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.

Optimal Timing of Surgical Procedures in Pediatric Patients.

The Pediatric Anesthesia Neuro Development Assessment (PANDA) team at the Anesthesiology Department at Columbia University Medical Center held its fifth biennial symposium to discuss issues regarding potential neurotoxicity of anesthetic agents in pediatric patients. Overall optimal surgical timing as well as a "critical window" for surgery on a specialty specific basis are areas of focus for the American Academy of Pediatrics Surgical Advisory Panel. An ad hoc panel of pediatric surgical experts representing general surgery, urology, neurosurgery, and ophthalmology was assembled for this meeting and provided a dialogue focused on the benefits of early intervention versus potential anesthetic risk, addressing parental concerns, and the need for continued interdisciplinary collaboration in this area.

Innovation in Robotics and Pediatric Urology: Robotic Ureteroureterostomy for Duplex Systems with Ureteral Ectopia.

INTRODUCTION: Robotic technology has been increasingly utilized for complicated reconstructive surgeries in pediatric urology, such as ureteroureterostomy (UU). The literature is limited regarding the performance of minimally invasive UU in children, and the existing published series utilize indwelling ureteral stents. We sought to report on our pediatric experience with robot-assisted laparoscopic (RAL)-UU using a temporary ureteral catheter in duplex systems with ureteral ectopia. METHODS: A retrospective chart review was performed of all pediatric patients who underwent RAL-UU at a single institution over a 2-year period. An externalized ureteral catheter was kept overnight and removed with the indwelling catheter on postoperative day 1. Intraoperative as well as postoperative complications, length of stay (LOS), and analgesia were recorded. Follow-up renal ultrasound (US) and evaluation for symptom resolution were completed 3 months postoperatively. RESULTS: Twelve patients (four male, eight female) underwent RAL-UU at a mean age of 19.4 months (range 9-48 months) during the study period. The majority of patients (83.3%) presented with hydronephrosis, and all were found to have duplicated systems with ureteral ectopia. No child had ipsilateral vesicoureteral reflux. Two children had bilateral duplicated systems, one of which required bilateral surgery. Median operative time was 138 minutes (IQR 119-180 minutes), and mean estimated blood loss was 1.5 mL. There were no intraoperative complications, and no case required open conversion. Median hospital LOS was 31 hours (IQR 30-39 hours). Median follow-up time was 11 months (range 3-22 months). One patient developed a postoperative febrile upper respiratory infection. All patients had improved hydroureteronephrosis on US at 3 months postoperatively. One patient with preoperative urinary incontinence was dry postoperatively. Therefore, the overall success rate was 100%. CONCLUSION: Our institutional results demonstrate that RAL-UU utilizing a temporary ureteral catheter is a safe and effective technique for managing duplicated, ectopic ureters in children and infants.

Intra- and inter-observer variability of functional MR urography (fMRU) assessment in children.

BACKGROUND: Functional MR urography (fMRU) provides comprehensive functional data that can be subject to variability. To interpret the results of fMRU, it is essential to know the intra- and inter-observer variability of the measured parameters. OBJECTIVE: To define the range of variability in fMRU, particularly that of the differential renal function based on volume (volumetric differential renal function) and Patlak differential renal function measurements in children. MATERIALS AND METHODS: We included 15 fMRU studies, 10 of non-duplicated and 5 of unilateral duplex kidneys. We recruited six observers with a range of fMRU experience, including two MRI technologists, one resident, one fellow, one pediatric radiologist and one pediatric urologist. The observers underwent intensive training in using the Children's Hospital of Philadelphia (CHOP)-fMRU freeware for analysis. They conducted the fMRU analysis on each case twice, at least 1 week apart. Mean and standard deviation were calculated for each set of absolute volume, absolute Patlak, volumetric differential renal function and Patlak differential renal function. We calculated the statistical significance of these deviations using the student's t-test. We also calculated interclass correlations for intra-observer and inter-observer agreement of both volume and Patlak measurements using SPSS software. RESULTS: Intra- and inter-observer variability did not differ significantly, measuring 6% and 4% for relative volume (volumetric differential renal function: P > 0.05) and 5% and 3% for relative function (Patlak differential renal function: P > 0.05). Absolute values of parameters showed more variability than the relative values. Intra- and inter-observer agreement was well above 0.90 (P < 0.001) for all volume measures except for duplex upper pole intra-observer measurements (0.80, P < 0.01). Intra- and inter-observer agreement for Patlak values were also above 0.90 (P < 0.001) except for duplex upper pole measurements, which were 0.54 (P = 0.13) and 0.81 (P < 0.01), respectively. CONCLUSION: Functional MRU analysis using CHOP-fMRU software is reproducible, with overall intra- and inter-observer variability rates of 5% for volumetric differential renal function and 4% for Patlak differential renal function. There was higher variability in volume and function measurements between upper and lower pole moieties of duplicated kidneys and for absolute volume and function values overall. A range of 45-55% for relative values of volumetric differential renal function and Patlak differential renal function could serve as the normal range.

