Atypical Presentation Delays Treatment of Pediatric Testicular Torsion.

OBJECTIVE: The aim of the study is to identify patient- and care-related factors associated with time to treatment for acute testicular torsion and the likelihood of testicular loss. METHODS: Data were retrospectively collected for patients 18 years and younger who had surgery for acute testicular torsion between April 1, 2005, and September 1, 2021. Atypical symptoms and history were defined as having abdominal, leg, or flank pain, dysuria, urinary frequency, local trauma, or not having testicular pain. The primary outcome was testicular loss. The primary process measure was time from emergency department (ED) triage to surgery. RESULTS: One hundred eleven patients were included in descriptive analysis. The rate of testicular loss was 35%. Forty-one percent of all patients reported atypical symptoms or history. Eighty-four patients had adequate data to calculate time from symptom onset to surgery and time from triage to surgery and were included in analyses of factors affecting risk of testicular loss. Sixty-eight patients had adequate data to evaluate all care-related time points and were included in analyses to determine factors affecting time from ED triage to surgery. On multivariable regression analyses, increased risk of testicular loss was associated with younger age and longer time from symptom onset to ED triage, while longer time from triage to surgery was associated with reporting atypical symptoms or history.The most frequently reported atypical symptom was abdominal pain, in 26% of patients. These patients were more likely to have nausea and/or vomiting and abdominal tenderness but equally likely to report testicular pain and swelling and have testicular findings on examination. CONCLUSIONS: Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

Enhanced Recovery After Surgery for an Uncommon Complex Urological Procedure: The Complete Primary Repair of Bladder Exstrophy.

PURPOSE: ERAS (enhanced recovery after surgery) protocols are designed to optimize perioperative care and expedite recovery. Historically, complete primary repair of bladder exstrophy has included postoperative recovery in the intensive care unit and extended length of stay. We hypothesized that instituting ERAS principles would benefit children undergoing complete primary repair of bladder exstrophy, decreasing length of stay. We describe implementation of a complete primary repair of bladder exstrophy-ERAS pathway at a single, freestanding children's hospital. MATERIALS AND METHODS: A multidisciplinary team developed an ERAS pathway for complete primary repair of bladder exstrophy, which launched in June 2020 and included a new surgical approach that divided the lengthy procedure into 2 consecutive operative days. The complete primary repair of bladder exstrophy-ERAS pathway was continuously refined, and the final pathway went into effect in May 2021. Post-ERAS patient outcomes were compared with a pre-ERAS historical cohort (2013-2020). RESULTS: A total of 30 historical and 10 post-ERAS patients were included. All post-ERAS patients had immediate extubation (P = .04) and 90% received early feeding (P < .001). The median intensive care unit and overall length of stay decreased from 2.5 to 1 days (P = .005) and from 14.5 to 7.5 days (P < .001), respectively. After final pathway implementation, there was no intensive care unit use (n=4). Postoperatively, no ERAS patient required escalation of care, and there was no difference in emergency department visits or readmissions. CONCLUSIONS: Applying ERAS principles to complete primary repair of bladder exstrophy was associated with decreased variations in care, improved patient outcomes, and effective resource utilization. Although ERAS has typically been utilized for high-volume procedures, our study highlights that an enhanced recovery pathway is both feasible and adaptable to less common urological surgeries.

Telemedicine for Pediatric Urological Postoperative Care is Safe, Convenient and Economical.

