Post-hypospadias urethrocutaneous fistulae: no difference in repair success between proximal and distal fistulae.

INTRODUCTION Urethrocutaneous fistulae are the most common complication after hypospadias repair. We sought to compare outcomes of proximal versus distal urethrocutaneous fistula repair and hypothesized that patients with proximal fistulae would have lower rates of success than those with distal fistulae. We also aimed to evaluate factors that affected these outcomes. MATERIAL AND METHODS: Current procedural terminology codes were used to identify patients undergoing urethrocutaneous fistula repair after hypospadias surgery between 2014 and 2017 at an academic, pediatric urology referral center. Characteristics for each initial hypospadias repair and each fistula repair were noted, including location of meatus, location of fistula, type of magnification, suture type, interposition layer and post-operative stenting. The primary outcome was successful fistula repair. Univariate and multivariate analysis was performed. RESULTS: During the study period, 416 hypospadias repairs were performed. Thirty-one of these later presented with a fistula (8% fistula rate). Sixty-eight percent of fistulae were successfully closed with a single repair. There were 17 distal fistulae and 14 proximal fistulae. There was no difference in success between distal (71%) and proximal (64%) fistulae (p = 0.73). There was no statistically significant association between the primary outcome (successful fistula repair) and fistula location (p = 0.71), magnification (p = 0.38), suture type (p = 0.49), interposition coverage layer (0.43), or postoperative stenting (p = 0.92) on univariate or multivariate analysis. CONCLUSION: There is no difference in success when repairing distal versus proximal urethrocutaneous fistulae. Neither fistula location, type of magnification, suture type, interposition layer nor stenting affected outcomes.

Restoration from acute urinary dysfunction using Utah electrode arrays implanted into the feline pudendal nerve.

OBJECTIVES: To investigate intrafascicular pudendal nerve stimulation in felines as a means to restore urinary function in acute models of urinary incontinence, overactive bladder, and underactive bladder. MATERIALS AND METHODS: Felines were anesthetized, and high-electrode-count (48 electrodes; 25 electrodes/mm(2) ) electrode arrays were implanted intrafascicularly into the pudendal nerve trunk. Electrodes were mapped for their ability to selectively or nonselectively excite the external anal sphincter, external urethral sphincter, and the detrusor bladder muscle. Statistical analysis was carried out to quantify reflexive voiding efficiencies, mean impedances of the microelectrodes used in this study, and to determine what differences, if any, in bladder contraction amplitudes were evoked by different electrode configurations. RESULTS: Multielectrode arrays implanted into the pudendal nerve trunk were able to selectively and nonselectively excite genitourinary muscles. After inducing urinary incontinence with bilateral pudendal nerve transections (proximal to the implants), electrical stimulation delivered through certain microelectrodes was able to significantly reduce leaking (p = 0.008). Electrical stimulation delivered through detrusor selective electrodes was able to inhibit reflexive bladder contractions and excite bladder contractions, depending on the stimulation frequency. Specific electrode configurations were able to drive significantly (p < 0.001) larger bladder contractions than other electrode configurations, depending on the preparation. Successful reflexively or electrically driven bladder contractions were achieved in 46% and 38% of the preparations, respectively, an observation that has not been noted in previously published feline pudendal stimulation studies. CONCLUSIONS: Multielectrode arrays implanted intrafascicularly into the pudendal nerve trunk may provide a promising new clinical neuromodulation therapy for the restoration of urinary function.

Padded self-adhesive strap immobilization following newborn bladder exstrophy closure: the Utah straps.

