The changing gender landscape of pediatric urology fellowship: results from a survey of fellows and recent graduates.

INTRODUCTION: Women are entering the subspecialty of pediatric urology at an accelerated rate. Gender differences affecting fellowship and job selection have been identified in other fields of medicine. OBJECTIVE: The objective of this study was to understand gender differences in pediatric urology fellowship and job selection and how they may affect the workforce. STUDY DESIGN: A 47-question electronic survey consisting of questions regarding demographics, residency training, and factors influencing fellowship and job selection was distributed to current fellows and recent graduates in pediatric urology in May 2017. RESULTS: A total of 111 recent and current fellows were contacted, and 72% completed the survey (55% female [F] and 45% male [M]; 61% current fellows and 39% recent fellows). Respondents rated factors important in choosing pediatric urology on a scale of 1-5 (1, not important and 5, extremely important), and the top three for both genders were 1-working with children, 2-influential mentors, and 3-bread and butter cases such as inguinal orchiopexy. During residency, 93% of respondents reported having influential mentors in pediatric urology. However, mentorship was more important in fellowship choice for males than females (3.6 F, 4.1 M; P-value = 0.048), and 45% reported having only male mentors. Rating factors important in job choice on a scale of 1-5, respondents reported the top factors as 1-rapport with partners/mentorship (4.5), 2-geography/family preferences (4.3), and 3-participation in mentoring/teaching (3.8). Although most job selection criteria were rated similarly between genders, females rated call schedule higher than males (3.5 F, 2.9 M, P-value = 0.009). Although most females and males (79% of F, 78% of M, P-value = 0.868) sought primarily academic positions, a smaller proportion of females accepted academic positions (52% of F, 72% of M, P-value 0.26), and females reported lower satisfaction regarding the availability of jobs on a scale of 1-5 (1, very dissatisfied and 5, very satisfied; 3.1 F, 3.7 M; P-value = 0.034), particularly in academic positions (3.1 F, 3.7 M; P-value = 0.06). This difference was more pronounced in current fellows than recent graduates and may represent a worsening trend. CONCLUSION: Although significant gender differences in fellowship and job selection may exist in other fields, we found that women and men choose pediatric urology fellowships and jobs using similar criteria, which include work-life balance. Gender differences exist in the influence of mentors, indicating a need for more female mentors. While men and women sought similar types of jobs, women were less satisfied with the availability of jobs, particularly academic jobs, than men, which warrants further investigation.

Trisomy 21 in one of twin fetuses.

Both the detection of twins and the successful execution of a double amniocentesis pose significant technical problems in prenatal diagnosis. A case is reported in which one of twins fetuses had trisomy 21 and the other was chromosomally normal. Following counseling, the family chose to continue the pregnancy. At term, the mother was delivered of a healthy infant and a severely macerated fetus with stigmata suggestive of Down's syndrome.

Laparoscopic Roux-en-Y gastric bypass for super/super obesity.

Laparoscopic gastric bypass has been recently introduced as an alternative method to conventional open gastric bypass. This procedure has been generally limited to patients with a BMI <60 kg/m2 due to the possible technical limitations of the laparoscopic instruments. In this article, we present a patient with super/super obesity (61 kg/m2) who underwent Rouxen-Y gastric bypass using the laparoscopic approach.

A prospective evaluation of intracorporeal laparoscopic small bowel anastomosis during gastric bypass.

