Spinal anesthesia in children: most pediatric urologists are not on board.

OBJECTIVE: In 2016, the Food and Drug Administration issued a warning on general anesthetic medications used for lengthy procedures (>3 h) in children younger than 3 years. Spinal anesthesia can be a safe alternative to general anesthesia for many pediatric urology procedures. It can shorten total operating room (OR) time, provide excellent pain control, and allow parents to reunite with their child immediately after surgery. However, use of spinal anesthesia can also directly affect the operating surgeon (awake patient, time constraints of spinal, and prolonged preoperative time). Members of the Societies for Pediatric Urology (SPU) and European Society of Pediatric Urology (ESPU) were surveyed to get their opinions on the use of spinal anesthesia for routine pediatric urology procedures. It was hypothesized that half of pediatric urologists would favor spinal anesthesia and that SPU members would be more likely to favor spinal anesthesia than their European colleagues. MATERIALS AND METHODS: A short survey with five clinical scenarios was created. Scenarios assessed physicians' recommendations regarding timing and the type of anesthesia (general or spinal) for common pediatric urology procedures: undescended testicle, inguinal hernia, hypospadias, phimosis, and phimosis with penoscrotal webbing. Surveys were emailed to members of the SPU and ESPU. Responses and demographic information were collected and analyzed. RESULTS: The survey was completed by 113 SPU members (46% response rate for members who opened the invitation) and 109 ESPU members. For all clinical scenarios, < 20% of pediatric urologists from the SPU and <25% from the ESPU favor doing any procedure with spinal anesthesia. The majority of respondents practice in children's hospitals with pediatric anesthesiologists, but roughly half of the responders (54% SPU and 43% ESPU) do not think their anesthesia colleagues would be comfortable performing spinal anesthesia. Furthermore, only 51% of SPU and 36% of ESPU members discuss the possible neurodevelopmental side-effects of anesthesia with parents; similarly, less than half of all respondents think their anesthesia colleagues address these potential side-effects when obtaining consent. The only significant difference between SPU and ESPU responses was that ESPU members tended to delay penile surgery more than SPU respondents. CONCLUSION: Whether general anesthesia has any effect on the developing brain of children undergoing routine pediatric urology procedures is unclear. Yet, few pediatric urologists, independent of their region of practice, prefer spinal to general anesthesia. Collaboration in the OR is the key to success, and it is important that pediatric urologists and pediatric anesthesiologists work together to balance the benefits and risks of general and spinal anesthesia.

Surprising interobserver and intra-observer variability in pediatric testicular ultrasound volumes.

INTRODUCTION: Testicular volume (TV) can be obtained by either scrotal ultrasound (SU) or orchidometer. Scrotal ultrasound allows for a more objective measurement; however, the interobserver and intra-observer variability of TV measurements has not been rigorously studied. OBJECTIVE: The authors measured intra-observer and interobserver variability of SU TV measurements in pediatric patients to assess the reliability and reproducibility of SU. Special attention was paid to how often a 20% discrepancy in TV was noted as this has previously been utilized as an indication for varicocelectomy. DESIGN: Patients with an indication for SU or undergoing an ultrasound for another reason were prospectively recruited. Two different urologic specific ultrasound technicians (A and B) performed SU to assess interobserver variability. A second measurement was taken by technician A within 90 days to assess intra-observer variability (A vs A1). The technicians were blinded to other ultrasound results. RESULTS: Fourteen patients (28 testes, 56 volume measurements) were included in the intra-observer group and 17 patients (34 testes, 68 volume measurements) in the interobserver group. The mean time to repeat intra-observer ultrasound measurements (range) was 46 days (23-84). Mean age (range) in the intra-observer group was 14.3 years (11-19) and 14.1 years (11-19) in the interobserver group. Indication for ultrasound was varicocele (n = 6), scrotal pain (4), hydronephrosis (3), hydrocele (2), epididymal cyst (2), posterior urethral valves (1), and testis asymmetry (1). Utilizing Bland-Altman analysis and plots, variability was seen in both intra-observer and interobserver measurements. The mean values for testicular sizes for technician A and technician B were 13.0 ± 9.7 cm3 vs 13.8 ± 9.9 cm3, respectively. The mean values for TV measurement for technician A's first and second measurements (A, A1) were 14.3 ± 9.7 cm3 and 14.8 ± 8.9 cm3, respectively. An errant 20% difference in TV measurements for the same testis was seen in 25% (7 of 28) of intra-observer measurements and 35% (12 of 34) of interobserver measurements. These 20% differences were more common with a lower body mass index (odds ratio, OR = 0.74, p = 0.01) in the interobserver group, and lower TV was a predictor in the intra-observer group (OR: 0.82, p = 0.009). CONCLUSIONS: Variability exists in both interobserver and intra-observer measurements of TV by dedicated urologic ultrasonographers, and greater than 20% of differences in measured TV in same testicles occurred in over 25% of cases. Caution should be exercised in basing operative decisions and scientific studies on limited measurements of TV.

