Use of ChatGPT in Urology and its Relevance in Clinical Practice: Is it useful?

ABSTRACT Purpouse: One of the many artificial intelligence based tools that has gained popularity is the Chat-Generative Pre-Trained Transformer (ChatGPT). Due to its popularity, incorrect information provided by ChatGPT will have an impact on patient misinformation. Furthermore, it may cause misconduct as ChatGPT can mislead physicians on the decision-making pathway. Therefore, the aim of this study is to evaluate the accuracy and reproducibility of ChatGPT answers regarding urological diagnoses. Materials and Methods: ChatGPT 3.5 version was used. The questions asked for the program involved Primary Megaureter (pMU), Enuresis and Vesicoureteral Reflux (VUR). There were three queries for each topic. The queries were inserted twice, and both responses were recorded to examine the reproducibility of ChatGPT's answers. Afterwards, both answers were combined. Finally, those rwere evaluated qualitatively by a board of three specialists. A descriptive analysis was performed. Results and Conclusion: ChatGPT simulated general knowledge on the researched topics. Regarding Enuresis, the provided definition was partially correct, as the generic response allowed for misinterpretation. For VUR, the response was considered appropriate. For pMU it was partially correct, lacking essential aspects of its definition such as the diameter of the dilatation of the ureter. Unnecessary exams were suggested, for Enuresis and pMU. Regarding the treatment of the conditions mentioned, it specified treatments for Enuresis that are ineffective, such as bladder training. Therefore, ChatGPT responses present a combination of accurate information, but also incomplete, ambiguous and, occasionally, misleading details.

Parapelvic cyst: A rare cause of ureteropelvic junction obstruction in a pediatric patient managed with robotic cyst decortication.

INTRODUCTION: We report a case of a right parapelvic renal cyst causing intermittent ureteropelvic junction obstruction (UPJO). DIAGNOSTIC EVALUATION: A 13-year-old male was referred for right flank pain. Stone protocol CT revealed renal pelvis dilation with punctate stones. Due to concern for intermittently obstructive calculi, he underwent ureteroscopy, which was unremarkable. A diuretic renogram showed symmetric uptake with partial emptying on the right with pain after diuretic administration. In office, we potentiated a Dietl's crisis with ultrasound obtained before and after fluid intake. Comparison of ultrasounds revealed a parapelvic cyst causing calyceal dilation. He was counseled for robotic cyst decortication and possible pyeloplasty. SURGICAL CONSIDERATIONS: A robotic cyst decortication was performed. Once decorticated, the cyst base was fulgurated and pararenal fat was interposed into the cyst base. Console time was 70 min with minimal blood loss. The patient was discharged post-operative day 1. Follow-up renal ultrasound at 4 months demonstrated resolution of hydronephrosis and parapelvic cyst. CONCLUSION: Parapelvic renal cysts causing intermittent UPJO is a rare entity that may be missed on a diuretic renogram. Clinical suspicion and appropriate imaging with ultrasound or magnetic resonance imaging are useful. Robotic cyst decortication is a technically feasible approach to treat this condition.

Armamentarium to treat primary vesicoureteral reflux in children.

Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.

Outcomes of complex robot-assisted laparoscopic ureteral reimplantation after failed ipsilateral endoscopic treatment of vesicoureteral reflux.

BACKGROUND: Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR). OBJECTIVE: We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO). METHODS: A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution. RESULTS: A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N = 10) or symptomatic ureterovesical junction obstruction (UVJO, N = 6). Mean console times were 102 min (range 70-240 min) for RALUR vs 128 min (range 70-180 min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction. CONCLUSION: RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Role of a Preoperative Catheter Regimen in Achieving Early Primary Endoscopic Valve Ablation in Neonates with Posterior Urethral Valves.

