Early administration of oxybutynin improves bladder function and clinical outcomes in newborns with posterior urethral valves.

PURPOSE: Abnormal bladder function following posterior urethral valve ablation can lead to deleterious effects on renal function and urinary continence. We performed a pilot study to determine if bladder dysfunction could be ameliorated by the early administration of oxybutynin. MATERIALS AND METHODS: We enrolled infants who underwent primary posterior urethral valve ablation by the age of 12 months. On initial urodynamics patients demonstrating high voiding pressures (greater than 60 cm H(2)O) and/or small bladder capacity (less than 70% expected) were started on oxybutynin. Urodynamics and ultrasound were performed every 6 months until completion of toilet training, at which time oxybutynin was discontinued. RESULTS: Oxybutynin was started in 18 patients at a mean age of 3.4 months and was continued for a mean of 2.2 years. Urodynamics revealed that initial high voiding pressures improved from a mean of 148.5 to 49.9 cm H(2)O in 15 of 17 patients. All 8 patients with initially poor bladder compliance demonstrated improvement on oxybutynin. All 7 patients with initially low bladder capacity (mean 47.7% expected bladder capacity) demonstrated improvement while on oxybutynin (mean 216% expected bladder capacity). CONCLUSIONS: This pilot study demonstrates that early use of anticholinergic therapy in infants with high voiding pressures and/or small bladder capacity after primary posterior urethral valve ablation has beneficial effects on bladder function.

Randomized trial of prophylactic antibiotics vs. placebo after midshaft-to-distal hypospadias repair: the PROPHY Study.

BACKGROUND: Use of prophylactic antibiotics after stented hypospadias repair is very common, but most research has not identified any clinical benefits of this practice. Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Data from the same trial suggested that prophylaxis may also reduce urethroplasty complications. No studies on this subject have been placebo-controlled. OBJECTIVE: We performed a randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-to-distal hypospadias. STUDY DESIGN: Boys were eligible for this multicenter trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5-10 days. Participants were randomized in a double-blind fashion to receive oral trimethoprim-sulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI), and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis. RESULTS: Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis. CONCLUSIONS: In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject. GOV IDENTIFIER: NCT02096159.

Fetal pyelectasis as predictor of decreased differential renal function.

PURPOSE: A decreased percent of differential function is a common indication for infant pyeloplasty but there is no recognized fetal ultrasound parameter to predict this deficit. We determined whether there is a correlation between fetal pyelectasis and the newborn percent differential function that may enhance prenatal counseling and guide postnatal evaluation. MATERIALS AND METHODS: Our database was queried for fetal and newborn measures with fetal pyelectasis on ultrasound and the percent of differential function on renal scintigraphy. Fetal pyelectasis data were stratified by estimated gestational age and the percent of differential function. The affected cohort was defined as having 35% or less differential function and the unaffected cohort was defined as having greater than 35%. The Wilcoxon 2-sample test was used for statistical analysis with logistic regression to generate estimated probability models of a decreased percent of differential function vs mm fetal pyelectasis. RESULTS: A total of 831 cases had fetal and newborn ultrasound data available with a total of 229 renal scans identified. Of the 229 cases 36 (16%) had 35% or less differential function on scintigraphy. At estimated gestational age 33 weeks or less the affected cohort had 8 mm greater pyelectasis than the unaffected cohort (OR 1.2, p <0.0001). At estimated gestational age greater than 33 weeks the affected cohort had 4 mm greater pyelectasis than the unaffected cohort (OR 1.07, p <0.07). Subgroup analysis before 33 weeks of estimated gestational age showed similar significance (OR >1, p

Ultrasound fails to delineate significant renal pathology in children with urinary tract infections: a case for dimercapto-succinic acid scintigraphy.

