Expert Consensus on Pediatric Urodynamics Reporting Using Modified Delphi Technique.

PURPOSE: Urodynamic testing (UDS) is an important tool in the management of pediatric lower urinary tract conditions. There have been notable efforts to standardize pediatric UDS nomenclature and technique, but no formal guidelines exist on essential elements to include in a clinical report. We sought to identify ideal structure and elements of a pediatric UDS assessment based on expert consensus. MATERIALS AND METHODS: Pediatric urologists regularly performing UDS were queried using a Delphi process. Participants were invited representing varied geographic, experience, and societal involvement. Participants underwent 3 rounds of questionnaires between November 2022 and August 2023 focusing on report organization, elements, definitions, and automated electronic health record clinical decision support. Professional billing requirements were also considered. Consensus was defined as 80% agreeing either in favor of or against a topic. Elements without consensus were discussed in subsequent rounds. RESULTS: A diverse sample of 30 providers, representing 27 institutions across 21 US states; Washington, District of Columbia; and Canada completed the study. Participants reported interpreting an average number of 5 UDS reports per week (range 1-22). The finalized consensus report identifies 93 elements that should be included in a pediatric UDS report based on applicable study conditions and findings. CONCLUSIONS: This consensus report details the key elements and structure agreed upon by an expert panel of pediatric urologists. Further standardization of documentation should aid collaboration and research for patients undergoing UDS. Based on this information, development of a standardized UDS report template using electronic health record implementation principles is underway, which will be openly available for pediatric urologists.

David J. Chalmers.

David Chalmers is a philosopher who studies consciousness. After sketching his background in mathematics, science, and philosophy, he describes the problems of consciousness and his collaboration with neuroscientists. He also discusses the roles of neuroscience and philosophy in studying consciousness and other topics as well as the future of these fields.

The computational and the representational language-of-thought hypotheses.

There are two versions of the language-of-thought hypothesis (LOT): Representational LOT (roughly, structured representation), introduced by Ockham, and computational LOT (roughly, symbolic computation) introduced by Fodor. Like many others, I oppose the latter but not the former. Quilty-Dunn et al. defend representational LOT, but they do not defend the strong computational LOT thesis central to the classical-connectionist debate.

An adversarial collaboration protocol for testing contrasting predictions of global neuronal workspace and integrated information theory.

The relationship between conscious experience and brain activity has intrigued scientists and philosophers for centuries. In the last decades, several theories have suggested different accounts for these relationships. These theories have developed in parallel, with little to no cross-talk among them. To advance research on consciousness, we established an adversarial collaboration between proponents of two of the major theories in the field, Global Neuronal Workspace and Integrated Information Theory. Together, we devised and preregistered two experiments that test contrasting predictions of these theories concerning the location and timing of correlates of visual consciousness, which have been endorsed by the theories' proponents. Predicted outcomes should either support, refute, or challenge these theories. Six theory-impartial laboratories will follow the study protocol specified here, using three complementary methods: Functional Magnetic Resonance Imaging (fMRI), Magneto-Electroencephalography (M-EEG), and intracranial electroencephalography (iEEG). The study protocol will include built-in replications, both between labs and within datasets. Through this ambitious undertaking, we hope to provide decisive evidence in favor or against the two theories and clarify the footprints of conscious visual perception in the human brain, while also providing an innovative model of large-scale, collaborative, and open science practice.

A Cystic Renal Mass in the Setting of a Pneumothorax: More Than Meets the Eye?

DICER1 syndrome is a rare hereditary cancer predisposition syndrome that has relevance to pediatric urology providers due to its association with many various pediatric genitourinary malignancies. We describe the case of a pediatric patient who was eventually diagnosed with a pathogenic DICER1 germline variant after undergoing resection of a cystic nephroma and pleuropulmonary blastoma.

Multicystic Dysplastic Kidney With Mass Effect in a Neonate Treated With Nephrectomy: Case Report.

Multicystic Dysplastic Kidney is a developmental disease that results in a lobulated kidney of noncommunicating cysts and abnormal parenchymal tissue. Dysplastic kidneys are usually benign and often involute over time with conservative management. The second most common cause of palpable abdominal mass in a neonate, Multicystic Dysplastic Kidney can cause respiratory distress secondary to extrinsic compression. However, such cases are sparse. Here we present the case of an otherwise healthy term newborn with an exceptionally large MCDK requiring CPAP support and intubation. His respiratory distress improved immediately after nephrectomy. Communication about cases like this will inform management of future comparable cases.

Antireflux Surgery at National Surgical Quality Improvement Program-Pediatric Hospitals.

PURPOSE: This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data. MATERIALS AND METHODS: Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures). RESULTS: In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections. CONCLUSIONS: Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

Posterior Reversible Encephalopathy Syndrome Following Failure of Conservative Management in Renal Trauma: Case Report.

