The diversity of hypospadias management in North America: a survey of pediatric urologists.

PURPOSE: To determine trends in hypospadias management, including surgical techniques and perioperative care, by pediatric urologists in North America. METHODS: An anonymous online survey was devised to assess approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. The survey was sent to all practicing members of the Societies for Pediatric Urology. RESULTS: The survey was completed by 133 (34.5%) respondents. Hypospadias repair was overwhelmingly recommended between ages 6-12 months (89.5%). A local or regional anesthetic block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). The majority of surgeons perform distal repairs outpatient (70.7%), while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Nearly all respondents preferred either VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%) for urethroplasty. All but one respondent leaves a stent for midshaft to proximal repairs whereas stenting for glanular repairs was split with 53.4% leaving a stent. Most surgeons (60.9-70.9%) prescribe postoperative antibiotics regardless of severity and the majority (72.9%) prescribe narcotics for analgesia. CONCLUSIONS: Approaches to hypospadias repair are extremely varied such that there is a lack of consensus among pediatric urologists regarding most aspects of hypospadias management. Investigations comparing hypospadias practice patterns are necessary to develop a standard of care for this complex pediatric urologic entity.

The use of Alloderm® for correction of severe chordee in children: An initial experience.

INTRODUCTION: Correction of chordee remains a prerequisite prior to urethroplasty in children with severe hypospadias. The use of an interposition graft is indicated when significant chordee (>300) persists after division of the urethral plate. The use of free dermis or tunica vaginalis are most often used, but the use of a pre-packaged graft material is attractive with regards to efficiency. The success with small intestine submucosa (SIS) has been variable and experience with Alloderm® has not been published. OBJECTIVE: To determine if Alloderm®, an acellular dermal matrix with regenerative properties, can effectively, safely, and efficiently be used for corporal grafting in cases of severe chordee in children associated with hypospadias or intersex STUDY DESIGN: All boys underwent planned staged repair of severe hypospadias (penoscrotal or more proximal). If artificial erection (AE) demonstrated chordee >450 after penile degloving and removal of fibrotic tissue, and again after urethral plate division, the ventral tunica albuginea was incised 1800 transversely and the oval defect measured in both axes. Alloderm® was trimmed to size and sewn into the defect. AE confirmed chordee correction. At the second stage repair (>6 months later), AE was performed to confirm continued absence of chordee. CONCLUSION: Alloderm®is safe, effective and simple to use graft material for correcting severe chordee. The benefits include performance efficiency without need for separate harvesting and donor site closure, and redundancy of material, if needed. Additional series and longer follow up must confirm these results and better assess durability.

Attitudes towards child life specialists and their utilization within pediatric urology.

INTRODUCTION: The American Academy of Pediatrics views Certified Child Life Specialists (CCLS) as "an important component of pediatric hospital based care to address the psychosocial concerns that accompany hospitalization." CCLSs help patients and parents navigate the complex medical system in order to minimize psychosocial and emotional stress by implementing age appropriate coping skills. This survey explores the perceptions towards CCLS and their utilization with pediatric urology. MATERIALS AND METHODS: A Survey Monkey questionnaire was developed and distributed to Society for Pediatric Urology members (SPU) (n = 314). Providers were queried about CCLS implementation and their perception regarding CCLS's role in improving health related quality of life (HRQOL). RESULTS: There was a 34.1% response rate (n = 107). Ninety-four providers (87.9%) reported CCLS interaction with their patients and greater than 95% of providers felt CCLS imparted some degree of benefit to their patients' HRQOL. Only 4.7% felt CCLS offered no benefit to the patients. CCLS were consistently used in a minority of inpatient and outpatient settings and never in the radiological setting. They were used at least 50% of the time by the most responders in inpatient and radiological setting and nearly the same in the ambulatory surgery setting. CONCLUSIONS: This survey illuminates that the majority of providers interact with CCLS in clinical settings and believe their involvement is beneficial. However, CCLSs are under-utilized during invasive urological procedures where patient anxiety is high. By understanding perceptions of providers and their practice patterns we can overcome barriers to CCLS use and improve their quality of life.

Influential Factors in Pursuit of Pediatric Urology Fellowship Training.