PURPOSE: We compared virtual visits, ie remote patient encounters, via a live video system, with conventional in-person visits with respect to clinical outcomes, family experience and costs in a pediatric urology surgical population. MATERIALS AND METHODS: Patients were enrolled in a prospective cohort study comparing postoperative virtual and in-person visits during a 4-month period in 2018. Appointment status and time metrics were tracked. The primary outcome was the safety of virtual visits, assessed by comparing the number of additional in-person visits, emergency department encounters and hospital readmissions. Secondary outcomes included the family assessment of the encounter and associated costs. After each visit families were prompted to complete a survey that assessed missed work/school and direct costs. Opportunity cost was estimated using reported missed work time, average national hourly wage and visit duration. RESULTS: Overall 107 virtual and 100 in-person postoperative visits were completed. There was no difference in patient characteristics, appointment compliance or clinical outcomes between the cohorts. Travel and waiting for care accounted for 98.4% of the total time spent for an in-person visit. With the virtual visit significantly less work and school were missed by parents and children, respectively. The opportunity costs associated with an in-person visit were computed at $23.75 per minute of face time with a physician, compared to $1.14 for a virtual visit. CONCLUSIONS: For pediatric postoperative care virtual visits are associated with shorter wait times, decreased missed work and school, and clinical outcomes similar to those of in-person visits. Telemedicine appears to reduce the costs associated with these brief but important encounters.

Anxiety, distress, and pain in pediatric urodynamics.

AIMS: No one has assessed urodynamic studies (UDS) to determine those steps that elicit the greatest anxiety, distress, and pain in children. We sought to systematically evaluate a child's UDS experience to mollify these reactions. METHODS: Prospective study involving children aged ≥5 undergoing UDS over a 6-month period (from 10 December 2018 to 22 May 2019). Upon arrival, patients completed a visual analog scale for anxiety (VAS-A, 0-10) about the upcoming procedure. A research assistant assessed the patient's behavior during each major step of UDS using a validated brief behavioral distress scale. Nursing staff also obtained patients' pain ratings (0-10) for these key elements. Immediately after UDS, each child completed a posttest VAS-A along with a survey about the UDS experience. RESULTS: A total of 76 UDS were observed; almost half included sphincter needle electromyography (EMG). Mean patient VAS-A scores were 2.3 before UDS, compared to 0.8 afterward (P < .001). The highest proportion of distressful behaviors were observed during EMG needle (31%) and urethral catheter (29%) insertion, in agreement with the highest mean pain scores of 3.2 and 2.7, respectively. Fifty-four percent of children reported not being completely aware of what was going to happen before the procedure and 50% of those patients exhibited at least one interfering or potentially interfering behavior. Similarly, 60% of children with no prior history of UDS exhibited at least one interfering or potentially interfering behavior. CONCLUSIONS: EMG needle and urethral catheter placement, initial urodynamic testing and not knowing what to expect were associated with greater pain and distress during pediatric UDS.

The Use of Telemedicine for the Postoperative Urological Care of Children: Results of a Pilot Program.

PURPOSE: For postoperative visits, which are often brief interactions between family and clinician, patients may prefer the convenience of receiving postoperative care from home. We evaluated the feasibility of telemedicine for postoperative encounters in pediatric urology. MATERIALS AND METHODS: We performed a prospective telemedicine pilot study during an implementation period from November 10, 2017 to March 22, 2018. All postoperative patients deemed eligible by 1 of 4 urologists were offered enrollment in the telemedicine program. Enrollees underwent at least 1 virtual visit within 6 weeks of surgery. Technical difficulties and the number of unscheduled visits and readmissions were noted. After each virtual evaluation the family and clinician were prompted to complete a survey pertaining to perceptions of the telemedicine experience, including how effective the virtual visit was in delivering care. For each virtual visit with a urologist we estimated roundtrip travel cost and time. RESULTS: There was 96% technical success when using the software. A total of 125 postoperative virtual visits were completed in 83 patients. Median age of the children was 3.4 years and 87% were boys. Clinicians found that the virtual visit was "very effective" in 86% of cases, delivering the same care that they would have provided during a visit in person. Families were estimated to have saved a mean $150 travel cost and a median of 113 minutes of travel time per visit. No adverse postoperative outcomes were observed. CONCLUSIONS: This pilot study demonstrates that telemedicine can be successfully implemented in the postoperative care of pediatric urology patients.

Factors contributing to telemedicine efficacy in pediatric urology.

