Self-guided Online Medical Hypnosis Program Improves Dry Nights in Children With Nocturnal Enuresis in a Prospective Single-Center Pilot Study.

Bedwetting is a common condition in children. We evaluated the effectiveness of medical hypnosis as a first-line therapy in children with primary monosymptomatic nocturnal enuresis (PMNE). The study enrolled children in a prospective single-center pilot clinical trial consisting of 1 month diary of dry nights prior to using the commercially available hypnosis intervention (www.keepingthebeddry.com), followed by 3 consecutive months diary following intervention. Seventeen children aged 8 to 15 years old were enrolled and 12 recorded at least 1 month data after the hypnosis intervention. The median dry nights prior to intervention was 8 (0-17) days and improved to 15.5 (7-28) days by the third month post-intervention (P = .0033). All patients who completed the study showed an improvement. Self-guided medical hypnosis therapy showed significant improvement in dry nights without any side effects and any identifiable risk to patients. It should be considered for use in children as first-line therapy for PMNE.

Robotic assisted retrovesical approach to prostatic utricle excision and other complex pelvic pathology in children is safe and feasible.

INTRODUCTION: Excision of the prostatic utricle has been a challenging surgical problem due to the location deep in the pelvis between the rectum and bladder. Robotic-assisted laparoscopic surgery allows minimally invasive access to this location. OBJECTIVE: To describe the robotic surgical outcomes and important techniques associated with robotic excision of the prostatic utricle and explain how these techniques apply to similar pediatric pelvic pathology. STUDY DESIGN: Retrospective chart evaluation of patients treated at a single institution with robotic excision of a prostatic utricle as well as two other patients in which the similar approach was employed. RESULTS: 4 patients underwent robotic excision of a prostatic utricle. A fifth patient underwent excision of urethral diverticulum that was the remnant of an ectopic ureter. The sixth patient had a high urogenital sinus that required laparoscopic assisted vaginoplasty approached in a similar manner to the above listed cases. Mean age at surgery was 35.5 months for the utricle patients. Mean follow-up duration for the utricle patients was 30.75 months. Average hospital stay for the utricle patients was one day. In the utricle patients one patient developed transient urinary retention and one had a postoperative urinary tract infection. Concomitant cystoscopy used in the two non-utricle patients was a key step in defining the proper location of dissection. DISCUSSION: Robotic-assisted laparoscopic retrovesical excision of the prostatic utricle is a safe operation that requires a skill set that can be readily applied to other complex pelvic pathology such as the ectopic ureter, urethral diverticulum, and urogenital sinus. Concomitant cystoscopy can aid significantly in defining the location and limits of dissection.

Parental perception of bladder spasms and hematuria after surgery for vesicoureteral reflux: A prospective multicenter study.

INTRODUCTION: Anti-reflux surgery success has been well-documented in the literature. Little data exists about the characterization of the child's symptoms regarding pain, bladder spasms, and hematuria following these procedures. These symptoms may affect the choice of surgery for families and providers. OBJECTIVE: To characterize parent's perception of recovery from surgery and preparedness for recovery from surgery. We hypothesized that parents of children undergoing open intravesical reimplantation (Open) would report a higher incidence of bladder spasms and hematuria compared to children undergoing robotic extravesical reimplantation (RALR) or endoscopic treatment (DxHA). STUDY DESIGN: A 20-question survey was developed to assess perception of recovery preparedness, pain, and symptoms. Parents completed the survey at a follow-up visit occurring 3-6 weeks post-discharge. Chi-square and t-test or their non-parametric equivalents were used for between-group comparisons. RESULTS: Participating were three institutions and eleven surgeons. Eighty-four parents completed the survey a median of 33 days (IQR 27-40) post-surgery. More parents reported bladder spasms and hematuria in the Open group vs RALR and DxHA. Although there was no difference in maximum bladder spasm pain, duration of pain medication for spasms was longer with Open vs RALR. Most parents (87%) reported they were prepared for their child's symptoms after surgery. Approximately one-quarter of parents whose child underwent Open (33%) or RALR (36%) reported the bladder spasms were more painful than expected, and almost half of parents whose child underwent Open (49%) reported hematuria was worse than expected. DISCUSSION: We found that Open had significantly worse parental reports of bladder spasms, pain medication usage, and severity of hematuria than RALR and DxHA. Although most parents said they were prepared for their child's recovery, many reported the symptoms were worse than expected. These contradictions may reflect a need for improved physician to parent communication when discussing anti-reflux surgery.