PURPOSE: Several methods have been described for immobilization of the pelvis following bladder exstrophy closure, which can be challenging to manage. We hypothesized that immobilization can be significantly simplified using a modified mermaid wrap with padded Velcro® straps around the thigh and lower leg. MATERIALS AND METHODS: We retrospectively reviewed all patients who underwent bladder exstrophy closure in the newborn period at our institution from 1990 through 2010. Patients with cloacal exstrophy and those who underwent delayed closure due to other medical conditions were excluded. We collected data on closure technique, length of stay and complications of the primary closure as outcomes. RESULTS: A total of 20 boys and 7 girls underwent closure of classic bladder exstrophy. Followup ranged from 2 to 22 years. Seven boys underwent complete primary repair and 13 underwent staged repair. All patients had the legs stabilized with a modified wrap technique using 2 lengths of Velcro straps lined with self-adhering open cell foam pads for 3 weeks. Complications of exstrophy closure included bladder dehiscence in 1 patient (4%) and incisional hernia in 2 (7%). Following complete primary repair urethrocutaneous fistula developed in 2 patients and urethral stricture in 2. Average length of stay for patients without significant prematurity was 15 days. CONCLUSIONS: Padded Velcro strap immobilization simplifies postoperative care, provides secure fixation, decreases length of stay, and enables parents to hold and bond with the child shortly after repair. We advocate this simplified technique, which can be applied with a rate of complications that is comparable to other procedures.

Internal hernia with volvulus after major abdominal reconstructions in pediatric urology - An infrequently reported and potentially devastating complication.

INTRODUCTION: Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and appendicocecostomy (APC) can facilitate continence and prevent renal damage for patients with congenital urologic or bowel disease. Bowel obstruction is a well-documented complication of these procedures, and the etiology of obstruction is variable. The aim of this study is to determine the incidence and describe the presentation, surgical findings, and outcomes of bowel obstruction from internal herniation due to these reconstructions. METHODS: In this single institution retrospective cohort study patients who underwent EC, APV, and/or an APC between 1/2011 and 4/2022 were identified via CPT codes within the institutional billing database. Records for any subsequent exploratory laparotomy during this same timeframe were reviewed. The primary outcome was an internal hernia of bowel into the potential space between the reconstruction and the posterior or anterior abdominal wall. RESULTS: Two hundred fifty seven index procedures were performed in 139 patients. These patients were followed for a median of 60 months (IQR 35-104 months). Nineteen patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/257). The complications occurred between 19 months and 9 years after their index procedure (median 5 years). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. One complication was caused by small bowel and cecum passing around the APC and subsequently volvulizing. A second was caused by bowel herniating behind the EC's mesentery and the posterior abdominal wall. A third was caused by bowel herniating behind the APV mesentery and subsequently volvulizing. The exact etiology of fourth internal herniation is unknown. Of the three surviving patients, all required resection of ischemic bowel and 2 required resection of the involved reconstruction. One patient died intraoperatively from cardiac arrest. Only 1 patient required a subsequent procedure to regain lost function. CONCLUSION: Internal herniation caused by small or large bowel passing through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 257 reconstructions performed over 11 years. This complication can arise many years after abdominal reconstruction, resulting in bowel resection and possibly takedown of the reconstruction. When anatomically possible and technically feasible, the surgeon should close any potential spaces created during the initial abdominal reconstruction.

Parameatal urethral cysts in prepubertal males.

PURPOSE: Parameatal urethral cyst in boys is an uncommon and often poorly understood condition. We describe the largest known series of 18 prepubertal boys with parameatal cysts. MATERIALS AND METHODS: We retrospectively reviewed the charts of all pediatric patients at our institution diagnosed with a penile cyst according to our office database between 1992 and 2010. Charts were reviewed to determine patient demographics, symptomatology, pathology, cyst characteristics and treatment. RESULTS: We identified 18 patients during the last 18 years who were diagnosed with a parameatal cyst. Most patients (66%) were asymptomatic. All cysts were less than 1 cm in diameter. Of the patients 50% were circumcised before presentation and 78% underwent surgical excision. There have been no recurrences in patients who underwent excision. One patient had spontaneous resolution of the cyst during the first few weeks of life. Pathology results were available for 6 patients. Three specimens contained a single type of epithelium and 3 contained a combination of transitional, cuboidal and/or columnar epithelia. The transitional and cuboidal epithelia were the most common components. There was no evidence of malignancy in any of the specimens and only 1 specimen contained an inflammatory infiltrate. CONCLUSIONS: Parameatal cysts are a benign, usually asymptomatic condition that may contain a variety of epithelial types. The cysts may resolve spontaneously in neonates but are also easily excised with minimal risk of recurrence.

