Patient and Parent Perspectives on Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia.

BACKGROUND: Testicular adrenal rest tumors (TARTs) increase the risk of infertility in males with classic congenital adrenal hyperplasia (CAH). There is no consensus regarding at what age screening testicular ultrasounds should begin and how often they should be repeated. Furthermore, it is unknown whether patients and parents are aware of the significance of TARTs. OBJECTIVE: The objective of the study was to investigate awareness, concern, and screening rates for TARTs in males with classic CAH. METHODS: Males with CAH and parents completed an online questionnaire from 2019 to 2020. Responses to questions about TARTs were analyzed. Fisher's exact test was used to determine statistical significance. RESULTS: Of 123 responders, 14 were males with CAH (range 16-54 years) and 109 were parents of males with CAH (son's age range infancy to 37 years). Of all responders, 74% were concerned about the possibility of TARTs, 48% had discussions about TARTs with their endocrinologist, and 42% were aware of possible infertility in males with CAH. There was no difference between responses provided by affected males and parents for these topics (p ≥ 0.08). Among male responders with CAH, 93% had at least one testicular ultrasound, and 77% had undergone more than one. Among parent responders, 30% of their sons had at least one testicular ultrasound, and 61% had more than one. The frequency, total number, and age when the first testicular ultrasound was obtained were inconsistent in both groups. Fifty percent of male responders with CAH and 11% of sons were referred to a urologist for evaluation. CONCLUSIONS: Although most responders were concerned about TARTs, less than half recalled discussing this issue with their endocrinologist, and less than half were aware of the possibility of infertility. Although TARTs are most often treated medically, several responders were referred to a urologist. Standardized patient education and consensus guidelines are needed for the surveillance and management of TARTs in males with classic CAH.

The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures.

PURPOSE: The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures. METHODS: We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models. RESULTS: 805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures. CONCLUSIONS: Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.

The effect of surgeon versus technologist control of fluoroscopy on radiation exposure during pediatric ureteroscopy: A randomized trial.

BACKGROUND: Fluoroscopy is commonly used during pediatric ureteroscopy (PURS) for urolithiasis, and the most important contributor to overall radiation exposure is fluoroscopy time (FT). One factor that may impact FT is who controls activation of the fluoroscope: the urologist (with a foot pedal) or the radiation technologist (as directed by the urologist). While there are plausible reasons to believe that either approach may lead to reduced FT, there are no systematic investigations of this question. We sought to compare FT with surgeon-control versus technologist control during PURS for urolithiasis. METHODS: We conducted a randomized controlled trial (Clinicaltrials.gov ID number: NCT02224287). Institutional Review Board approval was sought and obtained for this study. All subjects (or their legal guardians) provided informed consent. Each patient (age 5-26 years) was randomized to surgeon- or technologist-controlled fluoroscope activation. Block randomization was stratified by the surgeon. For technologist control, the surgeon verbally directed the technologist to activate the fluoroscope. For surgeon control, a foot pedal was used by the surgeon. The technologist controlled c-arm positioning, settings, and movement. The primary outcome was total FT for the procedure. Secondary outcomes included radiation exposure (entrance surface air kerma [ESAK] mGy). We also analyzed clinical and procedural predictors of FT and exposure. Mixed linear models accounting for clustering by surgeon were developed. RESULTS: Seventy-three procedures (5 surgeons) were included. The number of procedures per surgeon ranged from seven to 36. Forty-three percent were pre-stented. Thirty-one procedures were left side, 35 were right side, and seven were bilateral. Stones were treated in 71% of procedures (21% laser, 14% basket, and 65% laser/basket). Stone locations were distal ureter (11.5%), proximal/mid-ureter (8%), renal (69%), and ureteral/renal (11.5%). An access sheath was used in 77%. Median stone size was 8.0 mm (range 2.0-20.0). Median FT in the surgeon control group was 0.5 min (range 0.01-6.10) versus 0.55 min (range 0.10-5.50) in the technologist-control group (p = 0.284). Median ESAK in the surgeon control group was 46.02 mGy (range 5.44-3236.80) versus 46.99 mGy (range: 0.17-1039.31) in the technologist-control group (p = 0.362). Other factors associated with lower FT on univariate analysis included female sex (p = 0.015), no prior urologic surgeries (p = 0.041), shorter surgery (p = 0.011), and no access sheath (p = 0.006). On multivariable analysis only female sex (p = 0.017) and no access sheath (p = 0.049) remained significant. There was significant variation among surgeons (p < 0.0001); individual surgeon median FT ranged from 0.40 to 2.95 min. CONCLUSIONS: Fluoroscopy time and radiation exposure are similar whether the surgeon or technologist controls fluoroscope activation. Other strategies to reduce exposure might focus on surgeon-specific factors, given the significant variation between surgeons.