PURPOSE: Routine radiological evaluation in children with urinary tract infections includes ultrasound. Additional dimercapto-succinic acid scintigraphy in this setting is a common but not routine practice to determine whether there is parenchymal injury. Because dimercapto-succinic acid scintigraphy involves further time, expense and radiation, we determined whether ultrasound findings could substitute for dimercapto-succinic acid scintigraphy. Therefore, in children with urinary tract infections we researched the incidence of discordant findings between dimercapto-succinic acid scintigraphy and normal ultrasound. MATERIALS AND METHODS: A retrospective review of children with a history of urinary tract infections who had normal ultrasound and dimercapto-succinic acid scintigraphy within 6 weeks of each other was performed through a chart review. Children with pyelonephritis within 4 months of the radiological tests were excluded. Dimercapto-succinic acid scintigraphy was considered abnormal if there was less than 40% differential function, global atrophy or focal defects. RESULTS: From January 2005 to December 2006, 100 children met inclusion criteria. Median patient age was 4.5 years (range 4 months to 19 years) and 84% were female. Of the 100 children 74 (74%) demonstrated vesicoureteral reflux and 18 (18%) showed abnormal dimercapto-succinic acid scintigraphy despite normal ultrasound. Children with vesicoureteral reflux showed an increased incidence of abnormal dimercapto-succinic acid scintigraphy compared to those without vesicoureteral reflux (20.3% vs 11.5%), although this did not attain statistical significance (p = 0.04). CONCLUSIONS: Although dimercapto-succinic acid scintigraphy is not part of routine practice in all children with urinary tract infections and/or vesicoureteral reflux, it is frequently abnormal despite normal ultrasound. Therefore, dimercapto-succinic acid scintigraphy should be considered in these patients to evaluate cortical defects and possibly guide further management.

A new computer enhanced visual learning method to train urology residents in pediatric orchiopexy: a prototype for Accreditation Council for Graduate Medical Education documentation.

PURPOSE: Residency programs must continue to restructure teaching and assessment of surgical skills to improve the documentation of Accreditation Council for Graduate Medical Education competencies. To improve teaching and documenting resident performance we developed a computer enhanced visual learning method that includes a curriculum and administrative reports. The curriculum consists of 1) study of a step-by-step surgical tutorial of computer enhanced visuals that show specific surgical skills, 2) a checklist tool to objectively assess resident performance and 3) a log of postoperative feedback that is used to structure deliberate practice. All elements of the method are repeated with each case performed. We used the Accreditation Council for Graduate Medical Education index case of orchiopexy to pilot this project. MATERIALS AND METHODS: All urology residents who trained at our institution from January 2006 to October 2007 performed orchiopexy using the computer enhanced visual learning method. The computer enhanced visual learning tutorial for orchiopexy consisted of customized computer visuals that demonstrate 11 steps or skills involved in routine inguinal orchiopexy, eg ligate hernia. The attending urologist rated resident competence with each skill using a 5-point Likert scale and provided specific feedback to the resident suggesting ways to improve performance. These ratings were weighted by case difficulty. The computer enhanced visual learning weighted score at entry into the clinical rotation was compared to the best performance during the rotation in each resident. RESULTS: Seven attending surgeons and 24 urology residents (resident training postgraduate years 1 to 8) performed a total of 166 orchiopexies. Overall the residents at each postgraduate year performed an average of 7 cases each with complexity ratings that were not significantly different among postgraduate year groups (average 2.4, 1-way ANOVA p not significant). The 7 attending surgeons did not differ significantly in assessment of skill performance or case difficulty (1-way ANOVA p not significant). Of the 24 residents 23 (96%) showed improvement in computer enhanced visual learning score/skill performance. In the entire group the average computer enhanced visual learning weighted score increased more than 50% from entry to best performance (137 to 234 orchiopexy units, paired t test p <0.0001). CONCLUSIONS: Computer enhanced visual learning is a novel method that enhances resident learning by breaking a core procedure into discrete steps and providing a platform for constructive feedback. Computer enhanced visual learning, which is a checklist tool, complies with Accreditation Council for Graduate Medical Education documentation requirements. Computer enhanced visual learning has wide applicability among surgical specialties.

A review of pediatric glans malformations: a handy clinical reference.

