Clearance While Upright on Initial Diuretic Renography Predicts the Need for Surgery in Children With Congenital Hydronephrosis.

OBJECTIVE: To improve the predictive ability of diuretic renography (DR) for surgical intervention in children with congenital hydronephrosis (CH) and concern for ureteropelvic junction obstruction. METHODS: Children with CH born between 2007 and 2021 who underwent initial DR prior to 6months of life, had both clearance while upright (CUP) and T ½ reported, and did not have immediate surgical intervention after the first DR were retrospectively evaluated for surgical intervention during the period of clinical observation. Once the optimal cut-points were identified for CUP and T ½, they were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: In total 65 patients were included in the final analysis with 33 (50.8%) undergoing surgical intervention (pyeloplasty) and 32 (49.2%) still on observation at last follow-up. The optimal cut-points for predicting surgical intervention were 28.1 minutes for T ½ and 22.4% for CUP. Applying the CUP cut-point of 22.4% we achieved a sensitivity of 60.6% (95% CI: 43.9-77.3), specificity of 96.9% (95% CI: 90.1-100.0), positive predictive value of 95.2% (95% CI: 86.1-100.0), and negative predictive value of 70.5% (95% CI: 57.0-83.9). CONCLUSION: A low CUP accurately predicts surgical intervention in children with CH who are initially observed. Although there is no singular measure on DR that can with absolute certainty predict future clinical course, our data do suggest there is utility in incorporating CUP (if <22.4%) into the decision process. Further research is necessary to help guide the management of children with intermediate CUP values.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Robotic upper tract surgery in infants 6 months or less: is there enough space?

Robot-assisted laparoscopic surgery (RALS) has recently been described in children < 1 year old. However, little data exist on robotic utilization in infants ≤ 6 months old, likely due to concerns for limited intraabdominal space and decreased distance between ports in this cohort. We hypothesized that the robotic approach can be successfully used for infants ≤ 6 months old. A prospectively collected database of patients undergoing urologic robotic surgery at our institution was reviewed. Patients ≤ 6 months and ≥ 4 kg were included. Patient demographics, intraoperative details, hospital length of stay, and complications were reviewed. Descriptive statistics were performed. Twelve patients ≤ 6 months old underwent urologic robotic surgery by three surgeons at our institution (2013-2019): pyeloplasty (6), ureteroureterostomy (4), heminephrectomy (1), and nephrectomy (1). Median age at surgery was 4.75 months (IQR 4, 6). Median weight was 7.09 kg (IQR 6.33, 7.78). Median console time was 105 min (IQR 86, 123). For all procedures, 8-mm robotic arm ports were used. No procedures were converted to open. Median post-operative hospital stay was 24 h (IQR). Febrile UTI was the only complication occurring within 30 days of surgery (n = 4, 33%; 7-20 days, Clavien grade 2). For those undergoing pyeloplasty or ureteroureterostomy (n = 10), postoperative ultrasound showed improved (n = 9) or stable hydronephrosis (n = 1). At a median follow-up of 19.73 months (IQR 4.27, 38.32), no patient required an unplanned secondary intervention. Robotic upper urinary tract surgery is feasible and safe in patients ≤ 6 months of age and can be performed successfully with the same technique as for older children.

Prediction of kidney failure in children with chronic kidney disease and obstructive uropathy.

