Doppler Ultrasound and Resistive Indices in the Diagnosis of Ureteropelvic Junction Obstruction in the Pediatric Population.

OBJECTIVES: Mercapto acetyl tri-glycine renogram (MAG3) scan has been the gold standard assessment of pediatric ureteropelvic junction obstruction (UPJO) but requires intravenous access and radiation exposure. While Doppler ultrasound measurements of resistive indices (RI) of the arcuate arteries have been proposed as an alternative assessment of obstruction, they have not been widely adopted in the pediatric population. We hypothesized that RI of the main renal artery (RA) is more strongly correlated with MAG3 findings than arcuate RI. METHODS: Pediatric patients with unilateral Society for Fetal Urology grade 3-4 hydronephrosis undergoing concomitant RUS and MAG3 were recruited. Doppler ultrasound peak systolic velocity (PSV); RI of bilateral RA at the origin, middle, and hilum; and RI of the superior, middle, and lower pole arcuate arteries were obtained. MAG3 differential renal function (DRF) and T½ were recorded. Differences in RI measurements (DRI) between the affected and normal kidney were calculated and compared with DRF and T½. RESULTS: 31 patients (median 4.6-month-old) were enrolled. Only RA RI at the origin differed between affected and normal kidneys (p < .001). DRI RA at the origin showed weak evidence for an association with MAG3 DRF < 40% (p .07). DRI was not associated with T½ > 20 minutes. CONCLUSION: There was weak evidence for an association between RA DRI at the origin and DRF but not with T½. These findings suggest that RA DRI may provide additional data in the evaluation of patients with UPJO to tailor the use of MAG3 and associated risk of radiation exposure to those patients most at risk for concomitant renal function impairment.

Use of electronic health record best practice alerts to improve adherence to American Urological Association vesicoureteral reflux guidelines.

PURPOSE: To evaluate the effect of a guidelines-based best practice alerts (BPA) in the electronic health record (EHR) on adherence to American Urological Association (AUA) vesicoureteral reflux (VUR) guidelines. METHODS: Retrospective cohort study of patients aged 0-17 years old with primary VUR with an initial urology clinic visit the year before or year after BPA implementation was done. Primary outcomes include obtaining vital signs, urinalysis, and ultrasound at initial and 1-year follow-up visit. RESULTS: We identified 123 patients with initial visits during the study period, 58 of whom returned for 1-year follow-up visits. Patients seen post-BPA were more likely to have height measured at initial visit than those seen pre-BPA (47.3% vs. 11.8%, p < 0.001). The majority of patients were screened with weight (98.3%) and ultrasound (87.9%) at 1-year follow-up both before and after BPA implementation. Neither blood pressure measurements (59.1% vs. 55.6%, p > 0.5) nor urinalysis orders (23.8% vs. 19.4%, p > 0.05) significantly increased post-BPA. CONCLUSION: The use of an EHR-based BPA increased the likelihood of obtaining height measurements by clinic intake staff but did not significantly affect provider adherence to other practice guideline recommendations. Our findings suggest that BPA implementation alone is not sufficient to impact provider uptake of VUR guideline recommendations.

Prenatal and Early Postnatal Outcomes for Fetuses with Anatomic or Functional Renal Agenesis.

INTRODUCTION: The advent of novel fetal interventions has increased interest in interventions for previously "lethal" anomalies such as bilateral renal agenesis or other congenital anomalies of the kidney and urinary tract (CAKUT) associated with in utero renal failure. While there have been rare reports of successful births following intervention in these cases, there is a paucity of data regarding the risks, benefits, and outcomes of intervention. To address this gap, this study presents our experience with fetal intervention for anatomic or functional renal agenesis. CASE PRESENTATION: A retrospective review was conducted for patients referred to the Colorado Fetal Care Center (CFCC) between 2013 and 2019 for evaluation of CAKUT anomalies. Eligibility was determined by a multidisciplinary team. Amnioinfusion was scheduled prior to 24 weeks gestation, with normal saline or lactated ringers infused as needed to obtain a "normal" amniotic fluid volume. During this time period, a total of 5 cases received fetal amnioinfusion for treatment of bilateral renal agenesis or bladder outlet obstruction. All 5 cases reached birth. 3/5 cases expired on day one of life. 1/2 of the remaining infants expired at 3 months secondary to peritoneal dialysis failure. The remaining infant is 4 years. Developmentally, she is on track with cognitive and language skills but is behind with general motor skills. We observed a 30-day mortality of 60% and 1-year mortality of 80%. CONCLUSIONS: Individuals carrying a pregnancy complicated by CAKUT anomalies face a difficult choice when considering intervention. Morbidity and mortality remain high at this stage of this evolving therapy, including difficulty with retaining infused intra-amniotic fluid >72 h and complications with peritoneal dialysis after birth. The surviving infant in this case series is 4 years. She currently awaits renal transplantation. These findings reinforce that treatment of these cases should remain experimental and large-scale multicenter trials are needed to determine the optimal indications for prenatal intervention.

