Much, if not all, of what I do today in pediatric urology, I do because of Doug Canning—empathic leader, mentor, and friend. Part of why going to India means so much to me is that we shared our first experience going there. When Aseem Shukla returned to CHOP (Children’s Hospital of Philadelphia) as a faculty member in 2012, he brought with him the Civil Hospital Ahmedabad partnership—one he had founded in 2009. I had the opportunity to first go to India as a second-year fellow in 2014, and this was the year that Doug decided to go as well, to experience firsthand what this surgical collaboration was really about (Figure 1). This collaboration demonstrated a true partnership in the care of children.

Figure 1. A, B, Images from my first trip to Civil Hospital, Ahmedabad, in 2014.

From the time of our first trip, Doug was committed to ensuring that the care of children with bladder exstrophy (BE) in India would be the same as the care in the States. In 2018, having been a part of our local exstrophy team for nearly 4 years, I had the chance to return to Ahmedabad as teaching faculty. Seeing the same children, now 4 years older but with clearly recognizable faces and personalities, was elating. I then continued to return each year, now as part of the operating faculty in 2023.

As I now strive to promulgate the teachings and lessons that I gained from Doug Canning, and the theories that we pondered over for nearly 10 years, one of the most important concepts that I have learned and continue to use is that pelvic floor strength can make a huge difference in the ultimate development of urinary continence in children with BE. We have seen children go from wet to dry with intensive therapy—whether it be through active physical therapy sessions or through independent activities such as horseback riding. We have partnered with physical therapists at our center who began identifying muscular impairments inhibiting continence in school-age children that were most likely present immediately postoperatively or even preoperatively. They hypothesized that addressing these impairments would assist in minimizing their impact on continence as the child continued to grow. Crucial abdominal and pelvic floor muscle development occurs with each developmental milestone including rolling, sitting, and crawling. Each of these intermediary developmental skills is essential for the development of the hip and core musculature that stabilizes the pelvic floor and allows it to properly function. While all children with BE will reach the end result of walking, skipping these intermediary steps may set them back in the long term by not providing sufficient core strength to support their pelvic muscular strength. Because of this, the quality of a BE child’s developmental skills, and the use of specific muscles, are more important than just achieving each milestone.

As we now incorporate pelvic floor physical therapy into the care of all our children with exstrophy and epispadias, it is crucial to extend this care to the children in India (Figure 2). We now provide early evaluation and intervention starting at 6 to 8 weeks after surgery. This evaluation helps to ensure that these babies, who have undergone a major reconstruction of both their lower abdomen and pelvic bones, are guided to develop in a similar way as a baby without exstrophy. This Urology Care Foundation Humanitarian Grant will support the pelvic floor therapist who has worked with our team for the past 6 years, Sarah Cooper, DPT, to develop a focused training program, thus ensuring that the care of the child with BE in India is the same as the care of the child with BE in the States.

Figure 2. Sarah Cooper, DPT, at work with a patient with epispadias.

Sarah Cooper will evaluate and treat patients during the workshop in India and also will train the local team in pelvic core exercises, which could be applicable to families of children of all ages. As access to pelvic floor physical therapy is yet another of the criteria for Centers of Excellence in BE, it is critical that we offer this to the patients treated at Civil Hospital, Ahmedabad.

As our collaboration reaches a critical stage in its maturity, we must find more ways to improve the overall care for these patients. The Urology Care Foundation Humanitarian Grant is making it possible for Sarah Cooper to join our team this coming year, and we believe that the expansion of a physical therapy service will open a new dimension in comprehensive care and will close the loop on unifying care in India and at CHOP, just as Doug envisioned.