PURPOSE: Lesions of the pediatric glans penis are an uncommon but important aspect of pediatric urological care. We reviewed the available literature on this topic and did not identify a comprehensive reference resource. We compiled our multi-institutional experience with such conditions to prepare a handy clinical reference source. MATERIALS AND METHODS: The diversity of pediatric glans penis lesions was documented by searching the English and nonEnglish literature as well as the archives at our institutions. Cases were included in the study if the patient(s) identified were younger than 18 years at initial presentation or documented to have first had a glans penis lesion when younger than 18 years. Hypospadiac-epispadiac anomalies of the glans were excluded. RESULTS: From our institutions we identified 6 new cases of various pediatric glans lesions. Altogether the literature describes 137 distinct nondiphallia glans lesions and more than 100 cases of diphallia, including glans duplication. The nondiphallia reports consist of a total of 61 cystic lesions (44%), 33 vascular malformations (24%), 20 dermatological lesions (15%), 20 infectious lesions (15%) and 3 neurogenic lesions (2%). We did not identify a compact resource to compare these anomalies. Visual comparison permits structuring a differential diagnosis and determining urological treatment, which is typically excisional biopsy, laser treatment, sclerotherapy or topical steroid administration. CONCLUSIONS: We present a visual reference of varied lesions of the pediatric glans penis, including 6 new cases, with urological significance. These lesions are always benign but they typically require surgical excision for a definitive pathological diagnosis.

Complete excision or marsupialization of ureteroceles: does choice of surgical approach affect outcome?

PURPOSE: Two accepted open surgical techniques exist for lower urinary tract reconstruction for ureteroceles, that is complete excision/enucleation and marsupialization/partial excision. To our knowledge it is currently unknown whether 1 method offers better clinical outcomes. We sought to answer this question. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent open surgical repair for ureterocele at 3 academic institutions. The 2 groups (complete excision vs marsupialization) were compared for each clinical outcome, including ongoing vesicoureteral reflux, new bladder diverticulum, hydronephrosis, continence, urinary tract infection and voiding dysfunction. Each clinical outcome was analyzed for independence from the surgical method. RESULTS: A total of 33 cases of complete excision and 24 of marsupialization were collected. The excision and marsupialization groups were similar with respect to patient age at surgery, gender and average followup (55 and 38 months, respectively). Most ureteroceles were unilateral and part of a duplicated system. Approximately half were intravesical and vesicoureteral reflux was the primary indication for surgery. In the excision group 82% of ureteroceles were previously punctured but only 50% were punctured in the marsupialization group (p = 0.09). Postoperatively the groups did not differ significantly in terms of ongoing vesicoureteral reflux (13% and 14%), bladder diverticulum (3% and 9%), continence (100% and 95%), urinary tract infection (43% and 46%) or voiding dysfunction (24% and 25%, respectively). They varied significantly in terms of improved or stable hydronephrosis (70% vs 91%, p = 0.05). CONCLUSIONS: When performing lower urinary tract reconstruction for ureterocele, this study demonstrates that the choice of complete excision vs marsupialization/partial excision does not appear to differentially affect clinical outcomes.

Low Serum Testosterone Level Predisposes to Artificial Urinary Sphincter Cuff Erosion.

OBJECTIVE: To examine the association between decreased serum testosterone levels and artificial urinary sphincter (AUS) cuff erosion. MATERIALS AND METHODS: We evaluated serum testosterone levels in 53 consecutive patients. Low testosterone was defined as <280 ng/dL and found in 30/53 patients (56.6%). Chi-square and Student t tests, Kaplan-Meier analysis, binary logistic regression, and Cox regression analysis were used to determine statistical significance. RESULTS: Nearly all men with AUS cuff erosions had low serum testosterone (18/20, 90.0%) compared to those without erosions (12/33, 36.4%, P < .001). Mean time to erosion was 1.70 years (0.83-6.86); mean follow-up was 2.76 years (0.34-7.92). Low testosterone had a hazard ratio of 7.15 for erosion in a Cox regression analysis (95% confidence interval 1.64-31.17, P = .009) and Kaplan-Meier analysis demonstrated decreased erosion-free follow-up (log-rank P = .002). Low testosterone was the sole independent risk factor for erosion in a multivariable model including coronary artery disease and radiation (odds ratio 15.78; 95% confidence interval 2.77-89.92, P = .002). Notably, history of prior AUS, radiation, androgen ablation therapy, or concomitant penile implant did not confound risk of cuff erosion in men with low testosterone levels. CONCLUSION: Men with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. Appropriate counseling before AUS implantation is warranted and it is unclear whether testosterone resupplementation will mitigate this risk.

