Pediatric urothelial cancer: a cross-sectional descriptive analysis of the National Cancer Database.

Background: Urothelial cancer is a rare pediatric malignancy; previous analyses suggest lower rates of recurrence and death as compared to adults. We analyzed pediatric bladder cancer information in a national database, hypothesizing that survival would be better in children than adults. Methods: We analyzed the 2004-2016 National Cancer Database (NCDB) for children and adolescents (0-18 years) with urothelial bladder cancer. Rhabdomyosarcoma patients were excluded. Assessed variables included TNM staging, pathology, tumor size, surgical procedures, and post-operative re-admissions. Overall survival was defined as months since diagnosis as of last follow-up. Results: Of 140 urothelial tumors reported to NCDB between 2004-2016, 75.7% (N=106) were stage 0 at diagnosis, 6.4% (N=9) were stage I, 2.9% (N=4) were stage II and 3.6% (N=5) were stage IV, while 11.4% cases (N=16) were unknown. From available mortality data (121 patients), no patients died after definitive surgical resection. Only 1 mortality was reported at 90 days, although cause of death was reportedly unknown. Three (2.5%) patients were lost to follow-up, and most (96.7%) were alive at 90 days. Conclusions: Short-term survival outcomes among children and adolescents with urothelial bladder tumors captured in NCDB are reassuring. Future investigations focused on long-term outcomes and appropriate surveillance in this rare patient cohort are imperative to better guide management options.

Leveraging behavioral modification technology for the prevention of kidney stones.

PURPOSE OF REVIEW: The purpose of this review is to examine the use of technology to help promote and maintain behaviors that decrease stone recurrence. RECENT FINDINGS: Behavior change is a complex process with various interacting components. Recent developments have sought to utilize technology in combination with behavioral change techniques to promote behavior that lowers stone recurrence risk. Smart water bottles are becoming a popular way to accurately measure fluid intake with variable impact on adherence to the recommended daily fluid intake. Mobile apps have also been explored as a method to improve fluid intake. Interventions that combine smart water bottles, mobile apps, and behavioral change techniques have shown the most promise in promoting increased daily fluid intake. Other technologies, such as smart pill dispensers and hydration monitors, have potential applications in promoting behavioral change for stone disease but have yet to be evaluated for this purpose. SUMMARY: There is a limited number of studies exploring technology as a means to promote and maintain behaviors that decrease urinary stone recurrence. Future research is needed to elucidate how to maximize the potential of these technologies and better understand which behavioral change techniques best promote habit formation for the prevention of stones.

Single-port hidden incision endoscopic (HIdES) pediatric nephrectomy via pfannenstiel incision.

Laparoendoscopic single-site surgery (LESS) and hidden incision endoscopic surgery techniques are increasingly used in pediatric urology. For pediatric nephrectomy, access through a single Pfannenstiel incision is novel and may offer cosmetic benefit. In this retrospective study, we describe this approach and assess operative outcomes associated with this technique. Patients who underwent LESS nephrectomy through a single Pfannenstiel incision had minimal blood loss, short length of stay, low risk of surgical complications, and satisfactory wound healing. The Pfannenstiel approach to LESS nephrectomy is feasible, versatile, and achieves excellent operative and cosmetic outcomes, although direct comparison to other approaches is warranted.

Medical management of neurogenic bladder in patients with spina bifida: A scoping review.