Antireflux Surgery at National Surgical Quality Improvement Program-Pediatric Hospitals.

PURPOSE: This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data. MATERIALS AND METHODS: Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures). RESULTS: In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections. CONCLUSIONS: Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

Ureteropelvic junction obstruction: diagnosis and management.

PURPOSE OF REVIEW: Ureteropelvic junction obstruction (UPJO) is the most common cause of prenatally diagnosed hydronephrosis. Although associated with obstruction of the kidney, the natural history is variable, ranging from spontaneous resolution to progressive loss of function over the first few years of life. As a result, the optimal evaluation strategy and indications for treatment have not been well defined. The purpose of this article is to review recent literature focused on the prenatal and postnatal evaluation of infants with prenatally diagnosed hydronephrosis suspicious for UPJO. RECENT FINDINGS: Recent studies have focused on the effect of the urinary tract dilation (UTD) ultrasound classification system, as well as use of magnetic resonance imaging both prenatally and postnatally to stratify the risk of infants with prenatally diagnosed hydronephrosis to develop renal impairment or undergo surgery. Additionally, urinary biomarkers have been identified as a potential noninvasive alternative to diuretic renography in identifying infants with clinically significant UPJO. SUMMARY: Although continued work is needed to develop clear guidelines for evaluation and treatment and to better define long-term outcomes, these studies offer novel approaches to improve the care of these patients.

Imaging of fetal cystic kidney disease: multicystic dysplastic kidney versus renal cystic dysplasia.

With the advent of routine prenatal imaging, the number of renal anomalies identified prenatally has significantly increased; however, the underlying etiologies of these anomalies and the clinical significance of these findings remains unclear. This confusion is especially true for the prenatal diagnosis of cystic renal changes. The terms "cystic kidney disease" and "renal cystic dysplasia" encompass myriad renal diseases. Although renal cystic dysplasia in infants shares many similarities with multicystic dysplastic kidney (MCDK), it is important to distinguish MCDK from other etiologies that would lead to renal cysts, to ensure proper patient diagnosis and appropriate counseling regarding risks and to guide clinical management. The purpose of this review is to highlight the multiple etiologies of cystic kidney disease, including genetic associations, associations with underlying syndromes, and associations with underlying anatomical abnormalities. Here we focus on prenatal imaging, associated pathological findings, and clinical significance, with an emphasis on the defining characteristics of MCDK as compared to other forms of cystic renal disease.

The role of preoperative instructions in parents' understanding of preoperative fasting for outpatient pediatric urology procedures.

PURPOSE: To assess the impact of modifications in preoperative instructions on parental understanding of preoperative fasting guidelines. METHODS: A prospective postoperative parental survey was conducted to assess parental understanding of preoperative fasting requirements in patients undergoing surgery before and after institution of instructions that included visual aids. Data regarding demographics, procedure type, and time to surgery from preoperative visit were also captured. Survey data were compared between pre- and post-intervention groups using Chi-squared tests for categorical variables and Wilcoxon rank sum test for continuous variables. RESULTS: 173 parents in the pre-intervention group and 162 parents in the post-intervention group were included in the analysis. Parent identification of aspiration risk as the reason for fasting almost doubled after intervention (72.2% vs. 38.2%). There was some evidence of demographic differences between groups; however, in an adjusted model, there was strong evidence (p < 0.001) that parents in the post-intervention group were more likely to identify aspiration as the reason for preoperative fasting (OR 4.73; 95% CI 2.93-7.63). CONCLUSIONS: Addition of visual aids in preoperative instructions was associated with improvement in parents' understanding of the rationale behind preoperative fasting instructions. Further studies are needed to determine whether improved understanding is associated with improved adherence.

