Metabolic evaluation of urolithiasis and obesity in a midwestern pediatric population.

PURPOSE: The incidence of urolithiasis has been proved to be increasing in the adult population, and evidence to date suggests that the same holds true for the pediatric population. While adult urolithiasis is clearly linked to obesity, studies of pediatric patients have been less conclusive. We hypothesized that a population of otherwise healthy children with stones would have an increased body mass index compared to a control population, and that obese pediatric stone formers would have results on metabolic assessment that are distinct from nonobese stone formers. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients 10 to 17 years old with upper tract urolithiasis without comorbidities treated between 2006 and 2011. Mean body mass index of our population was compared to state data, and 24-hour urine collection results were compared between obese and nonobese patients with stones. RESULTS: The obesity rate in 117 patients with urolithiasis did not differ significantly from the obesity rate derived from the 2007 National Survey of Children's Health (observed/expected ratio 1.11, 95% CI 0.54-1.95). Using t-test and chi-square comparisons, overall 24-hour urine collection data did not show statistically significant differences. CONCLUSIONS: Our results do not confirm obesity as a risk factor for pediatric urolithiasis in otherwise healthy patients. We also found no substantial metabolic differences between healthy nonobese stone formers and obese patients. While the pediatric literature is mixed, our study supports the majority of published series that have failed to establish a link between pediatric urolithiasis and obesity.

Urolithiasis in patients on high dose felbamate.

PURPOSE: We report 4 cases of felbamate urolithiasis. We identified only 1 prior case report of a felbamate stone. Felbamate is an antiepileptic drug used to treat refractory seizures and has minor side effects when given in recommended doses. We analyzed the characteristics, evaluation, treatment and outcomes in this challenging group of patients. MATERIALS AND METHODS: Following institutional review board approval, we conducted a retrospective chart review of all patients who presented with a diagnosis of urolithiasis, were on felbamate and had stone analysis consistent with a felbamate origin. RESULTS: All 4 patients had refractory seizures and 3 had severe developmental delay. Presentation ranged from an incidental finding to gross hematuria to agitation and pain. Stones were not visible on plain x-ray except in 1 case involving mixed stone composition. Decrease or cessation of the drug has not been feasible in 2 patients, and 3 patients have had recurrent stones. Initial stone analysis did not correctly identify the stone composition as felbamate in 2 cases, suggesting that the origin of these stones may not always be recognized. CONCLUSIONS: We report the occurrence of felbamate stones in a series of patients on high dose felbamate therapy. Accurate diagnosis is made more difficult by the clinical complexity of the patient population (including severe developmental delay), the radiolucent nature of the stones and the possibility of inaccurate analysis of stone composition.

Antibiotic Prophylaxis with Trimethoprim-Sulfamethoxazole versus No Treatment after Mid-to-Distal Hypospadias Repair: A Prospective, Randomized Study.

PURPOSE: To evaluate the impact of prophylactic antibiotics after distal hypospadias repair on postoperative bacteriuria, symptomatic urinary tract infection, and postoperative complications in a prospective, randomized trial. MATERIALS AND METHODS: Consecutive patients aged 6 months to 2 years were enrolled at our institution between June 2013 and May 2017. Consenting patients were randomized to antibiotic prophylaxis with trimethoprim-sulfamethoxazole versus no antibiotic. Patients had catheterized urine samples obtained at surgery and 6-10 days postoperatively. The primary outcome was bacteriuria and pyuria at postoperative urine collection. Secondary outcomes included symptomatic urinary tract infection and postoperative complications. RESULTS: 70 patients consented to the study, of which 35 were randomized to receive antibiotics compared to 32 who did not. Demographics, severity of hypospadias, and type of repair were similar between the groups. Patients in the treatment group had significantly less pyuria (18%) and bacteriuria (11%) present at stent removal compared to the nontreatment group (55% and 63%; p=0.01 and p < 0.001, resp.). No patient had a symptomatic urinary tract infection. There were 11 postoperative complications. CONCLUSIONS: Routine antibiotic prophylaxis appears to significantly decrease bacteriuria and pyuria in the immediate postoperative period; however, no difference was observed in symptomatic urinary tract infection or postoperative complications. Clinical Trial Registration Number NCT02593903.

Surgical management of urolithiasis.

Pediatric patients with urolithiasis present unique challenges. Interventional techniques developed for adult patients have been adopted and adapted to facilitate effective and safe treatment in this population. Management must be stratified and individualized, taking into account the many factors described in this article. Long-term follow-up and metabolic evaluation are essential components of the overall treatment strategy. Interventional management will continue to evolve with progressive refinements in instrumentation and techniques.

Clinical pathway for early discharge after complete primary repair of exstrophy and epispadias by using a spica cast.

