Training low-middle-income (LMIC) pediatric surgeons in a high-income country (HIC) program.

BACKGROUND: A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership. METHODS: Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training. RESULTS: All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort. CONCLUSION: This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity. LEVEL OF EVIDENCE: V.

Cardiac Autonomic Nervous System Activity in Children with Bladder and Bowel Dysfunction.

PURPOSE: Bladder and bowel dysfunction is a common reason for referral to pediatric urology. The role of the autonomic nervous system in the pathogenesis of bladder and bowel dysfunction has not been well investigated. We compared autonomic nervous system activity in children with bladder and bowel dysfunction to that in healthy controls. We hypothesized that children with dysfunction have a different autonomic profile as measured by parameters from spectral analysis of heart rate variability and impedance cardiography. MATERIALS AND METHODS: We recruited 40 children, including 25 girls, with a median age of 10 years (range 5 to 18) in whom bladder and bowel dysfunction was clinically diagnosed by a validated questionnaire and 19 healthy controls, including 9 girls, with a median age of 8 years (range 5 to 16). Cardiac autonomic activity was assessed at baseline and during voiding. The primary outcome measures were the main parameters of heart rate variability, including total power and high frequency, as well as pre-ejection period and heart rate. RESULTS: Comparison of outcomes at baseline showed significantly lower total power and high frequency heart rate variability in bladder and bowel dysfunction cases (p = 0.001 and 0.002, respectively). Children with dysfunction also showed a significantly smaller decrease in sympathetic nervous system activity during voiding (p = 0.05). CONCLUSIONS: Our results demonstrate that compared to healthy controls children with bladder and bowel dysfunction show a different cardiac autonomic profile at rest and in response to voiding. This difference may be used in future studies to further clarify the pathophysiology of bladder and bowel dysfunction, and introduce novel treatment targets to manage the condition.

Filum Section for Urinary Incontinence in Children with Occult Tethered Cord Syndrome: A Randomized, Controlled Pilot Study.

PURPOSE: Occult tethered cord syndrome, in which there is normal neuroanatomic imaging despite clinical and urodynamic evidence of neuropathic bladder behavior, is controversial. Several uncontrolled series describe improvement in bladder function following section of the filum terminale. We performed a pilot randomized, controlled study comparing medical treatment to surgical section of the filum plus medical treatment in children with occult tethered cord syndrome. MATERIALS AND METHODS: Children refractory to standard medical management for 1 year or more with normal conus position on magnetic resonance imaging and abnormal urodynamics were randomized. Exclusion criteria included any neurological conditions, spinal dysraphism, bladder outlet obstruction and an atonic bladder. Patients were assessed at randomization and 1 year later with a standardized urodynamic score, the validated PEMQOL (Pediatric Enuresis Module on Quality of Life™) scale, and a validated bowel and bladder dysfunction score. RESULTS: After 8 years we accrued 21 patients. The bowel and bladder dysfunction score improved in the surgical and medical arms (20% and 24%) and the urodynamic score improved slightly (6% and 4%, respectively). The PEMQOL Child and Family Impact Scales improved modestly in both groups. All differences were nonsignificant. Interim analysis indicated that more than 700 patients in each arm would be required to demonstrate a statistical difference with respect to urodynamic score based on our preliminary data. CONCLUSIONS: There appears to be no objective difference in urological outcome between medical management plus or minus filum section for patients with occult tethered cord syndrome. These data challenge the existence of the concept of occult tethered cord syndrome, in which bowel and bladder dysfunction score is attributed to tethering by the filum despite a normally located conus.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic.