INTRODUCTION: Despite swift implementation of telemedicine with the coronavirus disease 2019 pandemic, there is a paucity of research on its use for management of pediatric urology patients. Specifically, there is limited knowledge and inconsistent data on the effectiveness of telemedicine for various pediatric urologic conditions. Our aim was to evaluate the efficacy of pediatric urological care provided via video visits (VVs) at a large tertiary care children's hospital. MATERIAL AND METHODS: We performed a prospective assessment of pediatric urology patients younger than 21 years who had a VV between 5/18/2022 and 5/17/2023. New patients with a testicular diagnosis were not eligible for VVs. After entering the diagnosis and submitting billing using a modifier for telemedicine, clinicians were mandated to select whether the VV allowed for: complete case management (CCM), suboptimal case management (SCM), or incomplete case management (ICM) requiring an in-person visit. Case management categorizations were analyzed according to patient pathology, visit type (i.e., new or established), and patient-centered variables including age, sex, race, insurance type, need for an interpreter, and distress score [a proxy for socioeconomic status]. RESULTS: During the one-year period, there were 3267 telemedicine patients with a median age of 9 years (IQR 3-13) and 57.0% were male. Most VVs (89.3%) were established encounters. Almost 12% of telemedicine patients had external organ pathology (EOP, e.g., phimosis), 43.0% had internal organ pathology (IOP, e.g., hydronephrosis), and 45.1% had functional urological pathology (FUP, e.g., dysfunctional voiding). Clinicians deemed 96.9%, 2.7%, and 0.5% of VVs as having CCM, SCM or ICM, respectively. Telemedicine patients with IOP or FUP were more likely to have CCM, than those with EOP (98.5% and 97.8% vs 87.1%, p < 0.0001). On multivariable analysis, patient age, pathology, and visit type were predictive of VV efficacy. DISCUSSION: Now that telemedicine use has slowed, it is necessary to evaluate and establish its optimal role in pediatric urology. Factors associated with VV efficacy included older patient age, internal organ or functional urological pathology, and established encounters. The long-term success of telemedicine requires suitable patient selection. CONCLUSIONS: Telemedicine is quite effective for the management of a wide variety of pediatric urology patients. Continued evaluation of telemedicine, including multi-institutional investigation and corroboration, is necessary for the development of evidence-based best practice guidelines regarding appropriate, safe, and effective integration of telemedicine that drives pediatric urological care forward to meet the demands of the future.

The impact of procedural activities on musculoskeletal pain experienced by pregnant surgeons.

BACKGROUND: Two-thirds of surgeons report work-related musculoskeletal disorders (WRMD). There is limited data on WRMD symptoms experienced by pregnant surgeons. METHODS: We distributed an electronic survey via personal contacts to attending and trainee surgeons across six academic institutions to assess the impact of procedural activities and surgical ergonomics (SE) on WRMD symptoms during pregnancy. RESULTS: Fifty-three respondents were currently or had been pregnant while clinically active, representing 93 total pregnancies. 94.7% reported that symptoms were exacerbated by workplace activities during pregnancy and 13.2% took unplanned time off work as a result. Beyond 24 weeks of pregnancy, 89.2% of respondents continued to operate/perform procedures, 81.7% worked >24-h shifts and 69.9% performed repetitive lifting >50 pounds. No respondents were aware of any institutional pregnancy-specific SE policies. CONCLUSIONS: Procedural activities can exacerbate pain symptoms for the pregnant surgeon. SE best practices during pregnancy warrant further attention.

Environmental Impact of a Pediatric and Young Adult Virtual Medicine Program: A Lesson from the COVID-19 Pandemic.

OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) pandemic led to the expansion of virtual medicine as a method to provide patient care. We aimed to determine the impact of pediatric and young adult virtual medicine use on fossil fuel consumption, greenhouse gas, and nongreenhouse traffic-related air pollutant emissions. METHODS: We conducted a retrospective analysis of all virtual medicine patients at a single quaternary-care children's hospital with a geocoded address in the Commonwealth of Massachusetts prior to (March 16, 2019-March 15, 2020) and during the COVID-19 pandemic (March 16, 2020-March 15, 2021). Primary outcomes included patient travel distance, gasoline consumption, carbon dioxide and fine particulate matter emissions as well as savings in main hospital energy use. RESULTS: There were 3,846 and 307,273 virtual visits performed with valid Massachusetts geocoded addresses prior to and during the COVID-19 pandemic, respectively. During 1 year of the pandemic, virtual medicine services resulted in a total reduction of 620,231 gallons of fossil fuel use and $1,620,002 avoided expenditure as well as 5,492.9 metric tons of carbon dioxide and 186.3 kg of fine particulate matter emitted. There were 3.1 million fewer kilowatt hours used by the hospital intrapandemic compared to the year prior. Accounting for equipment emissions, the combined intrapandemic emission reductions are equivalent to the electricity required by 1,234 homes for 1 year. CONCLUSIONS: Widespread pediatric institutional use of virtual medicine provided environmental benefits. The true potential of virtual medicine for decreasing the environmental footprint of health care lies in scaling this mode of care to patient groups across the state and nation when medically feasible.

Speaking and listening: The importance of stakeholder engagement in quality improvement in pediatric urology.

To improve health care, we as clinicians must work to change processes that make it easier to do our job well and reliably every day. Before improving a process, we must understand it and this often requires employing the expertise of others. Indeed, quality improvement work is often done in teams. The key is identifying and engaging the right stakeholders for each improvement initiative. The goal of this review is to provide health care professionals with the basis for how to do this. We describe four essential stakeholder steps that aid in the success of a quality improvement initiative. The steps of 1.) identifying and 2.) categorizing stakeholders involve spending the time to think about who the necessary stakeholders are and how to organize them. It is essential to consider stakeholders who are balanced for expertise, skills, experience, perspective, gender, race, and ethnicity. The process then moves on to 3.) analyzing stakeholders, which supports efforts that are focused on the stakeholder relationships that will most impact project success. The final step is 4.) stakeholder engagement. This represents a critical opportunity, not only upfront, but also to maintain a high level of stakeholder engagement throughout the quality improvement project. As the improvement work evolves, it is important to return to the earlier steps and reflect on the stakeholder group; the process is iterative. Devoting sufficient energy and time to these stakeholder steps will provide ample returns. This review should assist health care professionals in establishing an improvement team for each quality improvement initiative, which is foundational to initiating change efforts that better system performance, enhance the quality of care, and ensure patient safety.

Characterizing digital access in pediatric urology.

BACKGROUND: Virtual medicine has the potential to improve access for underserved populations by facilitating timely remote evaluation. However, challenges in the real-world implementation of this technology may paradoxically exacerbate health disparities. We sought to characterize families' digital access and how social determinants of health may impact virtual medicine access within pediatric urology. We hypothesized that disadvantaged socioeconomic status would be a barrier to virtual medicine access. STUDY DESIGN: A digital access screening tool was prospectively developed and launched in July 2021. Schedulers are prompted to complete this optional screening questionnaire at the time of patient intake, for video or in-person encounters. The parent is screened for access to a device and reliable internet or cellular data that could be used to participate in a video visit. These represented the primary study outcomes. A modality preference for an in-person visit, video visit, or no preference was also recorded. Patient demographics were retrospectively evaluated, and socioeconomic status was estimated using the Distressed Communities Index generated for each patient's zip code. For each zip code, the Distressed Communities Index produces a normalized, comparative distress score ranging from 0 ("prosperous") to 100 ("distressed"). RESULTS: 3885 patients were included, with median age of 5 years (IQR 1-11). Almost 74% were male, 71.3% were White, 20.9% had public insurance, and 2.9% required an interpreter. The median distress score was 14.2 (IQR 7.2-27.5). Screening revealed that 136 families (3.5%) lacked digital access. On multivariable logistic regression analysis, insurance type (p = 0.0020) and distress score (p = 0.0125) were significant predictors of digital access (Summary Table). Those patients who lacked access to a device (p < 0.0001) or reliable internet/cellular data (p < 0.0001) were more likely to prefer an in-person visit. DISCUSSION: Family screening revealed that there is a small but significant proportion of families who lack digital access, and this cohort disproportionately represents underserved communities with higher distress scores, likely reflecting lower socioeconomic status. Those families without digital access were more likely to prefer an in-person visit. Improved identification of these socially complex "at-risk" patients can assist in the development of more inclusive health care strategies. CONCLUSIONS: Despite the chance for virtual medicine to expand access for underserved populations, lack of digital tools may hinder its potential impact on health disparities in pediatric urology. Ongoing digital access screening and further studies are needed to design interventions tailored to the specific needs of our patients, allowing for more equitable pediatric urological care.