BACKGROUND: Obstructive uropathy (OU) is a leading cause of pediatric kidney injury. Accurate prediction of kidney disease progression may improve clinical outcomes. We aimed to examine discrimination and accuracy of a validated kidney failure risk equation (KFRE), previously developed in adults, in children with OU. METHODS: We identified 118 children with OU and an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 in the Chronic Kidney Disease in Children study, a national, longitudinal, observational cohort. Each patient's 5-year risk of kidney failure was estimated using baseline data and published parameters for the 4- and 8-variable KFREs. Discriminative ability of the KFRE was estimated using the C statistic for time-to-event analysis. Sensitivity and specificity were evaluated across varying risk thresholds. RESULTS: Among the 118 children, 100 (85%) were boys, with median baseline age of 10 years (interquartile range, 6-14). Median eGFR was 42 mL/min/1.73m 2 (32-53), with a median follow-up duration of 4.5 years (2.7-7.2); 23 patients (19.5%) developed kidney failure within 5 years. The 4-variable KFRE discriminated kidney failure risk with a C statistic of 0.75 (95% CI, 0.68-0.82). A 4-variable risk threshold of ≥ 30% yielded 82.6% sensitivity and 75.0% specificity. Results were similar using the 8-variable KFRE. CONCLUSIONS: In children with OU, the KFRE discriminated the 5-year risk of kidney failure at C statistic values lower than previously published in adults but comparable with suboptimal values reported in the overall CKiD population. The 8-variable equation did not improve model discrimination or accuracy, suggesting the need for continued research into additional, disease-specific markers.

Trends in robotic surgery utilization across tertiary children's hospitals in the United States.

BACKGROUND: A growing number of tertiary children's hospitals are utilizing robotic surgical technology. We sought to characterize national trends in pediatric surgical robotic case utilization and related drivers. METHODS: Pediatric urology and pediatric surgery (abdominal and thoracic) procedures, performed from January 2010 to December 2019 across 19 U.S. tertiary care children's hospitals, were identified using the Pediatric Health Information System (PHIS). Trends in robot utilization were evaluated by surgical subspecialty, procedure type, and number of individual operating surgeons. RESULTS: Increases were noted in the overall numbers of pediatric surgery (1.3% per quarter, p = 0.005) and urology robotic procedures (2.0% per quarter, p < 0.001), as well as the numbers of pediatric surgeons (7.5% per year, p < 0.001) and pediatric urologists (7.8% per year, p < 0.001) operating robotically. Biliary system and spleen surgery were the most common robotic pediatric surgery procedures (45.5%) and had stable utilization over time (- 0.8% per quarter, 95% CI - 2.3-0.8). Robotic foregut surgery showed the most rapid growth in utilization (2.1% per quarter, 95% CI 0.7-3.6, p = 0.004) in pediatric surgery, while mediastinal/thoracic surgery demonstrated a decrease in utilization (- 4.6%, 95% CI - 7.9-1.2, p = 0.008). Renal pelvis/ureter surgery was the most common robotic urologic procedure (55.8%) and also demonstrated the fastest growth utilization (2.2% per quarter, 95% CI 1.5-2.9, p < 0.001) in urology. CONCLUSIONS: Utilization of robotic-assisted surgery in pediatric surgery and pediatric urology has increased both in case volume and the number of operating surgeons, with foregut and renal pelvis/ureter surgery responsible for the areas of greatest growth.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction.

INTRODUCTION: Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly. METHODS: We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables. RESULTS: A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3 h 7 min vs. 3 h 41 min, p < 0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p = 0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction. CONCLUSION: We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

Utilization of Augmentation Cystoplasty for Myelomeningocele Patients Remained Stable Over the Past Decade.

OBJECTIVE: To understand the utilization of augmentation cystoplasty (AC) for the management of neurogenic bladder in children with myelomeningocele (MMC). AC carries considerable risk. To mitigate this, recent studies have emphasized alternatives to AC, but it is unknown if these interventions have resulted in fewer ACs being performed. Our goal was to evaluate the use of AC in MMC patients over the past decade. We hypothesized that the use of AC had decreased and that the age at AC increased. METHODS: Using the Pediatric Health Information System, we studied patients with MMC who had an AC between January 2009 and December 2018. International Classification of Disease procedure codes were used to identify AC procedures. We quantified trends in AC utilization by estimating the annual proportion of MMC admissions with an AC. We also assessed trends in patient age at the time of AC. RESULTS: Proportion of AC per MMC admissions across the study period was 4.8%. There was no significant annual trend in the overall number of ACs performed each quarter over the past decade nor was there any change in the estimated annual incidence rate ratio of AC (1.01, 95% confidence interval 0.96, 1.05; P =.75). The estimated annual change in patient age at procedure remained relatively constant over the study period (-0.03 years, 95% confidence interval -0.13, 0.07; P = .51). CONCLUSION: Practice patterns for the utilization of AC in MMC did not change significantly over the past decade despite prominent voices in the literature emphasizing alternative interventions in this patient population.

