Mental health, psychosocial functioning, and health-related quality of life of children and adolescents with bladder exstrophy, cloacal exstrophy, and epispadias: A scoping review.

BACKGROUND: The exstrophy-epispadias complex (EEC) is a spectrum of rare congenital defects affecting the genitourinary system that includes epispadias, bladder exstrophy, and cloacal exstrophy. EEC patients may require several surgeries throughout their lifetime and experience a number of difficulties that may impact their quality of life (QoL), mental health, and psychosocial functioning. OBJECTIVE: The purpose of this scoping review is to systematically map existing literature that explores the mental health, psychosocial functioning, and QoL of children and adolescents with EEC. STUDY DESIGN: A search strategy on multiple bibliographic databases was created using a combination of Medical Subject Headings (MeSH) and keywords for the concepts of bladder exstrophy, cloacal exstrophy, or epispadias. RESULTS: The initial search identified 6303 unique articles. 254 articles were selected for full-text review, and 76 articles were identified for data extraction. Articles were excluded if they solely focused on adults. 25 articles are included in this review regarding child and adolescent experiences with EEC. DISCUSSION: Many child-focused studies utilized HRQoL measures to explore changes to an individual's quality of life after undergoing specific continence surgeries, with many studies finding improved QoL after surgery. As children age into adolescence, the research also demonstrates that experiences with QoL may change, with additional differences by gender. Body- and self-image seemed to become more of a concern as patients aged into adolescence, with special consideration for cloacal exstrophy patients who often undergo routine neonatal assignment genetic male to female. CONCLUSIONS: The existing literature suggests that current measures do not demonstrate that children and adolescents with EEC function differently than the general population, but children with EEC have a greater likelihood of experiencing a wide range of emotional and behavioral problems as they reach adolescence. Future studies should further explore manifestations of mental health and QoL throughout the life course.

A Randomized Trial Evaluating Acceptance and Commitment Therapy and Smart Phone Care Management Application to Augment Buprenorphine Therapy for Opioid Use and Chronic Pain.

There is high comorbidity of opioid use disorder (OUD) and chronic pain (CP), which is often addressed by prescribing buprenorphine (BUP). While BUP is effective in preventing overdose, it does not address the psychological aspects of OUD and CP comorbidity and treatment retention rates are as low as 50%. The Virtual Opioid use disorder Integrated Chronic Pain Treatment (VOICE) study (NCT05039554) is a novel effectiveness-implementation trial to test a 12-week virtual group Acceptance and Commitment Therapy (ACT) protocol and a care management smartphone application (app; Valera Health) on pain and opioid use in patients with OUD and CP receiving BUP. Using a 2 × 2 factorial design, participants (expected N = 280) are randomized into: ACT, Valera app, ACT + Valera, or Treatment as Usual arm. This study is taking place in the Bronx, NY, a racially/ethnically diverse community that faces numerous socioeconomic stressors and is one of the nation's epicenters of the opioid epidemic. We created a culturally responsive ACT group protocol, and Valera psychoeducational material. Outcome measures include NIH HEAL Common Data Elements and ACT and Valera-specific measures. We are conducting a novel 2 × 2 trial investigating augmenting BUP treatment with ACT and Valera, with the goal that improved mental health and access to care will result in decreased and opioid use and pain interference.

Human umbilical cord allograft associated with higher pediatric urethrocutaneous fistula repair success rates.