INTRODUCTION: We investigated factors that helped recent fellows achieve a successful match and sought to understand the influences in pursuing a career in pediatric urology. Selecting to continue training after urology residency entails much consideration. However, there are few tangible resources available to help residents understand the process. METHODS: A 20-item web based survey was e-mailed to second year fellows and recent graduates of pediatric urology fellowships (103) from the graduating classes of 2013 to 2015. The survey explored factors that affected the decision to pursue this field along with the influence of mentors, fellows and other residents who applied to pediatric urology. We assessed the key factors that helped applicants achieve a successful match. Descriptive statistics and univariate logistic regression analysis were used to determine relationships between program characteristics and respondents' decisions to apply and interview at various programs. RESULTS: In total, 59 of 103 individuals surveyed (57.3%) responded to the survey. Faculty, program reputation and clinical volume had key roles in ranking programs, while satisfaction with the match result was contingent upon accurately assessing programs based on key factors such as family considerations, location, program reputation, faculty, clinical year volume and gut feeling. In addition, our survey demonstrated that having a pediatric urology fellow at one's institution had little impact on a resident's decision to pursue pediatric urology. CONCLUSIONS: As the subspecialty of pediatric urology continues to grow, we identified key elements that help shape and influence choices to participate in the future of this ever evolving field.

The role of inheritance in the development of adolescent varicoceles.

BACKGROUND: The prevalence of varicoceles is estimated to be 15% in the general population but is nearly 35% among men with primary infertility and increases by 10% with each decade of life. Studies among adults infer a higher rate of varicoceles among first-degree relatives of patients with varicoceles. However, these studies do not consider the presence of varicoceles, or other venous abnormalities, at the time of desired paternity in first-degree relatives of adolescent patients. Our aim was to document the prevalence of varicoceles and varicose veins among first-degree relatives of pediatric patients diagnosed with varicoceles. METHODS: A series of 884 patients between the ages of 17 and 22 diagnosed with a varicocele were contacted and of the responders, permission was asked to discuss family history. Each patient underwent a telephone survey regarding the presence of a varicocele in the father prior to achieving paternity, the presence of a varicocele in brothers in childhood, or varicose veins in the father and mother prior to achieving pregnancy. If a varicocele or varicose vein was present, a history of intervention was surveyed. Descriptive statistics were performed to assess overall prevalence of varicocele and varicose veins in first-degree relatives. Chi-squared and logistic regression analyses were performed. RESULTS: In total, 152 patients (17.2%) responded and 139 (91.4%) consented to the telephone survey (mean age 19.5±1.84 years old). Overall, 12.9% of fathers had varicoceles and 8.6% of fathers underwent surgical intervention. Among siblings, 18 individuals had a varicocele and 5.6% of siblings with varicocele required intervention. Varicose veins were diagnosed in 7.9% of fathers and 25.2% of mothers; 8.6% of mothers underwent intervention. Surveillance was employed in 76.3% of patients, and surgery undertaken 21.6%. Patients with grade 2 or 3 varicoceles were more likely to have a father with a varicocele than those with grade 1 varicocele (P=0.037). Patients with grade 2 varicocele were more likely to have a father who required varicocele surgery than grade 1 (P=0.019). There was no statistical association of adolescent varicocele and varicose veins in first degree relatives (P=0.306). CONCLUSIONS: This series shows that while a father's prevalence is similar to that of the general population, higher grade varicoceles were associated with a higher prevalence of varicoceles and surgical ligation. This suggests the existence of a hereditary predisposition to high grade varicoceles. Furthermore, varicocele is not associated with varicose veins in first degree relatives.

Renal sonographic changes in heterogeneity index and echogenicity in children with hypertension: a novel assessment.