Quality improvement education in surgical specialty training: A comparison of Vascular Surgery resident and Urology Resident experiences and attitudes.

BACKGROUND: Academic institutions have increasingly focused on educating physicians and surgeons in concepts of value-based care, including quality improvement (QI). The extent to which QI curricular competencies are addressed in specialty surgical residency training is unclear. METHODS: A survey instrument was developed by content experts and sent to Vascular Surgery and Urology residents electronically. Descriptive statistics and bivariate associations were calculated using StataMP 13.1. RESULTS: Vascular Surgery and Urology residents reported exposure to similar types of QI curriculum. Fewer than half of residents reported achieving targets for graduation (Vascular 31%, Urology 42%) related to QI, and few residents in either group felt very well-prepared to lead a QI initiative (Vascular 13%, Urology 8%). CONCLUSION: QI education in surgical specialty training amongst Vascular Surgery and Urology residencies is similar and insufficient. Surgical specialties may benefit from collaborative efforts to improve the quality of QI education.

250 consecutive unilateral extravesical ureteral reimplantations in an outpatient setting.

PURPOSE: Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. MATERIALS AND METHODS: A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. RESULTS: A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. CONCLUSIONS: Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

Utilization of Radiographic Imaging for Infant Hydronephrosis over the First 12 Months of Life.

PURPOSE: The workup and surveillance strategies for infant hydronephrosis (HN) vary, although this could be due to grade-dependent differences in imaging intensity. We aimed to describe the frequency of imaging studies for HN within the first year of life, stratified by initial HN grade, within a large regional healthcare system. Study Design and Data Source. Retrospective cohort using Intermountain Healthcare Data Warehouse. Inclusion criteria: (1) birth between 1/1/2005 and 12/31/2013, (2) CPT code for HN, and (3) ultrasound (U/S) confirmed HN within four months of birth. Data Collection. Grade of HN on initial postnatal U/S; number of HN-associated radiologic studies (renal U/Ss, voiding cystourethrograms (VCUGs), and diuretic renal scans); demographic and medical variables. Primary Outcome. Sum of radiologic studies within the first year of life or prior to pyeloplasty. Statistical Analysis. Multivariate poisson regression to analyze association between the primary outcome and the initial HN grade. RESULTS: Of 1,380 subjects (993 males and 387 females), 990 (72%), 230 (17%), and 160 (12%) had mild, moderate, and severe HN, respectively. Compared with those with mild HN, patients with moderate (RR: 1.57; 95% CI: 1.42-1.73) and severe (RR: 2.09; 95% CI: 1.88-2.32) HN had a significantly higher rate of imaging use over 12 months (or prior to surgery) after controlling for potential confounders. CONCLUSIONS: In a large regional healthcare system, imaging use for HN is proportional to its initial grade. This suggests that within our system, clinicians treating this condition are using a risk-stratified approach to imaging.

Continence outcomes following a modification of the Mitchell bladder neck reconstruction in myelomeningocele: A single institution experience.