BACKGROUND: We evaluated the safety and feasibility of performing a laparoscopic intracorporeal end-to-side small bowel anastomosis using a stapling technique as part of a Roux-en-Y gastric bypass operation (RYGBP). METHODS: 80 consecutive patients who underwent RYGBP with laparoscopic jejunojejunostomy were evaluated. Operative time and intraoperative and postoperative complications directly related to the jejunojejunostomy anastomosis were recorded. RESULTS: All 80 laparoscopic jejunojejunostomy procedures were successfully performed without conversion to laparotomy. Mean operative time was longer for the first 40 laparoscopic RYGBP than for the last 40 RYGBP (32+/-18 min vs 21+/-14 min, respectively, p<0.05). Intraoperative complications were staple-line bleeding (2 patients) and narrowing of the anastomosis (1 patient). Postoperative complications were four small bowel obstructions: technical narrowing at jejunojejunostomy site (2 patients), angulation of the afferent limb (1 patient), and food impaction at the jejunojejunostomy anastomosis (1 patient). These four patients underwent successful laparoscopic re-exploration and creation of another jejunojejunostomy proximal to the original anastomosis. There were no small bowel anastomotic leaks. The median time to resuming oral diet was 2 days. CONCLUSIONS: Laparoscopic jejunojejunostomy as part of the RYGBP operation is a safe and technically feasible procedure. Postoperative small bowel obstruction is a potential complication, which can be prevented by avoiding technical narrowing of the afferent limb.

Evaluation of intra-abdominal pressure after laparoscopic and open gastric bypass.

BACKGROUND: Increased intra-abdominal pressure (IAP) postoperatively can adversely affect cardiovascular, pulmonary, and renal function. In this prospective, randomized trial, we compared the IAP in morbidly obese patients after laparoscopic and open gastric bypass (GBP) surgery. METHODS: 64 patients with a body mass index of 40 to 60 kg/m2 were randomized to undergo laparoscopic or open GBP. IAPs were obtained at baseline (after induction of anesthesia), immediately after the operation, and on post-operative day (POD) 1, 2, and 3. Intraoperative and postoperative fluid requirements, urine output, and creatinine clearance were recorded. RESULTS: Demographics of the two groups were similar. IAP increased from baseline immediately after laparoscopic and open GBP (p < 0.05). IAP returned to baseline by POD 2 after laparoscopic GBP but remained elevated through POD 3 after open GBP. In fact, IAP was lower after laparoscopic GBP than after open GBP on POD 1, 2 and 3 (p < 0.05). The amount of intraoperative IV fluid was similar between groups, but laparoscopic GBP required less IV fluid and facilitated higher urine output postoperatively than open GBP. There was no significant difference in creatinine clearance between groups. CONCLUSIONS: Laparoscopic GBP resulted in significantly lower IAP, less postoperative fluid required, and greater postoperative urine output than open GBP.

Congenital urethrocutaneous fistulas.

We report on 2 cases of congenital urethrocutaneous fistulas in otherwise normal children. There were no associated congenital anomalies. Satisfactory surgical results were obtained. Potential causes are discussed.

Distribution and variability of resistive index values in undilated kidneys in children.

OBJECTIVES: To assess better the utility of duplex Doppler sonography in the diagnosis of obstructive hydronephrosis in children, we specifically studied undilated urinary tracts with the intention of establishing a nomogram of resistive index (RI) values and determining if the RI value of 0.7 reliably precludes an undilated collecting system. METHODS: Renal duplex Doppler ultrasound was performed in a standard fashion on 47 children more than 12 months of age (93 renal units) where there was no suspicion of upper urinary tract dilation. RI and RI ratio (RIR) were calculated and statistical analysis performed. RESULTS: There were 27 males and 20 females 12 to 180 months old (mean, 63.9 months). Kidney size ranged from 5.0 to 9.8 cm (mean, 7.28 cm), RI ranged from 0.34 to 0.94 (mean, 0.65), and RIR ranged from 1.00 to 1.76 (mean, 1.14). There was no statistically significant relationship between the RI and renal size or laterality, gender, or age (p > 0.05). However, between the ages of 24 and 108 months, the RI was significantly higher in females compared with males (p = 0.002). If one were to use 0.7 and 1.10 as discriminatory values for RI, 37% of renal units had values above 0.7, and 41% of RIR values were above 1.10. CONCLUSIONS: We believe that RI values in undilated kidneys of children vary significantly and its routine use and reliability need to be evaluated further in the pediatric population.