Transitional care in pediatric urology.

The transition from childhood to adolescence and into adulthood occurs as a natural component of human development. As children progress through school and gain independence, health care practitioners must facilitate a parallel transition from pediatric to adult providers. Modern medicine has succeeded in extending the life expectancy for many children with complex conditions, and adult providers are participating in their medical care through adulthood. Transitioning pediatric urology care to adult urology care is unique to every individual and his or her underlying condition, while the transition process is universal. The objectives of all pediatric urologists include preservation of the kidneys and lower urinary tracts, safe urine storage, safe urine drainage, urinary continence, fertility, sexual function, and genital cosmesis. For some children, these objectives can be attained during childhood, while other children require lifelong maintenance and management. Children with posterior urethral valves, exstrophy-epispadias complex, cloaca, vesicoureteral reflux, neurogenic bladder, disorders of sex development, cancer, hypospadias, nephrolithiasis, undescended testes, varicoceles, ureteropelvic junction obstruction, solitary kidney, and upper tract anomalies all require long-term evaluation and management. The obstacles of altering a patient and caregiver paradigm, locating adult urologists with special expertise, coordinating care with other adult specialties such as nephrology, and navigating the adult health care environment can impede the transition process.

Serum cystatin C as a novel marker to differentiate pseudoazotemia in the setting of intraperitoneal urine extravasation.

Urinary ascites results in pseudoazotemia due to urinary creatinine reabsorption across the peritoneum. We report a case of a pyeloplasty complicated by urine extravasation, in which the diagnosis was aided by discrepant findings of an elevated serum creatinine level but a stable cystatin C level. Cystatin C is a marker of renal function but is not typically excreted into the urine and therefore can be used to differentiate pseudoazotemia from true azotemia and is a better marker of renal function in the setting of known urinary ascites. These findings are relevant for patients with potential traumatic or nontraumatic sources of urine extravasation.

Pediatric urological emergencies.

Although few children are severely ill when evaluated in the pediatric office, developing the skills to recognize an infant or child who requires hospitalization is critical. Some children will require treatment in an emergency department or direct admission to an inpatient facility, whereas other children can be managed as outpatients. Determining when an infant requires an inpatient admission is particularly important because the metabolic reserve is less abundant in the newborn. Patients with hemodynamic instability must be emergently addressed. This article outlines the most common urgent and emergent pediatric urological conditions with the goal to direct initial evaluation and treatment.

Endoscopic management and the role of double stenting for primary obstructive megaureters.