BACKGROUND: Many surgical procedures have been developed to improve continence in myelomeningocele patients. Our modification of the Mitchell bladder neck reconstruction involves removal of a diamond-shaped wedge of the anterior bladder neck, tubularization of the bladder neck and urethra to increase outlet resistance, and addition of a bladder neck autologous fascial sling. OBJECTIVE: We aimed to evaluate rates of continence and re-operation in children with myelomeningocele undergoing this Modified Mitchell bladder neck reconstruction. STUDY DESIGN: We retrospectively identified children with myelomeningocele having undergone bladder neck reconstruction at our tertiary care referral center from 2012 to 2016. RESULTS: We identified twelve patients with myelomeningocele undergoing this modified bladder neck reconstruction with sling, four female and eight male, median age at the time of surgery was 7 years old. After initial bladder neck reconstruction with sling only 33% were dry. All patients with bothersome leakage after reconstruction underwent bladder neck bulking. Two patients of twelve (17%) ultimately underwent bladder neck closure and achieved dryness. 58% of patients ultimately achieved continence (Summary Figure). DISCUSSION: Our modification of the bladder neck reconstruction with autologous fascial sling showed midterm rates of incontinence near 60%, with initial post-operative continence at 33%. Our patients, however, required higher rates of reoperation (43%) than previous results would suggest (27%). The first line of re-treatment was bladder neck bulking, but this showed low success. While this procedure is minimally invasive and safe, reasonable expectations of efficacy should be established with families when offering this option. Two patients (17%) required bladder neck closure to achieve dryness. While bladder neck closure is often considered a procedure of last resort, both of these patients were immediately dry. Perhaps bladder neck closure should be considered earlier in our algorithm of surgical continence. CONCLUSION: Our rates of continence with the Modified Mitchell bladder neck reconstruction with a fascial sling were similar to prior bladder neck reconstructions. We did find higher rates of reoperation, and further modifications are warranted to continue to improve continence after surgical procedures in the myelomeningocele population. Select cases may warrant early consideration of bladder neck closure.

Experiences With Quality Improvement in Training: A National Survey of Urology Residents.

OBJECTIVE: To determine the quality improvement (QI) experiences of urology residents in the United States. MATERIALS AND METHODS: An Institutional Review Board approved national survey of Urology residents was administered in June 2019. The survey instrument sought to understand QI curricular methods and experiences of urology residents as well as their knowledge of QI fundamentals. RESULTS: Of 465 invited residents, 159 (34%) responded. Respondents represented all 8 AUA sections. The majority of respondents self-identified as white (66%). Females made up 30% of respondents. Less than 1/3 of residents (32%) report use of online modules, whereas nearly 2/3 (63%) report lecture-based didactics. Fifteen percent of residents report no QI curriculum. While nearly 2/3 of residents report receiving training in QI principles (64%), far less report receiving training in how to apply QI methodology (44%). Only 29% of residents report being required to lead a QI project. No differences were seen by training level. Only 3 respondents had heard of the Institute of Medicine's aims for quality improvement. Respondents had better knowledge of process, balancing and outcome measures, but less than half of respondents (49%) were able to correctly identify all 3. Having any QI curriculum is associated with correctly answering knowledge questions (P = .03). CONCLUSION: From a resident perspective, urology residency programs currently provide QI curricula that are inadequate to ensure residents achieve Accreditation Council for Graduate Medical Education milestones. It is imperative the urology community as a whole address these curricular gaps to ensure graduates are prepared to deliver high-quality, cost-conscious care to their patients once in practice.

A method to improve patient access in urological practice.

PURPOSE: Studies to improve patient access to care have generally involved office based primary care practices or highly managed systems. Surgical practices differ in their referral nature, the common need for imaging at the first appointment and the need to schedule subsequent surgical procedures. We determined whether new patient access to care can be improved in a surgical practice. MATERIALS AND METHODS: To reduce new patient appointment wait times to a goal of 5 working days (1 week), a 12-week transition period into a new scheduling approach was designed. At the next clinic with open slots (9 weeks away) 10% of the appointments were held open until the week before for new patient visits. For each of the following 4 weeks 10% additional appointments were held open each week until 50% were being reserved. These slots were not available until 1 week before the clinic date and then were only open for new patients calling to make an appointment. RESULTS: Appointment delay times improved significantly and this improvement has been durable for 2 years. Interestingly our no show rate did not change. CONCLUSIONS: A surgical office with long new patient appointment wait times can improve access to clinic consultations by implementing this system.

Efficacy and safety of transdermal and oral oxybutynin in children with neurogenic detrusor overactivity.