INTRODUCTION/OBJECTIVE: Secure closure of the pubic diastasis during bladder exstrophy and epispadias repair decreases the abdominal wall tension at the time of reconstruction. Pelvic osteotomies are routinely performed at the time of abdominal wall and bladder reconstruction in order to more easily facilitate pubic symphyseal diastasis approximation. Postoperative pelvic immobilization is performed by methods that include modified Buck's traction, modified Bryant's traction, and spica casting. People undergoing closure often require inpatient hospitalization for 2-8 weeks because of the pelvic immobilization. The present study examined the findings from a clinical pathway for early discharge after complete primary repair of exstrophy (CPRE) and proximal epispadias repair with spica casting. METHODS: The present study is a retrospective review of patients that underwent pelvic osteotomies with spica casting at the time of CPRE or proximal epispadias repair from November 2006 to March 2013. All patients had anterior innominate osteotomies and spica cast pelvic immobilization. RESULTS: Pelvic osteotomies and spica cast pelvic immobilization were performed on 17 children. The median postoperative stay was 6.0 days and the subdivided results are in Table. No children experienced an abdominal or orthopedic complication. A few children required minor cast adjustments to relieve pressure. After cast removal, no skin breakdown, pressure necrosis, or nerve palsy were found. The median length of casting without pinning was 31 (26-48) days. DISCUSSION: The use of spica cast pelvic immobilization after exstrophy and epispadias repair is safe and allows for earlier discharge when compared to other methods of pelvic immobilization. However, although the family appreciates early discharge and additional bonding, the priority is the success of the closure. The present findings demonstrate, and are corroborated by other spica cast publications, that spica casting is as effective as modified Bryant's traction or modified Buck's traction. The success rates for CPRE with spica casting are similar to published staged repairs and have the benefit of allowing for bladder cycling, which potentially enables better bladder growth and development. If success and complication rates are comparable amongst the different pelvic immobilization groups, then variables including hospital length of stay and cost become appropriate comparisons. CONCLUSION: The shortened discharge time, along with a significant decrease in acuity of care leads to significant decreases in hospital costs. Additional hospital stay when using modified Bryant's traction or modified Buck's traction with external fixation will accrue significant hospital costs.

Urologic problems of the neonate.

Maternal sonography is integrated into routine prenatal care, and numerous fetal anomalies are detected, with genitourinary anomalies the most common. This has profoundly influenced the presentation and natural history of neonatal urologic problems. This article is divided into two sections. The first addresses clinical questions raised by prenatally detected anomalies, abdominal masses, urosepsis, urinary retention, scrotal masses, and abnormal external genitalia. The second discusses evaluation and management of specific anomalies,including controversies, and optimum timing for tertiary care center referral. The selected anomalies include renal anomalies, tumors, the exstrophy complex, urogenital anomalies, ambiguous genitalia, posterior urethral valves, scrotal anomalies, spina bifida, and common urologic syndromes such as the triad syndrome. Readers are referred to urologic texts for additional information.

Advanced transitional cell carcinoma of the bladder in a 16-year-old girl with Hinman syndrome.

The present report describes a 16-year-old girl with a history of Hinman syndrome who was found to have invasive transitional cell carcinoma of the bladder. Bladder cancer is rare in children. Typically, the tumors are of low grade and stage. We present the first case of a teenage girl diagnosed with Hinman syndrome who developed an invasive bladder transitional cell carcinoma. The patient with a neurogenic bladder who has undergone bladder augmentation is at increased risk for bladder cancer. This risk may now have to be extended out to the non-neurogenic neurogenic bladder population if further cases are identified.

Creation and implementation of a prospective pediatric clinical outcomes registry.

OBJECTIVE: To build a pediatric clinical outcomes registry (COR) using a contemporary information system designed to support research and outcome studies and to improve patient care and quality of life. PATIENTS AND METHODS: In response to physician needs, this process was implemented: 1) database needs assessment survey, 2) evaluate existing systems and vendors, 3) pilot test a COR tool, and 4) build a COR. The COR was designed to include patients with the following conditions: scoliosis, neonatal surgery, urologic surgery, cleft palate, pain management, otitis media, and voice and airway problems. Agency for Healthcare Research and Quality methodology was followed to create the infrastructure and registry. RESULTS: The database needs assessment survey was completed by 99 individuals and most respondents wanted to collect more standardized data than currently available in existing systems. Satisfaction with the existing systems was rated low. The COR was created and a pilot test was successful. The COR was implemented and has been functioning for more than 2 years. CONCLUSIONS: By identifying physicians needs, evaluating existing technology and incorporating a multidisciplinary team, the COR was created and implemented to maintain clinical data on a variety of patient diagnoses and outcomes using a single technology platform that enhances potential research collaborations and minimizes redundant data entry and data collection, such as quality of life assessments for the patients.

Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite.

PURPOSE: With no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair. MATERIALS AND METHODS: A total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG. RESULTS: At 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters. CONCLUSIONS: Synthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.