BACKGROUND: Renal colic is acute pain caused by urinary stones. The prevalence of urinary stones is between 10% and 15% in the United States, making renal colic one of the common reasons for urgent urological care. The pain is usually severe and the first step in the management is adequate analgesia. Many different classes of medications have been used in this regard including non-steroidal anti-inflammatory drugs and narcotics. OBJECTIVES: The aim of this review was to assess benefits and harms of different NSAIDs and non-opioids in the treatment of adult patients with acute renal colic and if possible to determine which medication (or class of medications) are more appropriate for this purpose. Clinically relevant outcomes such as efficacy of pain relief, time to pain relief, recurrence of pain, need for rescue medication and side effects were explored. SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register (to 27 November 2014) through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: Only randomised or quasi randomised studies were included. Other inclusion criteria included adult patients with a clinical diagnosis of renal colic due to urolithiasis, at least one treatment arm included a non-narcotic analgesic compared to placebo or another non-narcotic drug, and reporting of pain outcome or medication adverse effect. Patient-rated pain by a validated tool, time to relief, need for rescue medication and pain recurrence constituted the outcomes of interest. Any adverse effects (minor or major) reported in the studies were included. DATA COLLECTION AND ANALYSIS: Abstracts were reviewed by at least two authors independently. Papers meeting the inclusion criteria were fully reviewed and relevant data were recorded in a standardized Cochrane Renal Group data collection form. For dichotomous outcomes relative risks and 95% confidence intervals were calculated. For continuous outcomes the weighted mean difference was estimated. Both fixed and random models were used for meta-analysis. We assessed the analgesic effects using four different outcome variables: patient-reported pain relief using a visual analogue scale (VAS); proportion of patients with at least 50% reduction in pain; need for rescue medication; and pain recurrence. Heterogeneity was assessed using the I² test. MAIN RESULTS: A total of 50 studies (5734 participants) were included in this review and 37 studies (4483 participants) contributed to our meta-analyses. Selection bias was low in 34% of the studies or unclear in 66%; performance bias was low in 74%, high in 14% and unclear in 12%; attrition bias was low in 82% and high in 18%; selective reporting bias low in 92% of the studies; and other biases (industry funding) was high in 4%, unclear in 18% and low in 78%.Patient-reported pain (VAS) results varied widely with high heterogeneity observed. For those comparisons which could be pooled we observed the following: NSAIDs significantly reduced pain compared to antispasmodics (5 studies, 303 participants: MD -12.97, 95% CI -21.80 to - 4.14; I² = 74%) and combination therapy of NSAIDs plus antispasmodics was significantly more effective in pain control than NSAID alone (2 studies, 310 participants: MD -1.99, 95% CI -2.58 to -1.40; I² = 0%).NSAIDs were significantly more effective than placebo in reducing pain by 50% within the first hour (3 studies, 197 participants: RR 2.28, 95% CI 1.47 to 3.51; I² = 15%). Indomethacin was found to be less effective than other NSAIDs (4 studies, 412 participants: RR 1.27, 95% CI 1.01 to 1.60; I² = 55%). NSAIDs were significantly more effective than hyoscine in pain reduction (5 comparisons, 196 participants: RR 2.44, 95% CI 1.61 to 3.70; I² = 28%). The combination of NSAIDs and antispasmodics was not superior to NSAIDs only (9 comparisons, 906 participants: RR 1.00, 95% CI 0.89 to 1.13; I² = 59%). The results were mixed when NSAIDs were compared to other non-opioid medications.When the need for rescue medication was evaluated, Patients receiving NSAIDs were significantly less likely to require rescue medicine than those receiving placebo (4 comparisons, 180 participants: RR 0.35, 95% CI 0.20 to 0.60; I² = 24%) and NSAIDs were more effective than antispasmodics (4 studies, 299 participants: RR 0.34, 95% CI 0.14 to 0.84; I² = 65%). Combination of NSAIDs and antispasmodics was not superior to NSAIDs (7 comparisons, 589 participants: RR 0.99, 95% CI 0.62 to 1.57; I² = 10%). Indomethacin was less effective than other NSAIDs (4 studies, 517 participants: RR 1.36, 95% CI 0.96 to 1.94; I² = 14%) except for lysine acetyl salicylate (RR 0.15, 95% CI 0.04 to 0.65).Pain recurrence was reported by only three studies which could not be pooled: a higher proportion of patients treated with 75 mg diclofenac (IM) showed pain recurrence in the first 24 hours of follow-up compared to those treated with 40 mg piroxicam (IM) (60 participants: RR 0.05, 95% CI 0.00 to 0.81); no significant difference in pain recurrence at 72 hours was observed between piroxicam plus phloroglucinol and piroxicam plus placebo groups (253 participants: RR 2.52, 95% CI 0.15 to12.75); and there was no significant difference in pain recurrence within 72 hours of discharge between IM piroxicam and IV paracetamol (82 participants: RR 1.00, 95% CI 0.65 to 1.54).Side effects were presented inconsistently, but no major events were reported. AUTHORS' CONCLUSIONS: Although due to variability in studies (inclusion criteria, outcome variables and interventions) and the evidence is not of highest quality, we still believe that NSAIDs are an effective treatment for renal colic when compared to placebo or antispasmodics. The addition of antispasmodics to NSAIDS does not result in better pain control. Data on other types of non-opioid, non-NSAID medication was scarce.Major adverse effects are not reported in the literature for the use of NSAIDs for treatment of renal colic.