Pediatric penile surgery by a nurse practitioner in the operating room.

INTRODUCTION: With the growing shortage of pediatric urological surgeons, it was our aim to streamline our system to get patients with less complex penile procedures performed in a timely manner. To do this, an advanced practice provider (APP) was trained to perform minor penile procedures in children in the operating room(OR). OBJECTIVES: The goal of our study was to show that with proper training an APP could safely perform a circumcision in the OR. STUDY DESIGN: After approval of the study center's credentialing committee, a NP was trained to perform revisions and initial circumcisions in children in the OR. The process involved: (1) observation, (2) first assisting and (3) performing the procedure with direct, and later in-direct, supervision. The first 100 cases were evaluated for surgical complications, post-operative complications and return rates to the OR. RESULTS: 100 independent cases were completed with 90 having only in-direct supervision. There were no operative complications, nor any documented emergency room or urgent care visits in the immediate post-operative period. There were no early returns to the OR and only 1 scheduled follow-up procedure for a penile skin bridge. DISCUSSION: It was demonstrated that with proper training a NP can safely perform minor penile procedures in the OR. This allows us to free up our pediatric urology physicians to see and operate on more complex pediatric urology problems. In addition, it allows those with minor penile issues to be cared for more expeditiously. A concern related to training NPs to do circumcisions could be the loss of control by urologists. In this situation, the attending physician is ultimately responsible from a medico-legal standpoint. That would not be true if the NP was practicing independently. With a shortage of urologists, this significantly expands the ability to care for our patient population. In additional, attending surgeons will have a greater freedom to perform major procedures. A limitation of the study was that a patient satisfaction survey was not obtained to see if there were concerns over a APP doing their circumcision. Personal feedback on 30 of the patients that did not return for the follow-up visit was not obtained. The authors of the study are primary providers of pediatric urology care in the study region, thus any individual with concerns would have been referred. CONCLUSIONS: It was demonstrated that a well-trained APP can safely perform minor penile procedures independently in the OR with indirect supervision.

Natural history of testicular size in boys with varicoceles.