PURPOSE: We determined the efficacy and potential complications of endoscopic incision and balloon dilation with double stenting for the treatment of primary obstructive megaureter in children. MATERIALS AND METHODS: We prospectively reviewed cases of primary obstructive megaureter requiring repair due to pyelonephritis, renal calculi and/or loss of renal function. A total of 17 patients were identified as candidates for endoscopy. Infants were excluded from study. All patients underwent cystoscopy and retrograde ureteropyelography to start the procedure. In segments less than 2 cm balloon dilation was performed, and for those 2 to 3 cm laser incision was added. Two ureteral stents were placed within the ureter simultaneously and left indwelling for 8 weeks. Imaging was performed 3 months after stent removal and repeated 2 years following intervention. RESULTS: Mean patient age was 7.0 years (range 3 to 12). Of the patients 12 had marked improvement of hydroureteronephrosis on renal and bladder ultrasound. The remaining 5 patients had some improvement on renal and bladder ultrasound, and underwent magnetic resonance urography revealing no evidence of obstruction. All patients were followed for at least 2 years postoperatively and were noted to be symptom-free with stable imaging during the observation period. CONCLUSIONS: Endoscopic management appears to be an alternative to reimplantation for primary obstructive megaureter with a narrowed segment shorter than 3 cm. Double stenting seems to be effective in maintaining patency of the neo-orifice. Followup into adolescence is needed.

Prospective long-term analysis of nerve-sparing extravesical robotic-assisted laparoscopic ureteral reimplantation.

OBJECTIVE: To prospectively review our experience with extravesical robotic-assisted laparoscopic ureteral reimplantation to determine whether postoperative voiding dysfunction can be avoided with pelvic plexus visualization and to assess the efficacy of this approach for the treatment of vesicoureteral reflux (VUR). METHODS: We prospectively followed 150 patients who underwent bilateral extravesical robotic-assisted laparoscopic ureteral reimplantation by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally, with 127 having parenchymal defects found on renal scans. All patients were toilet trained before surgical intervention. The operation was performed with an extravesical transperitoneal approach with robotic assistance using the daVinci Surgical System. All patients underwent voiding cystourethrography at 3 months postoperatively to document the resolution of VUR. Voiding dysfunction was assessed in each patient by uroflow, postvoid residual urine volume, and a validated questionnaire. RESULTS: The operative success rate was 99.3% for VUR resolution on voiding cystourethrography. One patient with bilateral grade 5 VUR that was downgraded to unilateral grade 2 VUR was considered to have treatment failure. This patient ultimately underwent subsequent subureteral injection therapy after an episode of pyelonephritis. No patient experienced de novo voiding dysfunction. CONCLUSION: Bilateral nerve-sparing robotic-assisted extravesical reimplantation has the same success rate as the traditional open approaches, with minimal morbidity and no voiding complications in our series.

Pyocele of the scrotum in the pediatric patient.

Pyocele of the scrotum has been reported but is not well described in the pediatric population. The majority of published cases have been treated definitively with surgical drainage, and the severity of some cases has led to orchiectomy. We report a cases series of four boys with idiopathic pyocele, two of whom were managed successfully without operative intervention. Of these, one case was likely due to hematogenous spread of infection, and one case was secondary to spread of abdominal contamination via a patent processus vaginalis. To our knowledge, this is the first case series reporting non-surgical management of infant pyocele. Although rare, this clinical entity should be considered in the differential diagnosis of acute scrotum in the pediatric patient.

Multiple metachronous fibroepithelial polyps in children.

PURPOSE: We present our experience with a new phenotype of fibroepithelial polyps recurring in the urinary tract in children after robotic or laparoscopic pyeloplasty, and discuss the most appropriate treatment for these multiple metachronous neoplasms. MATERIALS AND METHODS: At our institution 14 children had fibroepithelial polyps as the cause of ureteropelvic junction obstruction at pyeloplasty. Of the patients 12 had at least 1 additional polyp in the ureter, necessitating concomitant ureteroscopy at either robotic or laparoscopic pyeloplasty. Of these 12 patients 9 had followup of at least 1 year. RESULTS: In 6 patients with at least 1 year of followup neoplasms were seen on retrograde pyelography and ureteroscopy that were not present on ureteroscopy at pyeloplasty. At 6 months after stent removal following the first recurrence 2 patients (33%) showed a second recurrence on imaging at a different location in the upper tract requiring laser ablation. One of these patients had a third recurrence that required further intervention before all were disease-free. No major intraoperative or preoperative complications developed. CONCLUSIONS: We should always consider the possibility of recurrent fibroepithelial polyps in children with ureteropelvic junction obstruction, and recommend routine retrograde pyelography and ureteroscopy at stent removal after laparoscopic or robotic pyeloplasty. Although ureteroscopic management seems to be the most appropriate modality in children with multiple metachronous fibroepithelial polyps, larger studies are needed.