Accuracy of telemedicine for diagnosis and pre-operative assessment of pediatric penile conditions.

INTRODUCTION: Patients with penile conditions comprise a significant proportion of any pediatric urology practice, and physical examination is the mainstay of diagnosis for such conditions. While the rapid adoption of telemedicine (TM) facilitated access to pediatric urology care during the pandemic, the accuracy of TM-based diagnosis for pediatric penile anatomy and pathology has not been studied. Our aim was to characterize the diagnostic accuracy of TM-based evaluation of pediatric penile conditions by comparing diagnosis during the initial virtual visit (VV) with a subsequent in-person visit (IPV). We also sought to assess the agreement between scheduled and actual surgical procedure performed. METHODS: A single-institution prospective database of male patients less than 21 years of age who presented for evaluation of penile conditions between August 2020 and December 2021 was analyzed. Patients were included if they had an IPV with the same pediatric urologist within 12 months of the initial VV. Diagnostic concordance was based on a surgeon-reported survey of specific penile diagnoses, completed at both initial VV and follow-up IPV. Surgical concordance was assessed based on the proposed versus billed CPT code(s). RESULTS: Median age among 158 patients was 10.6 months. The most frequent VV diagnoses were penile adhesions (n = 37), phimosis (n = 26), "other" (n = 24), post-circumcision redundancy (n = 18), and buried penis (n = 14). Initial VV and subsequent IPV diagnoses were concordant in 40.5% (64/158); 40/158 (25%) had partial concordance (at least one diagnosis matched). There was no difference in age, race, ethnicity, median time between visits, or device type between patients with concordant vs. discordant diagnoses. Of 102 patients who underwent surgery, 44 had VV only while 58 had IPV prior to surgery. Concordance of scheduled versus actual penile surgery was 90.9% in those patients who only had a VV prior to surgery. Overall, surgery concordance was lower among those with hypospadias repairs vs. non-hypospadias surgery (79.4% vs. 92.6%, p = 0.05). CONCLUSION: Among pediatric patients being evaluated by TM for penile conditions, there was poor agreement between VV-based and IPV-based diagnoses. However, besides hypospadias repairs, agreement between planned and actual surgical procedures performed was high, suggesting that TM-based assessment is generally adequate for surgical planning in this population. These findings leave open the possibility that, among patients not scheduled for surgery or IPV, certain conditions might be misdiagnosed or missed entirely.

Press Ganey Ratings in Urology: Who is at Risk of Bias?

