Pyeloplasty with ureteral stent placement in children: Do prophylactic antibiotics serve a purpose?

OBJECTIVES: Ureteral stents are commonly used during pyeloplasty to ensure drainage and anastomotic healing. Antibiotic prophylaxis is often used due to concerns for urinary tract infection (UTI). Although many surgeons prescribe prophylactic antibiotics following pyeloplasty, practices vary widely due to lack of clear evidence-based guidelines. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not. METHODS: We reviewed the medical records of 741 patients undergoing pyeloplasty between January 2010 and July 2018 across seven institutions. Exclusion criteria were: age older than 22 years, no stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley duration, and urine culture results were recorded. Patients were categorized into two groups, those younger than four years of age and those four years and older as proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI. Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures. RESULTS: 672 patients were included; 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and similar in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups. Surgical approach, stent duration, and Foley duration were not associated with stent UTI. CONCLUSION: Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI.

Salvage Surgery Rates for Pediatric Testicular Torsion: Comparison of the Pre- and Post-Quality Metric Eras.

PURPOSE: Pediatric testicular torsion is a urological emergency that requires timely intervention. In 2015, quality metrics for testicular torsion were implemented in the U.S. News & World Report "Best Children's Hospitals" rankings. Our study examines and compares testicular salvage surgery rates before and after the institution of national quality metrics from a multi-institutional database. MATERIALS AND METHODS: The Pediatric Health Information System® was surveyed for all testicular torsion encounters using ICD (International Classification of Diseases), Ninth and Tenth Revisions coding from 52 hospitals between January 2010 and December 2019. Patients <1 year and ≥18 years of age were excluded. Only hospitals that reported outcomes before and after quality scoring were included. Testicular salvage surgery was defined as patients having undergone orchiopexy without concomitant orchiectomy. Age, race, distance from hospital, household income and insurance status were compared. RESULTS: A total of 890 patients (551 pre-metric and 339 post-metric) from 38 hospitals were included. The testicular salvage surgery rate was 12.5% higher in the post-metric cohort (70.9% versus 58.4%). Hospital compliance to testicular torsion quality metrics increased from 62% in 2015 to 98% in 2019. Mean age, race, distance to hospital, household income, insurance status and use of ultrasound were not statistically different between pre- and post-metric cohorts. CONCLUSIONS: Since the implementation of quality metrics, salvage surgery rates for testicular torsion increased to 70.9%, an improvement of 12.5% when compared to pre-metric outcomes. Patient factors were similar between the 2 groups. Multi-institutional prospective data are needed to validate this database study and evaluate overall testicular salvage rate.

Prospective evaluation of radiation dose with conventional fluoroscopic voiding cystourethrogram in pediatric patients.

INTRODUCTION: Skin entrance doses for voiding cystourethrogram (VCUG) have not been well characterized in the literature. Radiation exposure is measured as either dose area product (DAP) or air kerma, which estimates the effective dose, but does not accurately reflect absorbed dose at skin level. OBJECTIVE: The objective of this study was to measure the skin entrance dose during fluoroscopic VCUG study in pediatric patients using single point dosimeters. STUDY DESIGN: Pediatric patients undergoing fluoroscopic VCUG were prospectively enrolled in our study. Landauer NanoDot™OSLD dosimeters were affixed to the skin overlying the sacrum to measure skin entrance dose. The fluoroscopic unit was set to the following parameters: low dose setting, skin-to-source distance of 54 cm, pulsed fluoroscopy at 3 frames/sec. RESULTS: Forty-four patients with a median age of 13.6 months (IQR 3.7-42.3) were enrolled. Median fluoroscopic time was 54 s (IQR 36-72). The median values absorbed dose by dosimeter and air kerma were 0.32 mGy (IQR 0.13-0.56, range 0.01-2.9) and 0.24 mGy (IQR 0.14-0.37), respectively. There was a positive correlation between the air kerma and absorbed dose (r = 0.69, p < 0.001) and fluoroscopy time and absorbed dose mGy (r = 0.60, p < 0.001). Absorbed dose was independent of age, body mass index and body surface area (p = 0.19, p = 0.57 and p = 0.16, respectively). Median whole body effective dose was 0.04 mSv (IQR 0.02-0.7). DISCUSSION: Overall, the absorbed dose received by the dosimeter remained low at a median of 0.32 mGy (range 0.01-2.91). These values are remarkably low and well within the accepted radiation exposure norms. Our radiologists follow a strict protocol to reduce the overall radiation emitted during a VCUG. These measures include setting the x-ray source at a low dose mode, collimating to the smallest area possible, and using pulsed fluoroscopy at 3 frames/sec. Limitations to this study include a slight variability in technique of VCUG between different technicians and providers, for which we cannot control. CONCLUSION: The radiation dose absorbed at the skin entrance and uniform whole body effective dose is low for a single VCUG when utilizing strict parameters. While newer non-ionizing technologies continue to emerge, our data is encouraging and will serve as a valuable tool when educating parents regarding radiation doses associated with a VCUG.