PURPOSE: Primary valve ablation is preferred to vesicostomy in the initial management of posterior urethral valves. However, some neonates have a prohibitively small urethra. We describe our experience with a preoperative urethral catheter regimen to enhance the likelihood of neonatal valve ablation. MATERIALS AND METHODS: We performed a retrospective review of 126 neonates with posterior urethral valves treated between 2003 and 2019 with valve ablation prior to 10 weeks of age. The preoperative indwelling catheter either was gradually upsized to an 8Fr (progressive urethral dilation), was not upsized (nondilated) or was initially larger bore (8Fr only). The primary outcome was the ability to perform primary ablation by neonatal resectoscope. The secondary objective was to establish the parameters for considering progressive urethral dilation as well as its associated risks. RESULTS: Overall 97% could be ablated. The progressive urethral dilation group had the lowest mean weight (p <0.001). Only a larger catheter at the time of ablation was significantly associated with feasible ablation (p <0.001) and not urethral dilation, the infant's weight or his gestational age. Progressive urethral dilation was associated with a longer duration of catheterization as well as double the rate of febrile urinary tract infections (8.5%) over the nondilated group (3.6%). CONCLUSIONS: A much higher rate of primary ablation is feasible (97%) than previously reported (82%). More important than the infant's weight is whether a 6Fr to 8Fr catheter is in place at ablation. If an initial 6Fr to 8Fr catheter cannot be placed, urethral dilation to 8Fr should be performed before attempting ablation. This is both a technique and preoperative assessment that is useful for operative planning.

Standardized protocol for voiding cystourethrogram: Are recommendations being followed?

BACKGROUND: Voiding cystourethrogram (VCUG) images the urethra and bladder during filling and emptying, as well as ureters and kidneys when vesicoureteral reflux (VUR) is present, providing detailed information about both anatomical and functional status of the urinary tract. Given the importance of information obtained, and the varying quality depending on VCUG technique and radiology reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016. OBJECTIVE: We compared VCUG reports from multiple institutions before and after publication of the protocol to determine adherence to recommendations. STUDY DESIGN: VCUG reports generated during two separate time periods were assessed - before and after publication - to evaluate impact of the protocol. Adherence to the reporting template was evaluated. Studies performed on patients >18 years of age and those obtained for trauma evaluation were excluded from study. RESULTS: A total of 3121 VCUG reports were analyzed, 989 (31.7%) were generated before and 2132 (68.3%) after protocol publication. Comparing cohorts, there was no difference in gender (62.6% female versus 61.4%; p = 0.53) though children in the post-cohort were slightly older (3.34 ± 3.82 versus 3.68 ± 4.19 years; p = 0.03). A significant increase in scout image reporting (91.5%) and cyclic studies (20.5%) were observed in the post-cohort, in comparison to 79.2% and 13.1%, respectively, in the pre-protocol cohort (p < 0.001) [Figure]. Measured PVR and recorded infused volume actually decreased between study periods (84.7% vs 72.8% and 97.2% vs 91.5%, p < 0.001). There was no statistically significant difference between VUR grade reporting (99.4 vs 98.5%, p = 0.25). Recorded volume in which reflux occurred increased between periods (0.6% vs 2.3%, p < 0.05), while reporting of filling vs voiding reflux decreased in the post-cohort (84.4% pre-vs 77.4% post-protocol, p < 0.008). DISCUSSION: The 2016 VCUG protocol recommended inclusion of various data points, however the volume at which reflux occurs remained vastly underreported. Timing of reflux has been shown to predict likelihood of spontaneous resolution and risk of breakthrough urinary tract infection; thus, its omission may limit the information used to counsel families and provide individualized care. CONCLUSION: Despite consensus on standard VCUG protocol to best perform and record data, reports remain inconsistent. While VUR grade is routinely reported, other important anatomic and functional findings which are known to impact resolution and breakthrough urinary tract infection rates, such as volume at which reflux occurs, are consistently underreported.

Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

ABSTRACT Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.

Predicting Breakthrough Urinary Tract Infection: Comparative Analysis of Vesicoureteral Reflux Index, Reflux Grade and Ureteral Diameter Ratio.