Melanotic Neuroectodermal Tumor of Infancy Presenting With Fast-Growing Scrotal Swelling: A Case Report and Literature Review.

Testicular melanotic neuroectodermal tumor of infancy (MNTI) is extremely rare, with 2 cases reported in the literature. Its rarity and rapid and infiltrative growth pattern pose a diagnostic challenge. A previously healthy 3-month-old male, presented with a history of worsening left hemiscrotal swelling for 1 week. An outside ultrasound was suggestive of testicular torsion. Left orchiectomy demonstrated a mass occupying almost entire testicle with a variegated cut surface, with areas of pigmentation, necrosis, and hemorrhage. Histological examination confirmed MNTI of the testis and epididymis. MNTI should be included in differential diagnosis in infants presenting with fast-growing scrotal swelling.

Testicular Adrenal Rest Tumors in Boys and Young Adults with Congenital Adrenal Hyperplasia.

PURPOSE: Testicular adrenal rest tumors are a well-known complication in males who have congenital adrenal hyperplasia with potential infertility in adulthood. We assessed the prevalence of testicular adrenal rest tumors in infants to young men presenting to a congenital adrenal hyperplasia Comprehensive Care Center. MATERIALS AND METHODS: A total of 35 males with congenital adrenal hyperplasia due to 21-hydroxylase deficiency underwent scrotal ultrasonography, including 7 younger than 5 years, 9 who were 5 to 12 years old and 19 who were older than 12 years. Three and 35 patients had classic and nonclassic congenital adrenal hyperplasia, respectively. Bone age x-ray or advanced bone age x-ray history, glucocorticoid dose, fludrocortisone dose, and serum 17-hydroxyprogesterone, testosterone and androstenedione levels within 3 months of ultrasound were also recorded. RESULTS: Testicular adrenal rest tumors were detected in 5 of 35 patients (14%), including 1 of 9 (11%) who were 5 to 12 years old and 4 of 19 (21%) who were older than 12 years. The tumors were not detected in any patients younger than 5 years, including 1 infant with poor hormonal control. The youngest patient with positive findings was 6.6 years old. All patients with positive findings had bilateral disease and only 1 had suspicious physical findings. The glucocorticoid dose and 17-hydroxyprogesterone did not differ between patients with vs without a testicular adrenal rest tumor. Those with a tumor were more likely to have advanced bone age x-ray results (100% vs 42%, p = 0.04) and higher fludrocortisone dose (p <0.01). All males with nonclassic congenital adrenal hyperplasia had negative tumor findings. CONCLUSIONS: Testicular adrenal rest tumors were present in young males with classic congenital adrenal hyperplasia but not in infants or toddlers. These tumors were associated with higher fludrocortisone requirements and a history of advanced bone age x-ray results. However, the tumors did not develop in all poorly controlled males. Longitudinal studies are needed to understand the individual predisposition to testicular adrenal rest tumors and the age at which to begin screening patients with congenital adrenal hyperplasia.

Utility scores for vesicoureteral reflux and anti-reflux surgery.