Endoscopic management of bladder calculi following augmentation cystoplasty.

OBJECTIVES: We sought to evaluate the effectiveness and utility of an endoscopic approach to calculi that develop in the bladders of children following augmentation cystoplasty. In addition, we aimed to determine the indications for open vesicolithotomy. METHODS: We reviewed our experience between 1981 and 1993 with 26 children who formed bladder calculi following augmentation cystoplasty. Data were retrieved retrospectively with respect to management approach and outcome. RESULTS: Nineteen cases were managed cystoscopically using simple extraction and/or electrohydraulic lithotripsy; 3 cases required open vesicolithotomy and four calculi passed spontaneously. Complete stone extraction was achieved after a single endoscopic treatment in every case approached in this fashion. Every patient resumed preoperative voiding patterns and there were no infections, strictures, or other complications. Calculi reformed in 4 patients and were successfully managed endoscopically. CONCLUSIONS: An endoscopic approach to bladder calculi is a safe and effective method of managing this increasingly prevalent problem in children following augmentation cystoplasty even in the presence of a reconstructed bladder neck. Open vesicolithotomy should be reserved for the very large stone burden.

Myofascial wrap to treat intractable urinary incontinence in children.

OBJECTIVES: The management of intractable urinary incontinence in the patient with cloacal or bladder exstrophy/epispadias, failed bladder neck plasty, or failed augmentation cystoplasty remains a surgical challenge. The myofascial wrap, a modification of the rectus fascial wrap, was developed to treat intractable urinary incontinence due to sphincteric incompetence in these problematic cases. A full-thickness, vascularized pedicle of anterior rectus sheath, rectus abdominis muscle, and posterior rector sheath is incorporated into a bladder neck wrap to provide support, mucosal coaptation, and active muscular tone. METHODS: Eight patients (5 females and 3 males) with total urinary incontinence due to sphincteric incompetence underwent the myofascial wrap. Urinary tract pathology included cloacal exstrophy (2), female epispadias (2), classic bladder exstrophy (1), male epispadias (1), myelomeningocele (1), and a pelvic tumor (1). The procedure is performed by harvesting a full-thickness strip of pedicled rectus muscle along with the anterior and posterior fascial sheaths. The strip is passed underneath and then over the bladder neck in a near 360 degrees wrap. The free end of the wrap is anchored into the pubic bone in an ipsilateral subperiosteal pouch. RESULTS: Six of the 8 patients are completely continent, and 2 patients void spontaneously without the need for catheterization. CONCLUSIONS: The myofascial wrap provides support, mucosal coaptation, and muscular tone to an incompetent sphincter and bladder neck. Favorable results in a very difficult population of pediatric patients warrant its continued use.

Management considerations for treating vesicoureteral reflux in children with solitary kidneys.

OBJECTIVES: To evaluate the management approach for vesicoureteral reflux (reflux) into a solitary kidney. METHODS: Outcomes of all children with solitary kidneys and reflux managed between 1981 and 1996 were reviewed. Solitary kidneys were documented by nuclear renography and ultrasonography; reflux was graded after cystography. Management consisted of observation and antimicrobial prophylaxis or surgery by ureteroneocystostomy or subureteric injection of polytetrafluoroethylene (STING). Follow-up ranged from 3 months to 14 years and included serial cystography, sonography, and serum creatinine measurement. RESULTS: Twenty-one patients with a median follow-up of 26 months were identified. Etiologies included contralateral renal agenesis (14 children), multicystic dysplastic kidney (5 children), or nonfunctioning ureteropelvic junction obstruction (2 children). Low-grade (I to II) reflux was identified in 6 children, and high grade (III to V) was identified in 15. Reflux resolved in 20 patients. Five children with low-grade reflux were managed without surgery and demonstrated reflux resolution after a mean of 20.5 months. Renal function deteriorated in only 1 child. Ureteroneocystostomy was performed in 13 children with grades III to V reflux, and STING was performed in 1 child with grade II reflux. Every surgical patient maintained stable renal function and was infection-free during a mean follow-up of 56 months. Management by observation in 2 children with grades IV to V reflux resulted in spontaneous resolution in one and stable grade IV in the other. CONCLUSIONS: Reflux into the solitary functioning kidney may be managed by the same strategies used to manage unilateral reflux in children with two normally functioning kidneys: low-grade reflux by observation/ chemoprophylaxis until spontaneous resolution occurs, and higher grades by surgery to protect renal function; however, chemoprophylaxis and serial imaging may be used until well-defined indications for surgery are satisfied. Renal function should be monitored diligently.