PURPOSE: The vesicoureteral reflux index is a simple, validated tool for predicting resolution of reflux. Along with likelihood of spontaneous resolution identification of children at risk for febrile urinary tract infection impacts management. We evaluated the usefulness of the vesicoureteral reflux index as a predictive factor for breakthrough febrile urinary tract infection compared to reflux grade and distal ureteral diameter ratio. MATERIALS AND METHODS: Children with primary vesicoureteral reflux and detailed voiding cystourethrogram data were identified. A 1 to 6-point index was assigned, and ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 to L3 vertebral bodies. Random forest modeling and logistic multivariable regression were employed to estimate the predictive ability of grade, ureteral diameter ratio and vesicoureteral reflux index with regard to breakthrough febrile urinary tract infection. RESULTS: We analyzed 94 girls and 45 boys with a mean±SD age of 5.4±4.7 months at diagnosis. Mean±SD length of followup was 32.1±24.5 months. A total of 13 children (9.4%) experienced breakthrough febrile urinary tract infection. On univariate analysis ureteral diameter ratio (p=0.01) and vesicoureteral reflux index (p=0.0005) were associated with breakthrough urinary tract infection, while grade (p=0.09) did not reach significance. Area under the curve was generated as a measure of accuracy for each variable and was 0.77 for the vesicoureteral reflux index, 0.71 for ureteral diameter ratio and 0.68 for grade, indicating superiority of the vesicoureteral reflux index for predicting breakthrough febrile urinary tract infection. CONCLUSIONS: Children with higher vesicoureteral reflux index are at increased risk for breakthrough febrile urinary tract infection independent of reflux grade. The vesicoureteral reflux index provides valuable prognostic information about infection risk, facilitating improved clinical decision making.

Accuracy of subjective vesicoureteral reflux timing assessment: supporting new voiding cystourethrogram guidelines.

BACKGROUND: Bladder volume at the onset of vesicoureteral reflux (VUR) is an important prognostic indicator of spontaneous resolution and the risk of pyelonephritis. OBJECTIVE: We aim to determine whether pediatric urologists and pediatric radiologists can accurately estimate the timing of reflux by examining voiding cystourethrogram (VCUG) images without prior knowledge of the instilled contrast volume. MATERIALS AND METHODS: Total bladder volume and the volume at the time of reflux were collected from VCUG reports to determine the volume at the onset of VUR. Thirty-nine patients were sorted into three groups: early-/mid-filling reflux, late-filling and voiding only. Thirty-nine images were shown to three pediatric urologists and two pediatric radiologists in a blinded fashion and they were then asked to estimate VUR timing based on the above categories. A weighted kappa statistic was calculated to assess rater agreement with the gold standard volume-based report of VUR timing. RESULTS: The mean patient age at VCUG was 3.1±2.9 months, the median VUR was grade 3, and 20 patients were female. Overall agreement among all five raters was moderate (k=0.43, 95% confidence interval [CI] 0.36-0.50). Individual agreement between rater and gold standard was slight to moderate with kappa values ranging from 0.13 to 0.43. CONCLUSION: Pediatric radiologists and urologists are unable to accurately and reliably characterize VUR timing on fluoroscopic VCUG. These findings support the recently published American Academy of Pediatrics protocol recommending the routine recording of bladder volume at the onset of VUR as a standard component of all VCUGs to assist in a more accurate assessment of the likelihood of resolution and risk of recurrent urinary tract infections.

Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.

Opioid utilization is minimal after outpatient pediatric urologic surgery.

INTRODUCTION: There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution. MATERIALS AND METHODS: After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use. RESULTS: Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups. DISCUSSION AND CONCLUSIONS: Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Revisiting the success rate of one-stage Fowler-Stephens orchiopexy with postoperative Doppler ultrasound and long-term follow-up: a 15-year single-surgeon experience.