BACKGROUND: Management of vesicoureteral reflux (VUR) continues to be controversial. In conditions of uncertainty, decision analytic techniques such as cost-utility analysis (CUA) can help to structure the decision-making process. However, CUA analyses require a "utility," a value between 0 (death) and 1 (perfect health) corresponding to the quality of life associated with a health state. Ideally, utility values are elicited directly from representative community samples, but utilities have not been rigorously measured for pediatric urology conditions. OBJECTIVES: To elicit utility scores for VUR and open anti-reflux surgery (ARS) from a representative, well-characterized community sample of adults who have been parents. METHODS: Cross-sectional survey of nationally representative adults who had ever been parents. Each respondent saw one of four descriptions of VUR, with or without continuous antibiotic prophylaxis (CAP) and occurrence of febrile urinary tract infection (UTI). A 6-week postoperative health state following ARS was also assessed. We used the time trade-off (TTO) method to elicit utility scores. Factors associated with utility score were assessed with a multivariate linear regression model. RESULTS: The survey was completed by 1200 individuals. Data were weighted to adjust for demographic differences between responders and non-responders. Mean age was 52 ± 15 years, 44% were male, and 68% were White. In terms of education, 29% had a college degree or higher. The mean utility score for VUR overall was 0.82 ± 0.28. VUR utility scores did not differ significantly based on inclusion of CAP or UTI in the health state description (p = 0.21). The 6-week postoperative period garnered a utility of 0.71 ± 0.43. DISCUSSION: Our results showed that VUR has a mean utility score of 0.82, which indicates that the community perceives this condition to be a substantial burden. For comparison, conditions with similar utility scores include compensated hepatitis B-related cirrhosis (0.80) and glaucoma (0.82); conditions with higher utilities include neonatal jaundice (0.99) and transient neonatal neurological symptoms (0.95); and conditions with lower utility scores include severe depression (0.43) and major stroke (0.30). Our results suggest that parents consider the burden associated with VUR to be significant, and that the impact of the condition on families and children is substantial. CONCLUSIONS: VUR is perceived as having a substantial impact on health-related quality of life, with a utility value of 0.82. However, use of CAP and occurrence of UTI do not seem to affect significantly the community perspective on HRQOL associated with living with VUR.

New contralateral vesicoureteral reflux after unilateral ureteral reimplantation: predictive factors and clinical outcomes.

PURPOSE: Although unilateral ureteral reimplantation for vesicoureteral reflux is highly successful, new contralateral reflux will develop postoperatively in some patients. We examined predictors and clinical outcomes of postoperative contralateral vesicoureteral reflux. MATERIALS AND METHODS: We reviewed patients who underwent nontapered unilateral reimplantation for primary vesicoureteral reflux graded on a 3-point scale at our institution from January 1990 to December 2002, and identified those with subsequent contralateral vesicoureteral reflux. We analyzed the association of patient/procedure characteristics with incidence, and time to resolution of contralateral reflux and postoperative urinary tract infection. Multivariable models controlled for variables associated with incidence and time to resolution of contralateral reflux. RESULTS: A total of 395 patients (77.2% female, median age 5.3 years) underwent ureteral reimplantation for vesicoureteral reflux. Preoperative reflux was grade 1 in 2.8% of patients, grade 2 in 56.6% and grade 3 in 40.6%. Technical success was 95.4%. After reimplantation 39 patients (9.9%) had new contralateral reflux (grade 1 in 7, grade 2 in 27 and grade 3 in 5). Median followup was 51.8 months. On multivariate analysis younger age (less than 6 years, OR 3.7, p = 0.006) and low observed bladder capacity as percent of predicted bladder capacity (less than 50% of predicted capacity, OR 6.3, p = 0.02) were significant predictors of contralateral reflux. Contralateral reflux resolved in 21 of 27 patients (77.8%) on subsequent cystography at a median of 21.5 months. Two patients underwent reimplantation for persistent contralateral reflux. Four of 39 patients (10.3%) with contralateral reflux had postoperative febrile urinary tract infections at a median of 26 months, with spontaneous resolution of contralateral reflux in all. CONCLUSIONS: Younger patients and those with low observed vs predicted bladder capacity may be at increased risk for postoperative contralateral vesicoureteral reflux. A majority of contralateral reflux will resolve spontaneously, and the clinical course is typically benign.

Trends in revision circumcision at pediatric hospitals.