Androgen supplementation in rats increases the inflammatory response and prolongs urethral healing.

OBJECTIVE: To describe the effects of androgens on urethral wound healing, we compared the urethral healing process in castrated Sprague-Dawley rats with and without testosterone supplementation. METHODS: Of 30 castrated male Sprague-Dawley rats, 15 received testosterone cypionate (3 mg/kg; T+ rats). All rats underwent an urethroplasty procedure and were sacrificed at postoperative days 5, 10, and 20. Neutrophils, macrophages, vessels, myofibroblasts, Ki67+ cells, collagen, and cytokines were quantified with immunofluorescence and real-time polymerase chain reaction. RESULTS: Penile length was significantly increased in T+ rats (21.8 vs 13.25 mm; P <.001) and operative time decreased (20.8 vs 23.3 minutes; P <.017). On day 5, T+ rats showed elevated neutrophil (727.4 vs 30.75 per high power field; P = .051) and macrophage counts (1295.8 vs 481.5 per high power field; P = .051) compared with those of T- rats. This elevation persisted throughout day 10 (291.7 vs 34; P = .002 and 1283.7 vs 110.2; P = .005) and day 20 (252.7 vs 12.2; P <.001 and 1672.7 vs 115.2; P <.001) reflecting increased and prolonged inflammation. Myofibroblasts were decreased in T+ rats on day 5 (215.7 vs 808.3; P <.001) and increased by day 10 (1490.1 vs 263.0; P = .001) and day 20 (1964.0 vs 210.0; P <.001) consistent with a delayed onset but with prolongation of the proliferative phase. Limitations include the use of castrated rats, which may have been exposed to androgens before castration. CONCLUSION: Testosterone supplementation leads to an increased inflammatory response and myofibroblast proliferation accompanied by prolonged inflammatory and proliferative phases. These novel findings suggest a delayed and possibly impaired urethral healing in the presence of excessive androgens.

Analysis of primary urethral wound healing in the rat.

OBJECTIVE: To analyze the process of urethral healing, which is the basis of urethral reconstructive surgery but remains poorly understood, we have developed a rat model of urethroplasty. Understanding this process may provide strategies to prevent aberrant urethral healing and improve the healing process. METHODS: We performed urethroplasties on 36 male Sprague-Dawley rats. On postoperative days 2, 4, 6, 8, 10, and 12, animals were sacrificed. The number of neutrophils, macrophages, fibroblasts, blood vessels, and Ki67 proliferative index was evaluated with immunostaining and collagen I and III contents with picrosirius staining. Expression of VEGF, PDGF, TNFα, TGFß, and FGF was analyzed with quantitative real-time PCR. RESULTS: Urethral healing occurs in phases of inflammation, proliferation, maturation, and remodeling analogous to dermal healing, however, with extended duration of each phase. The inflammatory phase reached to postoperative day 4 being characterized by neutrophil and macrophage predominance and high levels of VEGF, PDGF, TGFß, TNFα, and IL-10. The proliferative phase extended until day 10 characterized by myofibroblast proliferation and angiogenesis. Maturation and remodeling started on day 10 with decreasing proliferation and angiogenesis, increasing collagen I formation, and periurethral alignment of connective tissue. The healing process involved >50% of the periurethral/spongiosum area in the inflammatory and >80% in the maturation and remodeling phase. CONCLUSION: Urethral healing occurs in phases similar to those observed in dermal healing, however, with extension of each phase. The healing process is not limited to the site of injury but involves the vast majority of periurethral tissue and corpus spongiosum. This appears to be the result of the unique anatomical features of the urethra.

Hemiscrotal agenesis: new variation in a rare anomaly.

Scrotal agenesis is a rarely encountered developmental anomaly of the scrotum, with only 6 cases of complete agenesis reported in published studies. We report, to our knowledge, the first case of hemiscrotal agenesis. The specific embryologic basis of scrotal agenesis is unknown but is likely multifactorial, involving localized androgen insensitivity, localized 5α-reductase deficiency, and/or failure of labioscrotal fold formation.