BACKGROUND: Urethrocutaneous fistula (UCF) formation is a known complication following hypospadias repair, affecting between 5 and 70% of cases. Moreover, approximately 30% of patients experience refistulization after UCF repair. The use of extracellular matrices, such as AmnioCord, a dehydrated human umbilical cord allograft manufactured by MiMedx®, may mitigate high rates of refistulization. OBJECTIVE: To determine whether the use of AmnioCord during UCF repair is associated with reduced incidence of subsequent UCFs among pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: Electronic medical records were retrospectively reviewed among 60 patients who underwent at least one UCF repair at a pediatric hospital in a large urban setting in the U.S. between January 2012-June 2018. Patients were followed through January 2024. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Adjusted generalized estimating equation regression models were used to assess the association between AmnioCord use and rates of refistulization, while controlling for confounding variables. RESULTS: The number of fistula presentations per patient ranged from one to four; 53.3% had one fistula, 30.0% had two, and 16.6% had three or more. Overall fistula repair success rate was 56.8% but significantly differed by AmnioCord use in adjusted modelling; 69.4% of cases that received AmnioCord were successfully repaired, compared to 47.2% of cases that did not receive AmnioCord. In adjusted models, patients who received AmnioCord had 2.66 times greater odds of surgical success than patients who did not receive AmnioCord (95% CI:1.13-6.24; p = 0.02). CONCLUSIONS: This study demonstrates a positive association between AmnioCord use and successful UCF closure among pediatric patients.

High HIV prevalence in gestational trophoblastic neoplasia patients.

OBJECTIVE: To assess the HIV prevalence in patients diagnosed with gestational trophoblastic neoplasia (GTN). DESIGN: A retrospective single centre cohort study. METHODS: A database from the Sheffield Trophoblastic Disease Centre (STDC), Sheffield, UK was searched between 1st January 2015 and 31st December 2021. A total of 3,591 patients were referred to STDC with a diagnosis of gestational trophoblastic disease (GTD), of which 221 (6.2%) were treated for GTN. The prevalence of HIV-positive tests in GTN patients was assessed. RESULTS: HIV testing was performed in 93% GTN patients ( n  = 205/221). Overall, 1.3% of GTN patients ( n  = 3/221) were HIV-positive, involving two known HIV-positive patients and one new diagnosis. This equates to a HIV prevalence of 14 : 1000, which is ∼7 to 9× higher than the HIV prevalence in Sheffield (1.9 per 1000) and Yorkshire and Humber (1.5 per 1000). CONCLUSION: Given the extremely high HIV prevalence in our population, 'opt out' HIV testing is recommended within our specialist trophoblastic centre for all referred GTD and GTN patients. There is little reason to suspect that the prevalence of HIV-positive patients is any lower in the cohort of GTD patients referred to specialist trophoblastic centres for hCG screening alone, without requiring chemotherapy, particularly considering that most GTN arises from GTD.

Nephrolithiasis in two patients on iron chelation therapy: A case report.

Drug-induced nephrolithiasis can arise from insoluble components within medications or crystallization of metabolites due to changes in metabolism and urinary pH. The connection between drugs utilized for iron chelation therapy (ICT) and nephrolithiasis is not well understood. In this report, we describe two pediatric patients diagnosed with nephrolithiasis while undergoing treatment with the chelating agents deferasirox, deferiprone, and deferoxamine for iron overload secondary to repeat blood transfusion.

Urogenital Sinus Diagnosed During Workup of Recurrent Urinary Tract Infections: A Case Report.

Urogenital sinus (UGS) is a rare anomaly characterized by a common cavity involving the reproductive and urinary tracts. We describe a patient with VACTERL syndrome who presented for urologic care at 11 years of age due to supposed "recurrent urinary tract infections" and was subsequently found to have UGS in which the vagina connected directly to the bladder. She underwent robotic UGS mobilization to disconnect the vagina from the bladder and vaginoplasty to mature the vagina to the perineum. The objective of this report is to describe the presentation, diagnosis, and management of a patient with rare high confluence UGS.

Imaging characteristics predicting elevated detrusor pressures in patients with spina bifida.

