Expert Consensus on Pediatric Urodynamics Reporting Using Modified Delphi Technique.

PURPOSE: Urodynamic testing (UDS) is an important tool in the management of pediatric lower urinary tract conditions. There have been notable efforts to standardize pediatric UDS nomenclature and technique, but no formal guidelines exist on essential elements to include in a clinical report. We sought to identify ideal structure and elements of a pediatric UDS assessment based on expert consensus. MATERIALS AND METHODS: Pediatric urologists regularly performing UDS were queried using a Delphi process. Participants were invited representing varied geographic, experience, and societal involvement. Participants underwent 3 rounds of questionnaires between November 2022 and August 2023 focusing on report organization, elements, definitions, and automated electronic health record clinical decision support. Professional billing requirements were also considered. Consensus was defined as 80% agreeing either in favor of or against a topic. Elements without consensus were discussed in subsequent rounds. RESULTS: A diverse sample of 30 providers, representing 27 institutions across 21 US states; Washington, District of Columbia; and Canada completed the study. Participants reported interpreting an average number of 5 UDS reports per week (range 1-22). The finalized consensus report identifies 93 elements that should be included in a pediatric UDS report based on applicable study conditions and findings. CONCLUSIONS: This consensus report details the key elements and structure agreed upon by an expert panel of pediatric urologists. Further standardization of documentation should aid collaboration and research for patients undergoing UDS. Based on this information, development of a standardized UDS report template using electronic health record implementation principles is underway, which will be openly available for pediatric urologists.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network.

BACKGROUND: Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. OBJECTIVE: With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. STUDY DESIGN: A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. RESULTS: Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. CONCLUSION: Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Low prevalence (0.13%) of COVID-19 infection in asymptomatic pre-operative/pre-procedure patients at a large, academic medical center informs approaches to perioperative care.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in reduced performance of elective surgeries and procedures at medical centers across the United States. Awareness of the prevalence of asymptomatic disease is critical for guiding safe approaches to operative/procedural services. As COVID-19 polymerase chain reaction (PCR) testing has been limited largely to symptomatic patients, health care workers, or to those in communal care centers, data regarding asymptomatic viral disease carriage are limited. METHODS: In this retrospective observational case series evaluating UCLA Health patients enrolled in pre-operative/pre-procedure protocol COVID-19 reverse transcriptase (RT)-PCR testing between April 7, 2020 and May 21, 2020, we determine the prevalence of COVID-19 infection in asymptomatic patients scheduled for surgeries and procedures. RESULTS: Primary outcomes include the prevalence of COVID-19 infection in this asymptomatic population. Secondary data analysis includes overall population testing results and population demographics. Eighteen of 4,751 (0.38%) patients scheduled for upcoming surgeries and high-risk procedures had abnormal (positive/inconclusive) COVID-19 RT-PCR testing results. Six of 18 patients were confirmed asymptomatic and had positive test results. Four of 18 were confirmed asymptomtic and had inconclusive results. Eight of 18 had positive results in the setting of recent symptoms or known COVID-19 infection. The prevalence of asymptomatic COVID-19 infection was 0.13%. More than 90% of patients had residential addresses within a 67-mile geographic radius of our medical center, the median age was 58, and there was equal male/female distribution. CONCLUSION: These data demonstrating low levels (0.13% prevalence) of COVID-19 infection in an asymptomatic population of patients undergoing scheduled surgeries/procedures in a large urban area have helped to inform perioperative protocols during the COVID-19 pandemic. Testing protocols like ours may prove valuable for other health systems in their approaches to safe procedural practices during COVID-19.

Physicians Voluntarily Using an EHR-Based CDS Tool Improved Patients' Guideline-Related Statin Prescription Rates: A Retrospective Cohort Study.