Postoperative management factors affect urinary retention following posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigates postoperative urinary retention (POUR) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and the effects of postoperative analgesia and mobility on retention. High opioid use and decreased postoperative mobility are proposed risk factors for retention in adults. There is a paucity of literature on POUR in the adolescent population undergoing surgery for AIS. The impact of pain control and mobility on POUR in these patients is unknown. METHODS: A retrospective cohort study was conducted of adolescents (11-18 years) undergoing elective PSF for AIS at a single institution (2012-2018). POUR was defined as the inability to void > 8 h after catheter removal. Possible risk factors for retention including opioid usage and ambulatory status at the time of catheter removal were assessed on univariate and binomial logistic regression analyses. RESULTS: One hundred and thirty-six patients were included, with 21 (15.4%) experiencing POUR. On the day of catheter removal, 24 patients had not attempted ambulation; these patients had 2.5 times higher rate of POUR than those who were walking (30% vs. 12%, p = 0.04). Patients who developed retention ambulated a mean threefold shorter distance than those without POUR (45 vs. 136 feet, p = 0.04). On binomial logistic regression, decreased ambulation distance was associated with retention (p = 0.038). While opioid use was not significant on univariate analysis, higher opioid use on the day of catheter removal predicted retention on logistic regression (p = 0.001). POUR resolved in all patients (median duration 0.5 days, range 0-12 days). CONCLUSIONS: The development of POUR after PSF for AIS affects one in six patients but resolves quickly. Non-ambulatory patients and patients who received large doses of opioids on the day of catheter removal were more likely to develop POUR. LEVEL OF EVIDENCE: III.

24 Hour urine metabolic differences between solitary and multiple stone formers: Results of the Collaboration on Urolithiasis in Pediatrics (CUP) working group.

INTRODUCTION: Specific factors associated with the risk of developing pediatric urinary stone disease remain unclear, especially those that may be associated with recurrent stone disease. OBJECTIVE: We compared the results of 24-h urine collections in children with a solitary stone episode to those with multiple stone episodes to determine if there is a difference that may be associated with multiple stone formation in children. STUDY DESIGN: A multi-institutional retrospective analysis was completed to assess 24-h urinary metabolic profiles in children with urolithiasis aged 2-18 years old. Differences in mean urine collections between the two groups were assessed using chi-square tests to test the associations among gender, stone type, and multiple stone status, as well as multivariate analyses using general linear models. RESULTS: We analyzed 142 solitary stone patients and 136 multiple stone patients from four centers were included. Multiple stone patients were older than solitary stone patients (mean 13.4 ± 3.6 years vs. 12 ± 3.9 years, p = 0.002). Females were more likely to have multiple stones (58% vs. 39%, p = 0.002). BMI was not associated with multiple stones (p = 0.8467). Multiple stone formers had lower urine volumes, although this did not reach statistical significance when compared with solitary stone formation (20.4 mL/kg/day ± 11.5 vs. 22.9 ± 13.0, p = 0.0880). Higher values for super-saturation of calcium oxalate were associated with multiple stone disease in univariate (p = 0.0485) and multivariate analysis (p = 0.0469) (Figure). Centers located in the Southeast of the United States saw a higher proportion of children with multiple stones (Tennessee 62.7%, Virginia 44.4%, Oregon 31.6%, Michigan 27.3%, p < 0.0001). DISCUSSION: In a large multi-institutional retrospective analysis we found that multiple stone disease was associated with higher super-saturations of calcium oxalate. Many urinary parameters changed with patient age, highlighting that the values should be interpreted with respect to patient age. The inability to comment on follow-up because of the nature of our dataset is a limitation of this study. CONCLUSION: Multiple stone disease in children is associated with higher super-saturation calcium oxalate, while lower urinary volume may also be associated with multiple stones; however, further study is required. Early metabolic evaluation may help risk stratify children likely to form multiple stones.

