Third-Line Therapeutic Interventions for Non-Neurogenic Bladder Dysfunction in Children.

PURPOSE OF REVIEW: The aim of this article is to review considerations and efficacy of third-line treatments for pediatric non-neurogenic bladder dysfunction, including Botulinum toxin A (BoTNA), Posterior Tibial Nerve Stimulation (PTNS), and Sacral Neuromodulation (SNM). RECENT FINDINGS: Federal Drug Administration approval for use of beta-3-agonists in overactive detrusor activity in pediatric patients may provide an additional step prior to third-line therapies. New long-term data on pediatric SNM efficacy, complications, and revision rates will provide valuable information for counseling families. BoTNA offers a safe and efficacious treatment to decrease detrusor contractility and improve bladder capacity but is limited by the half-life of BoNTA agent. Percutaneous or transcutaneous PTNS offers improved voided volumes or cure in some patients but is time-intensive. SNM can be utilized in a variety of LUTD pathology with high success rate and cure but should consider cumulative anesthetic and fluoroscopic exposures for battery replacements and re-positioning for patient growth.

Epidural pressure changes following caudal blockade: a prospective, observational study.

PURPOSE: Recent case reports raise the question as to whether anesthetic agents injected into the epidural space could lead to a 'compartment syndrome' and neurovascular sequelae. Single-shot caudal epidural anesthesia has been established as a safe technique, but changes in pressure in the caudal epidural space have not been described. Our aim was to study pressure changes to provide preliminary information for future studies design. METHODS: We prospectively measured the pressure changes in the caudal epidural space in 31 pediatric patients. The pressures were measured at loss of resistance, immediately after the bolus dose of local anesthetic (1 ml/kg), and at 15-s intervals up to 3 min. RESULTS: The pressure at loss of resistance was 35.6 ± 27.8 mmHg. A pulsatile waveform was observed once the epidural space was accessed. The pressure after administration of the local anesthetic bolus (1 ml/kg 0.2 % ropivacaine/bupivacaine with 1:200,000 epinephrine) was 192.5 ± 93.3 mmHg. The pressure decreased to 51.5 ± 39.0 mmHg at 15 s, 26.9 ± 9.9 mmHg after 2 min, and 24.7 ± 11.7 after 3 min. The return to baseline occurred at approximately 45-60 s. CONCLUSIONS: Following the administration of the local anesthetic into the caudal epidural space, there was a marked, but transient, increase in the pressure within the epidural space. It appears unlikely that a slow epidural catheter infusion could lead to a sustained increase in epidural pressure.

Uroepithelial Thickening on Sonography Improves Detection of Vesicoureteral Reflux in Children with First Febrile Urinary Tract Infection.

PURPOSE: The 2011 American Academy of Pediatrics clinical practice guideline for childhood febrile urinary tract infection recommends voiding cystourethrography if renal and bladder ultrasound reveals hydronephrosis, scarring or "other findings" that suggest high grade vesicoureteral reflux. We sought to determine if the finding of uroepithelial thickening indicates greater risk of high grade vesicoureteral reflux and whether uroepithelial thickening improves the screening value of renal and bladder ultrasound. MATERIALS AND METHODS: We retrospectively analyzed renal and bladder ultrasound and voiding cystourethrogram findings in children 2 to 24 months old with first febrile urinary tract infection during an 11-year period. Patients with uroepithelial thickening were compared to an age and gender matched sample without uroepithelial thickening. Logistic regression was used to identify factors associated with high grade vesicoureteral reflux. Test characteristics of renal and bladder ultrasound for high grade reflux were compared based on different criteria to define an abnormal renal and bladder ultrasound. RESULTS: Of 226 patients 143 (63%) had vesicoureteral reflux, of whom 37 (26%) had high grade reflux. On multivariable analysis uroepithelial thickening was a significant independent predictor of high grade vesicoureteral reflux (OR 5.41, 95% CI 1.74-16.79, p = 0.004). When hydronephrosis and hydroureter were considered the only abnormal renal and bladder ultrasound findings warranting voiding cystourethrography, sensitivity of renal and bladder ultrasound for high grade reflux was 84%, and 6 children with high grade and 82 with low grade reflux would have been missed. When uroepithelial thickening was also considered an abnormal finding, the sensitivity increased to 97%, and only 1 child with high grade and 57 with low grade reflux would have been missed. CONCLUSIONS: Uroepithelial thickening is associated with an increased risk of high grade vesicoureteral reflux and is an abnormal finding warranting voiding cystourethrography. Sensitivity of renal and bladder ultrasound as a screening test for high grade vesicoureteral reflux is markedly improved when uroepithelial thickening is considered.