OBJECTIVE: To evaluate effect of patient and physician demographics on Press Ganey (PG) survey ratings for urologists. METHODS: PG surveys (02/2020-08/2021) for urologists at a single tertiary care center were analyzed. Univariate and multivariate logistic regression models were used to assess the relationship between patient and physician-level covariates and the primary outcome of a "topbox" Overall Doctor Rating (topbox-ODR) score of 9 or 10 of 10. RESULTS: A total of 4155 surveys of 20 attending urologists (8 female (F)) across 7 subspecialties, were assessed. Mean ODR score for F physicians was 9.2 (SD 1.7) compared to 9.5 (SD 1.3) for males (M), P < .001. Univariate regression demonstrated that F patients are less likely (OR 0.27, P < .001) to give topbox-ODRs than M patients, and F physicians are 58% less likely (OR 0.42, P = .01) to receive topbox-ODRs than M physicians. Oncologists are more likely to receive topbox-ODRs (OR 3.3, P = .009) than all other subspecialists. Multivariate regression demonstrated that M patients are more likely to give M physicians top-box-ODRs (OR 0.32, P = .02), while F patients are less likely to give topbox-ODRs to physicians of both genders (M: OR 0.24, P < .001; F: 0.21, P < .001). Physicians in practice for >10 years are 66% less likely to receive topbox-ODRs (OR 0.33, P = .002). CONCLUSION: Urologists who care for F patients are at risk of being affected by bias in PG physician ratings. M physicians who care for M patients appear to be at the least risk; while F physicians who care for F patients appear to be at the highest risk.

Pediatric Clinicians' Use of Telemedicine: Qualitative Interview Study.

BACKGROUND: Bedside manner describes how clinicians relate to patients in person. Telemedicine allows clinicians to connect virtually with patients using digital tools. Effective virtual communication or webside manner may require modifications to traditional bedside manner. OBJECTIVE: This study aims to understand the experiences of telemedicine providers with patient-to-provider virtual visits and communication with families at a single large-volume children's hospital to inform program development and training for future clinicians. METHODS: A total of 2 focus groups of pediatric clinicians (N=11) performing virtual visits before the COVID-19 pandemic, with a range of experiences and specialties, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semistructured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded, and the corresponding transcripts were reviewed for data analysis. The transcripts were coded based on the identified main themes and subthemes. On the basis of a higher-level analysis of these codes, the study authors generated a final set of key themes to describe the collected data. RESULTS: Theme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialties and practices. A total of 3 key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt that telemedicine required new skills for patient interaction, and not all were comfortable with their training. CONCLUSIONS: Telemedicine provides benefits as well as challenges to health care delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. The inclusion of webside manner instructions within training curricula is crucial as telemedicine becomes an established modality for providing health care.

Management and outcomes for children with pyloric stenosis stratified by hospital type.

BACKGROUND: Access to health care has been a source of controversy and public attention in health policy. The issues of access to and utilization of the healthcare system by infants and children is less well documented. Moreover, the impact on outcomes of race, ethnicity, and economic status in infants is vaguely addressed. METHODS: We performed a retrospective analysis of children who had undergone pyloromyotomy from July 31, 1998 to July 31, 2008 at our public hospital and university teaching hospital. Data abstracted included gestational age at delivery, birth weight, gender, race, insurance status, age at presentation, symptom duration, preoperative ultrasound (US), operative date, laboratory evaluations, as well as preoperative, postoperative, and total length of stay (LOS). RESULTS: The mean total preoperative LOS was twice as long at our public hospital than our private hospital (1.78 d versus 0.85 d, P=0.003). Similarly, the mean total length of stay was 0.87 d longer at our public hospital (3.87 d versus 3 d), which trended toward significance (P=0.06). Significantly, 72% (27/33) patients at the private hospital had their US either as an out-patient or on the day of admission, while only 58% (28/48) had an US performed as expeditiously at the public hospital (P=0.03, chi(2) analysis). CONCLUSIONS: Care at our public hospital leads to delayed diagnosis and treatment, resulting in longer preoperative and total LOS in infants with pyloric stenosis, most likely related to the timing of the preoperative US. Efforts should be made to encourage patients to use the outpatient clinic facilities for their ill infants, or for physicians at public hospitals to expedite the US process once the diagnosis of pyloric stenosis is entertained.