Patients with disorders of sex development and proximal hypospadias are at high risk for reoperation.

PURPOSE: Surgical repair for proximal hypospadias has been associated with long-term success rates of 32-68%. In a prior study, outcomes for proximal hypospadias in patients with a diagnosis of disorders of sex development (DSD) were no different than those of patients without DSD. The objective of our study is to report our experience with proximal hypospadias repair in patients with and without DSD. METHODS: We retrospectively reviewed patients who underwent repair of proximal hypospadias between 2005 and 2016. Data collected included patient and disease characteristics, operative details, complications, and follow-up. The primary outcome was unplanned reoperation. RESULTS: Sixty seven patients were identified; 30 (44.8%) with DSD and 37 (55.2%) without DSD. Median follow-up was 28.3 months (IQR 18.9-45.7). 41 patients (61.2%) underwent at least one unplanned reoperation, median time to unplanned reoperation 10.3 months. More patients with DSD needed an unplanned reoperation (80 vs. 45.9%, p = 0.024). During the first 12 months after initial repair, there was no difference in unplanned reoperation rates (40 vs. 32.4%, p = 0.611), but there was a difference in the first 24 months post-operatively (76.7 vs. 43.2%, p = 0.007). On multivariate logistic regression, older age at initial repair (OR 1.144) and two stage repair (OR 7.644) were positively associated with unplanned reoperation in the first 2 years after repair. CONCLUSIONS: Proximal hypospadias repair is associated with an overall 61.2% reoperation rate regardless of associated DSD diagnosis. Patients with DSD are more likely to undergo an unplanned reoperation in the first 2 years after repair.

Managing adult urinary incontinence from the congenitally incompetent bladder outlet.

PURPOSE OF REVIEW: Treatment of urinary incontinence in adult patients with congenital incompetent bladder outlet (exstrophy-epispadias complex, cloacal anomalies, or neurogenic bladder secondary to myelomeningocele) is a challenging surgical problem. In this review article, we summarize and highlight recent studies in the management of incontinence in this patient population. RECENT FINDINGS: The literature regarding management of urinary incontinence in this patient population is scarce. Injection of bulking agents to the bladder neck, artificial/autologous slings, artificial urinary sphincters, bladder neck reconstruction, bladder neck closure, or a combination of these are the cornerstone of management. Augmentation cystoplasty is a major adjunct procedure that can help increase continence rate and success of surgery in select patients. The level of evidence on bladder neck procedures for this patient population is low because of significant limitations, including small sample, heterogeneity of primary diagnosis/surgical techniques, variable definitions of continence, and the retrospective nature of most studies in this field. SUMMARY: Standard options for treatment of urinary incontinence in the congenitally incompetent bladder outlet procedure remain unchanged. There is no single reproducible procedure to accomplish the goal of renal preservation and continence in these patients, and often patients require multiple procedures to achieve continence. Most importantly, the pediatric and adult urologist should continue to work toward achieving a well tolerated and efficient transition of care. There is a need to standardize data acquisition and reporting of outcomes. Although randomized control studies would be ideal, because of the small number of patients with these conditions, this may not be practical. Collaboration and continued discussion among experts in the field is needed to gain a better understanding of the optimal management strategy in this growing patient population.

Factors associated with age at pyeloplasty in children with ureteropelvic junction obstruction.