Active learning: a resident's reflection on the impact of a student-centred curriculum.

Classic medical education pedagogy typically involves the model of an active teacher and a passive student. There has been a shift in education theory to a more student-centred approach, and this is being reflected in resident education. Concepts, such as "competencies," "curricula" and "objectives," are becoming part of the fabric of the residency training equation. The University of British Columbia Department of Urologic Sciences had previously created a urology residency curriculum for its 15 residents in 2000. This curriculum was based on competencies and objectives outlined by the Royal College of Physicians and Surgeons of Canada. In an attempt to address a required change in the formal curriculum, an "accidental" student-centred curriculum emerged. This paper outlines this active learning approach, its benefits and challenges in implementation.

Computer-enhanced visual learning method: a paradigm to teach and document surgical skills.

INNOVATION: Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner. AIM OF INNOVATION: CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies. RESULTS: CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs.

Intravesical electrotherapy for neurogenic bladder dysfunction: a 22-year experience.

PURPOSE: Intravesical electrotherapy was previously shown to be effective for improving bladder capacity and compliance. We evaluated our 22-year experience with this therapy in patients with neurogenic bladder. MATERIALS AND METHODS: The charts of 405 patients who received intravesical electrotherapy were reviewed. Cystometrograms were performed at the start of each treatment series. Bladder capacity and pressure were determined for each patient before and after therapy. Patients were also questioned regarding the sensation of bladder filling. RESULTS: From 1985 to 2006, 372 patients with an average age of 5.5 years (range 0 to 43) had followup information available and were included for evaluation. Patients received a median of 29 treatment sessions (range 2 to 197). Mean patient followup was 6.6 years (range 0 to 19.7). Of the 372 patients 286 (76.9%) had a 20% or greater increase in bladder capacity after treatment. In this subset of patients bladder storage pressure at capacity was normal (less than 40 cm water) in 74.4% (213 of 286). Of the 17.2% of patients (64 of 372) who had no change in bladder capacity 81.21% (52 of 64) had normal bladder storage pressures after treatment. Bladder sensation was developed and sustained in 61.6% of patients (229 of 372), including 33.6% in the first series. CONCLUSIONS: Bladder stimulation is effective for increasing bladder capacity without increasing storage pressure in a majority of patients. This technique is safe and effective for improving bladder compliance. Some patients also have improved sensation of bladder filling and they should be able to catheterize when feeling full rather than by the clock.

Clinical urological outcomes following primary tethered cord release in children younger than 3 years.

PURPOSE: Current practice at our institution is to recommend tethered cord release at diagnosis to prevent the onset or worsening of symptoms. Tethered cord release is frequently performed in children younger than 3 years who often have no urological manifestations. To our knowledge there are currently no long-term data on urological outcomes in this age group. MATERIALS AND METHODS: We completed a retrospective review of 475 cases of tethered cord release performed at a single institution between 1995 and 2002. Of these surgeries 173 were performed in children younger than 3 years. Clinical outcomes, and preoperative and postoperative urodynamic and radiographic studies were evaluated. RESULTS: A total of 79 patients met study criteria. Average age at surgery was 9.6 months and average followup was 5.2 years (range 6 months to 11.2 years). At followup 49 patients (62.1%) had no urological complaints and 30 (38%) had urological problems. A total of 20 children (25.3%) had minor problems (constipation, delayed toilet training or other) and 10 (12.7%) had major problems (need for clean intermittent catheterization, febrile urinary tract infection or reflux). Of 66 patients 30 (45.5%) had abnormal preoperative urodynamics. One of 31 patients (3.2%) had hydronephrosis on preoperative ultrasound. Statistical analysis revealed that abnormal preoperative urodynamics and ultrasound were not predictive of major urological problems. Lipomatous dysraphism and preoperative musculoskeletal symptoms positively correlated with major urological problems (p = 0.0076 and 0.0484, respectively). CONCLUSIONS: The majority of children did not experience urological problems following tethered cord release. Only a small set of children had major urological problems. Children with lipomatous dysraphism and musculoskeletal symptoms were more likely to experience poor urological outcomes.