BACKGROUND: In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released a revised guideline on statin therapy initiation. The guideline included a 10-year risk calculation based on regression modeling, which made hand calculation infeasible. Compliance to the guideline has been suboptimal, as many patients were recommended but not prescribed statin therapy. Clinical decision support (CDS) tools may improve statin guideline compliance. Few statin guideline CDS tools evaluated clinical outcome. OBJECTIVES: We determined if use of a CDS tool, the statin macro, was associated with increased 2013 ACC/AHA statin guideline compliance at the level of statin prescription versus no statin prescription. We did not determine if each patient's statin prescription met ACC/AHA 2013 therapy intensity recommendations (high vs. moderate vs. low). METHODS: The authors developed a clinician-initiated, EHR-embedded statin macro command ("statin macro") that displayed the 2013 ACC/AHA statin guideline recommendation in the electronic health record documentation. We included patients who had a primary care visit during the study period (January 1-June 30, 2016), were eligible for statin therapy based on the ACC/AHA guideline prior to the study period, and were not prescribed statin therapy prior to the study period. We tested the association of macro usage and statin therapy prescription during the study period using relative risk and mixed effect logistic regression. RESULTS: Subjects included 11,877 patients seen in primary care, who were retrospectively recommended statin therapy at study initiation based on the ACC/AHA guideline, but who had not received statin therapy. During the study period, 125 clinicians used the statin macro command for 389 of the 11,877 patients (3.2%). Of the 389 patients for whom that statin macro was used, 108 patients (28%) had a statin prescribed during the study period. Of the 11,488 for whom the statin macro was not used, 1,360 (13%) patients received a clinician-prescribed statin (relative risk 2.3, p < 0.001). Controlling for patient covariates and clinicians, statin macro usage was significantly associated with statin therapy prescription (odds ratio 2.86, p < 0.001). CONCLUSION: Although the statin macro had low uptake, its use was associated with a greater rate of statin prescriptions (dosage not determined) for patients whom 2013 ACC/AHA guidelines required statin therapy.

National Trends and Characteristics of Success in the Urology Match Process.

INTRODUCTION: We examined temporal trends in urology residency applicant statistics and characteristics through time. METHODS: Match statistics during 2006 to 2016 were obtained from the American Urological Association and examined through time. Additionally applicant self-reported data were obtained from Urologymatch.com for those successfully matching in urology during the application cycles from 2014 to 2016. Variables including United States Medical Licensing Examination® Step 1 score, number of urology subinternships, research productivity, Alpha Omega Alpha Honor Medical Society status and application specific characteristics were trended through time. Univariable linear and logistic regression was used to determine statistical significance of trends. RESULTS: A total of 4,262 applicants entered the urology match between 2006 and 2016. The number of applicants increased by 19.1% yearly and the number of positions increased by 25.1% yearly during the study period. Of the applicants 2,934 (68.8%) successfully matched, with an annual match rate ranging from 60.9% to 79.1%. Of 874 applicants matched successfully between 2014 and 2016, 417 (47.7%) self-reported complete match data. During the study period the mean ± SD number of programs applied to by matched applicants increased from 60.0 ± 18.2 to 65.2 ± 19.3 (p = 0.037). Mean ± SD number of subinternships completed increased from 2.6 ± 0.7 to 2.8 ± 0.6 (p = 0.004). CONCLUSIONS: Urology has remained a highly competitive specialty with a competitive match rate and increasing number of applicants. These data may guide future applicants in achieving desired professional goals.

The UCLA Health Resident Informaticist Program - A Novel Clinical Informatics Training Program.

Few opportunities exist for physician trainees to gain exposure to, and training in, the field of clinical informatics, an Accreditation Council for Graduate Medical Education-accredited, recently board-certified specialty. Currently, 21 approved programs exist nationwide for the formal training of fellows interested in pursuing careers in this discipline. Residents and fellows training in medical and surgical fields, however, have few avenues available to gain experience in clinical informatics. An early introduction to clinical informatics brings an opportunity to generate interest for future career trajectories. At University of California Los Angeles (UCLA) Health, we have developed a novel, successful, and sustainable program, the Resident Informaticist Program, with the goals of exposing physician trainees to the field of clinical informatics and its academic nature and providing opportunities to expand the clinical informatics workforce. Herein, we provide an overview of the development, implementation, and current state of the UCLA Health Resident Informaticist Program, with a blueprint for development of similar programs.

Acute urinary retention secondary to Epstein-Barr virus infection in a pediatric patient: a case report and review of causes of acute urinary retention in children.

We present the case of a 12-year-old boy with acute urinary retention presumed secondary to Epstein-Barr virus infection. Workup revealed an atonic bladder, which was refractory to medical management. The patient subsequently developed axillary lymphadenopathy, and the biopsy specimen was consistent with Epstein-Barr virus. In addition to presenting this patient with acute urinary retention secondary to EBV infection, we review the causes of acute urinary retention in children, with a focus on viral etiologies.