BACKGROUND: We sought to determine the incidence of revision circumcision at freestanding children's hospitals, and examine trends over time. METHODS: We searched the Pediatric Health Information Systems database to identify boys undergoing revision circumcision (RC), primary non-newborn circumcision (PC), or lysis of penile adhesions (LPA) from 2004 to 2009. Rates of RC procedures were calculated by dividing the incidence of procedures by the total male ambulatory surgical volume. RESULTS: We identified 34,568 patients of whom 5632 underwent RC, 25,768 PC, and 3168 LPA. The rate of RC increased 119%, which was significantly more than PC (19%; P<.001) or LPA (37%; P<.001). Urologists performed 76% of RC and 12% were performed with other genitourinary procedures. Boys undergoing RC were predominately white (60%) and publicly insured (61%). CONCLUSIONS: There was a disproportionate increased rate of RC performed at Pediatric Health Information Systems hospitals compared with PC or LPA. Wide variation exists in rate increases among hospitals.

Prospective systematic intervention to reduce patient exposure to radiation during pediatric ureteroscopy.

PURPOSE: After prospective measurement of radiation exposure during pediatric ureteroscopy for urolithiasis, we identified targets for intervention. We sought to systematically reduce radiation exposure during pediatric ureteroscopy. MATERIALS AND METHODS: We designed and implemented a pre-fluoroscopy quality checklist for patients undergoing ureteroscopy at our institution as part of a quality improvement initiative. Preoperative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Primary outcomes were the entrance skin dose in mGy and midline dose in mGy before and after checklist implementation. RESULTS: We directly observed 32 consecutive ureteroscopy procedures using the safety checklist, of which 27 were done in pediatric patients who met study inclusion criteria. Outcomes were compared to those in 37 patients from the pre-checklist phase. Pre-checklist and postchecklist groups were similar in patient age, total operative time or patient thickness. The mean entrance skin dose and midline dose were decreased by 88% and 87%, respectively (p <0.01). Significant improvements were noted among the major radiation dose determinants, total fluoroscopy time (reduced by 67%), dose rate setting (appropriately reduced dose setting in 93% vs 51%) and excess skin-to-intensifier distance (reduced by 78%, each p <0.01). CONCLUSIONS: After systematic evaluation of our practices and implementation of a fluoroscopy quality checklist, there were dramatic decreases in radiation doses to children during ureteroscopy.

In utero closure of myelomeningocele does not improve lower urinary tract function.

PURPOSE: Recent data comparing prenatal to postnatal closure of myelomeningocele showed a decreased need for ventriculoperitoneal shunting and improved lower extremity motor outcomes in patients who underwent closure prenatally. A total of 11 children whose spinal defect was closed in utero were followed at our spina bifida center. We hypothesized that in utero repair of myelomeningocele improves lower urinary tract function compared to postnatal repair. MATERIALS AND METHODS: Eleven patients who underwent in utero repair were matched to 22 control patients who underwent postnatal repair according to age, gender and level of spinal defect. Urological outcomes were retrospectively reviewed including urodynamic study data, need for clean intermittent catheterization, use of anticholinergic agents and prophylactic antibiotics, and surgical history. The need for ventriculoperitoneal shunting or spinal cord untethering surgery was also reviewed. RESULTS: Mean followup was 7.2 years for patients who underwent in utero repair and 7.3 years for those who underwent postnatal repair. Mean patient age at compared urodynamic studies was 5.9 years for in utero repair and 6.0 years for postnatal repair. The in utero repair group was comprised of 5 lumbar and 6 sacral level defects with equal matching (1:2) in the postnatal repair cohort. There were no differences between the groups in terms of need for clean intermittent catheterization, incontinence between catheterizations or anticholinergic/antibiotic use. Urodynamic parameters including bladder capacity, detrusor pressure at capacity, detrusor overactivity and the presence of detrusor sphincter dyssynergia were not significantly different between the groups. There was no difference in the rate of ventriculoperitoneal shunting (p = 0.14) or untethering surgery (p = 0.99). CONCLUSIONS: While in utero closure of myelomeningocele has been shown to decrease rates of ventriculoperitoneal shunting and improve motor function, it is not associated with any significant improvement in lower urinary tract function compared to repair after birth.