OBJECTIVES: Our objectives were to: (1) delineate factors associated with surgery at <1 year and (2) determine if early intervention was associated with increased risk of readmission. METHODS: We conducted a retrospective review of children age 0-18 years with a diagnosis of UPJ obstruction who underwent pyeloplasty from 1/1/1999 to 9/1/2009 using the PHIS database. Data collected included patient factors (race, gender, insurance type, APR-DRG severity of illness) and hospital factors (annual case volume, census region, academic status). Outcomes assessed were: age at surgery and hospital readmission within 1 year of surgery. Data were analyzed using logistic regression and Cox PH for multivariate analyses. RESULTS: 4499 children met study criteria. Minority race (OR 1.55), male gender (OR 1.49), public insurance (OR 1.37), high severity of illness (OR 3.60), Southern region (OR 1.44), and low hospital volume (OR 1.37) were significant predictors of early surgery (p < 0.05). Only early surgery (HR 2.42; 95% CI 1.67-3.49 2.42) was associated with increased risk of readmission. CONCLUSIONS: In children with UPJ obstruction, age at surgery is associated with patient demographic and hospital factors. Early surgery is associated with higher rates of readmission, suggesting that variations in age at surgery may be associated with significant differences in outcomes.

Feasibility of integrating research data collection into routine clinical practice using the electronic health record.

PURPOSE: The electronic health record is becoming central to routine medical practice and has the potential to facilitate large scale clinical research. We evaluated the completeness and accuracy of data collection using designated research fields integrated into a semistructured clinical note. We hypothesized that prospective research data collection as part of routine clinical charting is feasible, with a high rate of utilization (greater than 80%) and accuracy (kappa greater than 0.80). MATERIALS AND METHODS: Infants with congenital hydronephrosis were followed prospectively at a single institution. Existing functionality in the electronic health record was used for data collection by creation of 28 different data elements captured from a hydronephrosis note or phrase template. Completeness (percent utilization) was calculated and accuracy was assessed by comparing the structured data to manual chart review. Comparisons were conducted using the chi-square test, with 2-tailed p values <0.05 considered statistically significant. RESULTS: A total of 80 patients were eligible for manual chart review. Data were recorded through template use in 64 patients for an overall completeness of 80.0%. Of 28 elements 17 (60%) demonstrated "almost perfect" agreement (kappa greater than 0.80), and all variables reached at least "moderate" agreement (greater than 0.40). CONCLUSIONS: Integrating research fields into routine clinical practice is feasible by using semistructured clinical templates within an electronic health record. High completion and accuracy rates were captured from a variety of fields within a hydronephrosis template.

Risk of acute kidney injury after lower urinary tract reconstruction with early NSAID therapy: A propensity matched retrospective analysis.

INTRODUCTION: The opioid epidemic response led to increased use of postoperative, non-opioid analgesia. Some pediatric urologists do not routinely use non-steroidal anti-inflammatory drugs (NSAIDs) for fear of causing acute kidney injury (AKI). While previous studies have demonstrated the safety and efficacy of NSAIDs in children, safety after lower urinary tract reconstruction has not been well characterized. OBJECTIVE: ptUsing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI (increase in creatinine ≥0.3 mg/dL or increase in creatinine ≥1.5x baseline or urine output <0.5 mL/kg/hr for 6 h), we hypothesized there would be a difference in the incidence of postoperative AKI between patients who did and did not receive NSAIDs following surgery. STUDY DESIGN: Patients 2-18 years old who underwent lower urinary tract reconstruction (i.e., bladder augmentation and/or creation of a catheterizable channel) from 2009 to 2021 and had documented urine output were retrospectively reviewed. Chronic kidney disease (CKD) stage was calculated from creatinine and cystatin C within 6 months of surgery using the CKiD U25 equations. Patients who received NSAIDs were propensity matched on 11 characteristics with patients undergoing similar surgeries who did not receive NSAIDs. The primary outcome was incidence of AKI within 48 h of surgery. RESULTS: The unmatched cohorts included 243 patients. Propensity matching identified 166 patients in the NSAID arm and 41 in the no NSAID arm. 26 patients with CKD stage 2-3 were included. There was no significant difference in the incidence of postoperative AKI based on any KDIGO criteria (17.1% no NSAID versus 16.3% NSAID, p = 0.87). Median postoperative opioids fell from 0.88 mg/kg in the no NSAID arm to 0.37 mg/kg morphine equivalents in the NSAID arm, although this was not statistically significant. Log-rank testing by Kaplan-Meier analysis demonstrated no difference in time to incidence of low urine output between the groups (p = 0.32). In the whole population not stratified by NSAID use, no differences were seen in AKI between those with and without CKD (16.7% with versus 17.9% without CKD). DISCUSSION: There was no difference in the incidence of postoperative AKI among patients who did and did not receive NSAIDs after lower urinary tract reconstruction, excluding those with advanced CKD. CONCLUSION: These results support that postoperative NSAIDs were an unlikely source of AKI. However, AKI remained a risk following these surgeries, regardless of NSAID use, likely owing to underlying disease, longer operations, and fluid shifts.