Prostatic cyst in a pediatric patient with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inheritable form of renal cystic disease and is associated with cysts in other organs. Prostatic cysts are rare though and have not been reported in the paediatric population. Reported is the presence of a prostatic cyst that was incidentally noted on routine sonogram in a 15 year old with ADPKD.

A government mandated consent safely reduces opioid utilization for major pediatric genitourinary surgeries.

INTRODUCTION: We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries. METHODS: All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data. RESULTS: After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p<0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75)(p<0.001). The rate of delayed non-opioid analgesic prescriptions (6.6% vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%)(p = 0.809) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p = 0.425). CONCLUSIONS: A state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries. LEVEL OF EVIDENCE: Level III.

Government Mandated Consent Dramatically Reduces Pediatric Urologist Opioid Utilization for Outpatient and Minor Emergency Surgeries.

PURPOSE: Postoperative opioids are overprescribed in the United States. In November 2016 the State of Pennsylvania required an opioid consent for minors. Our hypothesis is that this mandate decreased postoperative opioid prescriptions in our division. MATERIALS AND METHODS: All patients who received a urological outpatient or minor emergency procedure from August 2015 to August 2019 were identified. Surgeries performed within 6 months after mandate implementation were excluded to account for the transition period. Perioperative data including case type were extracted by a clinical data warehouse from preexisting fields within the health record. The frequencies of postoperative prescriptions, delayed prescriptions and emergency department encounters were assessed. A multivariable logistic regression to identify predictors of opioid prescription at discharge was performed. RESULTS: A total of 4,349 patients were analyzed. The frequency of postsurgical opioid prescriptions decreased from 45.3% to 2.6% (p <0.001). The median morphine milligram equivalent decreased by 22.5 among children prescribed an opioid (p <0.001). Rates of an emergency department visits (3% vs 2.7%) or delayed nonopioid prescriptions (0.8% vs 1.2%) within 30 days of discharge were unchanged (p >0.05). Fewer patients received a delayed opioid prescription after mandate implementation (0.03% vs 0.5%, p <0.001). Female patients were less likely (OR 0.309, 95% CI 0.195-0.491; p <0.001) to receive opioids prior to but not after the mandate (OR 0.309, 95% CI 0.544-2.035; p=0.122). Increasing age was predictive of receiving an opioid before (OR 1.187, 95% CI 1.157-1.218; p <0.001) and after (OR 1.241, 95% CI 1.186-1.299; p <0.001) the mandate. CONCLUSIONS: A state mandated opioid consent for minors greatly reduced post-urological surgery opioid prescription rates without increasing rates of readmission or delayed prescriptions.

A survey and panel discussion of the effects of the COVID-19 pandemic on paediatric urological productivity, guideline adherence and provider stress.