Do Overweight and Obese Pediatric Stone Formers Have Differences in Metabolic Abnormalities Compared With Normal-weight Stone Formers?

OBJECTIVE: To determine if 24-hour urinary parameters in children with nephrolithiasis across 4 institutions were influenced by body mass index (BMI). MATERIALS AND METHODS: The 24-hour urinary parameters obtained from children with nephrolithiasis between 2000 and 2013 were stratified by BMI percentile ≥85th and <85th (overweight and obese patients vs healthy weight, respectively). A total of 206 children were included in the study. Exclusion criteria included patients with a history of spina bifida, neurogenic bladder, and cerebral palsy, and patients on medical treatment before the first 24-hour urine collection. RESULTS: Overweight and obese patients consisted of 35.4% of the cohort (n = 73). Metabolic abnormalities were present in 130 children (63.1%). The most common abnormality present in the <85th percentile was hypercalciuria (32.3%), and in the ≥85th percentile, hyperoxaluria (37.0%). Univariable and multivariable analyses revealed that overweight and obese children were more likely to have low urinary volume and elevated uric acid compared to normal-weight children. CONCLUSION: Although there is a link between stone formation and BMI in adults, no definitive conclusions have been proven in the pediatric literature. Our study indicates that stone-forming children who are overweight or obese have low urinary volume and elevated uric acid compared to normal-weight stone-forming children.

Invasive High-grade Upper Tract Urothelial Carcinoma in a 14-Year-Old Girl.

We present an unusual pediatric case of invasive upper tract urothelial carcinoma with an associated genetic predisposition. A 14-year-old female presented with intermittent right flank pain, and was found to have a poorly functioning hydronephrotic right kidney. Laparoscopic nephrectomy was performed. Pathology demonstrated upper tract urothelial carcinoma, and she subsequently underwent completion ureterectomy. Genetic studies demonstrated a double-hit constitutional deletion of a DNA mismatch repair protein, revealing a rare Lynch syndrome variant known as Constitutional Mismatch Repair Deficiency Syndrome. This disease places her at high risk for multiple malignancies, including upper tract urothelial carcinoma.

National multi-institutional cooperative on urolithiasis in children: Age is a significant predictor of urine abnormalities.