INTRODUCTION: The optimal management of a high undescended testicle (UDT) remains debated. When tethering is due to shortened spermatic vessels, a one-stage or two-stage Fowler-Stephens Orchiopexy (FSO) can be performed. Published series suggest a higher success rate with a two-stage FSO, though its superiority has not been ascertained. The authors examine patient and surgical factors associated with success of one-stage FSO and compare our outcomes with the established literature. METHODS: We retrospectively reviewed the charts of 43 boys who underwent one-stage FSO for 45 testes from 2003 to 2018 by a single surgeon at our institution. Patient factors, surgical approach, and postoperative results were reviewed. Radiographic success was a testis with intact vascular flow or normal echotexture on scrotal ultrasound. Clinical success was a non-atrophic, intrascrotal testis at postoperative follow-up. Radiographic and clinical success was compared. Data analysis was performed with Fisher's exact test and t-test for categorical and continuous variables respectively. RESULTS: Follow-up (mean 29 months; 0.5 months-14.5 years) was available for 40 patients (42 testes; 21 bilateral, 21 unilateral). Average age at surgery was 21.8 months (4 months-10.4 years). Associated conditions were seen in 14 patients. Twenty-nine patients had postoperative scrotal Doppler ultrasound with radiographic success in 25/29 (86.2%). Overall clinical success was 34/42 (81%) with 4 (9.5%) each of atrophy and ascent. A second surgery to address ascent in four patients allowed correction in three for a success rate of 88%. Radiographic and clinical success was significantly associated (P = 0.01). Clinical success was also significantly associated with inguinal rather than laparoscopic testis mobilization (P = 0.03) but not to patient's age, associated conditions, unilaterality/bilaterality, or pre-operative hypoplasia or location. Greater than 3 years of follow-up was available in 11 (26.2%) cases, of which seven had successful results. All adverse outcomes occurred within 8 months after surgery. Success was otherwise durable. CONCLUSION: This is the largest series of one-stage FSO to date. The success rate of one-stage FSO in this series matches that published in the literature for two-stage FSO; equal success is achieved with fewer surgeries. Postoperative Doppler ultrasound demonstrating intact vascular flow or normal testis echotexture is significantly associated with clinical success and highlights the utility of postoperative ultrasound in patients with an equivocal exam.

Long-Term Clinical Outcomes and Parental Satisfaction After Dextranomer/Hyaluronic Acid (Dx/HA) Injection for Primary Vesicoureteral Reflux.

Purpose: Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection is a common treatment for vesicoureteral reflux (VUR) with excellent reported short-term clinical success rates. Long-term outcomes are less well-defined. We assessed long-term outcomes and parental satisfaction after Dx/HA injection for primary VUR with >5-year follow-up. Materials and Methods: Families of all patients who underwent Dx/HA injection for primary VUR at our institution between 2008 and 2012 were contacted for telephone interview. Data collected by phone included parental satisfaction and presence and severity of UTIs pre-operatively and post-operatively. Patient demographics, radiographic VUR data, need for secondary surgery, and surgical indications were obtained through chart review. Results: Five hundred and seventy-five patients underwent Dx/HA injection for primary VUR between 2008 and 2012. Ninety-nine (17.2%) of these patients' parents were successfully contacted and interviewed. Median follow-up time from surgery to survey was 8.4 (IQR 6.8-9.6) years. Secondary surgery was performed in 13/99 (13.1%), most commonly repeat Dx/HA injection. Seven patients (7.1%) underwent secondary Dx/HA injection for persistent VUR without UTIs at a median of 0.35 (IQR 0.33-0.77) years post-operatively. Five patients (5.1%) underwent Dx/HA injection (n = 3) or ureteral reimplantation (n = 2) for VUR with febrile UTIs (fUTIs) at a median of 2.2 (IQR 1.3-5.1) years. One patient had ureteral reimplantation for symptomatic obstruction 2.8 years after initial surgery. Only 3/99 (3.0%) required open or laparoscopic surgery after Dx/HA injection. Eighty-three families (84.7%) reported ≥1 fUTIs pre-operatively. Of these, only 9/83 (10.8%) reported fUTIs post-operatively, for an overall clinical success rate of 89.2%. Clinical success was 93.1% in patients whose pre-operative fUTIs were treated outpatient and 80.0% in those hospitalized at least once for fUTI treatment pre-operatively. Ninety-four percent of parents were highly satisfied, 2.4% partially satisfied, and 3.5% dissatisfied. Conclusions: Endoscopic injection with Dx/HA for primary VUR appears to have good long-term clinical success rates and high parental satisfaction, mirroring our previously reported short-term results. Post-operative ureteral obstruction is rare but may occur years post-operatively, justifying initial sonographic surveillance, and repeat imaging in symptomatic patients.

