Surgical Specialties Combine Forces to Care for Patients with Anorectal Malformations

Nelson Rosen, MD, trained in an era when pediatric surgeons treated children with urinary tract abnormalities. As a young doctor in New York specializing in colorectal surgery in the early 2000s, he was thrilled to discover a group of pediatric urologists to co-manage patients needing complex urological surgery for anorectal malformations (ARMs). But as his practice grew, he longed for better collaboration.

“The urologists had excellent surgical expertise, but they worked at many different hospitals, and care coordination was challenging, to say the least,” says Rosen, a pediatric surgeon at Cincinnati Children’s Colorectal Center. “Scheduling surgical cases with them took a long time and dragged out the process. After-care sometimes would be challenging. If one of my patients had a complex urological issue, I didn’t have a streamlined process to ask for help—it was like building a process from scratch each time for each patient.”

The desire for a collaborative care model for children with an ARM drove Rosen’s decision to join the Colorectal Center in 2018. “Everything I had been wanting to do, the center was doing as a matter of routine,” he recalls. “The in-person, weekly meetings with doctors and nurses to discuss mutual patients and make plans for surgical care. The respect for everyone’s expertise, especially subspecialty nursing. The follow-through after surgery to ensure kids and families have what they need. I call it the ‘Cincinnati way,’ and it makes a difference.”

Identifying “Silent” Bladder Issues

Weekly meetings with colorectal surgery, urology, and gynecology specialists, and nurses are at the heart of the collaboration, says pediatric urologist Brian VanderBrink, MD. “We discuss every patient with an ARM and consider whether they may need surgery,” VanderBrink says. “The urologists are screening for silent bladder issues that may cause severe renal problems down the road, which occur at different frequencies depending upon the type of ARM.”

Every care team member has to “sign off” on any surgery that a child with an ARM may need. If the patient is experiencing urine leakage, difficulty passing urine, painful urination or occasional urinary tract infections, the team will ask for time to learn more before a colorectal surgery is scheduled.

Coordinating a Split-Appendix Procedure

Such collaborative discussions are essential when patients need surgery that may involve using the appendix to achieve urinary and fecal continence. In 2021, the Division of Pediatric Urology and the Colorectal Center physicians published a paper demonstrating that using a split-appendix approach for creating urinary and fecal continent catheterizable channels does not affect 30-day complications or long-term revision rates compared to other established techniques.

“Whenever our team or the urologists encounters a patient who might need a Malone appendicostomy and Mitrofanoff procedure, we make a plan together in consideration of our colleagues’ expertise and the child’s needs,” Rosen says. “If you use the appendix for one surgery — when you could have used it for both surgeries at once — it’s a much bigger operation to go in a second time and creates risks for the patient.”

Coordination is just as crucial for less complex surgeries, adds VanderBrink. “If a child needs an intrauterine device at age 16, and I need to place a catheter or remove a bladder stone, the gynecologist and I can do the surgeries together to minimize the child’s exposure to anesthesia.”

Challenging and Necessary

The nursing team works closely with families to minimize outpatient visits and schedule tests as conveniently as possible. “Offering this level of care coordination can be cumbersome and challenging at times for the healthcare team,” VanderBrink says. “But it keeps us focused on what’s best for each child — their well-being is our highest priority. Parents repeatedly tell us that’s what differentiates our collaborative care team.”

It’s a far cry from the old days, Rosen says. “I used to have to make so many patient care decisions on my own,” he recalls. “Shared decision-making transforms what we can do for kids. Our team is greater than the sum of our parts.”

For more information, contact Brian.VanderBrink@cchmc.org.