Blunt renal trauma is relatively common in children. Conservative management has become the mainstay of treatment. A 4-year-old boy presented following a fall onto his right abdomen resulting in renal trauma. Initial conservative management was followed by complete embolization of the kidney. The resulting continued hypertension, as well as endothelial disruption, resulted in PRES as manifested by a single instance of generalized seizure. The patient regained normal neurological function following nephrectomy. Better understanding of the potential for acute hypertensive crisis resulting in PRES in the urology community may result in more urgent and effective management in these scenarios.

Incidence and risk factors for positive urine culture at the time of pediatric urologic surgery.

PURPOSE: Urinary tract infections are relatively common in pediatric patients. Unrecognized bacteriuria at the time of urologic surgery puts patients at increased risk for perioperative complications. Many pediatric urologists obtain preoperative or intraoperative urine cultures prior to surgery, but data are lacking regarding rates and risk factors for positive intraoperative urine cultures. We conducted a retrospective cohort study of patients undergoing pediatric urologic surgery to examine factors associated with positive intraoperative urine cultures. MATERIALS AND METHODS: Charts of patients of age 0-18 years from a single pediatric urologist with associated intraoperative urine culture results between 2008 and 2013 were retrospectively reviewed. Demographics, prior culture results, and information regarding possible risk factors of interest-history of constipation, hydronephrosis, neurogenic bladder, posterior urethral valves, ureterocele, UPJ obstruction, urolithiasis, vesicoureteral reflux, and circumcision status-were collected and analyzed. RESULTS: Seven hundred and fifty procedure encounters with associated intraoperative urine culture results were reviewed. Overall positive urine culture rate was 13.5%. Factors associated with increased odds of positive intraoperative urine culture included neurogenic bladder (odds ratio 26.3, p < 0.001), prior positive culture (OR 5.4, p < 0.001), female sex (OR 2.1, p 0.007), constipation (OR 2.9, p < 0.001), and urolithiasis (OR 1.58, p = 0.04). Patients without any of these risk factors had no positive intraoperative cultures (p = 0.03). CONCLUSIONS: Patients with neurogenic bladder, prior positive urine culture, constipation, female gender, and urolithiasis were at increased risk for positive intraoperative urine culture. This may aid in decision-making regarding obtaining preoperative or intraoperative urine cultures in pediatric urology patients.

Pediatric Urology for the General Surgeon.

Pediatric urology spans the neonatal period through the transition into early adulthood. There are a variety of common pediatric urologic conditions that overlap significantly with pediatric surgery. This article reviews the pertinent pathophysiology of a few key disease processes, including the pediatric inguinal hernia and/or hydrocele, cryptorchidism, and circumcision. General surgeons may find themselves in the position of managing these problems primarily, particularly in rural areas that may lack pediatric subspecialization. An understanding of the fundamentals can guide appropriate initial management. Additional focus is devoted to the management of genitourinary trauma to guide the general surgeon in more acute, emergent settings.

Clean intermittent catheterization as an initial management strategy provides for adequate preservation of renal function in newborns with persistent cloaca.

INTRODUCTION: Persistent cloaca is a rare, congenital anomaly involving the genital, urinary, and rectal organ systems. While prompt bowel diversion is the standard of care, the optimal method of genitourinary decompression is unclear. Bladder outlet obstruction and hydrometrocolpos are common complications that can lead to obstructive uropathy, abdominal distention, infection, perforation, and acidosis. Proposed management strategies include early surgical diversion (vesicostomy, vaginostomy, ureterostomy, nephrostomy) or clean intermittent catheterization (CIC) of the common channel. We hypothesized that CIC is an adequate means of genitourinary decompression and preservation of renal function, regardless of the severity of cloacal anomaly. METHODS: We reviewed all patients with persistent cloaca from a single, tertiary care center from 1995 to 2013. We collected data regarding renal function (serial serum creatinine prior to definitive reconstruction, and baseline estimated glomerular filtration rate [GFR]), presence of hydrocolpos, hydronephrosis, vesicoureteral reflux (VUR) or renal dysplasia, and length of the common channel. A linear mixed model was used to calculate creatinine change over time in relation to method of management and child age. Estimated GFR was calculated using the Schwartz equation for neonates = 0.45 × height in cm/serum creatinine in mg/dL. The t test was used for continuous data and Fisher's exact test was used for binomial data. A p value <0.05 was considered significant. RESULTS: Twenty-five patients were identified. Nine (36%) patients underwent early surgical diversion versus 16 (64%) managed by CIC prior to formal reconstruction. Seven had short common channels (<3 cm) and 18 had long common channels (≥3 cm). Hydrocolpos was present in 14 (56%) of the patients. When comparing the two management groups, there was no significant difference in hydronephrosis, high-grade hydronephrosis (grades III-IV, p = 0.62), any VUR (p = 0.33), high-grade VUR (grades III-V, p = 0.62), hydrocolpos (p = 0.21), or renal dysplasia (p = 0.42). No significant differences were found between mean baseline GFR for diversion (22.9 mL/min per 1.73 m(2)) versus CIC (39.2 mL/min per 1.73 m(2), p = 0.22). There was no difference in creatinine trend between the two groups. DISCUSSION: Currently, there is no consensus on the initial management of obstructive uropathy and resulting hydrocolpos in newborns with persistent cloaca. In addition to CIC, management strategies include surgical options such as vesicostomy, vaginostomy, or upper tract diversions such as ureterostomy or nephrostomy. Our results suggest that CIC is similar to these other proposed diversion procedures while minimizing morbidity. Creatinine trends over time were similar between the two groups and reached comparable nadirs. Limitations of our study include the retrospective nature of a small sample size. The primary risk is differences between the two groups that we were not able to appreciate. Furthermore, we did not attempt to assess the morbidity of the two different strategies. CONCLUSIONS: CIC is an adequate initial management strategy to decompress the genitourinary tract in patients with persistent cloaca. CIC preserves renal function similar to early surgical decompression.