PURPOSE: Patients with spina bifida require urologic follow up with assessments of bladder and renal function. The ideal screening protocol for bladder compliance remains controversial. This study assessed associations between bladder end filling pressure (EFP) and detrusor leak point pressure (DLPP) on urodynamic studies (UDS) and findings from renal bladder ultrasounds (RBUS) and voiding cystourethrograms (VCUG). METHODS: Pediatric spina bifida patients who underwent RBUS and/or VCUG within six months of UDS at a single institution from 2015 to 2021 were retrospectively reviewed. Demographics, VCUG and RBUS results, and UDS EFP and DLPP were recorded. Multiple linear regression analyses and Pearson chi-square tests were conducted to correlate RBUS and VCUG findings with DLPP/EFP. RESULTS: 129 patients were included. In adjusted analyses, moderate to severe hydronephrosis on RBUS was significantly associated with elevations in mean DLPP/EFP (p = 0.006). Patients with round bladders had significantly lower mean DLPP/EFP than patients with elongated or conical bladders (p < 0.0001). The presence of trabeculations was associated with increased mean DLPP/EFP (p < 0.0001) and increases in severity of trabeculations were associated with higher DLPP/EFP (p < 0.0001). The presence of vesicoureteral reflux (VUR) on VCUG was not associated with significant differences in mean DLPP/EFP (p = 0.20). CONCLUSIONS: Abnormal bladder shape and trabeculations on VCUGs in spina bifida patients had significant associations with increased mean bladder pressures on UDS. Assessment of bladder shape and contour by VCUG may be a valuable screening tool in conjunction with routine RBUS in determining the need for further assessment of bladder pressures in patients with spina bifida.

False positive pregnancy tests in pediatric patients with augmentation enterocystoplasty.

PURPOSE: Our primary aim was to determine the prevalence of positive over-the-counter (OTC) pregnancy tests among pediatric female and male patients who had undergone augmentation enterocystoplasty. A secondary aim was to determine whether patient factors or urinalysis (UA) results were associated with false positive OTC pregnancy test results in patients with a history of augmentation enterocystoplasty. METHODS: Patients at a tertiary pediatric hospital who had previously undergone augmentation enterocystoplasty, Mitrofanoff appendicovesicostomy only, and age- and sex-matched controls were prospectively recruited. Urine samples were obtained, and two OTC pregnancy tests were conducted - OTC Test A reported the ability to detect pregnancy at hCG levels as low as 9.6 mIU/mL, while OTC Test B reported positive pregnancy test results at hCG levels ≥25 mIU/mL. A point of care (POC) pregnancy test and UA were also completed. Mann-Whitney U tests and Fisher's exact tests were used to assess whether patient factors or UA results were associated with false positive pregnancy test results. RESULTS: Fifty pediatric patients were enrolled, including 20 with augmentation enterocystoplasty, 20 age- and sex-matched controls, and 10 with Mitrofanoff appendicovesicostomy only. Among the 20 patients who had undergone augmentation cystoplasty, 15 (75.0%) had positive pregnancy test results on OTC Test A, including 11/13 (84.6%) females and 4/7 (57.1%) males. No control patients or patients with Mitrofanoff appendicovesicostomy only had a positive test. No patients had positive pregnancy test results on OTC Test B or the POC test. While patients with augmentation enterocystoplasty were significantly more likely to test positive for blood (p = 0.01), nitrate (p = 0.03), and leukocytes (p < 0.0001), these factors were not significantly associated with false positive pregnancy results. No patient factors or UA results were associated with increased likelihood of false positive OTC pregnancy test results. CONCLUSIONS: These findings indicate that sensitive OTC pregnancy tests that detect low quantities of hCG in urine may result in false positive results among patients who have undergone augmentation enterocystoplasty. Female patients of reproductive age with bladder augmentations should be counseled regarding appropriate pregnancy testing options. Additional research is needed to determine the mechanism responsible for false positive pregnancy tests in this patient population.

Three cases utilizing the Hidden Incision Endoscopic Surgery approach to port placement during penile inversion vaginoplasty utilizing a peritoneal flap.