Sacral Nerve Stimulation for Pediatric Lower Urinary Tract Dysfunction: Development of a Standardized Pathway with Objective Urodynamic Outcomes.

PURPOSE: We propose that sacral nerve stimulation is a valid adjunctive therapy for refractory pediatric lower urinary tract dysfunction, and that prospective collection of preoperative and postoperative validated questionnaires and urodynamic data in a standardized fashion is beneficial in characterizing patient response. MATERIALS AND METHODS: Patients were candidates for sacral nerve stimulation if they had refractory voiding dysfunction and standard treatments had failed. Preoperative evaluation included urodynamic studies, spinal magnetic resonance imaging, and validated bladder and bowel related questionnaires. Children were stratified into 2 groups, ie overactive bladder with or without incontinence (group 1) and detrusor underactivity/urinary retention requiring clean intermittent catheterization (group 2). A staged procedure was used with initial test lead placement, followed by permanent device insertion 2 weeks later if patients demonstrated symptom improvement with test lead. Postoperatively children were followed with questionnaires and at least 1 urodynamic study. RESULTS: A total of 26 children underwent sacral nerve stimulation. Mean patient age was 10.8 years and median followup was 1.2 years. There were 23 patients in group 1 and 4 in group 2 (1 patient was included in both groups). In group 1 voiding dysfunction scores improved significantly, and urodynamic studies revealed a significant decrease in mean number of uninhibited contractions and maximum detrusor pressure during the filling phase. In group 2 there was significant improvement in mean post-void residual. CONCLUSIONS: Sacral nerve stimulation is a treatment option that may produce significant improvement in objective and subjective measures of bladder function in children with refractory lower urinary tract dysfunction.

Sacral nerve stimulation leads to long-term improvement in fecal incontinence and quality of life for children with functional and organic defecation disorders.

BACKGROUND: Our objective was to evaluate long-term outcomes of sacral nerve stimulation (SNS) for children with functional and organic defecation disorders. METHODS: We performed a prospective study of children <21 years of age who started SNS treatment between 2012 and 2018. We recorded demographics, medical history, and diagnostic testing. We obtained measures of symptom severity and quality of life at baseline and follow up at 1, 6, 12, 24, 36, 48, and ≥60 months. Successful response was defined as bowel movements >2 times/week and fecal incontinence (FI) <1 time/week. Families were contacted to administer the Glasgow Children's Benefit Inventory and to evaluate patient satisfaction. KEY RESULTS: We included 65 patients (59% female, median age at SNS 14 years, range 9-21) with median follow-up of 32 months. Thirty patients had functional constipation (FC), 15 had non-retentive FI (NRFI), and 16 had an anorectal malformation (ARM). The percentage with FI <1 time/week improved from 30% at baseline to 64% at 1 year (p < 0.001) and 77% at most recent follow-up (p < 0.001). Patients with FC, NRFI, and ARM had sustained improvement in FI (p = 0.02, p < 0.001, p = 0.02). Patients also reported fewer hard stools (p = 0.001). Bowel movement frequency did not improve after SNS. At most recent follow-up, 77% of patients with a functional disorder and 50% with an organic disorder had responded (p = 0.03). Nearly all families reported benefit. CONCLUSIONS AND INFERENCES: SNS led to sustained improvement in FI regardless of underlying etiology, but children with functional disorders were more likely to respond than those with organic disorders.