Megacystis Associated With an Underlying ACTA2 Variant and Diagnosis of Multisystemic Smooth Muscle Dysfunction Syndrome: A Case Report.

Fetal megacystis, or an enlarged fetal bladder, is most often attributed to embryological defects, occurring early in gestation. Recent investigations have demonstrated that the underlying etiology of megacystis may be more myriad than originally thought. We present the third reported patient with megacystis due to an ACTA2 Arg179 substitution variant causing Multisystemic Smooth Muscle Dysfunction Syndrome. We also provide a description of pediatric evaluation and follow up. The growing number of cases in which this ACTA2 variant has been identified in fetal megacystis suggests that molecular sequencing is an appropriate consideration, particularly prenatally, when other features of Multisystemic Smooth Muscle Dysfunction Syndrome cannot be detected.

Parental experience and understanding of parent-provider discussions of treatment for infants with ureteropelvic junction obstruction.

Objective: The purpose of the current study was to understand what families identify as necessary information to guide decision-making in the treatment of their child with UPJO. Methods: We conducted semi-structured interviews with parents of children with UPJO using phenomenological methodology. Data were systematically analyzed according to principles of thematic analysis, using a team-based inductive approach. Results: 32 parents were interviewed. Findings are organized by three major themes including barriers to meaningful participation in decision making, logistical aspects of the decision, and psychosocial aspects of the decision. Conclusion: These findings suggest the need to increase parent education and understanding around medical and surgical decision-making, and the need to enhance psychosocial support for more meaningful parental engagement in the surgical decision-making process. Practice implications: The findings from the interviews highlight the importance of caregivers needing clear and accurate information in order to engage in meaningful discussions related to surgical decision-making for decisions around surgery for UPJO treatment.

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach.

BACKGROUND: Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed. OBJECTIVE: The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique. METHODS: A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed. RESULTS: A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P = 0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P = 0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P = 0.294, log-rank P = 0.832, and log-rank P = 0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P = 0.236). DISCUSSION: This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal. CONCLUSIONS: Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

Management of pediatric renal trauma - Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study (Mi-PARTS).

BACKGROUND: Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A non-operative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury is not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This manuscript describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS: Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010-2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management and outcomes. RESULTS: In total 1216 cases were included in this study. 67.2% were male, and 93.8% had a blunt injury mechanism. 29.3% had isolated renal injuries. 65.6% were high-grade (AAST Grade III-V) injuries. The mean Injury Severity Score (ISS) was 20.5. Most patients were managed non-operatively (86.4%) 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in polytrauma. The rate of avoidable transfer was 28.2%. CONCLUSION: The management and outcomes of pediatric renal trauma lacks data to inform evidence-based guidelines. Non-operative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population, and highlights opportunities for further investigation. With data made available through Mi-PARTS we aim to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE: IV, Epidemiological (prognostic/epidemiological, therapeutic/care management, diagnostic test/criteria, economic/value-based evaluations, and Systematic Review and Meta-Analysis).

Contributing factors for cancellations of outpatient pediatric urology procedures: single center experience.