INTRODUCTION: Younger transgender patients undergoing penile inversion vaginoplasty (PIV) after pubertal suppression often require modified techniques to augment neovaginal tissue. Peritoneal flap vaginoplasty (PFV) is a well-established technique for improving neovaginal depth. Utilizing a Hidden Incision Endoscopic Surgery (HIdES) approach to port placement improves cosmetic outcomes of this identity-affirming procedure. OBJECTIVE: This video shows the efficacy of the HIdES port placement configuration on the daVinci robot for peritoneal flap creation and closure during PIV using the modified laparoscopic Davydov procedure. MATERIALS AND METHODS: Three young adult transgender females who had not undergone laser hair removal/epilation underwent PIV with robotic PFV utilizing HIdES port placement. The anterior superior iliac spine (ASIS) was demarcated bilaterally, and ports were placed at or below these lines. Two surgical teams, external genitoplasty and internal peritoneal flap closure via daVinci Xi robot, worked simultaneously. RESULTS: All patients underwent successful robotic assisted PIV with HIdES port placement. All patients had similar postoperative courses of return of bowel function with flatus on postoperative day (POD) 2, vaginal dressing, urethral catheter removal, and initiation of vaginal dilation on POD 5-6, and hospital discharge between POD 5-8. CONCLUSION: We present our initial experience with robotic/laparoscopic PFV using a hidden incision approach. This technique allows for excellent neovaginal depth with improved abdominal wound aesthetics.

Nephrolithiasis management and outcomes in pediatric patients with limited mobility.

INTRODUCTION AND OBJECTIVES: Pediatric patients with limited lower extremity mobility may be at increased risk of developing nephrolithiasis due to bone mineral metabolic derangements. This study sought to assess whether nephrolithiasis management and related outcomes differ between ambulatory versus non-ambulatory pediatric patients. METHODS: This was a retrospective review of ambulatory and non-ambulatory pediatric patients with nephrolithiasis from 2010 to 2021 from a single tertiary care center. Demographics, surgical history, stone compositions, and 24-h urine data were reviewed. Adjusted logistic and linear regression models were utilized to assess whether mobility status was associated with nephrolithiasis-related management and outcomes, including: age at first stone; requiring surgical intervention for stones; number of surgeries; stone compositions; urine culture results; and completion of 24-h urine studies. RESULTS: Among 339 pediatric patients with nephrolithiasis, 67 (19.8%) were non-ambulatory. In adjusted analyses, non-ambulatory patients had 3.24 times greater odds of requiring surgical intervention for stones (95% CI: 1.93-6.84; p < 0.0001); among those who required surgery, non-ambulatory patients required an average of 0.82 more surgical interventions (95% CI: 0.35-1.30; p = 0.0008) than ambulatory patients. Additionally, non-ambulatory patients had 5.28 times greater odds of having a positive urine culture at the time of surgery (95% CI: 2.35-14.08; p = 0.0001) and were significantly less likely to undergo 24-h urine studies (OR: 0.35; 95% CI: 0.15-0.83; p = 0.02). Stone composition significantly varied by mobility status, with non-ambulatory patients being significantly more likely to form calcium apatite (OR: 5.1; 95% CI: 2.18-11.93; p = 0.0002) or struvite (OR 3.72; 95% CI: 1.18-11.74; p = 0.03) stones, and significantly less likely to form calcium oxalate stones (OR: 0.19; 95 CI: 0.08-0.47; p = 0.0003). Among all patients, age at first stone occurred at a median age of 13.4 years (IQR: 8.2-16.4) and did not significantly differ by mobility status (p = 0.92). CONCLUSIONS: Patients with limited mobility required surgery for nephrolithiasis at significantly higher rates and had different stone compositions than ambulatory patients. Obtaining a 24-h urine study in patients with comorbidities affecting ambulation was uncommon, compared to ambulatory patients. Similarly to ambulatory patients, pediatric patients with limited mobility who develop nephrolithiasis tend to first present with stones in early adolescence.