PURPOSE: We evaluated the efficacy and safety of transdermal and oral oxybutynin in children with neurogenic detrusor overactivity. MATERIALS AND METHODS: Children with neurogenic detrusor overactivity 6 to 15 years old and previously receiving oxybutynin were assigned randomly at a 3:1 ratio to treatment with transdermal or oral oxybutynin. Initial dosages (transdermal 1.3, 2.9 or 3.9 mg daily; oral 5, 10 or 15 mg daily), based on pre-study dosages, were adjusted after 2 weeks and then maintained for 12 weeks. The primary efficacy end point was change from baseline to last observation in average urine volume collected by clean intermittent catheterization. RESULTS: A total of 57 patients were randomized to receive transdermal (41) or oral (16) oxybutynin. Safety data were available for 55 patients and efficacy data were available for 52. Mean +/- SD urine volume increased from 95 +/- 64 ml to 125 +/- 74 ml (p <0.001) with transdermal oxybutynin and from 114 +/- 75 ml to 166 +/- 92 ml (p = 0.002) with oral oxybutynin. Transdermal oxybutynin resulted in significant improvement in all measured urodynamic parameters. Similar trends and a significant increase in maximal cystometric bladder capacity were observed in the smaller oral oxybutynin group. There were 12 treatment related adverse events noted with transdermal oxybutynin (mild skin reaction) and 1 with oral oxybutynin (vasodilatation). The ratio of N-desethyloxybutynin-to-oxybutynin plasma concentrations was substantially lower with transdermal (1.4) than with oral (6.7) oxybutynin. CONCLUSIONS: Transdermal oxybutynin was a well tolerated and effective alternative to oral oxybutynin in treating neurogenic detrusor overactivity in children who previously tolerated oxybutynin.

Variation in diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine renal scans: clinical implications of interobserver and intraobserver differences.

PURPOSE: Diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine renal scans are commonly used to evaluate infants and children with hydronephrosis to assess for changes in kidney function and drainage. We evaluate the certified nuclear medicine technologist intraobserver and interobserver variability of data processing in diuretic renal scan interpretation of the percent differential function of the right kidney so that true physiological changes can be understood by the clinician. MATERIALS AND METHODS: A total of 30 renal scans (diethylenetriamine pentaacetic acid in 20 patients and mercaptoacetyltriglycine in 10) were randomly selected for evaluation by 3 technologists who processed the scan data for each patient on 5 different occasions at least 1 week apart. Regions of interest were drawn and background areas were subtracted, and percent differential function of the right kidney was calculated. Technologists were blinded to patient identification and previous interpretation results. The data were then statistically analyzed. RESULTS: The data focused on percent differential function of the right kidney. Confidence limits for the single scan interpretation at the 95% level showed +/-5.8% differential function variation, although this scan was the same renal scan processed 1 week later. CONCLUSIONS: For differential function determined on diethylenetriamine pentaacetic acid or mercaptoacetyltriglycine diuretic renal scan the single scan 95% confidence limits were +/-5.8% differential function. From one renal scan to the next the differential percent of kidney function must change +/-11.6% differential function for a clinician to be 95% confident that a real change in kidney function has occurred. This uncertainty is substantial and is likely larger than is currently allowed for in clinical practice.

Incidence of postoperative infections in non-immunocompromised pediatric patients with low absolute neutrophil counts preoperatively.

PURPOSE: To discover the incidence of postoperative surgical site infections in non-immunocompromised pediatric patients with an absolute neutrophil count (ANC) < or = 1,000 preoperatively. METHODS: Office and hospital charts of consecutive patients with preoperative ANC < or = 1,000 undergoing elective surgery over a three-year period were reviewed for evidence of postoperative surgical site infection. RESULTS: Six of 200 patients with preoperative ANCs < or = 1,000 developed a postoperative surgical site infection, an infection rate of 3.0%. One of 35 patients with preoperative ANCs < or = 500 developed a surgical site infection. The mean ANC of the study population was 800 (range 200 to 1,000); the mean ANC of the group with postoperative infection likewise was 800 (range 500 to 1,000). CONCLUSIONS: There was a postoperative surgical site infection rate of 3.0% in non-immunocompromised children who had a preoperative ANC < or = 1,000, similar to the overall surgical site infection rate in children. Cancellation of elective procedures in non-immunocompromised children with ANC < or = 1,000 is not warranted on the grounds of concern about postoperative infection.