PURPOSE: Surgery cancellations in the pediatric population are often due to preventable causes and can lead to decreased operating room efficiency. We hypothesized that clinical and demographic patient factors are associated with preventable cancellations of scheduled outpatient pediatric urology procedures at our institution. MATERIALS AND METHODS: A retrospective review of cancelled outpatient pediatric urology procedures from January 1 to July 31, 2010 was performed. Data regarding demographics, procedure type, time to surgery from preoperative visit, reason for cancellation, potential operating room and surgeon lost revenue, and ultimate patient outcome were extracted from the electronic medical record. RESULTS: We identified 114 cancellations during the study period, comprising 13.3% of scheduled outpatient procedures. Preventable cancellations included insurance/financial related (11.4%), preoperative fasting violation (8.8%) and condition improved the day of surgery (4.4%). Nonpreventable cancellations included patient illness (40.3%), weather/traffic related (1.7%) and other nonspecified reasons (29%). Compared to nonpreventable cancellations, preventable cancellations were more likely associated with circumcision (OR 2.39, CI 1.04-5.46). Preventable cancellations were also associated with a shorter distance to the hospital (p = 0.03). There was no significant association between preventable cancellations and age, race/ethnicity, caregiver type or time to surgery. Potential associated lost revenue averaged $4,802 per cancellation. CONCLUSIONS: While the most common cause of surgical cancellation is patient illness, a significant number of cancellations are preventable. These findings suggest that future targeted hospital interventions, including improved evaluation of insurance status and preoperative parental education regarding preoperative requirements, may improve operating room use.

Outcomes of dialysis in neonates with anuric end-stage renal disease at birth: ethical considerations.

INTRODUCTION: We present a case series of neonates with anuric ESRD undergoing renal replacement therapy (RRT) and discuss the associated ethical implications of RRT in this population. METHODS: We reviewed patients who initiated RRT within 1 week of life due to anuric ESRD from 2009-2019 at a single tertiary center. Primary outcomes were receipt of renal transplant (RT), one-year survival, and overall survival. RESULTS: Five patients met the inclusion criteria. Two patients received an RT. One-year survival was 80%, while overall survival was 60% with a median follow-up of 18 months. In the 2 still-living patients who have not undergone RT, they are ineligible, one due to recent malignancy and the other from acquired cardiovascular comorbidities. CONCLUSION: Patients with anuric ESRD requiring RRT undergo multiple treatment challenges with low RT and survival rates. These findings should be shared with families considering intervention for cases of severe renal disease diagnosed prenatally.

Unexpected challenges faced by caregivers of children with neurogenic bladder: A qualitative study.

BACKGROUND: Management of the neurogenic bladder is variable, complex, and often requires a demanding bladder care regimen which may present caregiver burdens that are unique among chronic disease. While research into patient quality of life is increasing, parallel study of the caregiver experience is scant. Existing research primarily comprises survey data using validated instruments originally developed for non-urologic conditions, such as dementia. These surveys may detect high caregiver burden and decreased quality of life amongst caregivers but are limited in their ability to understand the underlying causes. OBJECTIVE: To characterize the experience of those caring for children with neurogenic bladders, with a focus on unexpected burdens and challenges. METHODS: In light of limited existing research, a qualitative research methodology was selected to explore the caregiver experience. Semi-structured phone interviews were conducted with primary caregivers of children with neurogenic bladder, all of whom were patients in the pediatric urology department of a single tertiary pediatric referral center. Purposive sampling was used to ensure diverse representation. Interviews were recorded, transcribed, and professionally translated if needed. Transcripts were analyzed using a team-based inductive grounded-theory approach, facilitated by ATLAS. ti software. Member-checking focus groups were held to validate the results. RESULTS: Twenty-five caregivers were interviewed (20 in English, 5 in Spanish), at which point thematic saturation was reached. Three primary themes emerged surrounding the topic of unexpected challenges: 1. High caregiver burden, 2. Challenges with catheterization and supplies, 3. Urinary tract infections. Member-checking focus groups validated the thematic analysis and provided additional insights into mitigating factors for these challenges. A child's independence with his or her health care regimen was cited as particularly important for decreasing caregiver burden. DISCUSSION: Caregivers of children with neurogenic bladder report their role is more difficult than they anticipated it would be. Catheterization represents a particularly burdensome task, and recurrent infections are an unexpected and persistent medical challenge. Understanding unexpected challenges that caregivers face will help pediatric urologists target modifiable factors to decrease caregiver burden, address current gaps in counseling and expectation-setting, and set the stage for more complete shared decision-making. CONCLUSIONS: This study represents an initial qualitative characterization of the experience caring for a child with neurogenic bladder. This is a key first step in understanding how caregivers make decisions for their children and their families. This initial study is foundational to a larger project to create a decision aid for caregivers of children with neurogenic bladder.