INTRODUCTION: Testicular size is commonly used as a proxy for future fertility in adolescent boys diagnosed with varicoceles. Surgery is often performed based on a 15-20% reduction in volume of the ipsilateral testicle when compared to the unaffected side. Recent European Association of Urology guidelines, however, have highlighted the risk of overtreatment. Data on the natural progression of testicular size discrepancy are limited in this population. To evaluate the role of a non-surgical approach, the present study reports on testicular size progression in 35 boys with left-sided varicoceles managed with observation alone. METHODS: In the present study, 103 consecutive boys who were seen for varicocele were retrospectively evaluated; the 35 who were seen for at least three sequential visits by the same pediatric urologist for a unilateral left varicocele were selected. In the present practice, surgical management of varicoceles in teens is offered, but not recommended unless surgery is being performed for another reason (3/103). The Prader orchidometric testicular volumes that were documented for all visits were recorded and the volume of the left testicle as a percentage of the right was calculated. This analysis was performed for the entire population, and subgroup analysis was conducted for boys with a Grade 3 varicocele, with >10% asymmetry at diagnosis, and by dividing the population into prepubertal and pubertal age groups. Boys with bilateral varicoceles, concurrent testicular masses, or volumes recorded by a nurse practitioner were excluded from the study. RESULTS: The mean left testicular volume in the population was found to measure 96%, 95% and 96% of the right at the first, second and third visit (median interval was 2.0 years), respectively. Among the 26 boys seen for a fourth visit (median 3.3 years) and the 15 seen for a fifth visit (median 4.3 years), the mean left testicular volumes were 98% and 97% of the right at diagnosis and 97% at both the fourth and fifth visits (Figure). Likewise, no differences were seen after dividing the population into prepubertal (9-11 years, n = 9) and pubertal (12-14 years, n = 26) groups. Among the 13 (37%) boys with a Grade 3 varicocele at presentation, the left testicular volume was 95% (SD 11.4) of the right and remained unchanged by the third visit (96%, P = 0.69). In addition, among the 11 boys (31%) with greater than 10% size difference at the first visit, the left testicle measured 82% of the right (SD 5.3) at diagnosis and increased to 92% (SD 6.3) by the third visit (P < 0.001). DISCUSSION: In the 35 boys observed over a median of 2.0 years or three consecutive visits, there was no worsening of testicular asymmetry. This finding is consistent with some previous observational data on pediatric varicoceles, but carries the advantages of a narrower age range and longitudinal follow-up in all patients. At the same time, these results differ from other studies that show no improvement or worsening of asymmetry during follow-up. This difference is attributed to the inherent characteristics of the present study population and the choice of orchidometer for measurement. The present data have the advantage of excluding selection bias. Recognizing that this study is a retrospective, single-operator study with a small sample size, prospective, randomized trials are recommended to weigh surgery vs observation in adolescent varicocele patients. CONCLUSIONS: No progression in atrophy/hypotrophy of the left testis was found in a series of 35 consecutive patients who were followed non-surgically for left-sided varicocele. Our data thus support observation as management for childhood varicocele in younger teens.

Spermatic cord torsion: diagnostic limitations.

To distinguish spermatic cord torsion from other intrascrotal pathology, scrotal ultrasound and radionuclide scanning have been highly recommended on the basis of both clinical and experimental studies. We review the data from six patients in whom ultrasound or nuclear medicine examination was misleading. We emphasize that history, physical examination, and urinalysis remain the cornerstones of the diagnosis of spermatic cord torsion. Scrotal ultrasound and nuclear medicine scans are useful adjuncts and are reassuring when in agreement with the clinical picture. However, they are not 100% sensitive or specific, and a negative study should not prevent emergency operative exploration of a clinically suspicious lesion.

Urine concentration and enuresis in healthy preschool children.

OBJECTIVES: To determine whether children concentrate their urine overnight and to assess the correlation between specific gravity of a first morning urine specimen and the results of a questionnaire concerning bedwetting, voiding habits, and continence in 47 healthy children aged 3 to 6 years. DESIGN: A prospective observer-blinded consecutive sample. SETTING: Two San Francisco, Calif., preschools. PARTICIPANTS: Forty-seven children attending preschool during the study period. MEASUREMENTS/MAIN RESULTS: Forty of 47 children had a urine specific gravity greater than 1.020. None of these children wet the bed during this study, although four (11%) of 36 had a history of bedwetting. Furthermore, seven children with a urine specific gravity of 1.015 or lower had a history of bedwetting and wet the bed during this study. A voiding frequency of six or more times per day, by history, was associated with a 3:1 relative risk of bedwetting but did not segregate children with primary enuresis from those with secondary enuresis. CONCLUSIONS: Our results indicate that healthy children aged 3 to 6 years are able to concentrate their urine. In addition, urine specific gravity was an accurate predictor of the presence of nocturnal enuresis in this group of children. Our results suggest that a specific gravity of the first morning urine specimen should be correlated with appropriate history before extensive diagnostic evaluation or empiric therapy is performed in children with nocturnal enuresis.

Length of stay for specialized pediatric urologic care.