The development of surgical ability during pediatric urology fellowship and its evolution in the early years of practice.

BACKGROUND: North American Pediatric Urology fellowship programs underwent a structural change in 2021 that allows more flexibility in training. Given this opportunity as well as widespread concern about the development of contemporary surgical trainees, it is prudent to understand in detail the current state of preparedness of pediatric urology fellowship graduates for independent practice. OBJECTIVE: The study aimed to determine recent pediatric urology graduates' reported levels of comfort both at graduation and following the start of clinical practice in performing select index procedures. We also queried the aspects of training and clinical practice perceived to be the most valuable for the development of surgical confidence. STUDY DESIGN: Graduates of ACGME approved pediatric urology fellowships from 2016 to 2021 were surveyed. Index procedures were described via brief case vignettes. Respondents were asked to indicate their comfort level with each index procedure following fellowship graduation and at the current time point. Comfort levels were defined by the degree of support that respondents would seek from senior colleagues in preparation for case booking. Respondents were also asked about the most helpful operative settings during training and factors contributing to high and low comfort. RESULTS: Fifty-three pediatric urologists (49%) completed the survey out of 109 invited. Most respondents practiced at an academic center. Perceived comfort was very high for low complexity procedures. The responses varied more widely for procedures of moderate and significant complexity (Figure). Across the cohort, there was a substantial increase in comfort between graduation and the current time point for all procedures queried. The most highly valued operative settings in fellowship were those offering real or simulated independence. Respondents most often attributed high comfort to robust case volumes and overall surgical skill gained in fellowship. DISCUSSION: New pediatric urology faculty differ widely in surgical confidence, particularly for more complex procedures. There is meaningful growth in the confidence and self-perceived independence of pediatric urologists during their initial years of practice. The early years are a critical time of continuing maturation and development that should be supported with structured systems of mentorship. Future challenges include low case volumes for rare conditions and the centralization of complex care. CONCLUSION: These findings will provide valuable context for pediatric urology fellowship directors as they evaluate and redesign their programs under the new, more flexible structure. There are opportunities to formalize early practice mentorship to support the growth of new faculty.

Effectiveness of a Practical, At-Home Regimen of Parasacral Transcutaneous Electrical Nerve Stimulation in Pediatric Overactive Bladder.

OBJECTIVE: To describe and evaluate efficacy of a more practical, at-home regimen of parasacral transcutaneous electrical nerve stimulation (TENS) for pediatric overactive bladder (OAB). METHODS: We prospectively enrolled patients with OAB. INCLUSION CRITERIA: age 5-13 years and willingness to try TENS. EXCLUSION CRITERIA: urinary tract anatomic abnormalities, current use of OAB medications, neurologic condition, and elevated post-void residual. Patients were instructed to complete 20-minute sessions 2x/day for 1 month. Patients completed the Vancouver Symptom Score (VSS) and 48-hour frequency-volume chart before/after treatment. Compliance was assessed with a daily log. We recorded patient-reported improvement. Primary outcome was difference in VSS before/after treatment; secondary outcomes included: differences in frequency of voids/24 hours, max voided volume in 48 hours (%EBC), mean voided volume (%EBC), and mean number incontinence episodes/24 hours. RESULTS: We enrolled 21 patients (3 male, 18 female; median age 9.9 years). We had complete VSS data on 17 patients and frequency-volume chart data on 12 patients. Median % of TENS sessions completed was 98%. 8/17 patients reported subjective improvement. There was a significant difference between pre- and post-TENS VSS (median score: 23 pre-TENS and 21 post-TENS, P = .009). There were no differences in secondary outcomes before/after treatment. CONCLUSION: In our cohort of medically-refractory OAB pediatric patients, nearly half reported subjective improvement with our regimen, despite modest objective improvement. Our compliance rates suggest this regimen is practical but may be best used as an adjunct to other therapies.

