The 2021 SPU (Societies for Pediatric Urology) annual meeting proved a major success, transitioning nimbly to a virtual format that attracted hundreds of attendees. Drs. Fernando Ferrer and Rebecca Zee deserve huge congratulations for organizing a dynamic meeting elucidating cutting-edge topics in pediatric urology.

A major theme of the day consisted of updates in genitourinary reconstruction, opening with a panel centered around the tubularized incised plate (TIP) repair for hypospadias. First described by Dr. Snodgrass nearly 30 years ago,¹ the TIP procedure has become a mainstay in our toolkit for hypospadias repair. Dr. Walid Farhat and Dr. Ahmed Hadidi debated the risks and benefits of the technique, alluding that the TIP repair is not a one-size-fits-all procedure and very much depends on the size of the glans, quality of the tissue, and the width of the urethral plate. Dr. Farhat reviewed the importance of learning curve, citing changes in his own technique over time with a transition from dartos flap coverage to spongioplasty more recently.² Dr. Hadidi warned we must be cautious about complications associated with TIP, not the least of which include urethral stricture and diverticulum. He advised for a small urethral plate less than 8 mm and a small glans, a dorsal inlay graft should be considered. Dr. Kenneth Angermeier offered an adult urologist’s perspective on hypospadias patients transitioning to adulthood. As patients age, they become much more aware of differences in their anatomy and function after hypospadias repair, which may lead to dissatisfaction in adults. A versatile response to complications in adult men after hypospadias repair is application of a staged buccal mucosal graft. As pediatric urologists, we need long-term followup and multicenter data sets to track outcomes, especially as our patients enter their adult years.

The 2021 SPU Lecturer was Dr. Richard Redett, the Milton T. Edgerton, M.D. Director and Professor of Plastic and Reconstructive Surgery at Johns Hopkins University. Dr. Redett, a thought leader in reconstructive surgery, emphasized 4 primary outcomes for penile reconstruction: 1) aesthetically acceptable results, 2) creation of a competent neourethra, 3) return of both tactile and erogenous sensation, and 4) ability to achieve intercourse through a successful penile implant. Dr. Redett presented his team’s experience with the radial forearm free flap, which affords excellent aesthetics and sensation while issues with urethral stricture and implant complication persist. This has motivated the exploration of penile transplantation, a nascent yet promising procedure that may yield excellent outcomes in all domains of penile reconstruction.³

Dr. Redett’s lecture segued into a forward-thinking panel discussion on gender affirmation surgery and the role of the pediatric urologist. Recent data suggest 0.7%–2.9% of adolescents identify as transgender/nonbinary.^4–6 Dr. Beth Drzewiecki reviewed how despite growing demand, the health care needs of our transgender/nonbinary patients are not being met. Transgender/nonbinary youth encounter a number of hurdles in transitioning, including feeling vulnerable or uncertain with decision making and overcoming systemic barriers. Dr. Joshua Roth shared his surgical tips executing metoidioplasty, explaining how the techniques are akin to hypospadias repair. Dr. Geolani Dy described novel techniques in performing penile inversion vaginoplasty with peritoneal flaps.⁷ All panelists emphasized the importance of adhering to the WPATH (World Professional Association for Transgender Health) standards for the transitioning process.⁸

Highlighting the future of our specialty, Dr. Jonathan Ellison expanded on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP^®). Starting in 2006 with only 4 pediatric hospitals, NSQIP now includes 148 participating sites nationwide. NSQIP has introduced 3 novel tracking mechanisms for anti-reflux surgery, surgical antibiotic prophylaxis, and testicular torsion. Data supplied by NSQIP can drive quality improvement initiatives and opportunities for collaborative learning, particularly if large variations across centers are observed.

Dr. Amanda North delivered the Meredith Campbell Lecture centered on the past, present, and future of the urological workforce. Dr. North touched on many “firsts” in urology, particularly the growth of underrepresented groups in our field. While approximately 27% of current trainees are women, the proportion of underrepresented minorities (URMs) in urology residency has not recently grown.⁹ URM applicants find having URM faculty in a department substantially impactful when ranking programs, so we have much work to do in recruiting both URM faculty and residents to training programs in the U.S. Additionally, Dr. North described the obstacles women and URMs continue to face, including gaps in promotion and pay, imbalance of personal and professional responsibilities, and a leaky pipeline. Targeting these areas should be a high priority to prepare for the future and ensure the specialty of urology not only becomes more inclusive but reflects the communities we serve.

In recent years, pediatric specialists have increasingly embraced the concept of enhanced recovery after surgery (ERAS) pathways. Dr. Mary Brindle shared how ERAS experiences in pediatric general surgery set the stage for other surgical subspecialties. Dr. Megan Brockel and Dr. Kyle Rove outlined successes with ERAS at Children’s Hospital Colorado as well as development of the PURSUE (Pediatric Urology Recovery after Surgery Endeavor) collaborative among 8 pediatric centers.¹⁰ ERAS pathways aim to minimize length of stay, intraoperative fluids, and postoperative opioids, among a number of other metrics. Success hinges on multidisciplinary collaboration, buy-in from all stakeholders, decreasing variation, and embracing the iterative process.

Finally, we revisited vesicoureteral reflux, with Dr. Antoine Khoury offering an elegant historical overview of various anti-reflux procedures. Dr. Patrick Cartwright and Dr. Hans Pohl engaged in a point-counterpoint summarizing the optimal scenarios for surgery versus nonoperative management. Anti-reflux surgery should be considered in children at high risk for febrile urinary tract infections and low likelihood of resolution. Monitoring with continuous antibiotic prophylaxis remains a pillar of conservative management given that the majority of vesicoureteral reflux resolves spontaneously and that continuous antibiotic prophylaxis lowers the risk of urinary tract infection. Nitrofurantoin has maintained minimal resistance over the last 20 years, and thus we should consider this our first-line agent for continuous antibiotic prophylaxis.

Overall, this year’s SPU annual meeting highlighted advanced approaches for both long-standing and emerging issues in pediatric urology. In service to our pediatric patients, our field continues to be rich in energy and innovation.