Longitudinal kidney injury biomarker trajectories in children with obstructive uropathy.

BACKGROUND: Congenital obstructive uropathy (OU) is a leading cause of pediatric kidney failure, representing a unique mechanism of injury, in part from renal tubular stretch and ischemia. Tubular injury biomarkers have potential to improve OU-specific risk stratification. METHODS: Patients with OU were identified in the Chronic Kidney Disease in Children (CKiD) study. "Cases" were defined as individuals receiving any kidney replacement therapy (KRT), while "controls" were age- and time-on-study matched and KRT free at last study visit. Urine and plasma neutrophil gelatinase-associated lipocalin (NGAL), interleukin 18 (IL-18), and liver-type fatty acid-binding protein (L-FABP) levels were measured at enrollment and annually and compared between cases and controls. Urine values were normalized to urine creatinine. RESULTS: In total, 22 cases and 22 controls were identified, with median (interquartile range) ages of 10.5 (9.0-13.0) and 15.9 (13.9-16.9) years at baseline and outcome, respectively. At enrollment there were no differences noted between cases and controls for any urine (u) or plasma (p) biomarker measured. However, the mean pNGAL and uL-FABP/creatinine increased throughout the study period in cases (15.38 ng/ml per year and 0.20 ng/ml per mg/dl per year, respectively, p = 0.01 for both) but remained stable in controls. This remained constant after controlling for baseline glomerular filtration rate (GFR). CONCLUSIONS: In children with OU, pNGAL and uL-FABP levels increased over the 5 years preceding KRT; independent of baseline GFR. Future studies are necessary to identify optimal cutoff values and to determine if these markers outperform current clinical predictors.

Utilization of robotics for retroperitoneal lymph-node dissection in pediatric and non-pediatric hospitals.

The objective of this study is to determine recent trends in use of robotics and laparoscopy for pediatric retroperitoneal lymph-node dissection (RPLND) in pediatric and non-pediatric hospitals. We conducted a retrospective cohort study using data from 29 hospitals in the Pediatric Health Information System (PHIS), and data from 14 states in the State Inpatient Databases (SID), between 2008 and 2014. The study population was comprised of patients aged ≥ 10 years undergoing RPLND, with an inpatient diagnosis of testicular or paratesticular cancer, based on international classification of disease (ICD) codes. Robotic approach was identified by the presence of an ICD procedure code modifier. During the study period, a total of 90 RPLNDs were performed in pediatric hospitals (median patient age 16 years). Of these, 4 (4.4%) were performed robotically. A total of 3120 RPLNDs were performed in non-pediatric hospitals (median patient age: 32 years). Among these, 269 (8.6%) were performed robotically, with an increasing trend in the use of robotic RPLND (adjusted annual increase in probability of undergoing robotic vs. open procedure: 16%; 95% CI 8-24). Undergoing robotic RPLND was associated with a reduction in postoperative length of stay of 3.5 days (95% CI 2.9, 4.1). Open surgical approaches comprise the vast majority of RPLNDs performed at pediatric hospitals. This is in contrast with trends in non-pediatric hospitals where robotic RPLND is being increasingly utilized. Future research is necessary to investigate this discrepancy in adopting minimally invasive techniques for RPLND in pediatric centers.

Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial.