Does defective volume sensation contribute to detrusor underactivity?

AIMS: The urodynamic finding of detrusor underactivity (DU) in neurologically intact unobstructed patients may relate to impaired volume sensations rather than detrusor contractile defects. We hypothesized that DU patients would demonstrate higher volumes but similar wall stress at sensation thresholds, and similar voiding contractility, compared to other groups. METHODS: Chart review of urodynamic studies in neurologically normal, nonobstructed symptomatic patients. Urodynamic studies having the primary findings of DU, stress urinary incontinence (SUI), detrusor overactivity (DO), and increased sensations without detrusor overactivity (IS) were abstracted. Age, gender, and pressure/volume data associated with sensations and voiding parameters were collected. Wall stress at sensations was calculated. Urodynamic variables at standard sensations and progression across standard sensations were compared among the four groups. RESULTS: Fifty-one urodynamic studies were analyzed for comparison. Mean age did not differ between groups. The DU group was predominantly male versus the other groups. DU, SUI, and DO had higher volume thresholds for strong desire than did IS. DU and DO demonstrated higher wall stress at strong desire than did IS and SUI. Watts factor was not significantly different between groups, however, DU had a smaller voided volumes and a higher post-void residuals. CONCLUSION: Increased volume and wall stress at strong desire, and similar contractility but the smaller voided volumes and elevated PVRs in DU suggest that diminished central sensitivity to volume afferent activity contributes to DU in nonobstructed, non-neurogenic symptomatic patients.

Distal hypospadias repair in infants without a postoperative stent.

PURPOSE: To review our experience with infants undergoing distal hypospadias repair without a postoperative stent to determine if an unacceptable complication rate might justify its use. METHODS: Children <1 year of age who underwent distal hypospadias repair by a single surgeon were identified through a prospectively maintained database. The use of a postoperative urethral stent was recorded for each case. Demographics, meatus position, operative technique and complications were also recorded. Patients older than 1 year or with hypospadias proximal to a subcoronal position were excluded. RESULTS: Eighty-nine patients without a stent were identified in addition to 21 patients who had a stent for a minimum of 3 days. At 3 months follow-up, 4/89 (4.49 %) patients in the stentless group required circumcision revision. 1 patient experienced urinary retention. 1/21 (4.76 %) patients with a postoperative stent required reoperation for meatal stenosis. CONCLUSIONS: The complication rate for infants undergoing distal hypospadias repair is low, does not appear to be significantly increased by forgoing a postoperative urethral stent. Avoiding a stent likely reduces a variety of associated adverse events and needs for short-term follow-up.

Normal anatomic relationships in prepubescent female external genitalia.

OBJECTIVE: Female congenital abnormalities and concomitant ambiguous genitalia constitute the primary reason for female genital reconstruction, however, objective data describing normal female anatomy is lacking. The aim of this study is to describe the normal anatomical relationships and size of the external genital structures in prepubescent females. MATERIALS AND METHODS: Data were collected prospectively from consecutive Tanner stage 1 females undergoing surgery unrelated to the genitalia. Recorded measurements included: clitoris length and width, length from clitoris to anus, clitoris to urethra, clitoris to posterior labia majora, mucosa behind vagina or posterior fourchette, and radius to labia minora at vagina. Patients were stratified by age into four age groups: <2 years, 2-5 years, 5-11 years and >11 years. RESULTS: Fifty-six patients met inclusion criteria. Clitoral width was similar in all age groups. The regression plots for the remaining measurements modeled on age all show a significant linear growth distribution. CONCLUSIONS: The average clitoral width was 3.8 mm, which remained constant between age groups. Clitoral length, length from clitoris to anus, clitoris to posterior labia majora, clitoris to urethra and posterior fourchette length increased across age groups. This study provides insight into the dimensions of normal external genitalia in tanner stage 1 females.