Clinical outcomes and long-term resolution in patients with persistent vesicoureteral reflux after open ureteral reimplantation.

PURPOSE: Success rates of ureteral reimplantation for primary vesicoureteral reflux are high. Few studies document the natural history of children with persistent vesicoureteral reflux. We reviewed their clinical outcomes and long-term resolution. MATERIALS AND METHODS: We performed a retrospective review of all children with persistent vesicoureteral reflux (grade 1 or greater) into the reimplanted ureter(s) on initial cystogram after reimplantation for primary vesicoureteral reflux at our institution from January 1990 to December 2002. We evaluated subsequent cystograms (graded on the 3-point radionuclide cystogram scale), surgery and urinary tract infection. We performed survival analyses of time to resolution of persistent (grade 1 or greater) and clinically significant (grade 2 or greater) vesicoureteral reflux in patients with more than 1 postoperative cystogram. RESULTS: Of 965 patients 59 (94 ureters) had persistent vesicoureteral reflux (6.1%), including 19 grade 1/3, 29 grade 2/3 and 11 grade 3/3. Median patient age at reimplantation was 1.9 years (range 0.8 to 5.1) and 62.7% were female. Preoperative vesicoureteral reflux grade was 2/3 in 42.4% and 3/3 in 57.6%, and 30.5% of patients had ureteral tapering. Median followup was 47.1 months (IQR 19.3-650.3). Reflux was resolved in 26 of 36 (72.2%) patients and median time to resolution was 20.4 months. Grade 2 or greater reflux on postoperative cystogram resolved in 21 of 32 (65.6%) patients and median time to resolution was 20.4 months. There were 10 patients with persistent vesicoureteral reflux at last cystogram, grade 1 or 2 in 9 and 3/3 in 1 patient. One patient underwent repeat reimplantation for persistent vesicoureteral reflux and 7 (13%) had postoperative febrile urinary tract infection at a median of 37 months postoperatively (IQR 1.7-64.4). CONCLUSIONS: Persistent vesicoureteral reflux after reimplantation resolves spontaneously in most children and can be managed nonoperatively with good long-term outcomes.

Prospective measurement of patient exposure to radiation during pediatric ureteroscopy.

PURPOSE: Few data have been reported regarding radiation exposure during pediatric endourological procedures, including ureteroscopy. We measured radiation exposure during pediatric ureteroscopy and identify opportunities for exposure reduction. MATERIALS AND METHODS: We prospectively observed ureteroscopy procedures as part of a quality improvement initiative. Preoperative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Our outcomes were entrance skin dose and midline dose (both mGy). Specific modifiable factors were identified as targets for potential quality improvement. RESULTS: Direct observation was performed in 54 consecutive ureteroscopy procedures. Mean±SD patient age was 14.8±3.8 years (range 7.4 to 19.2), with 9 children being younger than 12 years. Mean±SD entrance skin dose was 46.4±48 mGy. Mean±SD midline dose was 6.2±5.0 mGy. The most important major determinant of radiation dose was total fluoroscopy time (mean±SD 2.68±1.8 minutes) followed by dose rate setting, child anteroposterior diameter and source to skin distance (all p<0.01). Analysis of factors affecting exposure levels revealed that use of ureteral access sheaths (p=0.01) and retrograde pyelography (p=0.04) were significantly associated with fluoroscopy time. We also found that dose rate settings were higher than recommended in up to 43% of cases and ideal C-arm positioning could have reduced exposure by 14% (up to 49% in some cases). CONCLUSIONS: Children receive biologically significant radiation doses during ureteroscopy procedures. Several modifiable factors contribute to dose and could be targeted in efforts to implement dose reduction strategies.

Durability of antireflux effect of ureteral reimplantation for primary vesicoureteral reflux: findings on long-term cystography.