Robotic Ureteral Reconstruction in the Pediatric Population.

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

Parental Preferences for Vesicoureteral Reflux Treatment: A Crowd-sourced, Best-worst Scaling Study.

OBJECTIVE: To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation. METHODS: Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes. RESULTS: We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time. CONCLUSION: High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux.

Spiral nesbit plication: A simple method for simultaneous correction of penile torsion and chordee ("spiral chordee").

Penile torsion and chordee may be corrected by a variety of techniques; however, when corporal body disproportion is involved plication may be necessary. Herein we describe a technique of placing oblique plication sutures to simultaneously correct both conditions, which we term "spiral chordee". The spiral Nesbit plication (SNP) has been performed on 21 boys at our institution. Median preoperative penile torsion and chordee were 49° (range 30-90°) and 35° (range 15-60°) respectively. Surgical success was 84.6% with two patients exhibiting mild residual chordee (15°) requiring no further treatment. This technique provides a simple and effective surgical option for correction of spiral chordee.

A Rare Case of Pediatric Vaginal Yolk Sac Tumor.

A 14-month-old girl was evaluated for intermittent vaginal bleeding. Vaginoscopy revealed a friable tumor, and biopsy results confirmed a yolk sac tumor. Alpha-fetoprotein was elevated (1386 ng/mL) at diagnosis but quickly normalized with chemotherapy. The patient remained tumor-free 12 months after diagnosis without the need for radical surgery. Although rare, malignant tumors of the vagina must be included in the differential diagnosis of prepubertal girls who present with vaginal bleeding. Primary yolk sac tumor of the vagina is seen in girls less than 3 years of age and is treated with chemotherapy with or without surgical excision. Prognosis is good with appropriate treatment.

National Trends in the Management of Primary Vesicoureteral Reflux in Children.

PURPOSE: In September 2011 the AAP (American Academy of Pediatrics) released updated guidelines for the evaluation of children 2 to 24 months old with a febrile urinary tract infection. We documented the impact of the guideline on diagnosis and surgical management of vesicoureteral reflux at U.S. children's hospitals. We hypothesized that voiding cystourethrogram studies and the vesicoureteral reflux treatment rate decreased concurrent with the national guideline release. MATERIALS AND METHODS: The Pediatric Health Information System was queried for children (younger than 18 years) with primary vesicoureteral reflux and their antireflux surgical history from January 2004 to June 2015. Voiding cystourethrogram orders were recorded. Interrupted time series analysis quantified trends surrounding several seminal vesicoureteral reflux publications (2007) and guideline publication (2011). RESULTS: A total of 43,341 voiding cystourethrogram encounters (male 23,946 [55.3%]) were identified for patients at a median age of 3 months (IQR 1-20). For all children monthly voiding cystourethrogram orders increased (+1.0 to +1.6 encounters per month, p <0.034) to September 2011, then sharply declined by 106 encounters per month from September to October 2011 (p <0.001) then did not change significantly (p=0.096, R2=0.79). For those children 2 to 24 months old with a urinary tract infection (3,379 records; male 1,384 [41.0%], median age 4 months [IQR 3-7]) voiding cystourethrograms gradually increased from January 2007 to September 2011 (+0.1 encounters per month, p=0.036), then similarly decreased by 21 encounters per month from September to October 2011 (p <0.001), then did not change significantly (p=0.064, R2=0.78). Overall 28,484 procedures for primary vesicoureteral reflux were identified (male 5,950 [20.9%], median age 4.8 years [IQR 2.5-7.2]). Total surgical procedures did not change significantly until October 2011, then declined (-1.5 procedures per month, p <0.001, R2=0.66). CONCLUSIONS: The number of voiding cystourethrograms ordered nationally in all children and those with a urinary tract infection decreased sharply with the 2011 AAP urinary tract infection guideline release and did not change thereafter. A steady decline in procedures for primary vesicoureteral reflux occurred after October 2011.

Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness.

INTRODUCTION: Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. OBJECTIVE: The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). STUDY DESIGN: Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. RESULTS: All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. CONCLUSIONS: The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.