Incidence based fetal urological counseling using the virtual pediatric urology registry: importance of insignificant fetal pyelectasis (sonographically evident renal pelvis).

PURPOSE: Since 1985, counseling for fetal renal pelvic dilatation has been done to determine whether there is need for newborn urological evaluation. This is likely if the anteroposterior width of the renal pelvis exceeds categorical cutoffs, ie 4 mm or greater before gestational age 33 weeks, or 7 mm or greater after 33 weeks. Cases below these categorical cutoffs are deemed not to merit newborn testing. We examined our fetal registry to determine the incidence of urological pathology in cases deemed not to merit newborn testing. MATERIALS AND METHODS: Since 1980, we have prospectively input fetal ultrasound and postnatal followup data into customized Virtual Pediatric Urology Registry software. The Virtual Pediatric Urology Registry compares index case findings against those archived in the registry and then outputs the incidence of newborn diagnoses. Diagnoses are grouped as having limited or extensive urological care. RESULTS: The Virtual Pediatric Urology Registry has 1,128 cases registered and data on 2,292 fetal ultrasound studies that were done between gestational ages 12 and 43 weeks (average +/- SD 29.3 +/- 7). There are measurements of anteroposterior pelvic width for 1,712 cases. Pediatric data include ultrasound for 2,596 cases, diuretic renal scan for 449 and voiding cystourethrogram for 574. Surgery was done for renal/bladder obstruction or vesicoureteral reflux in 358 cases (32%). Mean followup was 9.8 months old (range 1 day to 14 years). Of the total of 1,128 fetal cases 148 (13%) showed anteroposterior pelvic width below categorical cutoffs, so that they were deemed not to merit newborn testing. However, the Virtual Pediatric Urology Registry incidence based method identified that extensive urological care extended to 30 of these 148 cases (20%). There were 31 cases identified at less than gestational age 33 weeks, which showed newborn urological pathology in 11 (35%), including hydronephrosis in 4, surgery in 3, vesicoureteral reflux in 2, solitary kidney in 1 and death in 1. There were 117 cases identified at gestational age 33 weeks or greater, which showed newborn urological pathology in 19 (16%), including vesicoureteral reflux in 8, hydronephrosis in 7 and surgery in 4. CONCLUSIONS: We found that about 13% of cases of fetal renal pelvic dilatation were insignificant because the measurement was below currently accepted cutoffs that merit postnatal followup. However, 20% of these cases in fact showed extensive urological care needs. The Virtual Pediatric Urology Registry provides an array of likely newborn diagnoses in neonates. Counseling by the incidence based method is more effective than by the current cutoff method.

Office management of pediatric primary nocturnal enuresis: a comparison of physician advised and parent chosen alternative treatment outcomes.

PURPOSE: We compared the remission of pediatric primary nocturnal enuresis in groups of children who used a physician advised practice plan vs a parent chosen alternative. MATERIALS AND METHODS: Between January 2004 and January 2006 there were 119 patients with primary nocturnal enuresis enrolled in this prospective, nonrandomized study. For this study primary nocturnal enuresis was defined as wetting at night during sleep during any 6-month interval without any known causative problem. A total of 76 children received the physician advised treatment plan and used an alarm, oxybutynin, desmopressin, an elimination diet and a bowel program, as indicated. A total of 43 children received a parent chosen alternative treatment plan, which consisted of any single or combination of treatments involving an alarm, oxybutynin, desmopressin and an elimination diet or bowel program. Parents from each group completed an intake survey that measured functional bladder capacity using a 3-day home diary and they identified demographic variables. Followup occurred at 2 weeks and then monthly for 12 weeks to study end. RESULTS: We found that the probability of remission by the end of the study for the physician advised treatment group was significantly higher than that of the parent choice group (88% vs 29%, Kaplan-Meier curve p <0.0001). CONCLUSIONS: The group of children who followed physician advised treatment for primary nocturnal enuresis showed significantly earlier remission of primary nocturnal enuresis than children who followed the parent choice treatment (25th percentile 2 vs 10 weeks).