Urine levels of transforming growth factor-beta 1 in children with ureteropelvic junction obstruction.

OBJECTIVES: To determine if there are measurable quantities of transforming growth factor-beta 1 (TGF-beta 1) in the urine of children with either normal or pathologic conditions of the urinary tract, specifically vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO). We also sought to determine if the urine TGF-beta level could distinguish between renal obstruction and no obstruction. METHODS: Preoperative bladder urine from consecutive patients undergoing pyeloplasty (UPJO group; n = 13), ureteral reimplantation (VUR group; n = 11), or circumcision/orchiopexy (control group; n = 19) as well as urine from the renal pelvis of the UPJO group was collected. The urine level of TGF-beta 1 was measured using a quantitative sandwich enzyme immunoassay technique. RESULTS: Urine level of TGF-beta 1 was detected in each group: control (26.6 +/- 6.3 pg/mL), reflux (22.1 +/- 9.6), UPJO-pelvic urine (82.4 +/- 19.3), UPJO-bladder urine (31.2 +/- 8.2). The urine TGF-beta 1 concentration in pelvic urine in the UPJO group was significantly higher than that in bladder urine in children in the UPJO group (p = 0.03). TGF-beta 1 concentrations were similar from the bladder of children in all three study groups (p = NS). CONCLUSIONS: Urine TGF-beta 1 is detectable in children with normal and pathologic urinary tracts. The level of this urine marker is elevated in the renal pelvis of children with UPJO compared to the level in the bladder of either obstructed or nonobstructed upper urinary tracts.

A comparison study of laparoscopic versus open gastric bypass for morbid obesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (GBP) has been previously described, but a comparative study between laparoscopic and open GBP has not been reported. The purpose of this study was to compare surgical outcomes oflaparoscopic GBP with those of open GBP for treatment of morbid obesity. STUDY DESIGN: From August 1998 to September 1999, we prospectively collected outcome data on 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent laparoscopic GBP. Demographics, operative data, perioperative complications, and weight losses were collected and compared with those obtained from a retrospective chart review of 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent open GBP before August 1998. RESULTS: Age, gender, preoperative body-mass index, preoperative comorbidity, and earlier abdominal surgery were similar in both groups. All laparoscopic operations were completed without conversion to laparotomy. Mean operative time, operative blood loss, length of intensive care stay, and length of hospital stay were significantly less after laparoscopic GBP than after open GBP (p<0.05). There was no 30-day mortality in either group. At 1-year followup, analysis of the percentage of excess body weight loss showed no significant difference between the two groups (p<0.05). CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is technically feasible and safe. Laparoscopic GBP confers the clinical benefits of laparoscopy and an initial weight loss similar to that of open GBP.

Endocrine analysis of childhood monorchism.