Sociodemographic differences in opioid use and recovery following ambulatory pediatric urologic procedures.

Our aim was to examine associations between sociodemographic factors and postoperative opioid use and recovery among pediatric patients undergoing outpatient urologic procedures. We retrospectively evaluated 831 patients undergoing ambulatory urologic procedures from 2013 to 2017 at an urban pediatric hospital. Patients were evaluated for days of opioid use and days until return to baseline behavior. Differences in outcomes by race/ethnicity, primary language, median neighborhood household income, and health insurance type were analyzed using negative binomial regression models. Overall, patients reported a median of 1.0 day (IQR: 2.0) of postoperative opioid use and 3.0 days (IQR: 6.0) of recovery time. After controlling for covariates, patients with non-English speaking parents took opioids for 26.5% (95% CI: 11.4-41.7%) longer and had 27.8% (95% CI: 8.1-51.0%) longer recovery time than patients with English-speaking parents. Hispanic patients took opioids for 27.5% (95% CI: 0.1-54.9%) longer than White patients. Patients with public insurance used opioids for 47.6% (95% CI: 5.0-107.4%) longer than privately insured patients. Non-English speaking, Hispanic, and publicly insured patients had a longer duration of postoperative opioid use than primarily English-speaking, White, and privately insured patients, respectively. Identifying these disparities is important for designing equitable postoperative care pathways.

Epithelioid Hemangioma of the Glans Penis in an Adolescent Male: A Case Report.

Epithelioid hemangioma is a rare vascular lesion consisting of capillaries and inflammatory infiltrate containing lymphocytes, and mast cells. The presentation of penile epithelioid hemangioma has been previously described in the adult literature; however, few cases have been reported in the pediatric population. Herein we present a case of penile epithelioid hemangioma in a 15-year-old patient with regrowth following surgical resection, requiring more extensive surgical excision with urethral reconstruction. This rare case highlights the importance of a proper diagnosis and complete microscopic removal.

Continued use of scrotal ultrasounds for the workup of undescended testes: Confirmation bias and inaccuracies.

AIM: Scrotal ultrasounds are utilised in some primary care settings for suspected cryptorchidism, despite inaccuracies. We aim to identify the correlation between ultrasound and primary care provider (PCP) findings of undescended testicles (UDTs) as a potential source of confirmation bias. METHODS: Males referred for suspected UDT by PCPs who underwent scrotal ultrasound and paediatric urologist examination from 2014 to 2019 were included. Correlation between PCP and ultrasound findings and diagnostic accuracy were evaluated. Logistic regression was utilised to determine associations between patient factors and UDT misdiagnosis. RESULTS: Out of 145 testes, ultrasound corroborated PCPs' UDT diagnoses 87.6% of the time, 49.6% of which were confirmed as UDT by paediatric urologists. Ultrasound had a false positivity rate of 81.0% and specificity of 19.0%. Ultrasound versus paediatric urologist findings regarding testicle location were significantly different (P < 0.0001). Patients aged ≥8 years old had 5.2 times greater odds of being misdiagnosed with UDT than patients <8 years old (95% confidence interval: 1.6-16.7; P < 0.002) by PCP and ultrasound. CONCLUSION: Scrotal ultrasound highly corroborated PCPs' UDT diagnoses. Older patients were more likely to be misdiagnosed with UDT by PCP and ultrasound. As ultrasounds rarely refute PCP examinations for suspected UDTs and are highly inaccurate, confirmation bias may explain the use of ultrasound in the workup of UDT.

Utility of renal scintigraphy in diagnosis of multicystic dysplastic kidney.