INTRODUCTION: Neurogenic bladder is a common source of morbidity in patients with spina bifida and can cause renal damage. Medical management may include imaging, urodynamic studies (UDS), laboratory testing, clean intermittent catheterization (CIC), and medication. There is ongoing debate regarding the optimal management regimen. Approaches are described by two paradigms: proactive and expectant management. In a proactive approach, invasive interventions like CIC and UDS are initiated before the onset of renal abnormalities. In expectant management, UDS, CIC, and medications are started after abnormalities are identified. In this scoping review, we aim to comprehensively review existing literature on outcomes of proactive and expectant management of neurogenic bladder in patients with spina bifida. METHODS: We searched multiple databases and screened articles for inclusion using PRISMA-ScR guidelines. Included studies reported clinical outcomes of any aspect of proactive or expectant neurogenic bladder management in patients with spina bifida. RESULTS: Ultimately, 74 articles were included for review including 67 cohort studies, 4 cross-sectional studies, 2 sequential cohort studies, and 1 randomized control trial. Eleven studies directly compared management strategies. There was substantial heterogeneity in study designs, management protocols, and reported outcomes. Most studies addressed multiple simultaneous aspects of management without specifically analyzing individual aspects. However, some commented on individual aspects of management including UDS (13), CIC (32), imaging (7), and medication (5). Although there was no consensus about optimal management, all direct comparisons of paradigms supported a proactive approach. CONCLUSION: Our review identified a broad body of literature about optimal management of neurogenic bladder. Existing studies vary greatly in terms of treatment protocols, measured outcomes, and management recommendations. Overall, studies that directly compare management are scarce but favor proactive management. Given the implications on clinical outcomes, it is crucial to focus future work on directly comparing management strategies and isolating the effects of different individual management elements.

Infection rates following urologic prosthetic revision without replacement of any device components compared to partial or complete device exchange: a single-center retrospective cohort study.

Urologic implant revision carries a higher infection risk than virgin implantation. Historically, exchanging device components at the time of revision was performed to reduce infection risk. We hypothesize that revision without replacement of any parts of the device may not be associated with increased infection risk. A single-center, retrospective cohort study was performed on patients undergoing urologic implant revision from 2000 to 2021. Revisions involving exchange of any/all device components (+CE) were compared to revisions without exchange of any components (-CE). The primary outcome was infection or erosion within 12 weeks of revision. Infection rates were compared using Fischer exact test. Infection-free survival (IFS) was compared with Kaplan-Meier (KM) log-rank test and Cox proportional hazards (CPH) model. 551 revisions were included, including 497 revisions with CE and 54 without CE. Among those with at least 12 weeks follow-up, no difference was seen in infection rates within 12 weeks of revision [-CE 3/39 (7.7%) vs. +CE 10/383 (2.6%)], p = 0.109). In addition, IFS was comparable between groups (log-rank test p = 0.22, HR for -CE 1.65 (0.65-4.21). Revision surgery for IPP or AUS without CE may not present an elevated risk of infection in the properly selected patient.

COVID-19 vaccination in individuals with spina bifida: A national survey.

PURPOSE: This study aimed to conduct a national survey of individuals with spina bifida (SB) and their care partners to assess COVID-19 vaccination behaviors and vaccine uptake. METHODS: A survey instrument was designed to assess current vaccination status, general perceptions towards vaccinations, and barriers to vaccination within the SB community. Surveys were administered to individuals with SB or their representing care partner. Chi-squared and independent-samples t-tests were used to analyze the relationship between vaccine uptake and demographics. Multivariable logistic regression modeling was used to test which predictors impacted the odds that a participant received a COVID vaccine. RESULTS: A total of 1,412 participants completed the questionnaire, and 1,145 participants reported their COVID-19 vaccine status. The most common reason for not getting vaccinated was a concern about vaccine safety and efficacy. Overall, healthcare professional recommendations played a significant (OR 2.77 p < 0.001) role in whether to get vaccinated. CONCLUSION: About one in five individuals with SB have not received any COVID-19 vaccine. Actionable and modifiable factors were identified which may help increase vaccine uptake. Importantly, health providers play a critical role in COVID-19 vaccination messaging and should emphasize vaccine safety and efficacy.

Framing the picture: Impact of radiographic imaging on parental vesicoureteral reflux management preferences.