Validation of the modified Bosniak classification system to risk stratify pediatric cystic renal masses: An international, multi-site study from the pediatric urologic oncology working group of the societies for pediatric urology.

BACKGROUND: Pediatric cystic renal lesions are challenging to manage as little is known about their natural course. A modified Bosniak (mBosniak) classification system has been proposed for risk stratification in pediatric patients that takes ultrasound (US) and/or computed tomogram (CT) characteristics into account. However, literature validating this system remains limited. OBJECTIVE: To determine if the mBosniak classification system correlates with pathologic diagnoses. The hypothesis is that mBosniak classification can stratify the risk of malignancy in children with renal cysts. STUDY DESIGN: Patients treated for cystic renal masses with available imaging and pathology between 2000 and 2019 from five institutions were identified. Clinical characteristics and pathology were obtained retrospectively. Characteristics from the most recent US, CT, and/or magnetic resonance imaging (MRI) were recorded. Reviewers assigned a mBosniak classification to each scan. mBosniak scores 1/2 were considered low-risk and 3/4 high-risk. These groups were compared with pathology (classified as benign, intermediate, malignant). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated to assess this categorization as a screening tool to guide surgical intervention. Agreement between imaging modalities was also explored. RESULTS: 99 patients were identified. High-risk imaging findings were correlated with malignant or intermediate pathology with a sensitivity of 88.3%, specificity of 84.6%, PPV of 89.8%, NPV of 82.5%, +LR of 5.7, and -LR of 0.14. The sensitivity for detecting malignant lesions only was 100%. There was substantial agreement between US/CT (n = 55; κ = 0.66) and moderate agreement between US/MRI (n = 20; κ = 0.52) and CT/MRI (n = 13; κ = 0.47). DISCUSSION: The mBos classification system is a useful tool in predicting the likelihood of benign vs. intermediate or malignant pathology. The relatively high sensitivity and specificity of the system for prediction of high-risk lesions makes this classification applicable to clinical decision making. In addition, all malignant lesions were accurately identified as mBosniak 4 on imaging. This study adds substantial data to the relatively small body of literature validating the mBosniak system for risk stratifying pediatric cystic renal lesions. CONCLUSIONS: Pediatric cystic renal lesions assigned mBosniak class 1/2 are mostly benign, whereas class 3/4 lesions are likely intermediate or malignant pathology. We observed that the mBosniak system correctly identified pathology appropriate for surgical management in 88% of cases and did not miss malignant pathologies. There is substantial agreement between CT and US scans concerning mBos classification.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction.

INTRODUCTION: Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly. METHODS: We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables. RESULTS: A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3 h 7 min vs. 3 h 41 min, p < 0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p = 0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction. CONCLUSION: We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

Comparison of antegrade continence enema treatment and sacral nerve stimulation for children with severe functional constipation and fecal incontinence.

BACKGROUND: To compare antegrade continence enema (ACE) treatment and sacral nerve stimulation (SNS) in children with intractable functional constipation (FC) and fecal incontinence (FI). METHODS: We performed a retrospective review of children 6-18 years old with FC and FI treated with either ACE or SNS at our institution. We recorded symptoms at baseline, 6 months, 12 months, 24 months, and their most recent visit after starting treatment. We compared improvement in FI, bowel movement (BM) frequency, abdominal pain, laxative use, and complications. Patients were contacted to evaluate perceived benefit using the Glasgow Children's Benefit Inventory. KEY RESULTS: We included 23 patients treated with ACE (52% female, median age 10 years) and 19 patients treated with SNS (74% female, median age 10 years). Improvement in FI was greater with SNS than ACE at 12 months (92.9% vs 57.1%, P = .03) and 24 months (100% vs 57.1%, P = .02). Improvement in BM frequency was greater with ACE, and children were more likely to discontinue laxatives at all follow-up time points (all P < .05). Improvement in abdominal pain was greater with ACE at the most recent visit (P < .05). Rate of complications requiring surgery was similar between groups (26.3% vs 21.7%). Benefit was reported in 83.3% and 100% of ACE and SNS groups, respectively (NS). CONCLUSIONS AND INFERENCES: Although both ACE and SNS can lead to durable improvement in children with FC and FI, SNS appears more effective for FI and ACE more effective in improving BM frequency and abdominal pain and in discontinuation of laxatives.

