Reducing Opioid Prescriptions in Outpatient Pediatric Urological Surgery.

PURPOSE: We assessed the impact of a 2-phase Plan-Do-Study-Act cycle to decrease opioid prescriptions following pediatric urological surgery. MATERIALS AND METHODS: Parents of children undergoing outpatient urological procedures were given questionnaires to assess opioid dosing and pain scores using the Parents' Postoperative Pain Measure scale. Age, procedure and opioid prescription data were recorded, as well as volume of medication administered. During the first phase of data collection children received an opioid prescription for 10 doses. In the second phase opioid prescriptions were reduced by 50%. Nonparametric tests and Fisher exact test were used for analysis. RESULTS: Of 250 eligible children 98 (39%) with a median age of 3.0 years (IQR 7.0) participated. In the 81 patients prescribed opioids a median of 2 doses (IQR 3.6) were used in the preintervention and postintervention groups (p = 0.68). Using nonparametric statistical testing, no significant differences were found between pain scores in the 5-dose group (31 patients) and the 10-dose group (24 patients; p = 0.05 for day 1, p = 0.07 for day 2, p = 0.06 for day 3). There was no association between age and percent opioid used (p = 0.83). There were no significant differences in median pain scores or median doses among procedure types. CONCLUSIONS: In outpatient pediatric surgical practice opioid prescriptions can be decreased without increasing pain scores. Physician prescribing practices may contribute more to opioid consumption than actual pain patterns.

Long-term Management of Ureterocele in Duplex Collecting Systems: Reconstruction Implications.

PURPOSE OF REVIEW: Significant variance exists in the management of duplex collecting system ureteroceles (DSU). There is a great spectrum in classification, management, and surgical interventions. The practice of performing bladder level operations for vesicoureteral reflux (VUR) and trigonal anatomic distortion, either after ureterocele puncture or in a single setting, has come into question as to whether all DSU patients require it. In this review, we sought to discuss DSU management trends and the need for bladder reconstruction in these patients, as well as to describe our institution's practices. RECENT FINDINGS: Recent advances regarding DSU management revolve around differing surgical approaches, although adequately powered randomized control trials are lacking. These approaches include nonoperative management, various forms of endoscopic puncture, ureteroureterostomy, and most recently upper pole ureteral ligation. A common theme appears to reflect the acceptance that "less is more" when it comes to managing DSU. There is no consensus for the decision to treat or the surgical approach of DSU. Ureteral reimplantation and bladder neck reconstruction appears to be unnecessary in a significant portion of the DSU population, but ureterocele treatment needs to be individualized. There is an ongoing need for large, multi-institutional randomized control trials to evaluate this further.

Complications following Staged Hypospadias Repair Using Transposed Preputial Skin Flaps.

PURPOSE: Proximal hypospadias repair using a staged approach is a complex reconstructive operation with the potential for significant complications requiring repeat surgery. We report outcomes of staged hypospadias repair using transposed preputial skin flaps and factors predictive of postoperative complications. MATERIALS AND METHODS: We retrospectively analyzed patients who underwent staged proximal hypospadias repair using transposed preputial skin flaps between 2002 and 2013. Patient demographics, operative details, complications, reoperations and factors predictive of complications were reviewed. RESULTS: A total of 56 patients were identified with a mean age of 14.1 months (median 14.3) at first stage. Mean followup was 38.6 months (median 34.1). Complications requiring additional unplanned operation(s) were observed in 38 patients (68%), including fistulas in 32 (57%), diverticula in 8 (14%), meatal stenosis in 5 (9%), urethral stricture in 8 (14%) and glans dehiscence in 3 (5%). In addition, redo first stage repair was performed in 4 patients (7%). Since some patients had more than 1 complication, the total number of complications is greater than the number of patients undergoing a redo operation. On univariate analyses the use of small intestinal submucosa was significantly associated with an increased risk of fistula (91% vs 49%, p = 0.02) and urethral diverticulum (64% vs 24%, p = 0.04). Incision of the tunica albuginea of the corpora was associated with an increased likelihood of fistula (77% vs 44%, p = 0.03). Finally, patients with glans dehiscence were significantly younger at first stage (5.8 vs 14.8 months, p = 0.01). CONCLUSIONS: The reoperation rate for complications in children undergoing staged hypospadias repair using transposed preputial skin flaps is higher than previously reported.

Computed tomography-guided S3 lead placement for sacral neuromodulation.

Computed tomography (CT)-guided lead placement for sacral neuromodulation was used in a patient with arthritis and narrow S3 foramina. Bilateral S3 foramina were localized and guide needles were placed with CT guidance. Lead placement was further modified by placement of a tined, quadripolar lead through a dilated S3 tract without initial somatosensory testing. The lead was then interrogated to assess placement and to differentiate superiority of response between two leads. The patient has had greater than 50 % improvement in urinary symptoms by voiding diary. Using CT guidance, satisfactory localization of bilateral S3 foramina may be achieved where prior attempts with conventional fluoroscopy have failed.