IMPORTANCE: Although opioids are an important component of pain management for children recovering from surgery, postoperative opioid prescribing has contributed to the current opioid crisis in the United States because these medications are often prescribed in excess and are rarely properly disposed. One potential strategy to combat opioid misuse is to remove excess postoperative opioids from circulation by providing patients with drug disposal products that enable safe disposal of opioids in the home garbage. OBJECTIVE: To determine whether the provision of a drug disposal bag increases proper opioid disposal among the families of pediatric patients undergoing ambulatory surgery. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 202 parents or guardians of children 1 to 17 years of age who underwent otolaryngologic or urologic surgery at the outpatient surgery centers of a tertiary children's hospital in Columbus, Ohio, from June to December 2018 and who received an opioid prescription prior to discharge. INTERVENTIONS: Families randomized to intervention were provided a drug disposal bag containing activated charcoal and instructions for use plus standard postoperative discharge instructions on opioid use, storage, and disposal. Families in standard care arm received standard postoperative discharge instructions only. All participants completed a baseline survey and a follow-up survey 2 to 4 weeks postoperatively. MAIN OUTCOMES AND MEASURES: Primary outcome was proper opioid disposal, defined as disposal using a drug disposal bag or a disposal method recommended by the US Food and Drug Administration. RESULTS: Of 202 parents or guardians enrolled, 181 completed follow-up (92 in intervention arm and 89 in standard care arm). Most patients in both groups were white (75 [73.5%] vs 79 [80.6%]) and male (63 [61.2%] vs 54 [54.6%]), and the median (interquartile range) age was 6 (5-9) years in the intervention arm and 7 (6-10) years in the standard care arm. For intention-to-treat analyses, 92 families receiving a disposal bag and 89 families not receiving a disposal bag were included. Among them, 66 families (71.7%) randomized to receive a disposal bag reported properly disposing of their child's opioids, whereas 50 parents (56.2%) who did not receive a disposal bag reported proper opioid disposal (difference in proportions, 15.5%; 95% CI, 1.7%-29.3%; P = .03). Among only those families who filled an opioid prescription and had leftover opioids after resolution of their child's pain, 66 of 77 parents or guardians (85.7%) who had received a disposal bag and 50 of 77 parents or guardians (64.9%) who had received standard care reported properly disposing of their child's opioids (difference in proportions, 20.8%; 95% CI, 7.6%-34.0%). CONCLUSIONS AND RELEVANCE: Results of this study indicated that providing drug disposal bags to families of children receiving postoperative opioids increased the likelihood of excess opioid disposal. Greater availability of disposal products may complement ongoing prescribing reduction efforts aimed at decreasing opioid misuse. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03575377.

Common clinical markers predict end-stage renal disease in children with obstructive uropathy.

BACKGROUND: Obstructive uropathy (OU) is a common cause of end-stage renal disease (ESRD) in children. Children who escape the newborn period with mild-to-moderate chronic kidney disease (CKD) continue to be at increased risk. The predictive ability of clinically available markers throughout childhood is poorly defined. METHODS: Patients with OU were identified in the Chronic Kidney Disease in Children Study. The primary outcome of interest was renal replacement therapy (RRT) (cases). Controls were age matched and defined as patients within the OU cohort who did not require RRT during study follow-up. RESULTS: In total, 27 cases and 41 age-matched controls were identified. Median age at baseline and age at outcome measurement were 10 vs. 16 years, respectively. First available glomerular filtration rate (GFR) (36.9 vs. 53.5 mL/min per 1.73 m2), urine protein/creatinine (Cr) (0.40 vs. 0.22 mg/mg) and microalbumin/Cr (0.58 vs. 0.03 mg/mg), and serum CO2 (20 vs. 22 mmol/L) and hemoglobin (12.4 vs. 13.2 g/dL) differed significantly between cases and controls, respectively. GFR declined 3.07 mL/min per 1.73 m2/year faster in cases compared to that in controls (p < 0.0001). Urine protein/Cr and microalbumin/Cr increased by 0.16 and 0.11 per year more in cases compared to those in controls, respectively (p ≤ 0.001 for both). Serum phosphate increased by 0.11 mg/dL and serum albumin and hemoglobin decreased by 0.04 (g/dL) and 0.14 (g/dL) per year more for cases compared to those for controls, respectively (p < 0.05 for all). CONCLUSIONS: Age-specific baseline and longitudinal measures of readily available clinical measures predict progression to ESRD in children with mild-to-moderate CKD from OU.

