Shared decision-making for pediatric elective penile surgery.

INTRODUCTION: In pediatric surgery, proxy decision-makers are frequently involved in treatment planning and may experience decisional conflict (DC). Shared decision-making (SDM) approaches may be effective to remedy DC. This study investigates DC and SDM involvement in elective pediatric penile surgery. METHODS: Forty-four parents of children aged <8 years undergoing elective penile surgery consultations at a tertiary pediatric hospital were prospectively enrolled. Patient and physician questionnaires were used to assess the SDM process and the SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) screening test was used to assess DC. RESULTS: Thirty-seven (84.1%) mothers and seven (15.9%) fathers were enrolled for circumcision (n=33, 75.0%) and distal hypospadias repair (n=11, 25.0%) consultations, with 21 (47.7%) choosing to proceed with surgery. Seven (15.9%) participants experienced clinically significant DC. Participant gender was not associated with higher levels of DC (p=0.318). The average patient and physician SDM scores were 88.2±10.0 and 85.3±7.4, respectively, with no correlation found between participant and physician perception of SDM involvement (p=0.168, p=0.276). DC was significantly associated with lower participant and physician ratings of SDM. CONCLUSIONS: There was a high perception of SDM involvement by both parents and pediatric urologists regarding elective penile surgery. Of the 15% of parents experiencing DC, there was an association with lower participant and physician levels of SDM involvement. Despite high SDM scores overall, discrepancies exist between the perceived physician and participant SDM involvement.

Concurrent Multicystic Dysplastic Kidney, Posterior Urethral Valves, and Obstructive Ureterocele in a Male Pediatric Patient: A Case Report.

Congenital anomalies of the kidney and urinary tract (CAKUT) are diagnosed in approximately 3-6 per 1000 live births and represent a spectrum of urologic conditions impacting the kidneys, ureter, bladder, and urethra.1 Although both are considered under the classification of CAKUT, there is no known unifying pathophysiologic mechanism for ureteroceles and posterior urethral valves with only 1 case report noted in the literature. Herein we report the only documented case of a patient with CAKUT related to posterior urethral valves, ureterocele, and multicystic dysplastic kidney.

A survey of management preferences for bladder exstrophy and cloacal anomalies among Canadian pediatric surgeons and urologists.

PURPOSE: This study examined the current referral patterns and preferences of Canadian Association of Paediatric Surgeons (CAPS) and Pediatric Urologists of Canada (PUC) members for management of bladder exstrophy and cloacal anomalies (BECA). METHODS: We invited CAPS and PUC members to participate in an online survey using RedCap. Demographic variables, years in practice, current referral patterns and local expertise at the participants' institution were collected. Participants' preferences towards three distinct referral models were assessed using Likert scales: no centralization of care, centralization in one or two national centres of excellence, or a consortium-based approach. RESULTS: There were 82 survey respondents (2/3 were CAPS members, 35.4% female, 72% in practice for >10 years). Although >90% of participants agreed/somewhat agreed that surgical volumes impact outcomes, 58% reported not referring out BECA patients for treatment; about 50% recognized the existence of a local dedicated expert. In terms of referral preferences, 84% of participants favoured identification of a few centres with expertise based on geographic location (a consortium-based approach), while only 7% chose a one or two national centres of excellence model. Over half of participants agreed/somewhat agreed with participating in trials of a consortium-based approach in Canada. CONCLUSION: Most CAPS and PUC members do not refer BECA patients elsewhere for treatment. Nonetheless, most surgeons recognize the importance of volume to improve outcomes and show willingness to participate in trials to concentrate experience; most participants favour a consortium-based approach through identification of a few centres of excellence based on geographic location.

Psychosocial Distress in Parents with Children Awaiting Surgery during the COVID-19 Pandemic.

Due to resource restrictions related to the COVID-19 pandemic, many pediatric patients are facing substantial delays for surgery, potentially resulting in additional distress for caregivers. We aimed to assess the experiences and psychosocial distress of parents during COVID-19 as they relate to the pandemic, waiting for surgery, and the combined effects of both events. The was a cross-sectional qualitative study. Parents with children who faced treatment delays during the initial wave of the COVID-19 pandemic for elective, non-emergent procedures across a variety of surgical specialties were recruited. Semi-structured telephone interviews and thematic analysis were utilized. Thematic saturation was reached with eighteen participants. Four themes were identified: coping with COVID-19, distress levels, quality and nature of communication with the surgical team, and the experience of COVID-19 related hospital restrictions. Participants reported varying levels of distress due to the delay in surgery, such as the fear of developmental delay or disease progression for their child. They also indicated their own physical and mental health had been impacted by emotional distress related to both COVID-19 and delays in treatment. Most participants experienced the COVID-19-related hospital restrictions as distressing. This related predominantly to limiting in-hospital caregivers to only one caregiver. Participants were found to have substantial levels of psychosocial distress. Targeted social and emotional support may be helpful in reducing parental distress as the pandemic timeframe continues. Within the limits of individual health systems, reducing restrictions to the number of allowed care givers may help allay distress felt by parents.

Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion.

OBJECTIVES: The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database. STUDY DESIGN: This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression. RESULTS: A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR] = 0.54, confidence interval [CI]: 0.37-0.79, p < 0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1 h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n = 278), transfer was the only factor associated with increased risk of orchiectomy (OR = 2.41 , CI: 1.09-5.33; p = 0.03). DISCUSSION: This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage). CONCLUSIONS: Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.

The role of adenotonsillectomy in the treatment of primary nocturnal enuresis in children: A systematic review.

INTRODUCTION: Primary nocturnal enuresis (PNE) is a challenging condition for physicians, patients and families. Although the etiology remains unclear, sleep-disordered breathing (SDB) and sleep apnea have been suggested to play an important role. Recent research has suggested a potential therapeutic benefit of adenotonsillectomy (T&A) and surgical management of upper airway obstruction in the treatment of PNE. OBJECTIVE: The aim was to conduct a systematic review of relevant literature to determine the effectiveness of T&A in treating children aged 2-19 years with PNE. STUDY DESIGN: This was a systematic review using a comprehensive electronic search strategy that included PubMed, Embase, CINAHL, Cochrane Library, conference proceedings, and the gray literature up to July 2015. We included all studies of children aged 2-19 years with PNE and SDB who underwent T&A. The primary outcome was resolution of PNE following surgery. Observational studies and randomized trials were reviewed. Risk of bias assessment and meta-analyses of included studies were performed. RESULTS: We screened 3254 citations; following title and abstract screening, 42 studies were selected for full-text screening by two independent reviewers. We included 18 studies (890 patients) in our final analysis. All studies were observational and only one included a control group. Meta-analysis of proportions of all (18) studies revealed a pooled complete resolution rate of 51% (43-60%), with significant heterogeneity among studies (I2 = 82.2%). Partial resolution was seen in 20% (14-27%), with similar heterogeneity to the complete resolution group. Sensitivity analysis including only studies with a low risk of bias and with patients ≥5 years (n = 244 patients) yielded a complete resolution rate of 43% (36-49%) with minimal heterogeneity (I2 = 0%; figure). CONCLUSION: In our systematic review, T&A resulted in improvement of nocturnal enuresis in more than 60% of patients, with complete resolution rates in excess of 50%. Findings were persistent on meta-analysis focused only on studies including older patients (≥5 years) and those with short follow-up after surgery (≤3 months), which imply a higher cure rate than would be expected based on natural history alone. The limitations of this review include the lack of controlled trials, the overall quality of the evidence reviewed and the heterogeneity between included studies. The role for systematic investigation and treatment of sleep disorders in patients with PNE should be scrutinized further, since a near 50% complete resolution rate for PNE may be expected with T&A in some settings.

Urological Follow-up in Adult Spina Bifida Patients: Is There an Ideal Interval?

OBJECTIVE: To establish the time to development of urological issues over time in adult spina bifida (SB) patients. MATERIALS AND METHODS: This is a retrospective study of adult patients attending a multidisciplinary adult SB clinic from 2000 to 2013. Patient age, sex, number of clinic visits, and length of follow-up were recorded. For each unique visit, presence of symptoms, type of urological issue (if any), and time lapsed since last appointment were obtained. The interval between the development of urological issues was assessed using a time-to-event analysis. RESULTS: One hundred twenty-three patients (46% male, 54% female, median age 26.8years) were followed for a median of 48 months, contributing to 586 unique clinic visits. Urological issues were identified in 109 patients (88.5%) during 267 visits (46%), and of those 21% were asymptomatic. In symptomatic patients, the median time to present with a urological issue was 12 months. Among the asymptomatic cases, 12%, 23%, and 34% had developed a urological issue at 12, 24, and 36 months of follow-up, respectively. Eighty-one percent of the urological issues seen in the clinic required some form of treatment or intervention. The treatment or intervention in 56% of asymptomatic urological issues was surgery. CONCLUSION: Most adult SB patients with urological issues are symptomatic by 2 years of follow-up; however, over time the proportion of asymptomatic patients with urological issues rises steadily, reaching a worrisome 34% at 3 years. Closer follow-up seems warranted.

A two-stage spin cartridge for integrated protein precipitation, digestion and SDS removal in a comparative bottom-up proteomics workflow.

