Nationwide Circumcision Trends: 2003 to 2016.

PURPOSE: Among some populations access to neonatal circumcision has become increasingly limited despite evidence of its benefits. This study examines national neonatal circumcision trends before and after the 2012 American Academy of Pediatrics recommendation for neonatal circumcision reimbursement. MATERIALS AND METHODS: A retrospective cohort study of boys aged 28 days or less was conducted using data from the Kids' Inpatient Database (2003 to 2016). Boys who underwent neonatal circumcision prior to discharge were compared to boys who did not. Boys with coagulopathies, penile anomalies or a history of prematurity were excluded. RESULTS: An estimated 8,038,289 boys comprised the final cohort. Boys were primarily White (53.7%), privately insured (49.1%) and cared for at large (60.8%) teaching (49.4%) hospitals in metropolitan areas (84.1%). While 55.0% underwent circumcision prior to discharge, neonatal circumcision rates decreased significantly over time (p <0.0001). Black (68.0%) or White (66.0%) boys, boys in the highest income quartile (60.7%) and Midwestern boys (75.0%) were most likely to be circumcised. Neonatal circumcision was significantly more common among privately (64.9%) than publicly (44.6%) insured boys after controlling for demographics, region, hospital characteristics and year (p <0.0001). The odds of circumcision over time were not significantly different in the years before vs after 2012 (p=0.28). CONCLUSIONS: Among approximately 8 million boys sampled over a 13-year period 55.0% underwent neonatal circumcision. The rate of neonatal circumcision varied widely by region, race and socioeconomic status. The finding that boys with public insurance have lower circumcision rates in all years may be related to lack of circumcision access for boys with public insurance.

Proximal Hypospadias-Isolated Genital Condition or Marker of More?

PURPOSE: The prevalence of endocrine/genetic anomalies in boys with proximal hypospadias is unknown. We describe an endocrine/genetic evaluation for boys with proximal hypospadias to determine who may have a difference/disorder of sex development and/or benefit from additional testing. MATERIALS AND METHODS: We retrospectively reviewed boys with hypospadias seen at our hospital between January 2013 and October 2018. Those with proximal (penoscrotal, scrotal, perineal) hypospadias who presented before age 6 months and underwent endocrine/genetic testing were included. Demographics, test results, testicular examination at presentation, comorbidities and diagnoses were abstracted. RESULTS: A total of 1,789 boys with hypospadias were identified. Of 131 boys with proximal hypospadias all 60 who underwent endocrine/genetic evaluation were included. Most of these patients had bilateral palpable testes (52, 86%) that were fully descended (41, 68%). Associated anatomical anomalies were found in 53% of patients. All boys underwent endocrine testing, which was completely typical for a male infant in most (41, 68%). Common genetic tests included karyotyping (100%), microarray (38%) and multigene panel (13%). Genetic anomalies were found in 17 boys (28%), including 7 of 41 (17%) with bilateral descended testes and 10 of 19 (53%) with 1 or more undescended testes (p=0.01). Six of 8 boys with at least 1 nonpalpable testis had a genetic anomaly vs 11 of 52 with bilateral palpable testes (p=0.005). Differences/disorders of sex development were found in 9 patients (15%). CONCLUSIONS: Of 60 boys with proximal hypospadias 53% had nongenital anomalies, 28% had genetic anomalies and 15% had a difference/disorder of sex development. Although endocrine testing was clinically useful, genetic testing was most diagnostically revealing. Endocrine/genetic evaluation should be considered for boys with proximal hypospadias.

Patient and Caregiver Attitudes toward Disorders of Sex Development Nomenclature.

PURPOSE: The medical terminology applied to differences/disorders of sex development has been viewed negatively by some affected individuals. A clinical population of patients with differences/disorders of sex development and their caregivers were surveyed regarding current nomenclature, hypothesizing that those unaffiliated with support groups would have more favorable attitudes. MATERIALS AND METHODS: We recruited English and Spanish speaking patients 13 years old or older with differences/disorders of sex development and their caregivers at 5 national tertiary care clinics from July 2016 to December 2018. No diagnoses were excluded. Participants completed a survey rating terminology commonly applied to differences/disorders of sex development. Responses were compared between subgroups, including members vs nonmembers of a support group. RESULTS: Of 185 potential participants approached 133 completed the survey (72% response rate). Congenital adrenal hyperplasia (33%) was the most common diagnosis. "Variation of sex development" was the most liked term (37%) but was not liked more significantly than "disorders of sex development" (27%, p=0.16). No term was liked by a majority of respondents. "Disorders of sex development" (37%) and "intersex" (53%) were the only terms most frequently viewed unfavorably. Support group members were significantly more likely to dislike the term "intersex" (p=0.02) and to like "variation of sex development" (p=0.02). CONCLUSIONS: A clinical population of patients and their caregivers had generally neutral attitudes toward nomenclature applied to differences/disorders of sex development. Members of a support group had clearer terminology preferences. "Variation of sex development" was the most liked term, and "disorders of sex development" and "intersex" were the most disliked. No term was liked by most respondents, and no clear alternative to the present nomenclature was identified.