INTRODUCTION: The COVID-19 pandemic has led to an unprecedented need to re-organise and re-align priorities for all surgical specialties. Despite the current declining numbers globally, the direct effects of the pandemic on institutional practices and on personal stress and coping mechanisms remains unknown. The aims of this study were to assess the effect of the pandemic on daily scheduling and work balances, its effects on stress, and to determine compliance with guidelines and to assess whether quarantining has led to other areas of increased productivity. METHODS: A trans-Atlantic convenience sample of paediatric urologists was created in which panellists (Zoom) discussed the direct effects of the COVID-19 pandemic on individual units, as well as creating a questionnaire using a mini-Delphi method to provide current semi-quantitative data regarding practice, and adherence levels to recently published risk stratification guidelines. They also filled out a Perceived Stress Scale (PSS) questionnaire to assess contemporary pandemic stress levels. RESULTS: There was an 86% response rate from paediatric urologists. The majority of respondents reported near complete disruption to planned operations (70%), and trainee education (70%). They were also worried about the effects of altered home-lives on productivity (≤90%), as well as a lack of personal protective equipment (57%). The baseline stress rate was measured at a very high level (PSS) during the pandemic. Adherence to recent operative guidelines for urgent cases was 100%. CONCLUSION: This study represents a panel discussion of a number of practical implications for paediatric urologists, and is one of the few papers to assess more pragmatic effects and combines opinions from both sides of the Atlantic. The impact of the pandemic has been very significant for paediatric urologists and includes a decrease in the number of patients seen and operated on, decreased salary, increased self-reported stress levels, substantially increased telemedicine usage, increased free time for various activities, and good compliance with guidelines and hospital management decisions.

Point-of-care ultrasound is an accurate, time-saving, and cost-effective modality for post-operative imaging after pyeloplasty.

BACKGROUND: Dismembered pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). Although the frequency and timing of follow up imaging after pyeloplasty is variable, renal ultrasound (RUS) is commonly utilized. With minimal training, point-of-care ultrasound (POCUS) can be easily performed by a urologist during a post-operative visit. OBJECTIVE: Our hypothesis is that POCUS is an accurate, time-saving, and cost-effective alternative to a complete retroperitoneal ultrasound (CRUS) performed by the Radiology Department after pyeloplasty. STUDY DESIGN: The clinical records of all children who underwent pyeloplasty (by any method) over a 12 month period at our institution were retrospectively reviewed. The exact timing and method (POCUS vs. CRUS) of follow up imaging was surgeon-dependent. Statistical analysis was performed to compare the time and cost of POCUS vs. CRUS. The clinical course of each patient who had each type of imaging was assessed. RESULTS: A total 45 patients were included in this analysis. Over a mean follow up period of 29 months, a total of 73 CRUS and 67 POCUS were performed. Each CRUS on average added 2 h to each patient's healthcare encounter. Had the 73 CRUS been performed as POCUS instead, this would have corresponded to $83,751 less charges to payers. There was no difference in the rate of the detection of worsening, stable, or improved hydronephrosis (HN) between either modality (p > 0.05). The recommended follow up time for observed HN was no different between CRUS and POCUS (p > 0.05). Children with worsening HN on POCUS underwent functional studies without confirmatory CRUS. Interestingly, two patients had metachronous, contralateral UPJO discovered during post-operative imaging. These were both discovered by POCUS. Nineteen (42%) patients who had attended at least one post-operative visit were eventually loss to follow-up. This occurred exclusively in those who did not have worsening ultrasound (p < 0.01). There was no difference in the loss to follow-up after POCUS (8) or CRUS (12) (p > 0.05). CONCLUSIONS: POCUS performed by a urologist is an accurate assessment of HN after pyeloplasty with time and cost savings to compared to a CRUS performed by a radiologist. POCUS is not associated with any difference in rate of detection of worsening HN or rate of loss to follow up.

Discrepancies in Self-Reported and Actual Conflicts of Interest for Robotic Pediatric Urological Surgery.