The socioeconomic status of donors and recipients of living unrelated renal transplants in the United States.

PURPOSE: We evaluated unrelated living kidney donation in the United States and examined the characteristics of unrelated donor-recipient pairs. MATERIALS AND METHODS: We accessed United Network for Organ Sharing files to identify adult living donor renal transplant recipients who received a transplant between 1997 and 2007. We evaluated factors associated with unrelated donation and compared a composite index of the socioeconomic characteristics of donor and recipient ZIP Codes between living unrelated and living related renal transplantation pairs. Spousal pairs were categorized as living related. RESULTS: Of 39,168 adult renal transplant recipients 19% underwent living unrelated renal transplantation. These recipients were more likely white (vs black, Hispanic and other race OR 0.77-0.82, p <0.05) and more highly educated (college vs less than high school OR 0.66, 95% CI 0.54-0.77), and more commonly received care at high volume transplant centers (vs lowest volume centers OR 0.89, 95% CI 0.82-0.95). Living unrelated renal transplantation recipients and donors lived in higher socioeconomic status index ZIP Codes than living related recipients (mean ± SD recipients and donors 0.62 ± 3.74 and 0.44 ± 3.63 vs 0.03 ± 3.85 and 0.10 ± 3.87, respectively, each p <0.001). CONCLUSIONS: Living unrelated renal transplantation donors and recipients are generally of higher socioeconomic status than their living related renal transplantation counterparts. There is restricted access to unrelated donors among underserved populations.

Readability of health related quality of life instruments in urology.

PURPOSE: The average American adult reads at a fifth to eighth-grade level, with wide variability, presenting challenges for the assessment of self-reported health related quality of life. We identified the health related quality of life instruments used in patients with urological diseases and evaluated their readability. MATERIALS AND METHODS: We focused on the most burdensome urological diseases, based on total expenditures in the United States. We then identified disease specific instruments by systematically searching PubMed, the Cochrane Database of Systematic Reviews, Google, Google Scholar, the Patient Reported Outcome and Quality of Life Instruments Database (Mapi Research Institute, Lyon, France) and Yahoo! for health related quality of life studies in patients with these urological conditions. Where disease specific instruments were lacking, we noted the general health related quality of life measures most commonly used. For each instrument, we calculated the median Flesch-Kincaid grade level, the proportion of questionnaire items below an eighth-grade reading level, the mean Flesch Reading Ease, and the mean number of words per sentence and characters per word, all of which are validated measures of readability. RESULTS: The average +/- SD of the median Flesh-Kincaid reading levels was 6.5 +/- 2.1 (range 1.0 to 12.0). Of the 76 instruments 61 (80%) were at or below an eighth-grade reading level. The mean reading ease was greater than 30 for each of the 76 questionnaires and greater than 60 for 66 (87%). Urinary tract infection, the costliest urological disease, has only 1 disease specific health related quality of life measure. Urolithiasis, the second costliest, has none. CONCLUSIONS: The reading level of health related quality of life questionnaires in urology is appropriate for the reading ability of most adults in the United States. However, the most burdensome urological diseases lack disease specific health related quality of life instruments.

The evolving role of alemtuzumab (Campath-1H) in renal transplantation.

The introduction of new immunosuppressive agents into clinical transplantation in the 1990s has resulted in excellent short-term graft survival. Nonetheless, extended long-term graft outcomes have not been achieved due in part to the nephrotoxic effects of calcineurin inhibitors (CNIs) and the adverse effects of steroid on cardiovascular disease risk factors. Induction therapy with lymphocyte depleting antibodies has originally been introduced into renal transplantation to provide intense immunosuppression in the early post-transplant period to prevent allograft rejection. Over the past half decade, induction therapy with both non-lymphocyte depleting (basiliximab and daclizumab) and lymphocyte-depleting antibodies (antithymocyte antibodies, OKT3, alemtuzumab) has increasingly been utilized in steroid or CNI sparing protocols in the early postoperative period. Alemtuzumab is a humanized monoclonal antibody targeted against CD52 on the surface of circulatory mononuclear cells. The ability of alemtuzumab (Campath-1H) to provide rapid and profound depletion of lymphocytes from the peripheral blood has sparked interest in the use of this agent as induction therapy in steroid and/or CNI minimization or avoidance protocols. This article provides an overview of the literature on the evolving role of alemtuzumab in renal transplantation.