INTRODUCTION/OBJECTIVE: Given the variety of treatment options for vesicoureteral reflux (VUR), shared decision making between clinicians and parents is essential. Despite its importance, shared decision making is limited by the framing effect - people process the same information differently depending on how it is presented. Studies have also demonstrated that showing patients their radiology images can impact behaviors. In this pilot study, we sought to determine if showing parents radiographic images could serve as a framing tool that impacts the decision of whether to pursue surgery, endoscopic intervention, or conservative management for VUR. METHODS: We designed a survey instrument which provided background on VUR and a hypothetical scenario of a 2-year-old child with VUR who had a breakthrough febrile urinary tract infection (UTI). Guideline-concordant management options were presented: (1) change antibiotics, (2) endoscopic management, or (3) open or laparoscopic surgery. All options were similarly presented regarding risks, benefits, and length of stay. Respondents were randomized into a group with no image accompanying the clinical scenario or a group which had a labeled image of a voiding cystourethrogram (VCUG) demonstrating unilateral VUR. Respondents also answered demographic and health experience questions. The instrument was published on Amazon's Mechanical Turk online work interface which provides reliable and validated results in VUR experiments. Parents aged 18-60 years old were eligible. Responses with failed attention questions, duplicate internet addresses, or submission times <1 or >30 min were disqualified. Data were analyzed using t-test, chi-square, and multinomial logistic regression. Sensitivity analyses were performed after excluding all responses submitted under 2, 3, and 5 min. RESULTS: There were a total of 914 responses, 426 met inclusion criteria. The presence or absence of a VCUG image did not result in a statically significant difference in the management decision (p = 0.081). Multinomial logistic regression demonstrated that prior UTI experience influenced the management decision (p = 0.027). Sensitivity analyses revealed a significant difference in the management decision when excluding responses <5 min (p = 0.039). CONCLUSION: In this analysis, there was no statistically significant framing effect by radiographic images on parental management decision for VUR. Multinomial analyses suggested that prior experience with UTI has an impact on VUR management decisions. These results need to be considered within the limitations of this pilot study - the respondents were given a hypothetical clinical scenario and the survey instrument cannot replace an in-office discussion. Further analyses on framing and its role in pre-operative counseling is warranted.

Predicting postoperative complications in pediatric surgery: A novel pediatric comorbidity index.

INTRODUCTION/BACKGROUND: Comorbidity-driven surgical risk assessment is essential for informed patient counseling, risk-stratification, and outcomes-based health-services research. Existing mortality-focused comorbidity indices have had mixed success at risk-adjustment in children. OBJECTIVE: To develop a new comorbidity-driven multispecialty surgical risk index predicting 30-day postoperative complications in children. STUDY DESIGN: This retrospective cohort study investigated children undergoing surgical procedures across seven specialties in 2014-2015 using the MarketScan® Research databases. The risk index was derived separately for ambulatory and inpatient surgery patients using logistic regression with backward selection. The performance of the novel index in discriminating postoperative complications vis-à-vis three existing comorbidity indices was compared using bootstrapping and area under the receiver operating characteristics curves (AUC). RESULTS: We identified 190,629 ambulatory and 22,633 inpatient patients. The novel index had the best performance for discriminating postoperative complications for inpatients (AUC 0.76, 95% confidence interval [CI] 0.75-0.77) relative to the Charlson Comorbidity Index (CCI, 0.56, 95% CI 0.56-0.57), Van Walraven Index (VWI, 0.60, 95% CI 0.60-0.61), and Rhee Score (RS, 0.69, 95% CI 0.68-0.70). In the ambulatory cohort, the novel index outperformed all three existing indices, though none demonstrated excellent discriminatory ability for complications (novel score 0.68, 95% CI 0.67-0.68; CCI 0.53, 95% CI 0.52-0.53; VWI 0.53, 95% CI 0.52-0.53; RS 0.50, 95% CI 0.49-0.50). DISCUSSION: In both inpatient and ambulatory pediatric settings, our novel comorbidity index demonstrated better performance at predicting postoperative complications than three widely used alternatives. This index will be useful for research and may be adaptable to clinical settings to identify high-risk patients and facilitate perioperative planning. CONCLUSION: We developed a novel pediatric comorbidity index with better performance at predicting postoperative complications than three widely used alternatives.

Financial toxicity among individuals with spina bifida and their families: A qualitative study and conceptual model.

