To perform a narrative review of the literature pertaining to transitional care (from paediatric to adult urology) of individuals with voiding dysfunction, with a focus on barriers to appropriate transition of care, and management options described to overcome these.

A narrative review of the literature pertaining to transitional urologic care of those with voiding dysfunction was performed. The majority of relevant studies, describing barriers to transition and proposed methods to overcome these barriers, pertained to spina bifida and bladder exstrophy, hence an emphasis was placed on these conditions in the narrative review.

The rates of successful transition of spina bifida patients from paediatric to adult urological care is low, and many significant roadblocks to successful transition have been identified. Szymanski et al, found in an analysis of 77 patients discharged from a multidisciplinary paediatric spina bifida clinic, that only 40.3% had successful follow-up with any urologist within 2 years post-discharge (1). Even complex patients with significant surgical histories i.e. bladder augmentation, MACE, or Mitrofanoff formation have a poor rate of successful transition of 48.8% - which is of significant concern as these complex patients are in greater need of close follow-up and seamless transition to adult care. Further complicating the issue of transition in spina bifida patients – is that identification of risk factors for failed transition has proven difficult. Those with documented non-adherence have been shown to not have statistically significant rates of failed transition (0.79) (1). Further, logistical factors such as travel time and hospital familiarity are also potentially non-predictive of poor transition, as the paediatric and adult urology clinics in the described study by Szymanski were located across the corridor, with the same shared office staff. 
Similarly, risk of unsuccessful transition to adult urologic care for those with bladder exstrophy is also significant, described by Haddad et al to be 24% in their cohort of 67 bladder/cloacal exstrophy patients – defined as no visit within 2 years without a known reason for lack of follow-up (2). Once again, identification of at risk patients proves difficult as there was no significant difference found in distance to clinic, history of bladder reconstruction, sex or insurance between those with successful and unsuccessful transition. 
In spite of the above, several management strategies have been described in the literature to increase the chance of a successful transition to adult urologic care in those with spina bifida or bladder exstrophy. Firstly, the evidence demonstrates a growing consensus for the establishment of dedicated transitional spina bifida clinics – Tan et al compared outcomes of 71 and 116 patients who were and were not enrolled in transitional clinics respectively, and found that those in the dedicated transitional clinic had earlier evaluation by adult urologist (70.4% below 21 and 23.3% below 21), were more likely to perform CIC (78.9% and 57.8%), and less likely to undergo procedures in adulthood (3). Other studies also suggest that a short interval between paediatric discharge and adult follow-up is of benefit, and is associated with lower rates of UDS abnormality (specifically detrusor overactivity). Moreover, the same study described that 42% of patients required intervention on adult follow-up (regardless of interval period), and management change occurred in 59% - suggesting that any significant interval period between paediatric and adult urologic care thereby delays treatment. Another study interestingly highlights that in their sample, urological and neurosurgical outcomes did not impact transitional spina bifida patient or parent satisfaction – instead the most common factor negatively impacting satisfaction was a feeling that financial and employment factors were unaddressed. TRAQ (transition readiness assessment questionnaire) scores are also lower in the financial domain in other cohorts of paediatric patients with voiding dysfunction. Ultimately, this data is suggestive that a biopsychosocial approach must be applied to transitional urologic care of spina bifida and other causes of paediatric voiding dysfunction, with involvement of allied health.

Several roadblocks exist to successful transitional care of children with voiding dysfunction secondary to congenital conditions. In those with spina bifida, even those with significant surgical histories and therefore need for prompt adult urological follow-up have similarly poor rates of successful transition, and identification of risk factors is difficult as documented non-adherence, travel time and hospital familiarity have not been found predictive of successful or unsuccessful transition. Rates of successful transition in bladder exstrophy are similarly poor, again with logistical factors not having been shown useful in identifying patients at risk of failed transition. A gamut of potential management strategies to overcome the abovementioned issues have been evidenced in the literature, included dedicated transitional clinics, a brief interval between paediatric discharge and adult urologic follow-up, and a biopsychosocial focus involving allied health.

Transitional care (from paediatric to adult urology) of children with voiding dysfunction secondary to congenital abnormalities such as spina bifida and bladder exstrophy is complex. Rates of successful transition in the literature for these conditions is low, even with those with complex surgical history.  There are several biopsychosocial barriers to successful transition identified in the literature – chiefly the difficulty in identifying predictors of unsuccessful transition, with intuitive factors such as distance to clinic, hospital familiarity, travel time, and documented past non-adherence not having been shown to be predictive of failed transition. Several management strategies have been described that have been shown to improve transition in the literature, including dedicated transitional urology clinics, short interval between paediatric and adult urology appointment and a biopsychosocial focus with allied health involvement.

Szymanski KM, Cain MP, Hardacker TJ, Misseri R. How successful is the transition to adult urology care in spina bifida? A single center 7-year experience. Journal of Pediatric Urology. 2017;13(1):40.e1-.e6.
Haddad E, Sancaktutar AA, Palmer BW, Aston C, Kropp BP. Who, where, and why are patients lost to follow-up? A 20-year study of bladder exstrophy patients at a single institution. Journal of Pediatric Urology. 2018;14(3):276.e1-.e6.
Tan J, Hopson BD, Li P, Lloyd LK, Joseph DB, Dangle PP, et al. Urologic outcomes in Spina Bifida patients undergoing transitional care. Journal of Pediatric Rehabilitation Medicine. 2017;10(Supplement 1):S35.