Bladder debris on ultrasound as a predictor for positive urine culture in a pediatric population.

INTRODUCTION: Debris within the bladder is commonly seen on ultrasound. The etiology of bladder debris is varied and the likelihood that urinary debris represents positive urine culture is under investigation. We hypothesize that bladder debris will increase the likelihood that a urine culture is positive compared to those without bladder debris. METHODS: We performed a retrospective review on children aged 0-17 years who had a voiding cystourethrogram with a catheterized urinalysis or urine culture, and who also had a renal and bladder ultrasound up to 1 week prior, the day of, or up to 2 days after their urine studies. Presence of bladder debris and debris severity was recorded. Positive urine culture was defined as a single bacterial strain ≥50,000 cfu/mL. Demographic information, including findings of reflux and hydronephrosis were compared. Sensitivity, specificity, and risk ratios were calculated for predicting positive urine culture in patients with urinary debris on ultrasound. RESULTS: A total of 445 patients met inclusion criteria between January and December 2014. The positive urine culture rate was 20%, and the rate of bladder debris was 22%. The mean age for those with and without bladder debris was 6.6 and 5.5 years, respectively (p = 0.02). 23% of girls had bladder debris, compared to 12% of boys (p = 0.04, see results table). The sensitivity and specificity for bladder debris in detecting positive urine cultures was 52% and 86%, respectively. Forty-seven percent of those with bladder debris had positive cultures, compared with 12% of those without debris (p < 0.01). The relative risk of positive urine culture if debris is present is 3.90 (95% CI 2.73-5.55). Hydronephrosis or vesicoureteral reflux did not affect the relationship between bladder debris and positive urine cultures. CONCLUSIONS: Nearly half of pediatric patients undergoing urological evaluation found to have bladder debris on ultrasound will have a positive urine culture. Debris is noted more commonly in girls and at a slightly higher age. The presence of debris is associated with a fourfold increase in detecting a positive urine culture, regardless of debris severity, hydronephrosis, or vesicoureteral reflux. Given this, it is of value to routinely document and look for the presence of any amount of bladder debris seen on ultrasound, as this finding can be used to augment clinical decision-making and warrants strong consideration for obtaining urine culture.

Enterocystoplasty 30-day outcomes from National Surgical Quality Improvement Program Pediatric 2012.

INTRODUCTION: Enterocystoplasty is an important procedure in the management of children with difficult neurogenic bladder. We report on short-term complications as captured by National Surgical Quality Improvement Program (NSQIP) Pediatric. METHODS: We analyzed NSQIP Pediatric 30-day perioperative data on 114 patients who underwent enterocystoplasty in 2012 and compared those with and without complications. RESULTS: Neurogenic bladder was the most common diagnosis. The proportion of the children who underwent two or more procedures was 71.9%, in addition to enterocystoplasty, most commonly appendicovesicostomy. Median length of hospital stay was 8 days (mean 9.7 days, range 2 to 46 days). Thirty-day complication rate was 33.3%, and the most common complications were urinary tract infections (9.6%), wound complications (8.7%), blood transfusions (6.1%), and sepsis (3.5%). Reoperation rate and readmission rate were 9.6% and 13.2%, respectively. No statistically significant differences in perioperative characteristics were found between children with and without postoperative complications. Addition of appendicovesicostomy or bladder neck continence procedures was not associated with significantly increased complications. CONCLUSION: Enterocystoplasty is associated with significant perioperative morbidity, and reasonable expectations should be set during preoperative counseling.

Reliability of voiding cystourethrogram for the grading of vesicoureteral reflux.