INTRODUCTION: Pediatric nephrolithiasis is a growing problem and prior studies have shown the greatest increase in nephrolithiasis in the adolescent population. Metabolic abnormalities have historically been cited as the primary cause of pediatric nephrolithiasis; however, dietary and other factors such as obesity have also been studied with mixed results. OBJECTIVE: We reviewed the charts of pediatric patients with a history of nephrolithiasis to determine the number and types of metabolic abnormalities present on 24-h urine analysis. STUDY DESIGN: We retrospectively reviewed the charts of all pediatric patients with a history of nephrolithiasis from 1999-2013 across four different institutions. The subjects were excluded if they had a history of spina bifida, neurogenic bladder, cerebral palsy, isolated bladder stones, or if they were on medical therapy for nephrolithiasis before the first 24-h urine collection. RESULTS: There were 206 subjects included in the analysis with an average age of 13 (±3.9) years. The patients were stratified into two age groups based on an apparent bimodal distribution of metabolic abnormalities, ≤10 years and >10 years of age. Metabolic abnormalities were present in 130 children (63.1%) and there was a difference between the groups, with children ≤10 years more likely to have a metabolic abnormality compared with those >10 years of age (75% vs. 60.6%, p = 0.0443) on univariate analysis. In children ≤10 years hypercalciuria was the most common disorder present (48.4%), and in children >10 years hypocitraturia was the most common disorder present (26.1%). Children ≤10 years of age were more likely to have normal volume (p = 0.006), elevated urinary oxalate (p = 0.0351), elevated urinary calcium (p < 0.001), elevated supersaturation of calcium phosphate (p < 0.001), and elevated supersaturation of calcium oxalate (p = 0.002). On multivariate analysis, children ≤10 years of age were more likely to have normal volume, hyperoxaluria, elevated supersaturation of calcium phosphate and a trend towards hypercalciuria (Table). DISCUSSION: Our study reveals that younger children are more likely to have a metabolic abnormality present on 24-h urine analysis. This has important implications when deciding on treatment options, with younger children potentially requiring more aggressive management with medical therapy. Older children were more likely to have low urinary volume and their most common metabolic abnormality was hypocitraturia. Although dietary factors have not been established as the definitive reason behind the rising incidence of nephrolithiasis in the adolescent population, older children may benefit more from diet modification with a strong focus on increasing volume intake. CONCLUSION: We found differences in younger compared with older age groups in terms of the number and types of metabolic disorders present. Children ≤10 years of age were more likely to have a metabolic disorder including elevations in calcium, oxalate and supersaturation of calcium phosphate, while children >10 years of age were more likely to have low urinary volume. These differences have important implications for future investigative studies on the rising incidence as well as the best course of treatment for children with nephrolithiasis.

Nocturnal enuresis: an approach to assessment and treatment.

On the basis of strong evidence, although primary monosymptomatic nocturnal enuresis (PMNE) is common and most children will outgrow the condition spontaneously, the psychological effect to the child can be significant and represents the main reason for treatment of these children. On the basis of international consensus panels, treatment of PMNE should be targeted toward the specific type of bedwetting patterns the child has, using bladder diary, sleep history, and daytime elimination concerns as a guide (Table 3). On the basis of international consensus panels, it is important for the primary care physician to be able to differentiate children with PMNE from children with nonmonosymptomatic nocturnal enuresis (NMNE) and secondary nocturnal enuresis. On the basis of international consensus panels, children with NMNE should have their underlying voiding or stool problem addressed before initiation of therapy for the nocturnal enuresis. On the basis of strong evidence, both the bedwetting alarm and desmopressin are considered first-line therapy for children with PMNE.

Single-center experience with pediatric laparoscopic extravesical reimplantation: safe and effective in simple and complex anatomy.

PURPOSE: Minimally invasive approaches to the surgical management of vesicoureteric reflux (VUR) have become more prominent over the last 10 years with progress in both endoscopic and laparoscopic/robotic surgery. We hypothesized that laparoscopic extravesical detrussoraphy (LED) for the management of VUR in children with complex bladders and/or bilateral VUR was safe and effective. SUBJECTS AND METHODS: Under institutional review board approval we evaluated the charts of all patients seen at our institution over the last 8 years who had undergone LED for the management of VUR. We evaluated demographic variables, surgical variables, and postoperative results. Postoperative bladder function was examined in the patients as well as need for secondary procedures. Patients with complex bladders included all patients who had previous surgery on the affected side, neurogenic bladders, and duplex or complex anatomy. RESULTS: Ninety-eight patients with 144 ureters were treated during this time period. The overall VUR resolution by voiding cystourethrogram was 95.2%. The average age was 6.74 years, with 13 children over the age of 12 years old. Average length of stay (LOS) was 1.7 days for children 5 years and older and 1.0 days for children less than 5 years old (P=.004). LOS was not affected by body mass index or complexity of the procedure. There were 46 bilateral procedures, and the incidence of urinary retention was 6.5% versus 0% in the unilateral group (P=.09). Of our patients, 27.6% had complex bladders, including 9 patients with complete ureteral duplications, 10 with periureteral diverticula, and 8 with prior surgery on the affected side. There were two complications requiring a second procedure in this group (7%). No patient with a complex bladder had persistent VUR. CONCLUSION: LED for the management of children with complex bladders and VUR is safe and effective. This technique is versatile and achieves high VUR resolution rates with minimal morbidity.