Feasibility of integrating research data collection into routine clinical practice using the electronic health record.

PURPOSE: The electronic health record is becoming central to routine medical practice and has the potential to facilitate large scale clinical research. We evaluated the completeness and accuracy of data collection using designated research fields integrated into a semistructured clinical note. We hypothesized that prospective research data collection as part of routine clinical charting is feasible, with a high rate of utilization (greater than 80%) and accuracy (kappa greater than 0.80). MATERIALS AND METHODS: Infants with congenital hydronephrosis were followed prospectively at a single institution. Existing functionality in the electronic health record was used for data collection by creation of 28 different data elements captured from a hydronephrosis note or phrase template. Completeness (percent utilization) was calculated and accuracy was assessed by comparing the structured data to manual chart review. Comparisons were conducted using the chi-square test, with 2-tailed p values <0.05 considered statistically significant. RESULTS: A total of 80 patients were eligible for manual chart review. Data were recorded through template use in 64 patients for an overall completeness of 80.0%. Of 28 elements 17 (60%) demonstrated "almost perfect" agreement (kappa greater than 0.80), and all variables reached at least "moderate" agreement (greater than 0.40). CONCLUSIONS: Integrating research fields into routine clinical practice is feasible by using semistructured clinical templates within an electronic health record. High completion and accuracy rates were captured from a variety of fields within a hydronephrosis template.

Prenatal diagnosis of cloacal exstrophy: a case report and review of the literature.

Cloacal exstrophy (CE) is a rare congenital disorder with a number of significant associated anomalies. Fetal ultrasound has been used to identify CE; however, accurate diagnosis is challenging. Recently, magnetic resonance imaging has been reported to improve prenatal diagnosis and better characterize the associated defects. We report a case of CE accurately diagnosed using magnetic resonance imaging after fetal ultrasound was nondiagnostic and review the literature comparing the use of each modality.

How can we construct a science of consciousness?

This chapter gives an overview of the projects facing a science of consciousness. Such a science must integrate third-person data about behavior and brain processes with first-person data about conscious experience. Empirical projects for integrating these data include those of contrasting conscious and unconscious processes, investigating the contents of consciousness, finding neural correlates of consciousness, and eventually inferring underlying principles connecting consciousness with physical processes. These projects are discussed with reference to current experimental research on consciousness. Some obstacles that a science of consciousness faces are also discussed.

Does heparin prophylaxis reduce the risk of venous thromboembolism in patients undergoing robot-assisted prostatectomy?

BACKGROUND AND PURPOSE: Venous thromboembolism (VTE) is a major complication of urologic surgery. Data are limited regarding the benefits of heparin prophylaxis for patients undergoing minimally invasive urologic surgery. The American Urological Association recommends sequential compression devices (SCDs) for urologic laparoscopic and robot-assisted procedures but provides no clear recommendations for the use of pharmacologic prophylaxis. We compare the rates of postoperative VTE in two groups of patients undergoing robot-assisted prostatectomy (RP) by two surgeons-one who consistently used heparin with SCDs (group 1) and the other who used SCDs alone (group 2) for prophylaxis. PATIENTS AND METHODS: An Institutional Review Board approved, prospectively managed database was analyzed. Group 1 received SCDs just before induction and 5000 units of heparin subcutaneously just after induction. SCDs were continued postoperatively, and heparin was administered twice a day until discharge. VTE rate, patient age, body mass index (BMI), operative time, lymphocele rate, length of stay (LOS), estimated blood loss (EBL), Gleason score, and pathologic stage were compared. Categorical variables were analyzed with the chi square test of proportions and continuous variables with t test using SPSS v 14 software. RESULTS: There were 1486 consecutive patients who underwent RP between August 2007 and December 30, 2011. Of these, 922 patients received heparin/SCDs and 564 received SCDs alone. Age, BMI, EBL, medial LOS, Gleason score, and pathologic stage were the same in the two groups. There was a higher rate of positive nodes in group 2 (1.3% vs 3.5%). There was one lymphocele in each group. Although operative times were longer in group 2 (229 vs 170 min, P<0.001), the incidence of VTE was not statistically different (1.0% vs 0.7%, P=0.78). BMI, operative time, EBL, and the performance of lymph node dissection were not associated with VTE. CONCLUSIONS: The risk of VTE in patients undergoing RP is low and not significantly reduced with the administration of prophylactic heparin/SCDs compared with SCDs alone.