Selective use of voiding cystourethrography in children undergoing renal transplant evaluation.

PURPOSE: Voiding cystourethrography is a routine component in evaluating children awaiting renal transplantation. We examined whether this assessment is necessary in children with renal failure due to dysplasia/aplasia/hypoplasia syndrome and unknown etiology, which account for up to 25% of those with renal failure requiring renal replacement therapies. MATERIALS AND METHODS: We performed an institutional review board approved, retrospective review of 191 children undergoing transplantation between 2002 and 2007. We reviewed clinical factors associated with positive findings on voiding cystourethrogram. We also reviewed cystography results in children with chronic kidney disease due to renal dysplasia and unknown etiology. RESULTS: We identified 113 boys and 78 girls who underwent renal transplantation during the study period. Pre-transplant voiding cystourethrography was documented in 108 children (57%). Predictors of positive pre-transplant results included history of hydronephrosis, urinary tract infections and renal failure due to urological causes. No pre-transplant cystogram was positive in children with renal failure due to dysplasia or unknown etiology. CONCLUSIONS: We recommend selective use of voiding cystourethrography to evaluate children awaiting renal transplantation. We continue to support performing this test in children with renal failure due to urological causes and those with a history of urinary tract infection, hydronephrosis or voiding dysfunction. In the absence of these findings children with renal failure due to renal dysplasia/aplasia/hypoplasia syndrome or unknown etiology need not undergo pre-transplant voiding cystourethrography.

Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation.

PURPOSE: We compared the incidence of ureteral complications between the classic (Lich-Gregoir) technique and the recently popularized single stitch (Shanfield) technique in renal transplantation. MATERIALS AND METHODS: The charts of 721 consecutive transplant recipients from May 1999 to July 2002 were retrospectively reviewed. Ureteral and nonureteral complications were reviewed at 3 to 5-year followup. RESULTS: Of the 721 recipients evaluated 713 were included in the study. There were 360 recipients in the Lich-Gregoir group and 353 in the Shanfield group. A significantly higher rate of ureteral complications occurred in the Shanfield group compared to the Lich-Gregoir group (15.6% vs 3.9%, p <0.0001). The Shanfield group consisted of 20 patients with ureteral leakage, 21 with hematuria, 11 with strictures and 3 who had ureteral stones. The Lich-Gregoir group had 8 patients with ureteral leakage, 5 with hematuria and 1 with a stricture. In comparison, urinary tract infections, delayed graft function and rejection rates were not significantly different between the 2 groups (p = 0.76, 0.12 and 0.19, respectively). CONCLUSIONS: In contrast to other reports, the Shanfield group had significantly more ureteral complications. In particular the Shanfield technique may predispose patients to higher rates of hematuria and stone formation. Based on this large series and published meta-analyses we believe that the stented Lich-Gregoir anastomosis is the superior ureteroneocystostomy technique in renal transplantation.

Laparoscopic versus open renal procurement for pediatric recipients of living donor renal transplantation.

Despite reports demonstrating the safety of laparoscopic donor nephrectomy (LDN) for pediatric recipients of renal transplants, recent evidence has challenged using LDN for recipients 5 years of age or younger. We retrospectively reviewed the records of all pediatric recipients of living donor renal transplants from September 2000 through August 2004. We compared those who received allografts recovered by LDN (n = 34) with those recovered by open donor nephrectomy (ODN, n = 26). Outcomes of interest included operative complications, postoperative renal function, the incidence of delayed graft function or episodes of acute rejection and long-term graft function. Donor and recipient demographic data were similar for the LDN and ODN groups. Serum creatinine and calculated creatinine clearance were not significantly different between groups both in the early postoperative period and at long-term follow-up (p > 0.142). Rates of delayed graft function and acute rejection did not differ between groups. Among recipients aged 5 years old or younger stratified by donor technique (9 LDN, 5 ODN recipients), no difference was noted in graft outcomes both early and long-term (p > 0.079). At our center, pediatric LDN recipients have graft outcomes comparable to those of ODN recipients. At experienced centers, we recommend continued use of LDN for pediatric recipients of all ages.