The impact of surgical approach and urinary diversion on patient outcomes in pediatric pyeloplasty.

PURPOSE: Recent comparisons of the impact of the surgical approach on pediatric pyeloplasty outcomes have generally incorporated a form of internal ureteral drainage. We hypothesized that the surgical approach does not affect outcomes in children who undergo unstented pyeloplasty and stenting offers no long-term benefit in those with pediatric pyeloplasty. MATERIALS AND METHODS: After receiving institutional review board approval we examined the records of all children who underwent initial pyeloplasty from December 2001 to December 2009. We compared unstented and stented pyeloplasties, and each surgical approach in the unstented group. RESULTS: During the study period 367 pyeloplasties were performed, including 231 unstented and 136 stented procedures. When comparing unstented to stented pyeloplasties, there was no difference in the complication or failure rate. Of unstented pyeloplasties 71, 67 and 93 were done using a transperitoneal laparoscopic approach, a flank approach and dorsal lumbotomy, respectively. There were 5 failures, of which 2 were laparoscopic, 2 used a flank approach and 1 used dorsal lumbotomy (p = 0.51). A total of 31 patients, including 10 treated with a laparoscopic approach, 3 with a flank approach and 18 with dorsal lumbotomy (p = 0.02), required second procedures, of which 24 were temporary drainage for a urine leak. Univariate analysis of factors associated with secondary procedures in the unstented pyeloplasty group showed that only surgical approach was significant (p = 0.05). CONCLUSIONS: In pediatric pyeloplasty there is no significant difference in outcome between stented and unstented repairs. In unstented repairs complications may vary by surgical approach. Regardless of the approach unstented pyeloplasty is safe and effective in the pediatric population.

A single-center experience with prone retroperitoneoscopic versus open renal surgery in children: an age- and procedure-matched comparison.

PURPOSE: We determined how surgical outcomes differ among children undergoing prone retroperitoneoscopic (RP) and open total and partial nephrectomies for benign renal disease. PATIENTS AND METHODS: A retrospective analysis was performed, using medical records of children who were undergoing benign renal surgery at a single institution from 2001 to 2010. Patients were divided into open or RP cohorts, then subdivided into those who were undergoing total or partial nephrectomies. A further breakdown by age (<3 years and ≥3 years) was performed. Bilateral nephrectomies were separately evaluated. Surgical outcomes were compared across groups. RESULTS: There were 308 (333 renal units) children who underwent RP (n=154) or open (n=154) total or partial nephrectomies, 25 of which were bilateral (20 RP, 5 open); 199 patients underwent total nephrectomies (RP n=118, open n=81), and 109 underwent partial nephrectomies (RP n=36, open n=73). After controlling for age and concomitant procedures, operative times were similar for the RP total and bilateral nephrectomy groups, but longer for the RP partial nephrectomy group, compared with their open counterparts. In both total and partial nephrectomies, the RP group had a shorter hospital stay. There were no open conversions in any of the RP groups and no differences in complications in the total, partial, and bilateral analyses. There were 13 patients who previously received peritoneal dialysis (8 bilateral RP, 3 unilateral RP, and 2 unilateral open), all of whom resumed dialysis in a mean of 1.11 days. CONCLUSIONS: This is the largest series to date that compares RP and open renal surgeries in children. The RP and open approaches were comparably safe and efficacious. Hospital stays were significantly shorter in the RP total and partial groups, although operative times were significantly longer in the RP partial nephrectomy group. Prone retroperitoneoscopic surgery should be considered a viable option for renal surgery at any age.