PURPOSE: To compare the prevalence of vesicoureteral reflux (VUR), febrile urinary tract infection (fUTI), and chronic kidney disease (CKD) among patients with multicystic dysplastic kidney (MCDK) diagnosed by renal scintigraphy (RS) versus follow-up renal ultrasound (RUS) alone. METHODS: This was a retrospective review of patients seen at a tertiary care center from 2010 to 2020 with MCDK diagnosed by RS or follow-up RUS. Differences in the prevalence of VUR, fUTI, and CKD by cohort were assessed using logistic regression analysis, Pearson X2 , and Fisher's Exact tests. Temporal trends in diagnostic methods used (RUS versus RUS + RS) were evaluated using the Cochran-Armitage trend test. RESULTS: One-hundred seventy-two patients were included: 50% (n = 86) underwent RUS + RS and 50% (n = 86) underwent RUS alone to diagnose MCDK. Prevalence of VUR, fUTI, and CKD did not significantly vary between groups. Among patients who had a VCUG, 4.4% had contralateral VUR (1.7% RUS + RS group; 7.4% RUS group; p = 0.19) and 14.5% had at least one fUTI (16.3% RUS + RS group; 12.8% RUS group; p = 0.52). Females were significantly more likely to have at least one fUTI (p = 0.04). Four patients (2.3%) developed CKD, all in the RUS + RS cohort (p = 0.12). Diagnosis of MCDK by RUS versus RUS + RS did not significantly vary over time (p = 0.17). CONCLUSION: Patients with unilateral MCDK confirmed by RS versus RUS alone do not significantly vary in the prevalence of VUR, fUTI, or CKD. Renal scintigraphy studies may not be necessary in unilateral MCDK diagnosis but continue to be used.

Persistent Anhydramnios and Lower Urinary Tract Obstruction in a Patient With a Vesicoamniotic Shunt.

Persistent anhydramnios after placement of a vesicoamniotic shunt is a rare but potentially serious concern in a patient in utero. We present the case a male fetus who at 32-week gestation had bilateral hydroureteronephrosis, a distended bladder, and anhydramnios. A vesicoamniotic shunt was placed, but the anhydramnios persisted. Postnatally, the child was found to have a migrated shunt, left grade V vesicoureteral reflux and posterior urethral valves. He underwent a posterior urethral valves ablation and removal of the migrated shunt. The patient is now 2 years old and is doing well with no urinary tract infections or renal deterioration.

Employment and further study outcomes for care-experienced graduates in the UK.

Life outcomes for people who spent time in the care of the state as children ('care-experienced') are known to be significantly lower, on average, than for the general population. The reasons for this are complex and multidimensional, relating to social upheaval, disrupted schooling, mental and physical health issues and societal stigmatisation. Previous studies across several countries have demonstrated that they are significantly less likely to participate in higher education and more likely to withdraw early. However, little is currently known about their outcomes after graduation. This paper therefore explores the initial outcomes for the 1,010 full-time students identified as care-experienced within the cohort graduating from an undergraduate degree programme in the UK in 2016/17-the most recent year for which data are available. They were found to be slightly more likely to be unemployed and less likely to be in work (and particularly professional work) than their peers, but, conversely, more likely to be studying. These differences largely disappeared once background educational and demographic factors were controlled. The paper discusses the relationship between care-experience and other sites of inequality, concluding that care-experienced graduates are crucially over-represented in groups that are disadvantaged in the graduate labour market-e.g. by ethnicity, disability or educational history. This intersectional inequality largely explains their lower graduate outcomes. While there are important limitations with the data available, this speaks for the transformational potential of higher education in enabling care-experienced graduates to transcend childhood adversity. Recommendations for national policy and local practices conclude the paper.

Sample Size, Power, and Risk of Misclassification in Pediatric Urology Hospital Rankings.

