The impact of the distal ureteral diameter ratio, bladder volume at onset of vesicoureteral reflux, and/or grade in predictive models of clinical outcomes in children with vesicoureteral reflux.

PURPOSE: Vesicoureteral reflux (VUR) grade has been used as a primary factor in assessing a child's risk of clinical outcomes. Unfortunately, grade has poor inter-observer reliability. We hypothesized that more objective and reliable VCUG parameters including the distal ureteral diameter ratio (UDR) and volume at onset of VUR (Vol) may either augment or replace the current grading system to provide more reliable prediction of clinical outcomes. MATERIALS AND METHODS: Multivariate clinical outcome models were analyzed to assess the impact on predictive accuracy by the addition of voiding cystourethrogram (VCUG) data including grade, UDR, and Vol, alone or in combinations. Clinical variables from retrospective review of 841 children's records included age, gender, presentation, VUR laterality, bowel and bladder dysfunction, history of febrile urinary tract infection (UTI), and number of UTIs. The primary outcomes assessed included VUR resolution or persistence and need for operative intervention. RESULTS: Grade, UDR, and Vol were independent predictors of resolution and operative intervention. Vol increased predictive accuracy in resolution models with grade or UDR alone; however, no significant difference occurred in models with the substitution of grade with UDR. CONCLUSIONS: A more reliable classification system for VUR, with improved predictive accuracy regarding clinical outcomes, may be developed incorporating UDR and Vol. Whether VUR grade can be completely replaced by Vol and UDR measurements requires further evaluation with larger number of patients.

The Impact of Perioperative and Operative Variables on Early Postoperative Complications Following Primary Hypospadias Repair.

OBJECTIVE: To evaluate possible risk factors for complications following primary hypospadias repair relative to factors associated with timing of hypospadias repair in terms of case order, morning or afternoon scheduling, perioperative delays, and surgeon's daily work schedule as well as individual operative techniques. METHODS: We retrospectively reviewed charts of 422 boys undergoing primary hypospadias repair with a sutured urethroplasty by 1 of 3 surgeons over a 10-year period and the surgeon's daily schedule. RESULTS: The median age and IQR of the patients at time of operation was 0.79 (0.57) years, and median follow-up was 259 (664) days. A significant increase in the rate of any complication was noted with morning vs afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases (P =.012). Additionally, there was a significant increase in hazard of complication with increasing difference in time between actual procedure duration vs scheduled duration, with hazard of complication increasing 5% for each increase of 15 minutes of surgical time (P =.043). CONCLUSION: A variety of previously identified potential risk factors for hypospadias complications were identified. Our analysis also demonstrated variability in level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own results in response to changes in technique. Novel potential risk factors for some surgeons identified in our study included an increased risk of complications when the hypospadias was done in the morning rather than the afternoon and when the procedure lasted longer than scheduled.

Pilot study of a home use cystomanometer in patients with a neurogenic bladder.

INTRODUCTION: A novel device, the cystomanometer, was developed for home bladder pressure monitoring in patients with neurogenic bladder. OBJECTIVE: To report initial experience and proof of concept with home use of the cystomanometer. STUDY DESIGN: Patients were asked to use the device twice daily for two weeks. RESULTS: Fourteen patients with neurogenic bladder were enrolled. DISCUSSION: The cystomanometer initially functioned well and transmitted data to a smartphone and to the hospital server. However, over 50% of devices broke. CONCLUSIONS: We report the first home use of a handheld electronic cystomanometer with wireless data transmission to a smartphone and hospital database.

The additive impact of the distal ureteral diameter ratio in predicting early breakthrough urinary tract infections in children with vesicoureteral reflux.

INTRODUCTION: Many factors influence patient and provider decisions to surgically correct vesicoureteral reflux (VUR), including risk of breakthrough febrile urinary tract infections and likelihood of spontaneous resolution. Ureteral diameter ratio has been shown in several studies to be more predictive than reflux grade with regard to breakthrough urinary tract infection (UTI). We developed and investigated the accuracy of a computational model for predicating febrile breakthrough urinary tract infection within 13 months of starting prophylactic antibiotics in children with VUR. OBJECTIVE: The aim of this study was to validate a model for evaluating the impact of distal ureteral diameter ratio (UDR) in predicting early breakthrough urinary tract infections in children with VUR. STUDY DESIGN: Following a retrospective review, we recorded patient demographics, presenting symptoms, VUR grade, laterality, VUR during filling or voiding, initial bladder volume at the onset of VUR, ureteral duplication, voiding dysfunction, distal ureteral diameter ratio, and number of UTIs prior to VUR diagnosis. NeUROn++, a set of C++ programs, was used to model each data set using logistic regression and neural networks with different architectures. RESULTS: After exclusions, 136 children (93 girls and 43 boys) diagnosed with primary VUR had detailed VCUG and UDR data available. Fourteen children (10.3%) experienced breakthrough febrile UTI events within 13 months of VUR diagnosis. There was a significant association with UDR and breakthrough UTI (p = 0.008). Various computational prediction models for the outcome of breakthrough UTI were developed and evaluated. The computational model that fit best was a model using all variables with an ROC of 0.802. DISCUSSION AND CONCLUSIONS: Clinicians and parents often opt for intervention based on likelihood of spontaneous resolution of VUR as well as clinical course, thereby placing an emphasis on the ability to predict likelihood of breakthrough UTI infections. Our statistical analysis and prediction models further confirm UDR as an important variable predictive of breakthrough UTIs within the first 13 months of beginning prophylactic antibiotics. Furthermore, we developed a neural network model incorporating UDR and grade with an ability to yield the greatest accuracy of any breakthrough UTI predictive calculator to date at 80%.