PURPOSE: Transparency of conflicts of interest is essential when assessing publications that address the benefits of robotic surgery over traditional laparoscopic and open operations. We assessed discrepancies between self-reported and actual conflicts of interest as well as whether conflicts of interest are associated with favorable endorsement of robotic surgery. MATERIALS AND METHODS: We searched the Embase® and MEDLINE® databases for articles on robotic surgery within pediatric urology. We included English language articles published since 2013, when data in the Open Payments program (Centers for Medicare and Medicaid Services, Baltimore, Maryland) became available. For all United States based authors Open Payments was used to identify the total amount of financial payment received from Intuitive Surgical®. Chi-square test was used to assess the association between conflicts of interest and favorable endorsement of robotic surgery. RESULTS: A total of 191 articles were initially identified. After exclusion criteria were applied 107 articles remained (267 distinct authors). Of the articles 86 (80.4%) had at least 1 author with a history of payment from Intuitive Surgical, with 79 (91.9%) having at least 1 author who did not declare a conflict of interest despite history of payment. A total of 44 authors (16.5%) had a history of payment from Intuitive Surgical, with an average payment of $3,594.15. Articles with a first and/or last author with a history of payment were more likely to contain a favorable endorsement of robotic surgery compared to articles without a history of payment (85.1% vs 63.6%, p = 0.0124). CONCLUSIONS: Nondisclosure of conflict of interest with Intuitive Surgical is extremely common within pediatric urology. Steps to ensure accurate reporting of conflicts of interest are essential. There appears to be an association between a history of payment and favorable endorsement of robotic surgery.

Urologic Phenotype and Patterns of Care in Patients With Megacystis Microcolon Intestinal Hypoperistalsis Syndrome Presenting to a Major Pediatric Transplantation Center.

OBJECTIVE: To describe the phenotype, referral pattern, and trends of urologic management for children with megacystis microcolon intestinal hypoperistalsis syndrome. MATERIALS AND METHODS: We performed a retrospective review of all patients with megacystis microcolon intestinal hypoperistalsis syndrome treated at a large tertiary children's medical center over a 14-year period. Our primary outcomes included the rate of urology referral, urodynamic characteristics of bladder function, and the proportion of patients managed with clean intermittent catheterization. RESULTS: Twenty-six patients were evaluated at our institution with a median age at presentation of 1.3 years (73% female, 19 of 26). Most patients presented for intestinal transplantation evaluation and were dependent on parenteral nutrition. Megacystis was diagnosed prenatally in 15 patients and postnatally in 11 patients. Twenty patients (77%, 20 of 26) were evaluated by a pediatric urologist. Six patients (23%, 6 of 26) had varying degrees of vesicoureteral reflux. Early bladder management consisted of clean intermittent catheterization in 13 patients and vesicostomy in 8 patients. CONCLUSION: Megacystis microcolon intestinal hypoperistalsis syndrome is a severe form of intestinal failure and bladder atony with substantial urologic morbidity. Parents should be counseled accordingly and prompt urologic consultation should be included in the multidisciplinary approach to these complex patients.

Direction of Rotation in Testicular Torsion and Identification of Predictors of Testicular Salvage.

OBJECTIVES: To identify the rate at which testicular torsion occurs in a lateral direction and identify any predictors of direction of testicular rotation and orchiectomy. MATERIALS AND METHODS: We performed a retrospective review of 104 cases of emergent scrotal exploration performed for testicular torsion by 3 pediatric urologists from 2003 to 2017. Patients with neonatal torsion, negative scrotal exploration, or exploration for presumed intermittent testicular torsion were excluded. Univariable logistic regression was performed to assess if any factors predicted direction of testicular rotation. Univariable and multivariable logistic regression was used to identify predictors of testicular salvage. RESULTS: Of 104 cases of acute testicular torsion, information regarding the direction of testicular rotation was available in 81 patients. Lateral testicular rotation occurred in 38 cases (46%). No factors were found to be predictive of direction of torsion. Orchiectomy for testicular nonviability was performed in 50 of 104 cases (48%). On univariable analysis, younger age (p = .002), absence of gastrointestinal symptoms (P = .02), time to exploration (P < .001), testicular size differential on ultrasound (p = .002), absence of hydrocele (P = .01), abnormal ultrasound echotexture (P < .001), and degree of torsion (P = .04) were associated with orchiectomy. With the exception of absence of gastrointestinal symptoms, all predictors of orchiectomy remained statistically significant on multivariable analysis. CONCLUSION: Testicular rotation occurs in a lateral direction in 46% of cases. Lateral manual detorsion should be performed only with awareness of the potential for increasing the degree of testicular rotation. New independent predictors of testicular salvage were identified.

Trends in Urologic Indications for Pediatric Renal Transplantation Over a 27-Year-period United Network for Organ Sharing (UNOS) Database.