A rare case of necrotizing soft tissue infection following circumcision of buried penis.

Circumcision is generally a safe procedure with rare serious adverse events. We report the case of a 7-month-old male who developed necrotizing soft tissue infection following circumcision of his buried penis. A high index of suspicion must be present to diagnose necrotizing fasciitis, and treatment involves early, aggressive debridement, and broad spectrum antibiotics.

Mixed gonadal dysgenesis with an ovotestis on imaging mimicking ovotesticular disorder of sexual differentiation.

Mixed gonadal dysgenesis (MGD) is a rare disorder of sexual development. Also known as 45XO/46XY mosaicism, MGD is characterized by highly variable sexual phenotypes and an increased risk of gonadal malignancy. Patients with MGD often have a unilateral descended gonad and contralaterally either a streak gonad or no gonad. We present the case of a patient with a dysgenetic, nonpalpable gonad with imaging features of an ovotestis. These imaging features are generally more indicative of ovotesticular disorder of sexual development (previously true hermaphrodite), which is a condition with low risk of gonadal malignancy. Further evaluation with histology and genetic analysis confirmed the diagnosis of MGD. It is important to diagnose MGD to allow for early operative intervention and screening for malignancy.

Evaluation and Long-term Management of Neurogenic Bladder in Spinal Dysraphism.

Spinal dysraphism, which includes conditions such as myelomeningocele and sacral agenesis, is one of the most common causes of congenital lower urinary tract dysfunction. Early evaluation of the neurogenic bladder serves to minimize renal damage, and the main goals of management include preserving renal function, achieving acceptable continence, and optimizing quality of life. The survival of patients with such conditions has improved to greater than 80% reaching adulthood, owing to advances in diagnostic and therapeutic modalities. The result is a real, and unfortunately often unmet, need for successful transitional care in this complex patient population. Clinicians must be able to identify the unique challenges encountered by patients with neurogenic bladder as they shift through different stages of their life.

Cost analysis of removing pediatric ureteral stents with and without a retrieval string.

BACKGROUND: Indwelling ureteral stents are commonly placed in urologic surgeries where optimal urinary drainage is necessary. In the pediatric population, removing a stent without retrieval string (SWOS) requires a secondary operation and additional anesthetic exposure. Although these burdens can be mitigated through the placement of a stent with retrieval string (SWS), fears of complications may prevent widespread adoption of this practice by pediatric urologists. OBJECTIVE: The authors sought to assess the differential cost of removing SWS and SWOS. It was hypothesized that costs associated with removing SWS are significantly lower than those associated with removing SWOS, without increasing complications. STUDY DESIGN: A retrospective chart review was performed on pediatric patients undergoing common urologic surgeries with concurrent stent placement at a single tertiary referral center. Charges and healthcare costs surrounding the removal of ureteral stents were evaluated using the institution-specific ratio of cost to charges, by estimating lost wages, and by exploring differences in poststent healthcare-related events that incur additional cost. RESULTS: A total of 109 patients with a median age of 5 years (range: 6 months-20 years) were reviewed. A total of 29 patients had SWS, and 80 had SWOS. The theoretical cost of SWS removal in clinic was $400.48 compared with $2290.86 ± $119.30 for operative removal of SWOS, with mean difference of $1890.38 (P < 0.01). The mean stent duration of SWOS was 34.0 ± 13.2 days vs. 10.1 ± 4.9 days for SWS (P < 0.01). Subgroup analysis of the ureteral reconstruction group showed no difference in any complications (35% vs 27%, respectively), early dislodgment (7% vs 7%, respectively) or costly healthcare utilization (23% vs 20%, respectively) among patients with SWOS compared with those with SWS. In SWS group with early dislodgment, neither required a secondary procedure. DISCUSSION: With rising healthcare expenditures, physicians must be able to provide cost-effective treatment while not compromising safety or outcomes. Unlike prior analyses of cost related to the type of the stent used, the present study specifically reviewed costs of removing SWS versus SWOS and evaluated rates of costly complications. The study findings provide a preliminary basis for advocating the more economical use of SWS when indicated. Lack of power and heterogeneity of the groups need to be addressed in future analyses with larger, matched cohorts. CONCLUSION: Removal of SWS is more cost-effective than that of SWOS while maintaining similar safety outcomes and should be considered in certain pediatric urology cases to decrease healthcare cost. SWS should be preferred for uncomplicated ureteroscopy, but benefits are less certain in ureteral reconstruction; further studies are needed.