"Ramping up telemedicine in pediatric urology- Tips for using a new modality".

The COVID pandemic has incited the rapid implementation of telehealth services. Through telemedicine, pediatric urologists can counsel children and their families about genitourinary tract conditions, while adhering to social distancing requirements and keeping families safe at home. With the accelerated use of telemedicine, it is crucial to maintain standards of providing high-quality and secure urologic care. Clinicians must practice effective virtual communication or 'webside' manner. While research may not be a priority, collecting data on telemedicine efforts will be critical in bringing about both payer-based and legislative reforms to encourage and enable wider telemedicine use in the post-COVID world.

Accuracy of Ultrasound in Identifying Renal Scarring as Compared to DMSA Scan.

OBJECTIVE: To assess the accuracy of renal ultrasound (RUS) in detecting renal scarring (RS). METHODS: All initial DMSA scans performed from 2006 to 2009 for history of urinary tract infection (UTI) or vesicoureteral reflux (VUR) in patients under 14 years old were identified, and clinical history obtained via chart review. Patients who had RUS within 4 months of DMSA scan and no documented UTI during that interval were included. Decreased uptake of tracer associated with loss of contours or cortical thinning defined a positive DMSA study. Increased echogenicity/dysplasia, cortical thinning, atrophic kidney and/or abnormal corticomedullary differentiation defined a positive RUS. The sensitivity and specificity of RUS in identifying RS were calculated using DMSA scan as the gold standard. RESULTS: A total of 144 patients had initial DMSA scans performed for UTI or VUR, with a RUS within 4 months, and no UTI between the 2 studies. Ninety-five of 144 (66%) had RS on DMSA and 49/144 (34%) did not. Patients with or without RS on DMSA were not different in gender (P = .073), age (P = .432), insurance (P = 1.000) or VUR grade (P = .132). Only 39/144 (27.1%) patients had positive RUS. The sensitivity of RUS for RS was 35.8% and the specificity was 89.8%, leading to an accuracy of 54.2% (95%CI; 45.7-62.5%, P = .999). CONCLUSION: RUS demonstrated poor sensitivity for RS visualized on DMSA scan. This suggests that RUS is a poor screening test for RS or indicators of future renal scar. A normal ultrasound does not rule out RS or risk of future renal scar. Specificity of RUS was excellent.

Is outpatient robotic pyeloplasty feasible?

With increased experience, many laparoscopic procedures have evolved from mandatory same-day admission to the outpatient setting. Given the shorter operative time and length of stay, the potential to perform robotic surgery as an outpatient procedure exists. We sought to describe our initial experience with performing robotic-assisted laparoscopic pyeloplasty (RP) on children in an outpatient setting. We retrospectively reviewed a prospectively collected database of all patients undergoing RP from July 2012 to May 2014 by a single surgeon. All patients discharged home within 12 h of completion of surgery were included in the analysis. Prior to discharge the Wong-Baker Pain Scale 1-10 was reviewed and given to all patients. All patients were prescribed oxybutynin and phenazopyridine for bladder spasms and stent discomfort. Post-operative follow-up telephone calls were made inquiring about oral intake, pain control, constitutional symptoms, and voiding issues. Readmission rates and post-operative outcomes were reviewed. During the study period, 62 children underwent RP and 13 patients (21 %) were selected for outpatient management. These 7 boys and 6 girls had a mean age of 8.1 years old. Of the 13 patients, 11 patients had left-sided procedures and 2 had right; all had primary UPJO. Mean pain score was 2.7 in the first 12 h at home. Within 24 h, the pain score decreased to a mean of 2.2. No patient required opioid analgesics and no child required admission after surgery. At 3-month follow-up, 7 patients had resolved hydronephrosis, 5 had improved hydronephrosis and 1 was unchanged. MAG3 renal scan in the latter patient showed no sign of obstruction. Outpatient RP is feasible and appears to be safe. Great care must be taken when selecting which patients can be fast tracked.