PURPOSE: We investigated 2019 and 2020 U.S. News & World Report methodologies of assessing pediatric urology surgical revision rates for distal hypospadias, pyeloplasty, and ureteral reimplantation to evaluate statistical power and misclassification risks. MATERIALS AND METHODS: Median annual volumes of distal hypospadias, pyeloplasty, and ureteral reimplantation procedures by hospital from 2016 to 2018 were calculated using the Pediatric Health Information System® database. U.S. News & World Report 2019 and 2020 methodologies were assessed to calculate power required to detect differences between hospitals and risk of hospital misclassifications. RESULTS: Median (IQR) annual hospital procedure volume was 72 (43-97) for distal hypospadias procedures, 19 (9-34) for pyeloplasties, and 35 (19-50) for ureteral reimplantations. Based on 2019 methodology, in order to achieve 80% power 764 cases/hospital are required to distinguish between a 1% vs 3% surgical revision rate, 1,500 cases/hospital are required to distinguish between a 3% vs 5% revision rate, and 282 cases/hospital are required to distinguish between a 1% vs 5% revision rate. Based on 2020 methodology, 98.0% of hospitals do not have adequate ureteral reimplantation volume to achieve full points even when reporting no revisions; similarly, 66.0% do not have adequate pyeloplasty volume, and 10.9% do not have adequate distal hypospadias volume. Risks of misclassification exceed 50% in several instances among hospitals reporting distal hypospadias and pyeloplasty revisions using both 2019 and 2020 methodology. CONCLUSIONS: Based on median-volume hospitals, current U.S. News & World Report methods for classifying revision rates for distal hypospadias, pyeloplasty, and ureteral reimplantation have insufficient power and are at high risk for misclassification.

Association between severity of prenatally diagnosed hydronephrosis and receipt of surgical intervention postnatally among patients seen at a fetal-maternal center.

BACKGROUND: Hydronephrosis (HN) is the most common abnormality detected on prenatal ultrasound. This study sought to stratify outcomes of patients by severity of prenatal HN with postnatal outcomes. METHODS: This was a retrospective review of patients referred to a tertiary care fetal-maternal clinic with diagnosis of prenatal HN from 2004 to 2019. HN severity was categorized as mild, moderate, or severe. Data were analyzed to determine the association between HN severity and surgical intervention. Decision for surgery was based on factors including history of multiple urinary tract infections, evidence of renal scarring, and/or reduced renal function. Surgery-free survival time was represented by the Kaplan-Meier method, and hazard ratios were calculated using the log-rank test. RESULTS: 131 kidneys among 101 infants were prenatally diagnosed with hydronephrosis; 35.9% had mild HN, 29.0% had moderate HN, and 35.1% had severe HN. 8.5% of patients with mild HN, 26.3% of patients with moderate HN, and 65.2% of patients with severe HN required surgery. Patients with severe HN were 12.2 (95% CI 6.1-24.4; p < 0.001) times more likely to undergo surgery for HN than patients with mild HN and 2.9 (95% CI 1.5-5.3; p = 0.003) times more likely to undergo surgery than patients with moderate HN. Patients with moderate HN were 4.3 times more likely to require surgery than patients with mild HN (95% CI 1.5-12.9; p = 0.01). Median age at surgery was 11.8 months among patients with mild HN (IQR 11.7-14.1 months), 6.6 months among patients with moderate HN (IQR 4.2-16.4 months), and 5.4 months among patients with severe HN (3.7-12.4 months). CONCLUSION: Among this cohort of referrals from a fetal-maternal clinic, severity of HN correlated with increased likelihood of surgical intervention. Continued assessment of patients with prenatal HN should be evaluated to best determine the role of the pediatric urologist in cases of prenatal HN.

A multicenter study of acute testicular torsion in the time of COVID-19.

BACKGROUND: Testicular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure. OBJECTIVE: To assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period. STUDY DESIGN: Patients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal-Wallis tests, Chi-square tests, and logistic regression. RESULTS: A total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5-48.0) and 7.5 h (IQR 4.0-28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04). DISCUSSION: We found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group. CONCLUSIONS: In a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures.

PURPOSE: The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures. METHODS: We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models. RESULTS: 805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures. CONCLUSIONS: Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.