Feasibility of Awake Intravesical Botulinum Toxin Injection in Pediatric Neurogenic Bladder.

PURPOSE: Cystoscopic injection of botulinum neurotoxin (BoNT) is typically performed under general anesthesia in pediatric patients with neurogenic bladder, accumulating anesthetic exposures and operating room costs. As most of these patients already tolerate clean intermittent catheterization (CIC), it has become our practice to offer a trial of awake injection. We report our initial experience here. We hypothesized that higher sensory level, female sex and absence of mental health issues or cognitive delay might predict successful first awake injection and decreased operative times. MATERIALS AND METHODS: Surgical records from 2 academic hospitals from 2018-2020 were reviewed. Generalized linear models were fit to determine predictors of success and procedural length. RESULTS: Trial of awake injection was offered to 22 patients. Eighteen patients (8 female, 10 male, 4-20 years old) elected to proceed. All 18 patients were managed with CIC at baseline, 14 had anxiety or behavioral issues, 10 had cognitive delay and 7 had sensory level below S2. Two patients (11%) required conversion to general anesthesia and one of these subsequently opted for a repeat awake injection trial. Fifteen of the 18 patients (83%) had or planned subsequent injections awake. Of the remaining, 1 proceeded to bladder augment, 1 is considering ileovesicostomy and 1 requested subsequent injections under anesthesia. No intraoperative complications occurred. CONCLUSIONS: Awake BoNT injection is feasible in pediatric patients with neurogenic bladder managed with CIC, even in the setting of intact sensation, well-managed mental health issues or cognitive delay, thereby increasing the viability of BoNT as an early tool in the management of neurogenic bladder.

Demographics and baseline care among newly transitioning adult congenital urology patients.

INTRODUCTION: In 2017, UCSF established a formal Transitional Urology (TU) clinic co-run by pediatric and adult urology aimed at providing comprehensive urologic care for people progressing into adulthood with complex urologic histories. OBJECTIVE: We aim to describe baseline demographic and disease characteristics of this population, understand gaps in care, and gauge follow-through. STUDY DESIGN: We performed a retrospective chart review of all new patients in the TU clinic at UCSF from February 2017 through January 2019. After approval from an institutional review board, demographic and clinical data were collected from medical records. RESULTS: 39 new patients were seen in UCSF's TU clinic during a 23-month period. Our cohort included 20 patients with spina bifida and neurogenic bladder, 5 with bladder exstrophy, 3 with disorders of sexual development (DSD), 5 with obstructive uropathy, 2 with cloacal anomalies, and 1 patient each with calcinuria, reflux nephropathy, prune belly syndrome, and urachal cyst. Mean age of patients was 26 years, 63% were male, 88% spoke English, and 70% had public insurance. Patients lived an average of 94 miles from the clinic and had a mean zipcode-based household income of $70,110. There was an average of 19 months between the initial TU visit and the most recent prior urology visit. The median time since last creatinine as well as last renal ultrasound was 9 months. 19 (54%) patients warranted a total of 28 referrals to other providers at their initial visit, and 42% of these were obtained within 6 months. DISCUSSION: According to our demographic data, TU patients are likely to have public insurance, live far from the TU clinic, and come from low SES backgrounds. At initial presentation over half of patients warranted updated tests like creatinine and renal ultrasound. Furthermore, nearly two-thirds of patients required at least one referral to a different provider, suggesting a majority of these patients had unmet medical needs at the time of presentation to the TU clinic. CONCLUSION: Our data indicate that new patients to the TU clinic often warrant additional workup, updated testing, and referrals to sub-specialty care as these needs are often unmet at the time of presentation. The etiology of this is unclear and it may be due to insurance difficulties, inability to identify an appropriate adult subspecialty provider or access to care issues. Further investigation into barriers to implementation of transitional care is needed to provide comprehensive management to this challenging patient population.

Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma.

PURPOSE: Efforts have been made to reduce use of computerized tomography in children with blunt abdominal injury. Computerized tomography may be overused in pediatric patients with renal trauma. MATERIALS AND METHODS: We performed a retrospective chart review of all renal trauma patients younger than 18 years old treated at 2 urban trauma centers from 2002 to 2016. We collected demographic and clinical characteristics, renal trauma grades, urological interventions, and timing and use of computerized tomography and renal ultrasound. RESULTS: During the study period 145 patients presented with blunt renal trauma. During hospitalization 46 patients (32%) underwent repeat computerized tomography. About 20% of repeat computerized tomograms were performed less than 48 hours after the first scan. After controlling for center, isolated injury (yes/no), stent placement, age and surgical interventions (yes/no) patients who underwent delayed imaging on their first scan had decreased odds of undergoing a second computerized tomogram (adjusted OR 0.2, 95% CI 0.05-0.9, p = 0.04). Number needed to treat to prevent 1 repeat scan in high grade renal trauma patients was 3 (95% CI 2-4). Estimated sensitivity and specificity for ultrasound monitoring to detect an abnormality requiring urological intervention are 50% and 94%, respectively. CONCLUSIONS: Repeat computerized tomography in pediatric patients with renal trauma is common. Obtaining delayed imaging on the initial scan in patients with high grade renal trauma may prevent repeat scans. Renal ultrasound provides diagnostic usefulness in monitoring kidney injuries and should be considered before repeating computerized tomography.