INTRODUCTION: Spina bifida is the most common permanently disabling birth defect in the United States and requires lifelong, multi-specialty care. The cost of such care has the potential to result in financial toxicity - the 'objective financial burden' and 'subjective financial distress' which can negatively impact clinical outcomes. While this concept has been extensively studied in other areas of medicine, particularly oncology, financial toxicity has not yet been examined in pediatric urology or in individuals with spina bifida and their families/caregivers. OBJECTIVE: To qualitatively explore the presence of financial toxicity in individuals with spina bifida and their caregivers with the objective of identifying themes and creating a conceptual model. MATERIALS AND METHODS: We conducted semi-structured interviews with individuals with spina bifida and/or their caregivers with the aim of eliciting information regarding financial distress associated with spina bifida care. Interviews were transcribed and qualitative thematic analysis was performed to identify recurring themes. These insights were used to create a conceptual model of financial toxicity among individuals with spina bifida. RESULTS: A total of 14 interviews were conducted (total of 6 patients and 13 parents/caregivers). Average patient age was 17.9 years. Five dominant themes were identified: 1) resources (insurance type, community support, etc.), 2) direct costs (copays, deductibles, travel expenses, etc.), 3) indirect costs (lost work time, hindered career advancement, resource navigation burden, etc.), 4) coping (work adjustments, decreased spending, etc.), and 5) affect (lack of control, uncertainty, worry, etc.). These insights were used to create a conceptual model. DISCUSSION: This is the first study to explore financial toxicity in spina bifida and establish a conceptual model. Our findings are corroborated by prior spina bifida literature and are closely mirrored by studies in cancer patients. Given that financial toxicity is associated with negative outcomes in other medical domains, the impact of financial toxicity on health outcomes among individuals with spina bifida warrants further study, particularly in instrument development to better understand and quantify financial toxicity in this group. CONCLUSION: Financial toxicity is a concern among individuals with spina bifida and their caregivers. This concept will need to be investigated further in order to develop validated measurement tools, identify solutions, and provide optimal care; our conceptual model will help guide these future investigations.

Behavioral Economics in Urology: A Scoping Review.

PURPOSE: Behavioral economics is the study of human behavior in the context of irrationality, self-control and self-interest. It has been leveraged in a variety of ways in health care, including efforts to decrease smoking, encourage weight loss and promote medication adherence. Concepts from this field can be used to help urologists better understand and improve behavior-dependent clinical outcomes. Our objective in this scoping review was to assess the current state of behavioral economics in the urological literature. MATERIALS AND METHODS: We conducted a scoping review of behavioral economic research in urology by performing a broad search in MEDLINE®, Embase® and Scopus® databases from inception to August 30, 2021. Abstracts were screened, assessed for relevancy and selected for full-text review. A qualitative synthesis of selected manuscripts was then performed. RESULTS: A total of 1,855 articles were identified. Sixty-one articles were selected for full-text review. Of those, 13 were selected for qualitative synthesis. The selected articles included reports of prospective trials (6), ongoing prospective trial methods (1), abstracts without a published manuscript (4) and commentaries (2). A variety of topics were covered: prostate cancer (5), resident education (2), hematuria (1), incontinence (1), surgical costs (1), care pathways (1), nephrolithiasis (1) and bladder cancer (1). CONCLUSIONS: There is a very limited number of articles, and even fewer trials, in urology that leverage behavioral economic concepts. Given this, and the successful application of behavioral economics in other medical disciplines, there is a need for behavioral economic informed urological interventions and well-designed trials to evaluate behavioral economics outcomes in urology.

Machine Learning for Urodynamic Detection of Detrusor Overactivity.

OBJECTIVE: To develop a machine learning algorithm that identifies detrusor overactivity (DO) in Urodynamic Studies (UDS) in the spina bifida population. UDS plays a key role in assessment of neurogenic bladder in patients with spina bifida. Due to significant variability in individual interpretations of UDS data, there is a need to standardize UDS interpretation. MATERIALS AND METHODS: Patients who underwent UDS at a single pediatric urology clinic between May 2012 and September 2020 were included. UDS files were analyzed in both time and frequency domains, varying inclusion of vesical, abdominal, and detrusor pressure channels. A machine learning pipeline was constructed using data windowing, dimensionality reduction, and support vector machines. Models were designed to detect clinician identified detrusor overactivity. RESULTS: Data were extracted from 805 UDS testing files from 546 unique patients. The generated models achieved good performance metrics in detecting DO agreement with the clinician, in both time- and frequency-based approaches. Incorporation of multiple channels and data windowing improved performance. The time-based model with all 3 channels had the highest area under the curve (AUC) (91.9 ± 1.3%; sensitivity: 84.2 ± 3.8%; specificity: 86.4 ± 1.3%). The 3-channel frequency-based model had the highest specificity (AUC: 90.5 ± 1.9%; sensitivity: 68.3 ± 5.3%; specificity: 92.9 ± 1.1%). CONCLUSION: We developed a promising proof-of-concept machine learning pipeline that identifies DO in UDS. Machine-learning-based predictive modeling algorithms may be employed to standardize UDS interpretation and could potentially augment shared decision-making and improve patient care.