A practical approach to ambiguous genitalia in the newborn period.

The evaluation and management of neonates with ambiguous genitalia requires sensitivity, efficiency, and accuracy. The approach to these neonates is facilitated by a multidisciplinary team including urology, endocrinology, genetics, and psychiatry or psychology. Disorders of sex development (DSD) encompass chromosomal DSD, 46,XX DSD, and 46,XY DSD. The 46,XX DSD is the most common DSD and in the majority of these children congenital adrenal hyperplasia is the underlying etiology. The 46,XY DSD is a heterogeneous disorder that often results from a disruption in the production or response to testosterone, dihydrotestosterone, or Mullerian inhibitory substance. Chromosomal DSD includes conditions resulting from abnormal meiosis, including Klinefelter syndrome (47, XXY) and Turner syndrome. The evaluation of children with DSD demands a thorough physical examination, medical history, karyotype, metabolic panel, 17-OH progesterone, testosterone, luteinizing hormone, follicle stimulation hormone, and urinalysis. A radiographic evaluation should begin with an abdominal and pelvic ultrasound but may include magnetic resonance imaging, endoscopy, or laparoscopy.

Hypospadias rates in new york state are not increasing.

PURPOSE: The testicular dysgenesis syndrome describes urogenital abnormalities associated with exposure to environmental endocrine disruptors such as phthalates, specifically decreased semen quality, and increased rates of testis cancer and hypospadias. Recently there has been concern that these abnormalities described in animal studies may also be present in humans. To determine if hypospadias rates are increasing, we retrospectively reviewed the total prevalence of hypospadias in New York State from 1992 to 2005, categorized by maternal age younger than 35 years and 35 years or older. MATERIALS AND METHODS: Hypospadias rates were obtained from the New York State Congenital Malformations Registry from 1992 to 2005. An analysis was also performed on the rates of children with hypospadias who had mothers younger than 35 years and mothers 35 years or older. This investigation was approved by the Columbia University internal review board. RESULTS: There was no statistical change in hypospadias rates in New York State from 1992 to 2005 (r = 0.127, p = 0.6). Overall the mean +/- SE prevalence rate was 34.9 +/- 0.36 per 10,000 live births. However, mean +/- SE hypospadias rates in children of mothers 35 years old or older (38.7 +/- 0.7) were significantly greater than those in children of mothers younger than 35 years (34.1 +/- 0.386, t test p <0.01). CONCLUSIONS: Hypospadias rates have not changed in New York State from 1992 to 2005. Additionally advanced maternal age continues to be a risk factor for hypospadias. Combined with previous studies that demonstrate sperm counts are not declining, these data suggest that the testicular dysgenesis syndrome described in animal models may not be evident in humans.

How often do available preoperative risk factors accurately predict the risk assessed after surgery for localized prostate cancer?

OBJECTIVE: To describe how frequently new information obtained at surgery translates into a substantial change in the risk of recurrence for patients with localized prostate cancer, and to determine what factors contribute to this increase in risk, as the preferred therapy for prostate cancer is often chosen based on available preoperative variables and therefore appropriate decision-making requires an accurate preoperative assessment. PATIENTS AND METHODS: Using the Columbia Comprehensive Clinical Database of Urologic Oncology, we retrospectively analysed 3460 men who had radical prostatectomy (RP) for prostate cancer from 1988 to 2006. Kattan nomograms were used to calculate the 5-year progression-free probabilities before and after RP. The difference between these nomogram scores was used to divide patients into three groups, those with a decrease in the probability of disease-free survival (DFS) of > or =15%, those with an increase in the probability of DFS of > or =15%, and those with an absolute change of <15%. RESULTS: In all, 1804 men with complete data before and after RP were analysed; 1220 (68.4%) had no significant change in nomogram score, 238 (13.3%) had a significant increase and 327 (18.3%) had a significant decrease in the probability of recurrence. Those patients with an increased probability of recurrence had a greater proportion of patients with pathological Gleason sum of > or =8, higher rates of extraprostatic capsular invasion, positive margins, seminal vesical invasion and lymph node involvement (all P < 0.001). CONCLUSION: Accurate risk predictions both before and after RP are central to effective patient counselling and optimal management. Notably, 13.3% of the present patients were faced with a substantial increase of > or =15% in their risk of biochemical failure after pathological variables became available.