VURD syndrome--does it really preserve long-term renal function?

PURPOSE: VURD (posterior urethral valves, unilateral vesicoureteral reflux and renal dysplasia) syndrome is the combination of persistent unilateral vesicoureteral reflux associated with an ipsilateral dysplastic, poorly functioning kidney in patients with posterior urethral valves. It was postulated that this syndrome may result in preservation of long-term renal function due to a pressure release pop-off mechanism. We determined the effects of VURD long-term renal outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of boys diagnosed with posterior urethral valves between 1983 and 2009 at a single pediatric tertiary hospital. Patients were divided into those with and those without VURD syndrome. The outcome of interest was renal impairment, defined as stage 3 or greater chronic kidney disease (glomerular filtration rate less than 60 ml/min/1.73 m(2)). RESULTS: We identified 89 patients, of whom 23 (26%) had VURD. Median followup was 77 and 57 months in the VURD and nonVURD groups, respectively. Seven patients (30%) with and 26 (39%) without VURD had significant renal impairment. Survival analysis using a Cox proportional hazard model showed no association between VURD and renal impairment (HR 1.05, 95% CI 0.65-1.70). The main predictors of renal function were the creatinine nadir and patient age at diagnosis. CONCLUSIONS: VURD syndrome does not seem to have a long-term protective effect on renal function.

Prevalence of previously undiagnosed psychiatric symptom groupings in pediatric patients with bladder and bowel dysfunction.

INTRODUCTION AND OBJECTIVE: The incidence of concomitant psychiatric disorders in conjunction with bladder and bowel dysfunction (BBD) is thought to be higher than the general population. The identification of these disorders with validated tools followed by management may improve urological outcomes. The objective of this study was to determine the prevalence of undiagnosed psychiatric symptom groupings in children presenting with BBD. METHODS: Consecutive patients 6-18 yrs with a clinical diagnosis of BBD, a score ≥11 on the Vancouver Symptom Score (VSS) and no prior psychiatric diagnoses were recruited. Two validated questionnaires (Child Behavior Checklist for Ages 6-18 (CBCL) and Autism Spectrum Quotient 10 (AQ-10)) were used to screen for psychiatric comorbidities. Descriptive statistics for demographic variables were presented. Distribution of VSS for normal & abnormal categories (borderline/clinical) of CBCL scores were compared by Mann-Whitney U test. Spearman correlation coefficient was used to examine the relationship between VSS domain scores and CBCL. RESULTS: From Sept 2017-May 2022, 50 (17 male) of 110 eligible patients completed the study. Median VSS was 18 (11-33), indicating significant BBD. In 36 patients (72 %), at least one of the CBCL subscales scored as borderline/clinical. Thirty-two patients (64 %) scored in the abnormal range for Internalizing symptoms, 21 (42 %) for Externalizing symptoms, and 31 (62 %) for Total problem scores. Four patients of 48(8 %) scored ≥6 on the AQ-10. The only significant correlation found between CBCL and VSS sub scores was with the Bowel Habit Domain of VSS and Internalizing CBCL T-scores (P = 0.02). CONCLUSION: This study identified a high prevalence of previously undiagnosed psychiatric symptom groupings in patients presenting with BBD, with a higher prevalence of internalizing and externalizing symptoms and autism traits than reported in the general population. These findings should encourage urologists to use validated tools to screen for psychiatric comorbidities with referral for further assessment as appropriate. This may prevent unnecessary urological testing, save valuable health resources and potentially improve treatment outcomes of BBD in this population.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion for complex incontinence: closing the door for good.