OBJECTIVE: To evaluate the long-term durability of successful ureteral reimplantation (UR) for vesicoureteral reflux (VUR) through a review of late cystography (LC) findings. MATERIALS AND METHODS: We performed a retrospective chart review of all children with primary VUR who underwent successful open UR (grade 0 VUR into the reimplanted ureter[s] on initial cystogram) at our institution from January 1990 to December 2002. We identified successful UR patients who underwent LC ≥ 1 year after UR and reviewed the results for the presence of recurrent VUR into the reimplanted ureter(s). RESULTS: Seven-hundred ninety-four patients underwent successful open UR for primary VUR, of whom 60 (7.6%) had a subsequent LC. Preoperative VUR grade was ≤ II in 20 (34.5%) and ≥ III in 38 (65.5%). Median age at UR was 3.5 years (IQR 1.3-6.2 years); 51 (85%) were female. UR was intravesical in 45 (75%) and bilateral in 19 (32%). LC was performed at a median of 38.7 months after UR (IQR 19.6-66.1 months). Indication for LC was febrile urinary tract infection (UTI) in 16 (27%), nonfebrile UTIs in 15 (25%), follow-up of contralateral VUR in 16 (27%), and other clinical indications in 13 (21%). The recurrence rate was 0%; of the 79 reimplanted ureters, 100% (95% CI 95.4-100) had no VUR (grade 0). CONCLUSION: Among children who underwent successful open UR for primary VUR, there was no VUR recurrence on extended follow-up. This suggests that the late durability of open antireflux surgery is excellent.

Economic and radiation costs of initial imaging approaches after a child's first febrile urinary tract infection.

BACKGROUND. The traditional initial imaging approach following pediatric urinary tract infection is the "bottom-up" approach (cystogram and renal ultrasound). Recently, the "top-down" approach (nuclear renal scan followed by cystogram for abnormal scans only) has gained increasing attention. The relative cost and radiation doses of these are unknown METHODS. The authors used a decision model to evaluate these imaging approaches. Cost and effective radiation dose estimates, including sensitivity analyses, were based on one-time imaging only. RESULTS. Comparing hypothetical cohorts of 100 000 children, the top-down imaging approach cost $82.9 million versus $59.2 million for the bottom-up approach. Per-capita effective radiation dose was 0.72 mSv for top-down compared with 0.06 mSv for bottom-up. CONCLUSIONS. Routine use of nuclear renal scans in children following initial urinary tract infection diagnosis would result in increased imaging costs and radiation doses as compared to initial cystogram and ultrasound. Further data are required to clarify the long-term clinical implications of this increase.

Racial variation in timing of pyeloplasty: prenatal versus postnatal diagnosis.

PURPOSE: We have previously shown that nonwhite patients with ureteropelvic junction obstruction undergo pyeloplasty at a younger age than white patients. The mechanisms behind this finding are unclear, since there is no known racial variation in the natural history of ureteropelvic junction obstruction. We used a detailed clinical database to explain this phenomenon. MATERIALS AND METHODS: We retrospectively reviewed all patients undergoing primary pyeloplasty at our institution between 1992 and 2008. More than 360 data points were abstracted for each patient, including self-reported race, socioeconomic status, symptom duration and presentation. RESULTS: Of 847 patients undergoing pyeloplasty during the study period 741 met inclusion criteria. Nonwhite patients underwent surgery at a younger age (0.6 years) than whites (2.6 years, p <0.0001). When stratified by timing of clinical presentation (prenatal vs postnatal), there was no significant difference in race among patients presenting prenatally (0.37 vs 0.36 years, p = 0.22). Nonwhite patients presenting postnatally were significantly younger than white patients (6.3 vs 8.2 years, p = 0.03). This finding appeared to be due to differences in age at initial clinical presentation (5.4 vs 7.0 years, p = 0.03) and in time from initial clinical presentation to urological evaluation (0.6 vs 3.2 months, p = 0.03). These differences persisted after correcting for other factors, including markers of socioeconomic status. CONCLUSIONS: Consistent with previous studies, we found that nonwhite patients underwent primary pyeloplasty at a younger age than whites. This difference is limited to patients presenting after birth. Prenatally diagnosed patients underwent surgery at similar ages regardless of race.

Screening for malignancy after augmentation cystoplasty in children with spina bifida: a decision analysis.