Free-floating Paratesticular Calcifying Fibrous Pseudotumors in a Pediatric Patient.

Paratesticular masses are a relatively common finding in males. The majority are benign, as opposed to testis masses, which tend to be malignant. Fibrous pseudotumors are rare, but are the third most common paratesticular tumor after adenomatoid and lipoma. The exact cause is unclear but likely from a fibroinflammatory reaction. Because of the non-specific findings on physical exam and scrotal ultrasound, patients may undergo scrotal exploration and occasionally orchiectomy, in spite of the benign nature of this lesion. Here we report the rare case of free-floating paratesticular calcifying fibrous pseudotumors in a prepubertal patient.

A review of pediatric glans malformations: a handy clinical reference.

PURPOSE: Lesions of the pediatric glans penis are an uncommon but important aspect of pediatric urological care. We reviewed the available literature on this topic and did not identify a comprehensive reference resource. We compiled our multi-institutional experience with such conditions to prepare a handy clinical reference source. MATERIALS AND METHODS: The diversity of pediatric glans penis lesions was documented by searching the English and nonEnglish literature as well as the archives at our institutions. Cases were included in the study if the patient(s) identified were younger than 18 years at initial presentation or documented to have first had a glans penis lesion when younger than 18 years. Hypospadiac-epispadiac anomalies of the glans were excluded. RESULTS: From our institutions we identified 6 new cases of various pediatric glans lesions. Altogether the literature describes 137 distinct nondiphallia glans lesions and more than 100 cases of diphallia, including glans duplication. The nondiphallia reports consist of a total of 61 cystic lesions (44%), 33 vascular malformations (24%), 20 dermatological lesions (15%), 20 infectious lesions (15%) and 3 neurogenic lesions (2%). We did not identify a compact resource to compare these anomalies. Visual comparison permits structuring a differential diagnosis and determining urological treatment, which is typically excisional biopsy, laser treatment, sclerotherapy or topical steroid administration. CONCLUSIONS: We present a visual reference of varied lesions of the pediatric glans penis, including 6 new cases, with urological significance. These lesions are always benign but they typically require surgical excision for a definitive pathological diagnosis.

Combination treatment for cicatrix after neonatal circumcision: An office-based solution to a challenging problem.

Cicatrix formation, which can form after neonatal circumcision to entrap the glans penis, presents a therapeutic challenge. Previous studies in the literature have described either using a topical steroid cream or stretching of the scar tissue with an instrument but not a combination of both modalities. In our experience, monotherapy has resulted in significant recurrence and/or need for further treatment. We present our successful experience that combines cicatrix stretching with a hemostat using local anesthesia in the office followed by several weeks of topical steroids with a minority of patients needing any additional therapy.

Factors Predicting Complications After Sacral Neuromodulation in Children.