OBJECTIVE: To elucidate the trends in urologic causes for renal transplant in the pediatric population using a national database. Little is known about the specific pediatric urologic conditions and resultant trends that precede renal transplantation. MATERIAL AND METHODS: We reviewed the United Network for Organ Sharing (UNOS) database for pediatric patients (<18 years old) who underwent renal transplantation from January 1988 to September 2015. We included those patients who received a renal transplant because of a urologic condition. RESULTS: Over 27 years, 7291 of 20,213 children (36%) underwent renal transplant secondary to a urologic condition. The 2 most common indications were hypoplasia/dysplasia/dysgenesis/agenesis (HDDA, 35.1%) and congenital obstructive uropathy (COU, 25.7%). The incidence of COU has increased from 18% to 30%, and the incidence of Wilms tumor has remained relatively consistent at 1.8% per year. In addition, 68% of all urologic renal transplants were performed in men compared with women. However, a higher percentage of women required transplantation because of Wilms tumor (3.1% vs 1.2%) and chronic pyelonephritis (17.6% vs 7.9%). Overall, the majority of patients (61.5%) who underwent renal transplantation were white, 18.8% Hispanic, and 15.3% black. CONCLUSION: HDDA and COU consistently have been the most common urologic indications for renal transplantation. Both are the leading causes in men, whereas HDDA and chronic pyelonephritis are predominant in women. Higher rate of renal transplant during the ages of 11-17 years is suggestive of increased burden on poorly functioning kidneys during times of adolescent growth.

Bowel preparation prior to reconstructive urologic surgery in pediatric myelomeningocele patients.

INTRODUCTION: Mechanical bowel preparation (MBP) has historically been the standard of care for patients undergoing reconstructive urologic surgery, including urinary diversion. To date, several studies have examined the role of mechanical bowel preparation in postoperative outcomes in pediatric patients undergoing augmentation cystoplasty. However, these patient populations have been heterogeneous in nature, with no studies dedicated to examining the role of MBP prior to reconstructive urologic surgery in pediatric patients with myelomenginoceles. Thus, our objective was to retrospectively assess perioperative measures and postoperative complications after reconstructive urologic surgery with or without mechanical bowel preparation in pediatric myelomeningocele patients. MATERIALS AND METHODS: From 2008 to 2013, 80 patients with myelomeningocele underwent reconstructive urologic surgery involving the use of bowel. Seventy patients underwent a preoperative MBP while 10 did not. Perioperative measures and postoperative complications for these two cohorts were assessed. RESULTS: Eighty patients with myelomeningocele were identified; 70 patients underwent MBP while 10 patients did not. There were no statistically significant differences in demographics or operative time. There were no statistically significant differences in postoperative outcomes including time to first bowel movement and time to tolerating diet. There was also no significant difference in overall complication rate; patients with MBP had 31/70 (44%) complications while 2/10 (20%) of those without MBP had complications (p = 0.18). CONCLUSION: There was no significant difference in perioperative measures and postoperative complications for patients who did not receive a mechanical bowel preparation. Our findings indicate that it is safe and warranted to perform a prospective, randomized study to better characterize the risks and benefits of preoperative bowel preparation for patients with myelomeningocele.

Optimal Length of Follow-up for the Detection of Unsuccessful Pediatric Pyeloplasty: A Single-Center Experience.

OBJECTIVES: To assess the optimal length of follow-up for patients undergoing both open and minimally invasive pyeloplasties to ensure prompt detection of a recurrent obstruction. There are no standard guidelines on ideal follow-up and imaging post-pediatric pyeloplasty currently. METHODS: A retrospective chart review identified 264 patients (<18 years old) who underwent pyeloplasty for ureteropelvic junction obstruction between April 2002 and December 2014. Ultrasound was obtained every 3-4 months for the first year following pyeloplasty and thereafter at discretion of treating physician. Patient characteristics including symptoms and imaging were reviewed. RESULTS: Of the 264 patients, 72% were male with mean age of 51 months and follow-up of 26.8 months. Approximately 73% followed up to 3 years. Fourteen patients (5.3%) had a recurrent obstruction. Among the failures, 85% were diagnosed and underwent successful redo pyeloplasty within 3 years. Six infants had a recurrence (43% of all unsuccessful surgeries) and were diagnosed within 3 years of the initial surgery. Patients undergoing a minimally invasive procedure were less likely to be followed for more than 3 years compared to an open procedure (p < 0.001). Patients with severe hydronephrosis preoperatively were followed longer (p = 0.031). Age at surgery and type of surgical approach (p < 0.01) were significant predictors of length of follow-up in a negative binomial regression. CONCLUSION: Based on the results, a minimum of 3 years of follow-up is necessary to detect the majority of recurrent obstructions. Those patients who have higher than average lengths of follow-up tend to be younger and/or underwent an open surgical approach.