PURPOSE: Augmentation cystoplasty is the mainstay of surgical treatment for medically refractory neurogenic bladder in patients with spina bifida. Concerns regarding an increased risk of malignancy have prompted many centers to consider routine postoperative screening. We examine the potential cost-effectiveness of such screening. MATERIALS AND METHODS: A Markov model was used to compare 2 screening strategies among patients with spina bifida after cystoplasty, namely annual screening cystoscopy and cytology and usual care. Model parameters were informed via a systematic review of post-augmentation malignancy and cost estimates from published reports or government sources. RESULTS: In a hypothetical cohort the individual increase in life expectancy for the entire cohort was 2.3 months with an average lifetime cost of $55,200 per capita, for an incremental cost-effectiveness ratio of $273,718 per life-year gained. One-way and two-way sensitivity analyses suggest the screening strategy could be cost effective if the annual rate of cancer development were more than 0.26% (12.8% lifetime risk) or there were a greater than 50% increase in screening effectiveness and cancer risk after augmentation. After adjusting for multiple levels of uncertainty the screening strategy had only an 11% chance of being cost effective at a $100,000 per life-year threshold or a less than 3% chance of being cost effective at $100,000 per quality adjusted life-year. CONCLUSIONS: Annual screening for malignancy among patients with spina bifida with cystoplasty using cystoscopy and cytology is unlikely to be cost effective at commonly accepted willingness to pay thresholds. This conclusion is sensitive to a higher than expected risk of malignancy and to highly optimistic estimates of screening effectiveness.

Timeliness of surgical care in children with special health care needs: delayed palate repair for publicly insured and minority children with cleft palate.

BACKGROUND/PURPOSE: Disparities in access to health care are known to exist for the most vulnerable pediatric population, children with special health care needs. Timely access to surgical care in this population is critical, yet poorly studied. METHODS: A national database of pediatric hospitals in the United States was searched for nonsyndromic, healthy patients younger than 24 months who underwent cleft palate repair from 2003 to 2008. A multivariate, linear regression model was constructed to determine the relationship of public payer status and race with age at palatal repair. RESULTS: Age at palate repair was significantly delayed for patients who were publicly insured (1.2 weeks, P = .01), were of nonwhite race/ethnicity (1.5-3.5 weeks, P = .009), and had a diagnosis of cleft lip in addition to cleft palate (3.4 weeks, P = .006) compared to their counterparts in a sample of 2995 patients with cleft palate. CONCLUSION: There is a small but significant delay in age at repair for patients who are publicly insured or of nonwhite race/ethnicity. These results may herald broader access disparities that could adversely affect clinical outcomes and should be investigated further.

Variations in timing of surgery among boys who underwent orchidopexy for cryptorchidism.

OBJECTIVE: Current clinical guidelines recommend that orchidopexy be performed by the age of 1 in patients with congenital undescended testis. We sought to examine trends in surgical timing and to determine what factors are associated with age at surgery. METHODS: The Pediatric Health Information System (PHIS) is a national database of >40 freestanding children's hospitals. We searched the PHIS to identify boys with cryptorchidism who underwent orchidopexy between 1999 and 2008. Patient age at orchidopexy was evaluated, and we used multivariate models to determine factors associated with timing of surgery. RESULTS: We identified 28 204 children who underwent orchidopexy at PHIS hospitals. Of these, 14,916 (53%) were white, and 17,070 (61%) had public insurance. Only 5031 patients (18%) underwent orchidopexy by the age of 1 year; only 12,165 (43%) underwent orchidopexy by the age of 2 years. These figures remained stable over time (P=.32). After adjusting for patient clustering, race (P<.001) and insurance status (P<.001) remained associated with patient age at orchidopexy; however, the treating hospital (P<.001) was the most important factor in predicting the timing of the procedure. CONCLUSIONS: Only 43% had surgery by 2 years of age, which suggests that either significant numbers of boys with congenital cryptorchidism do not undergo surgery in a timely fashion or late-onset testicular ectopy is more common than generally recognized. Factors associated with the timing of orchidopexy include patient race, insurance status, and the hospital in which surgery is performed.