatric Urology in 2020–2021 [Table 1]. There were 23 papers from India; 17 (75%) of these were from pediatric surgeons, while only 6 (25%) were contributed by adult urologists. Similar results were found in an analysis published 13 years ago.[1] Thus, it is amply clear that for many decades, the pediatric surgeons of India have been passionate about both clinical and academic excellence in pediatric urology. It is time that they rightfully claim their legitimate right.

Table 1

International publications in the Journal of Pediatric Urology

Issue	Total	India	PS	Uro	Authors
August 2021	33	1	1	0	VVS Chandrasekaram/Ramesh Babu (Ankura Hyd/SRIHER Chennai, PS)
June 2021	36	2	0	2	Jayasimha/Chandrasingh (CMC Vellore, Uro) Ashwini Sekar, Aneesh Srivatsava (SGPGI, Lucknow, Uro)
April 2021	38	3	3	0	Sachit Anand, Minu Bajpai (AIIMS, New Delhi, PS) TK Jeyakumar, Aravind Sindha (AIIMS, Jodhpur, PS) Ketaki Garpure, Bibekanand Jindal (JIPMER, PS)
February 2021	37	7	6	1	Ramesh Babu, Utsav Shah (SRIHER, PS) Sajid Qureshi, Monica Bhagat (Tata, Mumbai, PS) S Jayasimha, Chandra Singh (CMC, Vellore, Uro) Sudipta Sen, Pavai (PSG, Coimbatore, PS) Sudipta Sen, Pavai (PSG, Coimbatore, PS) Prashant Jain, Ashish Prasad (BLK, New Delhi, PS) Poonam Vaze, Subhasis Saha (AMRI, Kolkata, PS)
December 2020	36	4	2	2	Dilip Mishra (Rainbow, Agra, Uro) Ramesh Babu, VVS Chandrasekaram (SRIHER Chennai/Ankura Hyd, PS) Cenita Sam, Sudipta Sen, Pavai (PSG, Coimbatore, PS) Ashwin Sekhar, Ansari (SGPGI, Lucknow, Uro)
October 2020	36	3	2	1	Manish Pathak, Arvind Sindha, (AIIMS, Jodhpur, PS) Ashwin Sekhar, Ansari (SGPGI, Lucknow Uro) Pradyumna Pan, (Jabalpur, PS)
August 2020	37	2	2	0	Jujju Kurian, Sudipta Sen (CMC, Vellore, PS) Sajid Qureshi, Monica Bhagat (Tata, Mumbai, PS)
April 2020	36	1	1	0	Tarun Jacob, Sudipta Sen (CMC, Vellore, PS)
Total	289	23	17	6

A comparison of contributions from PS versus Uro. PS: Pediatric Surgery, Uro: Urology

Most anomalies in pediatric urology are the part of syndromes involving multiple systems (e.g. VACTERAL). The conditions such as hypospadias (DSD/genetic/endocrine) or neurogenic bladder (meningocele) often need pediatric surgical input and multi-disciplinary care. In a country like India, this is the best deal with comprehensively by pediatric surgeons who later can specialize in pediatric urology.

When a full-time pediatric urology practice is commercially difficult an adult urologist will obviously turn to more lucrative TURP and stonework making him/her deskilled over years with delicate child surgery. Most pediatric surgeons are now well equipped with endourology instruments including URS and RIRS, although doing endourology alone does not make one eligible for pediatric urology. In fact most adult urologists would be anxious and unskilled to perform a new-born PUV fulguration which is regularly performed by pediatric surgeons. This leaves only transplants. Most transplants are done during adolescence and hardly any toddler or young child undergoes transplant. These too are currently focused only in transplant centers which itself is becoming a separate subspecialty.

Pediatric nursing, IV access, and pediatric anesthesia have their own intricacies and an adult urology unit cannot provide these. Hence, in the best interest of children, pediatric surgeons should not delay setting up of dedicated pediatric urology units, in all apex institutes so that a comprehensive and child-friendly care can be provided for these children by those who are best qualified and passionate to provide such care. Adult urologists should support this move for the benefit of children and refer those cases to nearly by pediatric urology units in the best interest of these children.

The way forward is to create dedicated pediatric urology units within pediatric surgery departments in all major teaching institutes. The creation of such units will ensure that pediatric urology remains within the fold of pediatric surgery but will help give pediatric urology its legitimate status, which is long overdue. Subspecialization is the order of the day, and we must remember that if we do not act fast enough and claim our right, someone else will. This is exactly what happened to pediatric surgeons of North America, and we do not want a repeat of the same in India.

To become a pediatric urologist, one should demonstrate the intent rather than just interest. One should show their involvement, exposure, and experience (both clinical and academic) to claim expertise in the field.[2] The Society of Pediatric Urology (SPU-IAPS) has come up with guidelines for fellowship (FSPU) and this could set the criteria for someone to be called a Pediatric Urologist. Those with at least 60% of workload as pediatric urology and minimum 200 cases in pediatric urology/year (of which 50% should be major), in addition to two publications and three conference presentation in pediatric urology (national and international) are considered eligible for FSPU.[3] If these criteria are applied, hundreds of pediatric surgeons across India would be eligible to start a dedicated pediatric urology unit while most urologists (with a few exceptions) would be found wanting to meet the criteria.

We feel that the setting up of pediatric urology units should be followed by fellowship courses in pediatric urology in the same units. At the same time, M.Ch pediatric surgical trainees should rotate in the pediatric urology units to keep their exposure intact and develop further interest in subspecialization. Junior pediatric surgeons who show intent to become pediatric urologist should be groomed and posted in such units to increase their experience. They should also be encouraged to audit, record, analyse, and publish their experience in pediatric urology. Obtaining FSPU certification is an added credential.

While we now are clear that pediatric urology in India has come of age, thanks to the contributions by pediatric surgeons, we should also be aware that sub-specialization is the mantra in urology. If we do not jump in the bandwagon, pediatric urology training and care of these children will be in jeopardy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.