PURPOSE: Bladder neck closure is an irreversible procedure requiring compliance with catheterization of a cutaneous stoma and historically has been reserved for the definitive treatment of intractable incontinence after prior failed procedures. We assessed long-term outcomes of our patients undergoing bladder neck closure including continence status, additional surgical interventions, postoperative complications, conception and sexual function, and satisfaction with bladder neck closure. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent bladder neck closure between 1990 and 2010 at our institution. RESULTS: A total of 28 consecutive patients (exstrophy 15 and neurogenic bladder 13 [myelomeningocele 4, cloacal anomaly 4, spinal cord injury 2, VACTERL (Vertebral Anorectal Cardiac Tracheo-Esophageal Radial Renal Limb) 1, sacral agenesis 1 and urogenital sinus 1]) were identified. Of these patients 19 (68%) had undergone 20 unsuccessful bladder neck procedures before bladder neck closure. Bladder neck closure was initially successful in 27 of the 28 (96.4%) patients. One patient required subsequent closure of a postoperative vesicovaginal fistula. Median time from bladder neck closure was 69 months (range 16 to 250). In 11 patients 16 additional procedures were required, including stomal injection of bulking agents (2), stomal revision for stenosis (2) or prolapse (1), percutaneous nephrolithotripsy for stone (1), open cystolithotomy (2), extracorporeal shock wave lithotripsy for upper tract stones (4), repair of augment rupture (3) and open retrograde ureteral stenting for stone (1). The total surgical re-intervention rate was 39.3% (11 of 28). There were no observed cases of progressive or de novo hydronephrosis. CONCLUSIONS: Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion is an effective means of achieving continence in complex cases as a primary or secondary therapy. Long-term urological followup into adulthood is essential.

Reliability assessment of international grading system for vesicoureteral reflux.

PURPOSE: The International Reflux Committee proposed a grading system for vesicoureteral reflux in 1985 which has been used extensively in everyday practice and research studies. Despite widespread use, based mainly on face validity, the interrater and intrarater reliability of this tool are not known. A tool cannot be considered valid unless it is reliable. Therefore, we estimated the interrater and intrarater reliability of the international grading system for vesicoureteral reflux. MATERIALS AND METHODS: A series of 28 voiding cystourethrogram studies were selected. The images were assembled in an electronic presentation in random fashion. Four pediatric radiologists, 5 pediatric urologists and 4 senior urology residents graded the studies. The images were then shuffled in a random fashion and re-rated after 7 days (total 728 observations). Cohen weighted kappa statistics were used to determine interrater and intrarater reliability. Subgroup analysis was then performed comparing the variability among the 3 groups of raters and different grades. RESULTS: The average interrater reliability was 0.53 (95% CI 0.52-0.55, p <0.0001). Agreement in subgroups was 0.61 for urologists, 0.59 for residents and 0.56 for radiologists. The lowest agreement was shown in grade III (0.36) and the highest in grade I (0.98). The intrarater reliability was 0.86 (95% CI 0.77-0.95, p <0.001). CONCLUSIONS: The international grading system for vesicoureteral reflux shows low interrater reliability for moderate degrees of vesicoureteral reflux whereas the intrarater reliability is high. Modification of this system may improve its reproducibility.

Bowel and Bladder Dysfunction Is Associated with Psychiatric Comorbidities and Functional Impairment in Pediatric Obsessive-Compulsive Disorder.

Objective: Neuropsychiatric disorders are common in children with bowel and bladder dysfunction (BBD), a syndrome associated with urinary frequency, urgency, holding, incontinence, and constipation. We evaluated BBD symptom severity in children and youth attending a tertiary care obsessive-compulsive disorder (OCD) clinic. Methods: Consecutive patients attending initial OCD assessments between 2016 and 2020 were invited to participate in a registry study. Diagnosis of OCD and comorbidities was established by structured clinical interview. OCD severity and impact were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and the Child Obsessive Compulsive Impact Scale (COIS-R; self-report), respectively. BBD symptoms were quantified with the Vancouver Symptom Score (VSS), a validated self-report measure. Results: One hundred twelve participants completed the VSS (mean age 13.5 ± 3.3, range 7-20). Based on a cutoff score of 11 corresponding to pediatric urologist-diagnosed BBD, 30.4% of participants screened positive, including more females than males (39.3% vs. 21.4%; p = 0.04). Daytime urinary incontinence was present in a greater proportion of participants with OCD forbidden thoughts (34.8% vs. 8.2%, p = 0.002), major depressive disorder (MDD; 38.5% vs. 6.8%, p = 0.001), and somatization disorder (60% vs. 9%, p = 0.001) compared with those without. A regression model including CY-BOCS, COIS-R, psychiatric comorbidities, medications, age, and gender explained 52.2% of the variance in VSS; COIS-R, tic disorder, and MDD were significant predictors. Conclusion: BBD symptoms are common and associated with high OCD-related impairment and psychiatric comorbidities. Standardized assessment may facilitate identification of BBD symptoms in this population and is critical to mitigating long-term physical and mental health impacts. Further studies are required to assess the relationship between BBD and OCD treatment outcomes.

Surveying unmet pediatric urological needs in low- and middle-income countries.