Robot-Assisted Laparoscopic Reoperative Repair for Failed Pyeloplasty in Children: An Updated Series.

PURPOSE: Reoperative pyeloplasty is commonly used in children with recurrent obstruction after pyeloplasty. We previously reported on reoperative robot-assisted laparoscopic repair for failed pyeloplasty in 16 children and concluded that short-term and intermediate outcomes were comparable to open reoperative repair. In this updated series we describe longer term outcomes from an extended study. MATERIALS AND METHODS: We retrospectively reviewed outcomes of consecutive children with prior failed primary pyeloplasty who underwent robot-assisted laparoscopic reoperative repair at a single institution from January 2008 to June 2018. RESULTS: Overall, 36 children 0.6 to 15.2 years old (median 3.7) underwent robot-assisted laparoscopic reoperative repair (pyeloplasty in 31, ureterocalicostomy in 5) at a median of 24.3 months (range 3.9 to 136.7) after primary repair. Median reoperative time was 285.0 minutes (range 207 to 556) and median length of stay was 1 day (1 to 8). Crossing vessels were present in 8 of 30 children (26.7%) with prior open repair and in 0 of 6 with prior minimally invasive repair. Clavien-Dindo grade 1 to 2 perioperative complications occurred in 4 children (11.1%) and grade 3 to 5 complications in 2 (5.6%). Median followup was 35.3 months (range 1.4 to 108.3), with 18 children (50.0%) being followed for more than 3 years. Postoperative ultrasound in 34 children revealed improvement in 31 (91.2%), stability in 2 (5.9%) and worsening hydronephrosis in 1 (2.9%). All 11 children undergoing preoperative and postoperative diuretic renography demonstrated stable or improved differential renal function. All children were symptom-free at last followup. CONCLUSIONS: To our knowledge, this is the largest series of robot-assisted laparoscopic reoperative repair for failed pyeloplasty in children. Our results indicate the feasibility, efficacy, safety and durability of this procedure.

The Correlation between Serial Ultrasound and Diuretic Renography in Children with Severe Unilateral Hydronephrosis.

PURPOSE: While serial renal ultrasound is often used as an alternative to functional renal imaging in children followed for hydronephrosis, it is unclear whether a lack of hydronephrosis progression safeguards against loss of renal function. In this study we characterize the association between findings on serial renal ultrasound and diuretic renography in children with severe unilateral hydronephrosis. MATERIALS AND METHODS: We retrospectively reviewed imaging among patients younger than 18 years old with a history of severe unilateral hydronephrosis, 2 renal ultrasounds and 2 diuretic renograms. Each pair of renal ultrasounds was interpreted by an independent blinded diagnostic radiologist and compared to a contemporaneous diuretic renogram. Change in hydronephrosis was considered as 1) a change in hydronephrosis grade or 2) any change by radiologist interpretation. A 5% or greater change in split differential function was considered significant. Chi-square and Spearman correlation analyses were performed. RESULTS: A total of 85 children were evaluated. Increased hydronephrosis was noted in 11.8% of children by grade and 32.9% by radiologist interpretation. Split differential renal function worsened by 5% or more in 17.6% of children. Overall, 13.3% of children with stable or decreased hydronephrosis demonstrated worsening split differential function at an average of 11.8 months. When renal ultrasound and diuretic renograms were directly compared, the Spearman correlation was poor (r = 0.24, 95% CI 0.03 to 0.43). CONCLUSIONS: The overall correlation between imaging modalities was poor, and 13.3% of children with stable or decreased hydronephrosis had worsening of split differential renal function. These findings are important to consider when counseling nonoperatively managed children followed without diuretic renography.

Update on Continent Catheterizable Channels and the Timing of their Complications.