The kidneys are thought to contribute to the pathogenesis of primary hypertension, but hypertension is also known to cause target organ damage in the kidney. Noninvasive methods to capture possible changes in the kidney related to hypertension are limited. A new program that has been used to quantify the heterogeneity and percent echogenicity in renal ultrasound images was implemented to assess patients with hypertension. Children and adolescents <21 years with primary hypertension diagnosed by ambulatory blood pressure monitoring were compared with normotensive age- and sex-matched controls. Renal ultrasound images were evaluated by a technique that measured pixels of gray-scale images and transformed them into a binary map, which was converted to a heterogeneity index (HI) and percent echogenicity score. This study included 99 children with hypertension and 99 control subjects. Body mass index (BMI) was greater in the hypertension group. Average HI for hypertension was significantly higher than in controls (1.37 ± 0.19 vs. 1.2 ± 0.23, P = .001), while echogenicity scores were not different (26.6 ± 8.9 vs. 25.9 ± 10, P = .8). In regression analysis adjusting for BMI z-score and race, hypertension was associated with greater HI compared with controls (ß = 0.11, 95% confidence interval 0.03-0.18, P = .005). In a model adjusted for age, sex, and BMI z-score in the hypertension group only, no ambulatory blood pressure monitoring measures were associated with HI or echogenicity scores (P > .05).HI was significantly greater in the hypertension group compared with normotensive controls. HI may be a novel method to detect changes in the kidney related to hypertension.

Synchronous, but separate, bladder and vaginal rhabdomyosarcoma: a novel genetic case report.

Embryonal rhabdomyosarcoma is a rare cancer that often requires multimodality therapy to treat; however, these therapies can cause changes in the biology of the tumor. Several reports have documented pathologic changes but only recently have genetic changes been mapped. We present case of two separate synchronous primary rhabdomyosarcomas in a 17-month-old patient and discuss the pathophysiology and genetic changes that occur with treatment. We hypothesize that a genetic field defect arising in development of the urogenital sinus caused the tumors, but that treatment modalities may have caused genetic alterations changing clinical behavior of the tumors and responses to treatment.

Cost-effectiveness of antimicrobial prophylaxis for children in the RIVUR trial.

PURPOSE: We evaluated the cost-effectiveness of antimicrobial prophylaxis to prevent recurrent UTIs in children with vesicoureteral reflux based on the RIVUR trial. MATERIALS AND METHODS: A decision tree model compared strategies of antimicrobial prophylaxis vs. placebo in children with reflux using results from the RIVUR trial. Risk reduction was 50% based on intention to treat analysis. Costs were based on Medicare reimbursement and data in literature. The model incorporated costs of medications, imaging and complications such as pyelonephritis, likelihood of surgery and loss of work. One- and two-way sensitivity analyses were performed evaluating the effect of changing variables on the cost-effectiveness of antibiotic prophylaxis in preventing recurrent UTIs. RESULTS: Mean costs were higher for treatment vs. placebo at $3092 and $2932, respectively, with 12.7 fewer infections per 100 children. One-way sensitivity analyses showed that antibiotics would be cost equivalent if the yearly medical cost was $386, rate of recurrent UTI increased to 32%, antibiotic risk reduction was 63%, or rate of pyelonephritis in the placebo group was 48%. Two-way analyses modifying antibiotic cost, risk reduction of antibiotics and probability of infection showed areas where antibiotics could be more cost-effective than placebo. CONCLUSIONS: Antibiotic prophylaxis is associated with marginally higher costs compared with placebo, but significantly fewer infections. A slight decrease in antibiotic cost or increase in recurrent UTIs on placebo may result in prophylaxis being more cost-effective. We recognize that the marginal overall cost in antibiotics may have a substantial impact on the quality of life for the individual patient and family.

Ultrasound self-referral does not increase utilization in pediatric urology.

INTRODUCTION: Costs of radiologic imaging are rising. The goal of this study is to examine the utilization practices of pediatric urologists who have access to in-office ultrasound imaging when managing children with primary hydronephrosis. MATERIALS AND METHODS: A retrospective cross sectional study was performed of children ≤ 5 years old with an isolated diagnosis of hydronephrosis. Ultrasound utilization was evaluated by tallying the number of ultrasounds obtained during the time each child was followed. Imaging frequency was determined from orders given by each overseeing physician. Ultrasounds were performed at either the practitioner's clinic or at outside radiology facilities based on insurance regulations. Analysis compared ordering frequency between imaging completed at the clinic versus outside radiology facilities. RESULTS: Of 1,816 ultrasounds ordered, 1,102 were performed at the practitioner's clinic and 714 at outside radiology centers. Overall, the number of ultrasounds obtained in the practitioner's clinic was 0.33 ultrasound studies per patient per month, in contrast to 0.38 obtained in outside radiology settings. Ultrasound utilization for low, intermediate and high grades of hydronephrosis in practitioner's clinic versus outside was 0.39 versus 0.31, 0.31 versus 0.31, and 0.37 versus 0.39 respectively. There were no significant differences in ultrasound ordering frequency for all groups compared. CONCLUSIONS: There is no increase in ultrasound utilization for managing primary hydronephrosis in children, regardless of whether the study was self or outside referral. Honest and ethical utilization of self-owned radiologic equipment is possible and allows for timing monitoring, physician and patient convenience, and potential cost savings.