Protein precipitation with organic solvent is an effective means of depleting contaminants such as sodium dodecyl sulfate (SDS), while maintaining high analyte recovery. Here, we report the use of a disposable two-stage spin cartridge to facilitate isolation of the precipitated protein, with subsequent enzyme digestion and peptide cleanup in the cartridge. An upper filtration cartridge retains over 95% of the protein (10 µg BSA), with 99.75% detergent depleted from a sample initially containing 2% SDS. Following precipitation, a plug attached to the base of the filtration cartridge retains the solution to enable tryptic digestion in the vial, while a solid phase extraction cartridge attached to the base of the filter facilitates peptide cleanup post-digestion. A GELFrEE fractionated Escherichia coli proteome extract processed with the spin cartridge yields similar protein identifications compared to controls (226 vs 216 for control), and with an increased number of unique peptides (1753 vs 1554 for control). The device is applied to proteome characterization of rat kidneys experiencing a surgically induced ureteral tract obstruction, revealing several statistically altered proteins, consistent with the morphology and expected pathophysiology of the disease. BIOLOGICAL SIGNIFICANCE: Conventionally, protein precipitation involves extended centrifugation to pellet the sample, with careful pipetting to remove the supernatant without disturbing the pellet. The method is not only time consuming but is highly subject to the skill of the individual, particularly at lower protein concentrations where the pellet may not be visible. As such, protein precipitation is often overlooked in proteomics, favoring column-based approaches to concentrate or purify samples. Here, all aspects of sample manipulation are integrated into a simple disposable cartridge. The device enables SDS depletion, sample preconcentration, resolubilization, derivatization, digestion, and peptide cleanup in a highly repeatable and easily multiplexed format. The device is ideally suited for comparative proteome studies. Antenatal hydronephrosis is a congenital disorder affecting 1-5% of all pregnancies, and can require surgical intervention to avoid loss of renal function. Using our device, we investigated the impact of hydronephrosis on the kidneys in a surgically induced animal model of the disease. Proteome analysis points to decreased metabolic activity in the obstructed kidney, with upregulation of proteins involved in cytoskeletal organization. This article is part of a Special Issue entitled: Protein dynamics in health and disease. Guest Editors: Pierre Thibault and Anne-Claude Gingras.

Management of pediatric neurogenic bladder.

PURPOSE OF REVIEW: To review the most current literature regarding the management of neurogenic bladder in children. RECENT FINDINGS: Several recent papers have addressed the investigation and management of children with neurogenic bladder. Bladder wall thickness as measured by ultrasound may identify the children with urodynamic risk factors for upper urinary tract deterioration. Strategies such as maximal anticholinergic therapy, total endoscopic management, conservative management throughout puberty, and isolated bladder neck procedures to avoid bladder augmentation show promise. However, at present, there is inadequate long-term follow-up to recommend widespread application of all of these approaches. As children with neurogenic bladder enjoy longer life spans, issues including risks of malignancy related to augmentation and transition to adult-centered care will continue to gain significance. SUMMARY: Pediatric urologists continue to face many challenges in the management of children with neurogenic bladder. This includes identifying predictors of upper urinary tract deterioration, finding efficacious strategies to avoid bladder augmentation, and long-term care. The most recent literature attempts to address these issues. Further prospective studies with adequate follow-up will benefit our understanding of this disease process and help to choose the best strategies to achieve continence and preserve renal function in this population.

Maternal and fetal risk factors associated with severity of hypospadias: a comparison of mild and severe cases.

OBJECTIVE: To determine maternal and fetal demographic factors which predict the risk of increasing severity of hypospadias. PATIENTS AND METHODS: A population-based study using the Nova Scotia Atlee Perinatal Database was performed. Demographic variables of mothers and boys with hypospadias were obtained from 1980 to 2007 inclusive. Hypospadias was graded by the position of the urinary meatus as glanular, coronal, shaft, or proximal to shaft. Maternal and fetal risk factors for hypospadias severity were compared using logistic regression. RESULTS: The total number of male pregnancy and birth records during the study period was 130,796. The total number of cases of hypospadias was 995, yielding an incidence of 0.76%. The severity of hypospadias was graded as glanular in 428 (77.8%); coronal in 77 (14%); penile shaft in 34 (6.2%); and proximal to the penile shaft in 12 (2.2%). The severity of hypospadias was not graded in 445 cases. Low birth weight, low gestational age and maternal age were associated with increased severity of hypospadias, but only maternal age (P<0.03) when logistic regression was performed. Limitations included self-reporting for some parameters, such as smoking, and lack of data, such as for the use of assisted reproductive technologies. CONCLUSIONS: Advanced maternal age was associated with increased severity of hypospadias in our population.