PURPOSE: We previously reported catheterizable channel associated outcomes and concluded that the incidence of postoperative complications was greatest in the first 2 years after surgery. At that time our followup was short. In this series we sought to determine whether complications continued to accumulate with longer followup in an updated cohort of patients. MATERIALS AND METHODS: We comprehensively reviewed the outcomes in 81 consecutive patients who underwent construction of a MACE (Malone antegrade continence enema) and/or a Mitrofanoff channel in association with complex genitourinary reconstruction. Mean followup was 80.1 months. Outcomes of these 119 stomas were classified by Clavien-Dindo grade and time to complication. RESULTS: The 48 unique, channel related events (40.3%) necessitated a total of 70 interventions with a mean 24.2 months to the first event. Difficult catheterization was the most common event, occurring in 20.1% of channels an average of 29.9 months after surgery. Stomal stenosis was also common, developing in 12.6% of channels at an average of 19.9 months after surgery. Unique complications clustered in the first 2 years, after which there was a statistically significant decline (p = 0.0013). High grade complications similarly clustered (p <0.0001). Channel composition was significantly associated with rates of difficult catheterization events. CONCLUSIONS: Compared to our previous cohort of patients with similar volume but shorter followup, our assumption that channel associated complications cluster postoperatively and then decrease significantly was correct. Our current and more detailed series demonstrates that the rate of postoperative complications decreases with time. However, with longer followup patients continue to experience lower grade events requiring fewer interventions.

Spontaneous and rapid transcanalicular translocation of a previously retractile testicle into the abdomen of a post-pubertal, teenage male.

We describe a case of spontaneous, rapid, atraumatic transcanalicular translocation of a previously retractile testis into the abdomen of a post-pubertal 16-year-old male. The testis was lowered back into the inferior scrotum laparoscopically, through a patent processus vaginalis, and was under no tension in that location without lengthening of cord structures. At 7 months postoperative, the patient reported bilateral intrascrotal testicles with no further complications. This exceptional case demonstrates that post-pubertal males with a history of retractile testis may be at risk for developing testicular translocation into the abdomen.

Internal hernia with volvulus after major abdominal reconstructions in pediatric urology - An infrequently reported and potentially devastating complication.

INTRODUCTION: Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and appendicocecostomy (APC) can facilitate continence and prevent renal damage for patients with congenital urologic or bowel disease. Bowel obstruction is a well-documented complication of these procedures, and the etiology of obstruction is variable. The aim of this study is to determine the incidence and describe the presentation, surgical findings, and outcomes of bowel obstruction from internal herniation due to these reconstructions. METHODS: In this single institution retrospective cohort study patients who underwent EC, APV, and/or an APC between 1/2011 and 4/2022 were identified via CPT codes within the institutional billing database. Records for any subsequent exploratory laparotomy during this same timeframe were reviewed. The primary outcome was an internal hernia of bowel into the potential space between the reconstruction and the posterior or anterior abdominal wall. RESULTS: Two hundred fifty seven index procedures were performed in 139 patients. These patients were followed for a median of 60 months (IQR 35-104 months). Nineteen patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/257). The complications occurred between 19 months and 9 years after their index procedure (median 5 years). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. One complication was caused by small bowel and cecum passing around the APC and subsequently volvulizing. A second was caused by bowel herniating behind the EC's mesentery and the posterior abdominal wall. A third was caused by bowel herniating behind the APV mesentery and subsequently volvulizing. The exact etiology of fourth internal herniation is unknown. Of the three surviving patients, all required resection of ischemic bowel and 2 required resection of the involved reconstruction. One patient died intraoperatively from cardiac arrest. Only 1 patient required a subsequent procedure to regain lost function. CONCLUSION: Internal herniation caused by small or large bowel passing through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 257 reconstructions performed over 11 years. This complication can arise many years after abdominal reconstruction, resulting in bowel resection and possibly takedown of the reconstruction. When anatomically possible and technically feasible, the surgeon should close any potential spaces created during the initial abdominal reconstruction.

National Trends and Outcomes in the Use of Intravesical Botulinum Toxin and Enterocystoplasty Among Patients With Myelomeningocele.

