Su-Anna Boddy, FRCSChair, Children’s Surgical Forum, RCS

Consultant Paediatric Urologist,St George’s Hospital

19 Nov 2014

Timing of Orchidopexy Keeping General Paediatric Surgery in DGH

Timing for Orchidopexy

• National Screening Committee• East Midlands Specialised Commissioning Group• British Association of Paediatric Urologists Consensus Document• APA + RCPCH• Clinical & Training Standards Manager RCS

• Miss Boddy and Mr Sudhakaran

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National Screening Committee

• Bilateral UDT on NNU refer to Paediatrician

• Single UDT examined by GP at 6 weeks, 3 months and 5-6 months of age

• If still UDT then refer to paediatric/adult urologist/surgeon around 1yr of age

• Operation currently planned to be done around 2 yrs of age

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• The work of the review group resulted in regionally agreed model of care and clinical standards for GPS in the East Midlands

• Managed Clinical Networks

• One outcome measure was age at orchidopexy – questioning the National Screening Committee current standard

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East Midlands Specialist Commissioning Group

Consensus Document

Germ cells differentiation into adult dark spermatogonia occurs at 3-6 months.

Due to morphology, biopsy and ultrasound changes at 3 to 6 months, early operation may optimise potential fertility outcome and may reduce malignancy

•Orchidopexy can occur within 3-6 months though surgery occurring between 6 and 12 months is acceptable.

• General anaesthetics and the developing brain – rat studies 2 years ago suggesting anaesthetic agents themselves cause harm to neurodevelopement under 1 yr of age but artificially high doses in rats ( Flack and Soriano ) not supported by FDA

• If surgery to under 1yr olds ? Higher mortality and morbidity and ? In tertiary centre

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Association of Paediatric Anaesthetists - APA

Commissioning Guide for orchidopexy for UDT needs to be aligned to UK National Screening Standards

• Richard Stewart , & Sharon Verne, East Midlands SCN• Bob Bingham, President APA• Feilim Murphy, Secretary BAPU• Jane Howdon, RCPCH• Su-Anna Boddy, Chair CSF at RCS• David Elliman, National Screening Committee• Hugh Davies and John Marshall, Public Health England• Emma Fernandez, Commissioning guides RCS• Apologies Rick Turnock Past President BAPS

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Teleconference – History of UDT

• 1970 - operation 4-6 yrs morphology showed testicular atrophy

• 1990 – operation 2 yrs before germ cell depletion

• 2000 – operation under 1 yr - the sooner the testis located outside the body greater reduction in changes that could impact on sperm cell production

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• Germ cell differentiation into adult spermatagonia occurs at 3-6 months

• 3-6 months temperature affects testis development (children undergo a mini puberty) this causes failure of transformation of the cells leading to abnormal cell developement

• UDT at 3 months will remain UDT in 98%9

Hadziselimovic and John Hutson

Morphology and later functional change

• Data not currently available

• Evidence is available from 1970’s shows this is the case but surgery too late

• Proxy measures of fertility ie sperm analysis flawed do not predict long term likelihood of parent hood

• 2 papers show earlier surgery reduces malignancy

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Questions from National Screening Committee

• Evidence would preferably be by controlled trial and the link between morphological changes and the ability to father children need to be firmly linked.

• Are children being operated on within the current time frame?

• Large number of boys referred later than current guidelines

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Recommendation from National Screening Committee after review of ‘evidence’

• GP review at 3 months • If still UDT refer to surgeon• Operation recommended on or around one

year of age

• This can be incorporated into National Screening committee Guidance without a major change

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Problems for keeping General Paediatric Surgery in DGHs

• How does an agreed age for orchidopexy of around 1 yr of age help this?!

• SAC in General Surgery currently only has an optional module for elective General Surgery of Childhood

• Trusts do not advertise jobs for General Surgeons with an commitment in General Paediatric Surgery

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Must keep GPS in DGH

• Trusts must advertise General/Urological Surgery + commitment to GPS

• Surgeon/anaesthetist to do UDT around 1yr

• BAUS obligatory module/25% of exam in Paediatric Urology good succession planning

• Shape of Training?

• ASGBI, BAUS, BAPS, + SAC Gen Surg

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CSF Guidance to Commissioners and Service Planners

• Provides guidance for the development of managed clinical networks

• CSF - July 2010

Endorsed by: RCS, RCPCH, RCoA, APS, APA,

ASGBI, BAUS

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Survey on GPS Service Provision

• Published in December 2010

• Delivered by CSF – Funded by DH England

• A map of GPS service across all hospitals in England

•Numbers of ENT, plastic, Orthopaed, Dental, across all hospitals in England

• Available online at: www.rcseng.ac.uk

• Planned update 2015

Children’s Surgical Forum (CSF)

• Advisory Multidisciplinary Panel

• Setting and monitoring standards

• Collaborating with external bodies

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CSF Membership

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Managed Clinical Networks• Interconnected system of providers• Not limited by boundaries• Multidirectional flow (not hub & spoke)• Contractual agreements specifying service requirements and outcomes

Benefits:

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What are the barriers to Managed Paediatric Surgical Networks?

• Competitive environment

• Lack of financial support

• Rigid contractual arrangements

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NHS Passport – Facilitating Cross-site work

• Flexible movement between hospitals

• Confirmation that all necessary requirements for safe practice have been carried out in home Trust

• Delivery through Appraisal and Revalidation – ‘Certificate’

• Administered via Academy of Royal Colleges – Alastair Henderson

NHS Passport – Facilitating Cross-site workCertificate of Fitness for Honorary Practice

• Flexible movement of Consultants between hospitals for short-term work and support of colleagues

• Cover for emergencies and absences in short notice

• Support for clinicians to extend and reinforce their skills

Provide and receive short-term specialist training

Take advantage of CPD opportunities in innovative techniques and technology

Certificate of Fitness for Honorary Practice – Content and Delivery

• Information currently included in the Honorary Contract

• Confirmation that all necessary requirements for safe practice have been carried out in the home Trust.

• No additional paperwork

• Delivery through Appraisal and Revalidation

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Managed local provider Paediatric Surgical Networks

•Support surgeons, anaesthetists, nurses, and whole MDT to ensure children can receive surgical care, in a safe and appropriate environment, which is as close to their home as possible.

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Configuration of Services

• Agreed guidelines and protocols for managing the service in place covering the full patient pathway

• Regular assessment of performance

• Forum for sharing best practice including all contributors

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Governance and leadership

• Written policy regarding age range of children anaesthetised and operated upon within the hospital (and for out-of-hours period if level of paediatric anaesthetic competences is different)

• Evaluated with audit of outcomes, transfers and untoward incidents

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Education and training

• Consultants work within limits of their professional competence

• All surgeons and anaesthetists operating on and anaesthetising children, regularly undertake paediatric life support training and safe guarding.

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Delivery and environment

• Care is delivered in a child and family-friendly environment with registered children’s nurses

• At any time the emergency department includes sufficient cover for emergencies in children

• Surgeons and anaesthetists providing this cover have appropriate training, competence and CPD

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Keeping GPS in DGH

• Managed Clinical Networks• Trusts to appropriately advertise• Shape of Training? A General Surgeon who

can deliver elective and emergency surgery in children ( and adults?)

• Paediatric surgeons from Tertiary centre?• Anaesthetists keeping appropriate skills for

young children29

Commissioning Guidance by all 10 Specialty Associations at RCS, badged by NICE

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SCNs need to establish Managed Paediatric Surgical

Networksfor all of Children’s Surgery

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Let’s Network!

CSForum@rcseng.ac.uk