Impact of anatomical and socioeconomic factors on timing of urological consultation for boys with cryptorchidism.

PURPOSE: Cryptorchidism is a common finding in infants and young boys. Early repair lessens the extent of testicular injury. We hypothesized that anatomical and socioeconomic factors affect the timing of consultation and treatment for boys with cryptorchidism. MATERIALS AND METHODS: Under an institutional review board approved protocol we reviewed the records at a single institution of children who underwent exploration for unilateral or bilateral cryptorchidism. Demographic and anatomical factors were recorded. RESULTS: The median age of 677 boys at consultation and surgery was 20.3 and 28.9 months, respectively. Median age at consultation for boys with nonpalpable and palpable testicles was 12.3 and 20.9 months, respectively (p = 0.03). Boys with a concomitant penile anomaly had a younger median age at consultation than boys without a penile anomaly (8.5 vs 20.3 months, p <0.01). Demographic factors did not vary with respect to time to consultation and surgery (p >0.05). Multivariate analysis showed that abdominal site and concomitant penile anomaly were associated with earlier time to consultation (p = 0.02 and <0.01, respectively). CONCLUSIONS: The timing of consultation for boys with undescended testicles does not vary in regard to race, language or insurance type at this tertiary care institution. Instead, anatomical factors influenced age at consultation for boys with cryptorchidism. This suggests that in some geographic regions access to care is not restricted for minorities or noncommercially insured children.

Factors associated with delayed treatment of acute testicular torsion-do demographics or interhospital transfer matter?

PURPOSE: Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition. MATERIALS AND METHODS: We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability. RESULTS: We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy. CONCLUSIONS: Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.

Dextranomer/hyaluronic injection for the management of vesicoureteric reflux in complete ureteral duplication: should age and gender be factors in decision making?

BACKGROUND AND PURPOSE: The injection of dextranomer/hyaluronic acid (DHA) has become an accepted treatment for children with vesicoureteral reflux (VUR). Complete ureteral duplication has been considered by some practitioners as counterindication for its use. We reviewed the Texas Children's Hospital (TCH) records for children with complete ureteral duplication who were treated with DHA for VUR. METHODS: We searched medical records at TCH for patients with a preoperative diagnosis of complete ureteral duplication who had undergone DHA injection between January 1, 2001, and October 15, 2008. Operative notes, imaging studies, and clinic notes were reviewed. RESULTS: In this period, 28 kidneys in 24 children were treated. The average grade of reflux before injection was 3.44 (range 1-5). First injection resolution of reflux was 57% with an increase to 73% after a second injection with an average volume of DHA of 1.05 mL. New contralateral VUR developed postinjection in three (15%) children with unilateral VUR. There were no perioperative complications. The average age of the children who were treated was 41.4 months. Mean follow-up was 45.94 months. Success of DHA injection tended to be higher in girls (65%) and older children. CONCLUSIONS: High levels of success can be achieved with DHA injection in children with complete ureteral duplication. DHA injection is more likely to be successful for older girls with VUR and complete ureteral duplication. If initial injection does not result in VUR resolution, a second injection offers an opportunity for improved success. For physicians and families who are seeking an alternative to open surgical management, DHA represents an attractive option for selected children with complete ureteral duplication.

A report of an iatrogenic bladder rupture in a normal healthy child during voiding cystourethrography.

Iatrogenic and spontaneous bladder disruption in healthy children during a voiding cystourethrography is very uncommon. We present a case of iatrogenic extraperitoneal bladder rupture in a healthy normal child during the filling phase of a voiding cystourethrography performed by a pediatric radiologist, using routine gravity technique. This injury completely healed after 48 hours of catheter drainage with observation and was confirmed with a normal voiding cystourethrogram. The patient's underlying disease, age, proper catheter placement, and appropriate speed and volume of the contrast instilled are important factors to prevent this very uncommon event in this very common radiologic test.