PURPOSE: We characterized follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels in boys with surgically documented unilateral absent testes (monorchism) to determine whether measurement of gonadotropin levels could distinguish them from boys with unilateral impalpable cryptorchidism. MATERIALS AND METHODS: Baseline serum gonadotropin levels were prospectively measured in 43 boys 2 months to 14 years old who presented with a unilateral impalpable testis that was confirmed to be absent at surgery. Control serum specimens were obtained from 63 age matched boys undergoing minor surgery with no evidence of hypospadias, or testicular, hormonal or renal diseases. Serum FSH and LH levels were drawn preoperatively and assayed by double antibody radioimmunoassay. A subgroup of 7 boys with monorchism was also evaluated following gonadotropin-releasing hormone (GnRH) stimulation and compared to age matched boys with a unilaterally impalpable testis discovered surgically. RESULTS: In the monorchism group mean plus or minus standard deviation basal FSH was 4.08 +/- 0.28 mIU/ml. and LH was 4.13 +/- 0.33 mIU/ml. In the control group mean basal FSH was 4.36 +/- 1.52 mIU/ml. and LH was 4.66 +/- 0.75 mIU/ml. No statistical difference existed between the 2 groups for mean basal gonadotropin level. While monorchid boys were more likely to have elevated FSH levels (p = 0.016), this was not true for LH (p = 0.21). Since gonadotropin levels less than 5 mIU/ml. are accepted normal values, this threshold was applied to FSH and carried a sensitivity of 23.8%, specificity 93.8%, positive predictive value 71.4% and negative predictive value 65.6%. Lower cutoff values marginally improved sensitivity but reduced specificity. Peak stimulated levels of FSH and LH following GnRH stimulation failed to distinguish between boys with 1 or 2 testes. CONCLUSIONS: Baseline FSH is more likely to be elevated in prepubertal boys with monorchism but it does not appear to be clinically useful when sensitivity and predictive value are poor. Similarly, gonadotropin level following GnRH stimulation is not sufficiently sensitive to advocate the use of hormonal measurements to diagnose prepubertal monorchism.

Transrectal electrostimulation therapy for neuropathic bowel dysfunction in children with myelomeningocele.

PURPOSE: We attempted to evaluate the efficacy of transrectal bowel stimulation for neurogenic bowel dysfunction in children with myelodysplasia. MATERIALS AND METHODS: Daily sessions of transrectal electrostimulation were performed on an outpatient basis for 2 to 3 weeks on children with myelodysplasia and stool incontinence. If benefits were noted, 5 to 10 additional daily sessions were performed. Complete success was defined as improvement in all parameters of interest, including decrease in the frequency of daily bowel movements, increased sensation, increased ability to hold stool and a significant subjective change in bowel habits. Moderate success implied improvement in 1 to 3 parameters and treatment failure was defined as lack of improvement in any parameter. RESULTS: A total of 55 children 2 to 14 years old (mean age 6.7) completed a mean of 18 daily sessions per patient of bowel electrostimulation. Followup ranged from 1 to 6 years. Diapers are no longer required due to defecation problems in 14 children older than 3 years. Complete success was achieved in 20 cases (36.3%) and moderate success in an additional 30 (54.5%, overall success rate 90.8%). Specifically, 89% of the patients reported elimination of stooling accidents, 82% reported increased sensation and 71% were able to hold the bowel movement. Overall 68% of the patients noticed significantly improved bowel function. Complete/moderate success of transrectal electro-stimulation was statistically significant for all 4 parameters (p < 0.05), and complete success was significant for increased sensation, ability to hold and episodes of accidents. Therapy failed in 5 children (9%). There were no untoward effects. CONCLUSIONS: Transrectal electrostimulation is a well tolerated and minimally invasive modality that provides sustainable improvement in stool continence in children with myelomeningocele and neuropathic bowel dysfunction.

Epidermoid cyst of the scrotum extending into the true pelvis.

A 9-year-old boy presented with an asymptomatic scrotal mass that was separate from the testes. The workup included a scrotal ultrasound scan and voiding cystourethrogram. On surgical exploration, the mass was solid, separate from the testes, and extended into the pelvis. The mass was removed, and pathologic examination revealed an epidermoid cyst. This is an uncommon scrotal lesion in boys and may represent a monodermal teratoma or abnormal closure of the median raphe. To our knowledge, this is only the second case report of an epidermoid cyst of the scrotum extending into the true pelvis.

Age related bladder capacity and bladder capacity growth in children with myelomeningocele.