INTRODUCTION: Access to pediatric urological surgery is low in low-and-middle income countries (LMICs). Pediatric Urological missions have often been undertaken without best practice guidelines. Many strides have been made in pediatric general surgery and other surgery but little in pediatric urology as a component of global surgery. STUDY AIMS: The purpose of this study was to identify challenges to delivery of pediatric urological care in LMICs and make recommendations for its advancement. STUDY DESIGN: An internet search for reports and websites was undertaken. Published surveys from Global Initiative for Children Surgery (GICS) and American Pediatric Surgical Association (APSA) were evaluated. We developed and administered an additional questionnaire. Respondents included LMIC pediatric surgeons, HIC pediatric surgeons and HIC pediatric urologists and LMIC urologists and general surgeons. RESULTS: Most global surgical visits were short one-time visit, and respondents citing complex pediatric urologic patients as most neglected in LMICs with the main challenge reported as a lack of specialist surgeons, poor communication between groups and poor infrastructure. Local specialist training was universally recommended as the most effective way to address unmet needs, although the form of training was not clear. DISCUSSION: Most published work has looked at global general surgery or pediatric general surgery [1][2][3][6][8][11][13] but little on pediatric urology. Most of the information provided was blog posts of social engagements but rarely did these websites provide information on the surgical experience, challenges and solutions gleaned overtime[41][43][44][45][56] It is recognised by pediatric urologists, general urologists and pediatric surgeons that complex urologic anomalies are the most neglected among children's surgical conditions with a higher disability weight attributed to urologic conditions compared to anorectal conditions. [6][8][14][27][31][36][46], yet there's little expertise on ground and many challenges to its advancement. This study was limited by the number of questions we could explore due to the need to make questions fewer and more concise. CONCLUSIONS: Pediatric urological conditions remain among the most neglected in global surgery. Current missions face significant challenges that may result in suboptimal outcomes. A comprehensive effort to establish guidelines for these missions is imperative.

Computer enhanced visual learning method to train urology residents in pediatric orchiopexy provided a consistent learning experience in a multi-institutional trial.

PURPOSE: Computer enhanced visual learning is a new method to train residents to perform surgery using components and provide them with access to a personalized surgical feedback archive using the Internet. At the parent institution in Chicago we have already noted that this method is effective to train residents to perform orchiopexy. To assess whether this new methodology to enhance resident surgical instruction is generalizable we performed a prospective, multi-institutional clinical trial. MATERIALS AND METHODS: We prospectively compared ratings of resident skills in performing pediatric orchiopexy at 4 institutions as novices to computer enhanced visual learning curriculum (study group) vs those at the single institution accustomed to that curriculum (control group). All urology residents and attending physicians accessed the computer enhanced visual learning curriculum. After each case was completed the attending urologist rated resident performance of each step and provided feedback on weaknesses for the resident to remediate at the next case. The learning score was calculated for each case as the sum of the ratings × case difficulty. Scores on the first case and the best case were compared between the study and control groups by resident and institution. RESULTS: The study group included 6 attending physicians and 36 residents (99 orchiopexies). The control group included 8 attending physicians and 21 residents (108 orchiopexies). Between the study and control groups we noted no significant differences in average resident postgraduate year (2.9 vs 2.7), number of procedures per resident (3.9 vs 4.9), frequency with which residents viewed computer enhanced visual learning preoperatively (63% vs 74%) or attending physician provision of feedback (63% vs 88%) (each p not significant). Similarly of residents who completed more than 1 surgery there was no significant difference in the percent who showed an improved learning score in the study vs the control group (86% vs 79%) or in the magnitude of average improvement (10.5 vs 13.4) (each p not significant). CONCLUSIONS: The institutional groups did not differ in training resident skills using computer enhanced visual learning for pediatric orchiopexy. Thus, the program provides a consistent learning experience and is generalizable across institutions. We believe that this tool will change the practice of how training programs educate residents by enhancing learning by a checklist approach and a computer platform to archive feedback and remediation.

The use of cryoplasty in a benign ureteric stricture.

Ureteral stricture is one of the most common complications following renal transplant. Current treatment options are limited to mainly surgery or balloon dilation, but mixed results and refractory cases present the opportunity for alternative treatments. Anterograde balloon cryoplasty of a benign ureteric stricture was performed in a renal transplant patient, after attempts with ballooning and stenting had failed. A 2-year follow-up demonstrates normal creatinine and no hydronephrosis on US images.

Development of a symptom score for dysfunctional elimination syndrome.