OBJECTIVE: To identify if any preoperative variables are associated with postoperative complications after pediatric sacral neuromodulation (SNM). MATERIALS AND METHODS: A review of all patients undergoing SNM with an implantable pulse generator at our institution was performed. Postoperative infection, lead migration, lead breakage, and need for reoperation were recorded in a prospective database. We collected demographic information and indication for the procedure. We defined indication for procedure as either primarily bowel or primarily bladder symptoms. Multivariate analysis was used to determine any associations between preoperative factors and postoperative complications. RESULTS: Sixty-three children (34 females, 29 males) underwent SNM from 2012 to 2015. Mean age was 11.5 years, and body mass index (BMI) was 51st percentile for age. SNM was placed for primarily bowel symptoms in 49% and for primarily bladder symptoms in 51%. Follow-up was 1.9 years (0.19-4.3). Reoperation was required in 25%, with mean time to reoperation of 10.9 months (0.9-31.5). Lead migration occurred in 17.4%, and wound infection in 8%. There were no significant associations between patient age, gender, or BMI, and need for reoperation, wound infection, or lead migration. Low BMI had no increased risk of lead complications (P = .115). There was a significant increase in lead migration in the children who underwent SNM for primarily bladder symptoms (P = .0034). CONCLUSION: There is no association between age, gender, or BMI and postoperative complications in this large cohort of pediatric SNM. Children with primarily bladder symptoms may have higher rate of lead complications for unclear reasons.

Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia.

BACKGROUND: Spinal anesthesia (SA) is an effective technique that has been used in children for years. With growing concern with regard to the risks of general anesthesia (GA), we developed a SA program to provide an alternative option. We present our initial experience with this program. OBJECTIVE: To implement a SA program at a large tertiary care pediatric center and assess the safety and efficacy of the technique as an alternative to GA for urologic surgery. STUDY DESIGN/METHODS: We prospectively collected data on all children undergoing SA at our institution. We recorded demographics, procedure, time required for placement of the SA, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA, and perioperative complications. RESULTS: SA was attempted in 105 consecutive children (104 boys, 1 girl) with a mean age of 7.4 ± 4.3 months (range 19 days-24 months) and mean weight of 8.3 ± 1.7 kg (range 3.5-13.7). Placement of the SA was successful in 93/105 children (89%). Inability to achieve lumbar puncture (cerebrospinal fluid was not obtained) meant that SA was abandoned in seven (7%) patients and GA was administered. In five patients in whom SA was successful and surgery was begun, 5/93 (5%) required conversion to GA: two because of evisceration of intestine through large hernia defects related to coughing and abdominal irritation, two because of lack of motor blockade despite an adequate sensory block, and one because of an inability to place an intravenous catheter in the lower extremities (required per SA protocol). If necessary, an intravenous catheter can be placed in the upper extremity, but this must be weighed against the fact that the block has already been placed and is of limited duration. Overall, SA was successful (SA was placed and surgery was completed without conversion to GA) in 88/105 children (84%). No additional sedation and no systemic anesthetic agents were required in 75/88 children (85%). The average time required to place the SA was 3.8 ± 2.7 min (range 1-12). The average time for the surgical procedure was 38.3 ± 23.1 min (range 10-122). No patient required conversion to GA because of recession of block. There were no surgical complications. DISCUSSION/CONCLUSIONS: SA is a safe and efficacious technique for routine pediatric urological procedures. SA should be considered for cases such as neonatal torsion or patients with significant cardiac or pulmonary comorbidities when the risks of GA are often weighed against the risks of non-intervention.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation.

BACKGROUND: Sacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. METHODS: Using a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. RESULTS: Twenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. CONCLUSIONS: In children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. LEVEL OF EVIDENCE: IV.

Novel Use of Pudendal Neuromodulation in a Pediatric Patient With Caudal Regression and Partial Sacral Agenesis for Refractory Bowel Bladder Dysfunction.

Sacral neuromodulation (SNM) has been used off-label in the United States for over a decade in the pediatric population. Many published studies have demonstrated efficacy with SNM in this population; however, a significant number of children with refractory bowel bladder dysfunction (BBD) also have underlying comorbidities. Children with certain spinal abnormalities pose a problem for the urologist treating BBD. Patients with caudal regression can have various sacral anomalies, making SNM challenging or impossible. We present the first case in the United States of pudendal neuromodulation in a pediatric BBD patient with caudal regression.