BACKGROUND: Pediatric urologic specialists have been excluded from many recent managed care contracts because they are believed to be more expensive and of no better quality than general urologists in managing common urologic problems in children. We believed this to be inaccurate. OBJECTIVES: To compare the length of stay at the University of California, San Francisco Medical Center for 2 common pediatric urologic operative procedures with data from other northern California hospitals and to document our results and patient satisfaction. DESIGN: Retrospective analysis of HCIA statewide database (HCIA Inc, Orange, Conn). SETTING: Northern California, 1995. SUBJECTS: Children younger than 12 years undergoing surgery for repair of an obstruction of the ureteropelvic junction or vesicoureteral reflux. MAIN OUTCOME MEASURE: Length of stay. RESULTS: The length of stay in our hospital was similar to that observed in other hospitals in which other full-time pediatric urologic specialists practiced and was significantly less than that observed in other northern California hospitals, even when adjusted for risk. In fact, a savings of 279 hospital days would have been realized if all patients had the same length of stay as that achieved at University of California, San Francisco Medical Center. In the 38 patients operated on at our center, there was uniform surgical success. Of the parents, 92% (11/ 12) were satisfied with their child's care and 92% (11/ 12) believed they received enough information to know what to expect and how to care for their child at home. There were no data available evaluating quality from other northern California hospitals for comparison. CONCLUSIONS: Our finding that actual and risk-adjusted length of stay were shorter when patients were treated by full-time pediatric urologists, while excellent quality was maintained, suggests that these specialists achieve their results with more efficiency and lower resource utilization than do general urologists. The implication of these results is that exclusive contracting that prevents patients from receiving care from full-time specialists results in overuse of valuable resources and possibly reduced quality. If our results are generalizable, they have important implications for health care reform in the United States.

Nongonococcal urethritis.

Nongonococcal urethritis is a venereal disease whose incidence is almost double that of gonorrhea. Despite this, the diagnosis, origin, treatment, and complications of nongonococcal urethritis remain unclear. Although some cases are undoubtedly caused by infection with Chlamydia trachomatis, the origin of many cases is uncertain. Treatment is recommended to shorten symptoms and prevent complications. This review presents the current status of this confusing disease.

Plexiform neurofibroma involving the genitourinary tract in children: case reports and review of the literature.

We report extensive genitourinary neurofibroma in two children who presented with massive bilateral hydroureteronephrosis and a thick-walled bladder. The best radiologic technique to stage the disease and determine treatment is magnetic resonance imaging. Management of extensive genitourinary neurofibroma is controversial. Based upon our experience and a review of the literature, aggressive surgery should be approached cautiously.

99mTc-DMSA scanning to diagnose pyelonephritic scarring in children.

99mTechnetium-labeled dimercaptosuccinic acid (99mTc-DMSA) scanning provides superior quality images of renal parenchymal detail, which makes it highly sensitive for the diagnosis of pyelonephritic scarring. Unlike most other imaging techniques, radionuclide scanning is not affected by bowel gas or bony structures overlying the kidneys. This makes it particularly useful in children. Furthermore, renal scarring can be demonstrated by 99mTc-DMSA even before the classic gross anatomic and radiologic changes are present. The use of 99mTc-DMSA scanning in over 300 children has demonstrated its benefits and advantages over standard radiographic techniques.

Therapeutic laparoscopy for intra-abdominal testes.

Fourteen laparoscopic surgical procedures were performed in 10 children with 11 intra-abdominal testes. In addition to localizing the testes, laparoscopy aided in the surgical approach. In 8 patients, the first phase of a two-stage Fowler-Stephens orchiopexy was performed. Five children underwent an open surgical procedure three months later and have a viable testis in the scrotum after at least nine months of follow-up. In 5 patients (6 testicles), laparoscopy was used to dissect the testis. Three patients underwent the second phase of the two-stage Fowler-Stephens procedure laparoscopically. In all 3 patients, the testicle could be easily mobilized into the scrotum. Two other testicles were mobilized by dissecting the spermatic vessels up to the renal hilum laparoscopically; this allowed the intra-abdominal testes to come into the scrotum without dividing the spermatic vessels. In one teenager with a small intra-abdominal testis and a normal contralateral testis, laparoscopic orchiectomy was performed. We believe laparoscopy has a role both diagnostically and surgically in the treatment of intra-abdominal testes.

Recurrent Staphylococcus aureus renal abscess in a child positive for the human immunodeficiency virus.

A 10-year-old girl with the human immunodeficiency virus was found to have a Staphylococcus aureus renal abscess with perinephric extension. The abscess was drained first percutaneously and then surgically, and the patient received a 6-week course of intravenous antibiotics. Three months later, the abscess recurred, necessitating a nephrectomy. The extended morbidity and difficulty of eradicating S aureus suggest that, in immunocompromised patients, early aggressive surgical management is indicated.