OBJECTIVE: The voiding cystourethrogram (VCUG) is a commonly employed radiographic test used in the management of vesicoureteral reflux (VUR). Recently, the reliability of VCUG to accurately grade VUR has been questioned. The purpose of this study is to examine reliability of the VCUG for the grading of VUR in a setting mimicking daily practice in a busy pediatric hospital. MATERIALS AND METHODS: Two-hundred consecutive VCUGs were independently graded by two pediatric urologists and two pediatric radiologists according to the International Classification of Vesicoureteral Reflux. A weighted kappa coefficient was calculated to determine inter-rater agreement and a modified McNemar test was performed to assess rater bias. Further assessment for impact on clinical and research decision-making was made for disagreement between grades II and III. RESULTS: Weighted kappa values reflect strong reliability of VCUG for grading VUR between and among urologists and radiologists ranging from 0.95 to 0.97. There was statistically significant bias with radiologists reporting higher grades. Despite high kappa values, disagreement between raters was not infrequent and most common for grades II-IV. CONCLUSIONS: VCUG is reliable for grading VUR, but small differences in grading between raters were detected and may play an important role in clinical decision-making and research outcomes.

Acute monitoring of genitourinary function using intrafascicular electrodes: selective pudendal nerve activity corresponding to bladder filling, bladder fullness, and genital stimulation.

OBJECTIVE: To investigate the use of a microelectrode array with a high spatial density of penetrating intrafascicular electrodes for selective recording of pudendal nerve activity evoked by a variety of genitourinary stimuli. MATERIALS AND METHODS: Felines were anesthetized with alpha-chloralose and high-density Utah slanted electrode arrays (48 microelectrodes; 200-µm spacing) were implanted into the pudendal nerve for acute experimentation. Neural activity was recorded during bladder filling, spontaneous reflexive distention-evoked bladder contractions, and tactile somatosensory stimulation. RESULTS: The intrafascicularly implanted pudendal nerve electrodes were able to selectively record neural activity that corresponded to various genitourinary stimuli. Across all seven experimental animals, a total of 10 microelectrodes recorded neural units that were selectively driven by bladder filling or distention-evoked bladder contractions. Twenty-two electrodes were selectively driven by tactile stimulation. CONCLUSION: Microelectrode arrays implanted intrafascicularly into the pudendal nerve can be used to selectively record the neural responses that reflect bladder status and urogenital tactile stimulation. This work sets the stage for developing future implantable closed-loop neuroprosthetic devices for restoration of bladder function.

Is there a learning curve for subureteric injection of dextranomer/hyaluronic acid in the treatment of vesicoureteral reflux?

OBJECTIVE: To answer the question: 'Is there a learning curve associated with a subureteric injection of Deflux(®)?' MATERIALS AND METHODS: We retrospectively reviewed charts of patients who received subureteric injection of dextranomer/hyaluronic acid (Deflux(®){AQ2}) (225 procedures) for treatment of vesicoureteral reflux (VUR) by four surgeons. The study included 55 patients, 82 ureters, who had postoperative follow-up with a voiding cystogram or nuclear medicine cystogram. Exclusion criteria were prior anti-refluxing procedures, duplicated collecting systems, and non-achievement of a negative intraoperative cystogram. Patients were divided into two groups based on whether or not they received an intraoperative cystogram after the injection. The two groups were compared for VUR resolution rates on follow-up imaging. RESULTS: Twenty patients underwent an intraoperative cystogram (Group 1, 33 ureters) and 35 did not (Group 2, 49 ureters). The two groups were similar in age, preoperative reflux grade, amount of Deflux injected into each ureter, and time to postoperative studies. In Group 1, 11 ureters (33.3%) and also, in Group 2, 11 ureters (22.4%) had reflux on follow-up imaging. CONCLUSIONS: There was no improvement in VUR resolution rate following subureteric injection of Deflux(®) when an intraoperative cystogram demonstrated no reflux to be present immediately after injection. Of ureters that did not reflux on intraoperative cystograms, one-third displayed return of reflux on follow-up imaging, which suggests no learning curve and that failures are not likely to be caused by poor surgical technique.