A Systematic Review of Complications of Minimally Invasive Surgery in the Pediatric Urological Literature.

PURPOSE: Minimally invasive surgery has been gaining momentum in pediatric urology and it is essential to analyze the unique complications pertinent to this approach. We conducted a systematic review to evaluate pediatric minimally invasive surgery complications in the published urological literature. MATERIALS AND METHODS: We searched PubMed®/MEDLINE® using relevant pediatric minimally invasive surgery terminology and applied specified eligibility criteria. The Clavien-Dindo classification scheme was used to categorize postoperative complications. For studies not using Clavien-Dindo, complications were recategorized into Clavien-Dindo grades. Primary outcome was frequency of grade III complications and conversions to open surgery. Covariates were surgery type (pyeloplasty, nephrectomy, partial nephrectomy, ureteral reimplantation and complex reconstruction) and surgical approach (laparoscopic, robotic assisted and/or laparoendoscopic single site). Proportions were compared using the chi-square test (α=0.05). RESULTS: Overall 123 studies met the inclusion criteria, reporting outcomes of 5,864 patients. About a third (35.8%) of studies used the Clavien-Dindo classification. Nephrectomy had a significantly lower frequency of grade III complications (1.18%) compared to pyeloplasty (3.64%), ureteral reimplantation (6.65%) and complex reconstruction (11.76%) (p <0.05). Complex reconstruction had a significantly higher frequency of grade III complications (11.39%) compared to all other analyzed surgeries (p <0.05). CONCLUSIONS: The rate of complications and open conversions varies by surgical procedure in pediatric urological minimally invasive surgery. Despite the existence of a standardized complication classification system, the majority of reviewed publications did not report complications in a standardized fashion. Our findings call for more robust studies in pediatric minimally invasive surgery and universal implementation of standardized complication reporting.

Prevalence and correlates of non-tissue prostate cancer diagnosis in the United States.

BACKGROUND: Given the potential complications of prostate biopsies, it is sometimes reasonable in selected patients to make a non-tissue diagnosis of prostate cancer. Little is known about prevalence and factors associated with non-tissue prostate cancer diagnoses in the United States. METHODS: We identified 40 to 99-year-old prostate cancer patients with prostate specific antigen (PSA) ≥20 ng/ml from the 2010-2015 National Cancer Database. Associations were examined between non-tissue prostate cancer diagnosis and age, race, clinical T (cT) and M (cM) categories, PSA, and Charlson-Deyo Comorbidity Index (CCI) with multivariable analyses. RESULTS: Among 62,635 patients, 6.2% had a non-tissue diagnosis. The proportion of patients with non-tissue diagnoses increased with advanced age (from 0.9% in ages 40-49 to 44.0% in ages 90-99) and disease stage (cT and cM) and higher CCI and PSA level. Demographic and clinical characteristics statistically significantly associated (all P < .001) with non-tissue diagnosis in adjusted analyses were older age (OR = 24.24, 90 to 99 vs. 60 to 69 years), and higher cT (OR = 4.83; T4 vs. T1), cM (OR = 5.25, M1C vs. M0), CCI (OR = 2.07; 3+ vs. 0), and PSA levels (OR = 3.19, >97.9 ng/ml vs.20 to 39 ng/ml), as well as hormonal therapy (OR = 0.51, with vs. without). CONCLUSIONS: Non-tissue diagnosis of prostate cancer, while rare, is not outside normal clinical practice and is strongly associated with advanced patient age, higher clinical stage, multiple comorbidities, and very high PSA levels.