OBJECTIVE: To compare trends in the treatment of patients with myelomeningocele receiving intravesical Botulinum (IVB) toxin and enterocystoplasty. METHODS: We identified patients with myelomeningocele in a commercial insurance database from 2008-2017 and stratified them into adult and pediatric samples. Index procedure was identified as either IVB toxin injection or enterocystoplasty. The annual rate of treatments was measured and a change in treatment rate was identified. Time to enterocysplasty was calculated using survival analysis and factors associated with clinical outcomes up to 10 years after index procedure were determined using multivariate Poisson regression. RESULTS: We identified 60,983 patients with myelomeningocele. Nearly twice as many pediatric patients had an enterocystoplasty (n = 317) compared to IVB (n = 138). Very few adult patients underwent enterocystoplasty (n = 25) compared to IVB (n = 116). We identified a significant increase in the annual rate of IVB use around mid-2010 among pediatric patients and around mid-2009 among adults. Twelve pediatric patients (8.6%) and 5 adults (4.3%) went on to receive an enterocystoplasty. Patients who received IVB as the index procedure experienced significantly lower rates of hospitalization days (RR 0.64; 95% CI 0.53-0.78), emergency department visits (RR 0.72; 95% CI 0.63-0.82), and an increased rate of urologic procedures (RR 1.44; 95% CI 1.28-1.62). CONCLUSION: The annual rate of IVB use has increased among patients with myelomeningocele. Nearly 1 in 10 pediatric patients and 1 in 20 adults go on to receive enterocystoplasty. Patients who receive IVB experience lower rates of hospitalization and emergency department visits compared to patients who receive enterocystoplasty.

Transition from trainee to educator in the operating room: A needs assessment and framework to support junior faculty.

BACKGROUND: Transitioning from trainee to attending surgeon requires learners to become educators. The purpose of this study is to evaluate educational strategies utilized by surgeons, define gaps in preparation for operative teaching, and identify opportunities to support this transition. METHODS: A web-based, Association of Surgical Education approved survey was distributed to attending surgeons. RESULTS: There were 153 respondents. Narrating actions was the most frequently reported educational model, utilized by 74% of junior faculty [JF] (0-5yrs) and 63% of senior faculty [SF] (>6yrs). Other models used included educational time-outs (29% JF, 27% SF), BID teaching model (36% JF, 51% SF), and Zwisch model (13% JF, 25% SF). Compared with 91% JF, 65% SF reported struggling with instruction (p < 0.001). Five themes emerged as presenting difficulty during the resident to attending transition: lack of relationships, ongoing learning, systems-based, cognitive load, impression management. CONCLUSIONS: Our results represent a needs assessment in the transition from learner to educator in the OR.

State-Level Public Insurance Coverage and Neonatal Circumcision Rates.

OBJECTIVES: Seventeen states do not provide Medicaid coverage for neonatal male circumcision, despite American Academy of Pediatrics recommendations supporting access for families that choose it. Our study objectives were to (1) compare state-specific trends in neonatal circumcision to previously established estimates and (2) assess the impact of changes in Medicaid coverage of the procedure. METHODS: The State Inpatient Databases were used to determine rates of neonatal male circumcision in 4 states (CO, FL, MI, and NY) at 4 time points (2001, 2006, 2011, 2016). Neonatal circumcision was defunded by Medicaid in Florida (2003) and Colorado (2011). A multivariable logistic regression model was created to assess associations between patient and state characteristics and odds of neonatal circumcision. RESULTS: Overall, 54.5% of neonates underwent circumcision. States where Medicaid defunded neonatal circumcision revealed a decrease in circumcision rates in subsequent years (47.4% to 37.5% in FL; 61.9% to 52.0% in CO). Neonates with private insurance had higher odds of circumcision compared with those with public insurance (adjusted odds ratio [aOR] 2.23; 95% confidence interval [CI] 2.21-2.25). When Medicaid coverage was available, Black neonates had higher odds of circumcision compared with white neonates (aOR 1.44; 95% CI 1.42-1.46). When Medicaid coverage was not available, Black neonates had lower odds compared with white neonates (aOR 0.40; 95% CI 0.39-0.41). CONCLUSIONS: State-specific data reveal trends in neonatal circumcision similar to previous national estimates. Colorado and Florida revealed 20.9% and 16.0% reductions in neonatal circumcision rates, respectively, after defunding. Black neonates appeared to be disproportionately affected by changes in Medicaid coverage.

Caregiver Reported Reasons for Delay of Neonatal Circumcision.

OBJECTIVES: To determine caregiver-reported reasons for delay of desired neonatal circumcision. METHODS: Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained. RESULTS: Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (P = .02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (P = .004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision. CONCLUSION: Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth.