An Inguinal Approach to Complex Extravesical Ureteral Reimplantation.

OBJECTIVE: To report our experience in applying the Lich-Gregoir extravesical ureteral reimplantation (EVR) approach to complex cases (megaureter, duplex systems) through a small inguinal incision, with the goal of minimizing invasiveness. MATERIALS AND METHODS: We reviewed the records of all patients who underwent common sheath or tapered EVR through an inguinal incision. Patient characteristics and reflux grade were obtained, and outcomes were assessed. The technique involved a 2-cm incision made in the lowest inguinal skin crease, standard cord exposure and lateral retraction, and opening the floor of the canal to isolate the ureter. Excisional tapering was performed with the ureter dismembered from the bladder and then reimplanted via detrusorrhaphy, whereas common sheath reimplantation was performed with advancement fixation sutures and the ureters in situ. RESULTS: Twenty-eight patients (15 males and 13 females) with a median age of 1.7 years (range: 0.9-4.8 years) were included. Fifteen patients had ureteral tapering, 12 underwent common sheath reimplantation, and 1 child had both. Success was seen in 94% for tapering and 92% for common sheath reimplants, with a mean follow-up of 29.6 months. There were no postoperative obstructions, urinary leaks, or wound infections. CONCLUSION: The inguinal approach can safely and effectively be applied to cases of extravesical ureteral tapering and common sheath reimplantation.

Robot-assisted Laparoscopic Urachal Excision in Children.

OBJECTIVE: To report the first exclusively pediatric series of robot-assisted urachal remnant excisions in children. METHODS: We reviewed the medical records of all children who underwent robot-assisted excision of urachal remnants from 2010 to 2016. For the procedure, a 3-port approach was performed in all cases. Excision of the urachus was performed, along with partial cystectomy if there was clear or suspected bladder involvement. Outcomes and complications were reviewed. RESULTS: Sixteen cases of robotic urachal excision were performed during the study period in patients aged 0.8-16.5 years. Complete excision was accomplished in all cases with no conversions. Partial cystectomy was performed in 11 cases, in which a urinary catheter was left for 1 day in all cases (no catheter was left in the absence of partial cystectomy). The only complication was a bladder leak requiring open surgical repair. There were no bowel injuries or hernias. The median operative time was 107 minutes. The length of stay was 2 days with partial cystectomy and 1 day without partial cystectomy. All patients were well at follow-up. CONCLUSION: We report the largest known series of robot-assisted urachal remnant excisions in children, demonstrating this minimally invasive approach to be safe and effective.

Wilms Tumor With Metastasis to the Vagina: A Case Report.

A 12-year-old female presented with abdominal pain, night sweats, weight loss, constipation, dysmenorrhea, menorrhagia, and vaginal discharge. Examination revealed a palpable flank mass and a large tumor adherent to the anterior vaginal wall. Computed tomography scan demonstrated a 23 cm mass in the left kidney, a separate 10.8 cm pelvic mass, and metastatic disease. Biopsies were consistent with Wilms tumor. Neoadjuvant chemotherapy and a left radical nephrectomy were performed for her stage IV disease as the kidney was amiable to complete resection. The patient received radiation and resumed chemotherapy. She was doing well with improved symptoms at follow-up.

Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion.