High-grade prostatic intraepithelial neoplasia is an independent predictor of outcome after radical prostatectomy.

OBJECTIVE: To examine the relationship between the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in retropubic radical prostatectomy (RP) specimens and cancer-specific outcomes, including pathological variables and biochemical disease-free survival (bDFS), as HGPIN shares many histopathological characteristics with prostate carcinoma and has been considered a precursor lesion to prostate cancer. PATIENTS AND METHODS: The Columbia University Urologic Oncology Database was reviewed; 3460 patients were identified who underwent RP between 1988-2006, and 2133 with or without HGPIN and >12 months of follow-up were included in the analysis. Analysis of variance methods were used to evaluate the relationship between HGPIN and pathological stage, Gleason sum, perineural invasion, multifocality, extraprostatic extension, margin and nodal status. Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard model fitted for preoperative prostate-specific antigen (PSA) level, Gleason sum and pathological stage were used to assess differences in bDFS. RESULTS: In all, 1885 (88.4%) patients had HGPIN in the RRP specimen and 248 (11.6%) had no HGPIN. There was no significant difference in the distribution of PSA level (P = 0.27), pathological stage (P = 0.18) or Gleason sum (P = 0.84) between patients with and with no HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs 57.5%; P = 0.003) and multifocality (63.0 vs 38.4%; P < 0.001). Patients with no HGPIN had a better bDFS, at 87.3% vs 81.0% at a median follow-up of 50 months, and 73.6% vs 67.0% at 9 years (P = 0.045). The risk of biochemical failure was 1.9 times greater in the HGPIN-positive group than the negative group (P = 0.006) when controlling for PSA level, pathological stage and Gleason sum. CONCLUSIONS: In addition to traditional pathological prognostic variables, the absence of HGPIN in RRP specimens, although found in a minority of patients, denotes a significantly lower rate of tumour multifocality, perineural invasion and ultimately biochemical recurrence.

Infertility and testis cancer.

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment.

Abnormalities of the distal ejaculatory ducts related to infertility have been well-documented. Although there are no specific findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. A diagnosis of ejaculatory duct obstruction is suggested in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. Other causes of infertility may be concomitantly present and need to be evaluated and treated. Trans urethral resection of ejaculatory ducts (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved. Proper patient selection and surgical experience are necessary to obtain optimal results. In case of testicular dysfunction, chances of success are minimal. Extended follow-up periods are needed after TURED to examine the long-term effects of this procedure. Better understanding of the anatomy and pathology of the ejaculatory ducts will continue to refine diagnostic and therapeutic procedures for this disorder.

The male biological clock.

Do men have biological clocks that affect their hormone levels, fertility, and the genetic quality of their sperm? Women can no longer be viewed as solely responsible for age-related fertility and genetic problems. The effects of andropause and advanced paternal age on fertility and offspring are still under investigation. Further research is needed to fully characterize the associated risks and to treat the underlying abnormalities. A better understanding of the cellular and biochemical mechanisms of "gonadal" aging is important in order to determine safe, effective ways to delay this process and "rewind" the male biological clock. The benefits may include decreasing the potential for adverse genetic consequences in offspring, improvement in the sexual and reproductive health of aging males, and increase a woman's chance of having healthy children by correcting defects in the male reproductive system.