Adherence to the 2011 American Academy of Pediatrics Urinary Tract Infection Guidelines for Voiding Cystourethrogram Ordering by Clinician Specialty.

OBJECTIVE: To evaluate rates of guideline adherence and associations with voiding cystourethrogram result. The American Academy of Pediatrics guidelines recommend voiding cystourethrogram after abnormal renal ultrasound or 2 febrile urinary tract infections. It is unclear whether guideline adherence increases vesicoureteral reflux detection. Additionally, guidelines targeting children 2-24 months are often applied to other ages. METHODS: Children undergoing voiding cystourethrogram from January 2012 to December 2013 at 1 institution were retrospectively reviewed. Children with known genitourinary abnormalities were excluded. The primary outcome was guideline adherence. Univariate and multivariate analyses were performed. Subgroup analysis of children 2-24 months was completed. RESULTS: Voiding cystourethrograms from 365 children were included in the primary analysis, including 187 (51.2%) aged 2-24 months. Overall, 60.3% of voiding cystourethrograms were ordered in accordance with the guidelines. Urologists/nephrologists were more likely to adhere to ordering guidelines than pediatricians/others (76.4% vs 51.7%, odds ratio 3.0 [1.9-4.9], P <.001). Subgroup analysis in children 2-24 months revealed similar findings (76.4% vs 51.5%, odds ratio 3.0 [1.5-6.2], P = .002). Voiding cystourethrograms were abnormal in 31.8% overall and 26.2% aged 2-24 months. Guideline adherence was associated with increased likelihood of abnormal voiding cystourethrogram among all children (P = .02), but not among children 2-24 months (P = .95). Older age, white race, and guideline adherence remained significantly associated with abnormal voiding cystourethrogram in a multiple logistic regression model. CONCLUSIONS: Guideline adherence was more likely among urologists/nephrologists than pediatricians/others and was not associated with abnormal voiding cystourethrogram among children 2-24 months. Multicenter evaluation is necessary to determine if ordering recommendations should be revised.

Varicoceles in the pediatric and adolescent population: threat to future fertility?

Determining the effect of varicoceles on future fertility is challenging owing to multiple issues in children/adolescents, including: limitations in obtaining and interpreting semen analyses; potential for unequal differential testicular growth during puberty regardless of varicocele presence; and the potential for a lengthy interval between surgical intervention for varicocele in adolescence and attempts at paternity. This review presents a summary and evaluation of the available evidence relating to future fertility among children and adolescents with varicoceles. Data relating to proxy fertility measures in children/adolescents, including testicular size asymmetry and semen analysis abnormalities, demonstrate that these proxy measures are imperfect predictors of future fertility. Two large, recently published series of adolescents undergoing varicocele treatment showed conflicting paternity outcomes. Pediatric and adolescent varicocele will remain a clinical conundrum, subject to both over- and under-treatment, until more definitive prospective data are available.

Middle turbinate flap for skull base reconstruction: cadaveric feasibility study.

OBJECTIVES/HYPOTHESIS: Surgical resection of intradural pathology through an endonasal corridor creates defects that communicate the subarachnoid space with the sinonasal tract. Reconstruction of these defects with vascularized tissue is superior to any other method. The purpose of this study is to describe a novel vascularized pedicled flap from the middle turbinate (MT) mucosa and to assess its feasibility using a cadaveric model. METHODS: Twelve middle turbinate flaps (MTFs) were raised in six fresh cadaveric heads previously injected with colored silicone. Arteries supplying the MT were identified as the turbinate mucoperiosteum was harvested from both its medial and lateral aspects. Length and surface area of the flaps, as well as their ability to cover dural defects of the sella, planum sphenoidale, and fovea ethmoidalis reach were noted. RESULTS: All MTFs adequately covered defects of the planum and fovea ethmoidalis; however, two of the twelve MTFs were not suitable to cover a sellar defect. The mean surface area of the MTFs was 5.6 cm(2). As an independent factor surface area did not correlate with the ability of the flap to cover the sellar defects. However, those flaps that were not suitable for sellar repair were less than 4.0 cm in length. CONCLUSIONS: Harvesting of a vascular pedicle flap from the MT is feasible, albeit technically demanding. It should be considered as an alternative for the reconstruction of small defects of the fovea ethmoidalis, planum, and sella, particularly for patients for whom a reconstruction with vascularized tissue is desirable but the nasoseptal flap is not available.