PURPOSE: Currently the relationship between bladder capacity and age in children with myelomeningocele is inadequately understood, such that nomograms derived from neurologically normal children are inappropriately applied to the myelodysplastic population. The aim of the present study was to evaluate age related bladder capacity and bladder capacity growth in children with myelomeningocele, and compare them to those of age matched, neurologically intact children. MATERIALS AND METHODS: Bladder capacity was determined by cystometrography in children with myelodysplasia. Regression analysis was used to derive a relationship between bladder capacity and patient age. Data were stratified by sphincter activity, bladder sensation and uninhibited contractions, and regression analysis was repeated. To evaluate serial growth change in bladder capacity divided by time yielded a yearly bladder capacity growth rate in patients who underwent 2 cystometrograms done at least 3 months apart before age 9 years. RESULTS: A total of 506 children satisfied study inclusion criteria. Bladder capacity (BC) was related to age for the first 9 years by the linear equation, BC = 24.5 (age) + 62. This equation is approximately 25% less steep than published age related bladder capacity in neurologically intact children using the formula, 32 (age) + 73. After data stratification bladder capacity in children with sphincter activity, bladder sensation or no uninhibited contractions approached that of neurologically intact children. In contrast, children without sphincter activity or bladder sensation, or with uninhibited contractions had markedly smaller age related bladder capacity. Bladder capacity growth in the subgroup of 55 children in whom 2 cystometrograms were performed at least 3 months apart before age 9 years confirmed a mean gain in capacity of 24 cc per year. CONCLUSIONS: Normal bladder capacity in children with myelodysplasia is approximately 25% less than in age matched, neurologically intact children. The bladder grows approximately 24 cc per year until age 9 years. When there is failure to store urine, bladder capacity is much smaller, while children with good storage features may attain the bladder capacity expected of age matched, neurologically intact children.

Laparoscopic orchidopexy: a review of a large clinical series.

OBJECTIVE: To report the overall success rate of a laparoscopic orchidopexy (LO) series over 5 years including over 100 procedures. PATIENTS AND METHODS: The records were reviewed of children who underwent laparoscopic procedures for an impalpable testis at our institutions. The laparoscopic procedures included the standard LO and one-stage and staged Fowler-Stephens (F-S) LOs. The success of orchidopexy was defined as a testis in the scrotum with no atrophy after surgery. RESULTS: From 1994, 80 children (101 impalpable testes) were treated using LO. Of these patients, 20 (25%) had impalpable testes on the right, 39 (50%) were on the left and 21 (25%) were bilateral. The testicular location was identified during laparoscopy as: intra-abdominal in 46, iliac in 14, in the internal ring in 22, 'peeping' in 12, behind the bladder in three and intracanulicular in four. Standard LO was used in 72 testes, a one-stage F-S in 20 and a two-stage F-S in nine (first stage two, second stage seven). The median (range) age of the patients was 18 months (0.5-12 years); the mean (range) follow-up was 5 (1-36) months. After orchidopexy the testis was scrotal in 90 (low 78, mid four and high eight), at the pubis in one and not stated in seven (no follow-up available). Four patients (4%) had testicular atrophy from failed F-S orchidopexies, two of whom had undergone previous testicular surgery and one caused by additional dissection around the vas. The overall success rate, including only those with follow-up, was 96% (90 of 94). Of the 20 one-stage F-S orchidopexies, 17 testes were successfully placed in the scrotum with no atrophy. The overall success rate for all F-S procedures was 85% (23 of 27). However, excluding patients who had previous testicular surgery or who required extensive dissection near the vas, 96% (23 of 24) of the testes were successfully placed into the scrotum with no atrophy. CONCLUSION: The high overall success rate in placing the testis into the scrotum through laparoscopic procedures is considerably better than reported in other series to date. LO is an effective method for managing intra-abdominal testes in children. Patients who had undergone previous surgery had a higher risk of developing testicular atrophy. The additional dissection around the vas almost inevitably leads to testicular atrophy.