PURPOSE: Dysfunctional elimination syndrome is a heterogeneous syndrome with no widely accepted diagnostic criteria. Previously developed questionnaires provide incomplete psychometric assessment. We developed a discriminative questionnaire for diagnosing dysfunctional elimination syndrome and assessed its validity and reliability. MATERIALS AND METHODS: A 14-item 5-point Likert scale questionnaire was devised using literature review, expert opinions and patient input. The questionnaire was administered to 62 children 4 to 16 years old (median age 8) clinically diagnosed with dysfunctional elimination syndrome by a pediatric urologist, of whom 71% were female. It was also administered to 50 healthy controls 4 to 16 years old (median age 7), of whom 66% were female. Children with structural abnormalities were excluded from study. To assess reliability 50 participants were asked to complete the questionnaire again 1 week later. RESULTS: Median total score in cases and controls was 14 of 52 (range 4 to 30) and 6 of 52 (range 1 to 13), respectively. The difference was statistically significant (p = 0.001). Discriminant function analysis showed 80% accuracy. ROC curve showed a score of 11 as the optimum threshold with an AUC of 0.903 (95% CI 0.814-0.948). Test-retest reliability was 84.5% (p = 0.001). Factor analysis showed unloading on 4 factors, corresponding to urinary incontinence, urgency, obstructive symptoms and constipation/fecal soiling. Of participants 85% classified the questionnaire as very easy or easy to complete. CONCLUSIONS: This new questionnaire is valid and reliable for diagnosing dysfunctional elimination syndrome. It can be used as a clinical or research instrument.

Impact of a training program on the performance of graduating Canadian residents on a national urology exam: Results of the last 20 years.

INTRODUCTION: Many factors impact the performance of graduating residents on certification exams. It is thought that most factors are related to the individual candidate's ability, motivation, and work ethic. Less understood, however, is whether a training program has any impact on the preparation and performance of its graduates on certification exams. We present 20 years of results of a national preparatory exam that all graduating residents complete about three months before the Royal College of Physicians and Surgeons of Canada (RCPSC) qualifying urology exam. This exam, known colloquially as QUEST, aims to simulate the RCPSC exam with written and oral components. We aimed to analyze the impact of a training program on the performance of its residents. METHODS: A retrospective review of exam results from 1997-2016 was conducted. During that time, 495 candidates from all 12 Canadian urology training programs undertook the exam. The performance of graduating residents from each individual program was grouped together for any given year. The different programs were anonymized, as the aim of this study is to assess the impact of a training program and not to rate the different programs. Statistical analysis using one-way ANOVA was conducted. RESULTS: All training programs fall within one standard deviation of the mean for the written component, the oral component, and the overall score. The residents of four training programs had statistically better scores than the overall mean of the written component. The residents of three out of these four training programs also had statistically better scores than the overall mean of the oral component and the overall results of the exam. CONCLUSIONS: Most Canadian training programs prepare their residents adequately for this simulated certification exam in urology. However, there are some training programs that consistently prepare graduating residents to outperform their peers.

Complications of the catheterizable channel following continent urinary diversion: their nature and timing.

PURPOSE: We reviewed the incidence, nature and timing of complications related to the catheterizable channel following continent urinary diversion. MATERIALS AND METHODS: We retrospectively reviewed the records of 67 patients who underwent continent urinary diversion at British Columbia Children's Hospital from 2000 to 2006. Catheterizable channels included 54 Mitrofanoff appendicovesicostomies and 13 ileovesicostomies. Medical records were reviewed for predetermined complications and their timing, that is early -12 months or less, or late - more than 12 months. RESULTS: At a median followup of 28 months (range 3 to 62) a total of 17 complications were identified in 14 patients (21%). Superficial cutaneous stenosis developed in 4 of 67 cases (6%) as an early and as a late complication. These cases were initially treated with operative dilation and surgical revision as necessary. Channel stricture, which developed in 4 of 67 patients (6%) as an early and as a late complication, was treated with operative revision in 2 and endoscopic resection in 2. Three patients (5%) had stomal prolapse, which was generally a late occurrence and required operative revision in all. Channel leakage developed in 6 of 67 patients, presenting as an early complication in 50%. Endoscopic injection of bulking agents was attempted in 4 of these patients and it was successful in 2. Overall 82% of complications were successfully managed by endoscopic or superficial procedures. CONCLUSIONS: Complications of the catheterizable channel are a frequent and challenging problem. They appear to occur throughout the life of the channel with most developing within the first 2 years. Further followup is required to assess the performance and durability of continent catheterizable channels in children as patients progress to adulthood.