BACKGROUND: Testicular torsion is surgical emergency. Prompt diagnosis and treatment of testicular torsion is essential for testicular viability. At surgical exploration, the spermatic cord is seen twisted a variable number of times around its longitudinal axis. There is scant data regarding the degree of twisting and its association with testis outcomes. The purpose of our study is to explore how the degree of torsion factors into testicular outcome using follow-up data. METHODS: We retrospectively reviewed the records of adolescent males who presented with testicular torsion to our institution, looking at duration of pain symptoms, degree of torsion documented in the operative note, procedure performed (orchiopexy versus orchiectomy), and follow-up clinic data for whether testicular atrophy after orchiopexy was present. A non-salvageable testis was defined as orchiectomy or atrophy. Receiver operator characteristics (ROC), multivariate, and logistic regression analyses were performed to determine the probability of a non-salvageable torsed testis based on time and degree of twisting. RESULTS: Eighty-one patients met our study criteria, with 55 testes deemed viable and 26 non-salvageable. We found a 25.7% atrophy rate after orchiopexy. Cut-off values of 8.5 h and 495 degrees of torsion would provide sensitivities of 73% and 53%, respectively, with specificity of 80% for both. Only duration and age were correlated with the risk of non-salvage on multivariate analysis. Logistic regression generated linear probability formulas of 4 + (3 ¡Á hours) and 7 + (0.05 ¡Á degrees) in calculating the probability of non-salvage with strong correlation. CONCLUSIONS: We were able to derive separate formulas to determine the viability of the torsed testis based on symptom duration and degrees of twisting. Fifteen h of symptoms and 860 degrees of torsion gives testes a 50% salvage rate. Interestingly, we also found that about 1 out of every 4 testes undergoes atrophy after orchiopexy.

Parental Status among Successful Applicants to Urology Residency.

INTRODUCTION: In this study we assessed academic and demographic factors, including parental status, associated with men and women entering urology residency. METHODS: An anonymous, Internet based survey was created, asking about academic and demographic characteristics at the time of residency application. The survey was e-mailed to 1,184 urology residents and fellows on 3 occasions. E-mail addresses were obtained through the AUA (American Urological Association) website, PubMed® or familiar contacts. Subjects were excluded from analysis if they had completed training, trained outside of the United States or if they had nonworking e-mail addresses. Chi-squared testing and logistic regression analysis were performed. RESULTS: A total of 215 responses were suitable for analysis (150 men, 65 women). There were no significant differences between successful male and female applicants in age, relationship status, AOA (Alpha Omega Alpha Honor Society) membership, publication status or medical school ranking. Successful male applicants were significantly more likely to have children than female applicants at residency application (18% vs 3.1%, OR 6.91, p=0.0038). Significance persisted on multivariable analysis after adjusting for age and relationship status (OR 6.75, p=0.0185). CONCLUSIONS: Despite similar demographics and academic achievements, successful female applicants to urology residency are less likely to have children upon residency application. Given the challenges women face in childbearing later in their careers, efforts should be considered to foster an academic and professional environment that enables them to have children earlier if they so choose.

Ultrasonographic Assessment of Testicular Viability Using Heterogeneity Levels in Torsed Testicles.

PURPOSE: Gross testicular heterogeneity on ultrasound has been associated with testis loss following testicular torsion in children. We aimed to quantify the extent of temporal heterogeneity associated with testis loss in testicular torsion cases using a noninvasive technique to determine a HI (heterogeneity index) on ultrasound images. MATERIALS AND METHODS: We retrospectively studied the records of patients who presented with acute scrotal pain to the Pediatric Emergency Department over a 6-year period. Ultrasound images of the affected testis and the unaffected contralateral testis were examined using a proprietary program to determine the extent of heterogeneity of each image. The difference between the HI of the torsed testis and that of the contralateral normal testis was termed ΔHI. Receiver operating characteristics curve analysis was performed to determine the ΔHI threshold for nonviability. RESULTS: Among 529 patients who presented with acute scrotal pain 147 had testicular torsion based on surgical findings. Of these 147 patients 110 (74.8%) were found to have a viable testis while 37 (25.2%) had a nonviable testis. Using the ΔHI cutoff of 0.394 or greater for nonviability, sensitivity and specificity were 100% and 94.5%, respectively. Positive and negative predictive values were 86% and 100%, respectively. CONCLUSIONS: Our results demonstrate that a quantifiable temporal gradation of heterogeneity exists and the heterogeneity index can be used as an objective parameter to determine the viability of a torsed testicle. By developing the technology to measure the heterogeneity index in real time, we could potentially identify which patients with testicular torsion have a nonviable testicle and, thus, would not require immediate surgical exploration.