Percutaneous Stone Surgery in Spina Bifida Patients--Are Stone-Free Rates Worth the Risk?

PURPOSE: Percutaneous stone surgery can be challenging in spina bifida (SB) patients due to their body habitus and spinal cord anomalies. A safe surgical approach may necessitate acceptance of lower stone-free (SF) rates. We seek to determine if anatomic complexity, as measured by spinal cord curvature and torso length, is associated with SF rates after percutaneous stone surgery in SB patients. We hypothesize that increasing anatomic complexity is associated with lower SF rates following percutaneous stone surgery. METHODS: We retrospectively reviewed all cases of percutaneous nephrolithotomy (PCNL) and percutaneous cystolitholapaxy (PC) in patients with SB at our institution. We calculated individual Cobb angles for scoliosis and kyphosis and measured torso lengths to serve as surrogates of anatomic complexity. These parameters were used to test for associations between anatomic complexity and SF rates. RESULTS: A total of 32 procedures were analyzed (15 PCNL, 17 PC). SF rates for PCNL and PC were 60% and 71%, respectively. For both the PCNL and PC cohorts, there was no difference in age, preoperative stone burden, body mass index, operative time, or estimate blood loss between patients deemed SF or not stone free (NSF) after a single procedure. In the PCNL cohort, worsening scoliosis (higher Cobb angle) and lower SF rates trended toward statistical significance (43° vs. 24°, p = 0.058). In the PC cohort, increasing torso length was associated with lower SF rates (34.1 vs. 28.5 cm, p = 0.02). CONCLUSIONS: Overall SF rates were modest in this population. Cobb angle measurements of scoliosis and kyphosis as well as torso length are novel tools for objectively defining anatomic complexity in the SB population and may help predict success following stone surgery.

Clinical and Radiological Risk Factors Predicting Open Surgical Repair in Pediatric Patients With Dilating Vesicoureteral Reflux.

OBJECTIVE: To study the individual patient-related risk factors in those undergoing open corrective vesicoureteral reflux (VUR) surgery in a contemporary series. The management of VUR remains controversial, and the indications for open surgery has evolved from that of surgeon and patient preference to criteria involving breakthrough urinary tract infections and grade of VUR. MATERIALS AND METHODS: A retrospective study was performed, and patients undergoing open surgical repair for dilating VUR (grade III-V) from 2005 to 2014 were included. Characteristics of patients were determined to identify predictors of operative intervention. Statistical analysis including Fisher's exact test and multivariable logistic regression of patient demographics and independent predictors of surgery was performed using the Stata (College Station, TX) version 13 software package. RESULTS: Of the 469 patients, 351 (74.8%) underwent open intravesical ureteroneocystostomy and 118 (25.2%) were managed conservatively. Based on the multivariable analysis, age, female sex, number of febrile urinary tract infections, maximum grade of reflux, prenatal hydronephrosis, ureteral dilatation, and persistence of VUR on voiding phase of voiding cystourethrogram were strong predictors of eventual surgery. Female sex (odds ratio [OR]: 19.8), ureteral dilatation (OR: 6.2), and persistence of VUR on voiding phase (OR: 5.03) were among the strongest predictors of surgical intervention. CONCLUSION: Female sex and higher grades of VUR were the strongest predictors of eventual surgical intervention. VCUG characteristics of ureteral dilatation >7 mm and persistence of VUR on the voiding phase were also very strong predictors of eventual surgical intervention.