Pediatric ureteropelvic junction obstruction treated with retrograde endopyelotomy.

OBJECTIVES: To determine the feasibility of retrograde endopyelotomy in the management of pediatric ureteropelvic junction (UPJ) obstruction. METHODS: We treated 2 boys aged 4 and 6 years with the Acucise endopyelotomy device for symptomatic ureteropelvic junction obstruction. The Acucise device was placed over a Lunderquist guide wire with fluoroscopic guidance only and routine Double J catheters were left in situ for 6 weeks after the procedure. The morbidity of the treatment and the short-term outcome were assessed. RESULTS: There were no acute complications and short-term follow-up results were satisfactory as determined by intravenous urography and diuretic renography. CONCLUSIONS: Ureteropelvic junction obstruction in children may be treated by retrograde endopyelotomy with the Acucise device. The principal potential advantage of this procedure is reduced morbidity. Our findings suggest that further evaluation is warranted.

Magnetic resonance imaging of vascular lesions of the scrotum and penis.

We report 2 rare cases of vascular lesions in the scrotum and penis: an arteriovenous malformation in a young man and a lymphohemangioma in a boy. Both patients had undergone previous treatment and had recurrent lesions. Magnetic resonance imaging was performed preoperatively for detailed information regarding lesion extent and involvement of adjacent structures.

Neonatal management. Role for early intervention.

Although performing pyeloplasty on an infant with a relatively healthy kidney prior to the onset of renal damage is not as well-accepted as "aggressive observation," the authors argue that early intervention is the more "conservative" or safe method of treatment for infants with ureteropelvic junction (UPJ) obstruction. Using experimental and clinical data, the authors demonstrate that prolonged partial UPJ obstruction in the developing kidney causes significant renal morbidity with time.

Upper ureteral reconstructive surgery.

Upper ureteral reconstructive surgery encompasses a wide variety of procedures directed at the correction of abnormal processes and structural defects in the proximal ureter. Although some of these techniques have strict indications for specific causes, technical innovations have led to development of numerous alternatives in upper ureteral reconstructive surgery. These innovations provide the practicing urologist with various options from which to choose for the management of upper ureteral disease.

Diuretic renogram clearance half-times in the diagnosis of obstructive uropathy: effect of age and previous surgery.

Diuretic renography with radiotracers has been used successfully to diagnose obstruction in patients with hydronephrosis. Controversy persists with regard to the best approach for the interpretation of renogram curves: visual analysis or a quantitative index, i.e. the clearance half-time. The latter is often reported to be in the intermediate or non-diagnostic range. It is important to measure the incidence of equivocal half-times in various subsets of patients with hydronephrosis in order to determine in which settings the measurement of this index may be clinically useful. We performed a retrospective study of diuretic renograms performed at our institution between 1997 and 2000 for the evaluation of suspected uretero-pelvic junction (UPJ) obstruction. Vigorous intravenous hydration, exceeding current guidelines, was employed in these patients. Three hundred and seventy-seven renogram curves in 205 patients were analysed. Patients were divided into three groups: >1 year of age; 20 min) or intermediate (half-time, 10-20 min). In patients >1 year of age, 37% of 101 renograms showed normal half-times before furosemide, 20% showed normal half-times after furosemide, 44% showed prolonged half-times and none (0%) showed an intermediate half-time. In patients 1 year. Caution is advised when interpreting this finding in this age group. The measurement of washout was less useful in patients who had undergone a corrective procedure, because of the high rate of 'indeterminate' and 'abnormal' values in spite of successful surgery. Vigorous intravenous hydration, exceeding current standards, may have contributed to the lower incidence of intermediate half-times than reported previously.

Fetal lower urinary tract physiology: in vivo studies.

Fetal lower urinary tract function is under continuous maturation throughout gestation and is an integrated neurophysiologic event by late gestation. Preliminary in vivo study suggests that peripheral and central nervous system regulation of micturition occurs in utero, and that these events can be modulated pharmacologically and through external stimulation. Normal bladder function in utero is essential to normal development of the entire fetus, and in utero modulation of bladder dysfunction may be feasible as our understanding and diagnostic acumen increase.