Technical Considerations for Nephron-Sparing Surgery in Children: What Is Needed to Preserve Renal Units?

BACKGROUND: Chemotherapy is used preoperatively for children with bilateral Wilms tumor (BWT) or unilateral high-risk Wilms tumor (UHRWT) to promote tumor regression to facilitate renal preservation with nephron-sparing surgery (NSS). In adults, various surgical techniques have been described to preserve renal tissue. Few studies have examined the use of surgical adjuncts in NSS in children with renal tumors. METHODS: We performed a multi-institutional retrospective review of patients with BWT or UHRWT. Patient demographics, tumor size at diagnosis, following neoadjuvant chemotherapy, utilization of surgical adjuncts including intraoperative ultrasound (IOUS), margin status, complications, renal function, and follow-up were recorded. RESULTS: The cohort comprised 23 patients: 18 BWT, 3 UHRWT, and 2 patients with solitary kidney. Twenty-two of the 23 patients had successful NSS. IOUS was used 19 times, and seven had positive margins after surgery. Cooling/vascular isolation was used six times. At a median follow-up of 18 mo, median estimated glomerular filtration rate Schwartz was 126 mL/min/1.73 m2 and median serum creatinine 0.39 mg/dL in the 22 patients who had successful NSS. There have been no tumor recurrences. CONCLUSIONS: In patients with BWT and UHRWT, surgical adjuncts such as cooling/vascular isolation are uncommonly performed. IOUS may be helpful but does not guarantee negative microscopic margins. LEVEL OF EVIDENCE: Level 4, Case series with no comparison group.

Is Delayed Phase Computed Tomography Imaging Necessary After Blunt Renal Trauma in Children?

OBJECTIVE: To characterize the utilization of delayed phase computed tomography (CT) imaging in blunt renal trauma and determine if the omission of delayed phase CT imaging affected clinical outcomes in children. MATERIALS AND METHODS: A prospectively collected trauma database was reviewed between 2006 and 2016 to identify patients aged ≤21 years with a diagnosis of renal injury from blunt trauma. Demographic characteristics, injury grade, Injury Severity Score, non-kidney organ injuries, radiologic studies, and clinical course were reviewed. Patients were categorized into 2 groups: those who received CT with delayed images in the emergency room and those who did not. RESULTS: In total, 121 patients met the inclusion criteria. Delayed scans were obtained in 50 patients (41%) but omitted in 71 (59%). Age, weight, non-kidney organ injuries, and imaging location did not differ between groups. Injury Severity Score was higher in the no-delay group than in the delay group (median 16 vs 10, respectively, P = .40). Median length of stay was 3 days without significant differences by cohort (P = .24). The proportion of patients who received abdominal CT scans after admission, underwent a urologic procedure, or were readmitted did not differ significantly between groups. CONCLUSION: This study was unable to demonstrate a difference in outcomes between patients who had a CT with delayed imaging and patients who did not. This questions the universal necessity for delayed images after blunt renal trauma. Future prospective studies are necessary to develop pediatric trauma guidelines that balance imaging needs and radiation exposure.

Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia.

BACKGROUND: Spinal anesthesia (SA) is an effective technique that has been used in children for years. With growing concern with regard to the risks of general anesthesia (GA), we developed a SA program to provide an alternative option. We present our initial experience with this program. OBJECTIVE: To implement a SA program at a large tertiary care pediatric center and assess the safety and efficacy of the technique as an alternative to GA for urologic surgery. STUDY DESIGN/METHODS: We prospectively collected data on all children undergoing SA at our institution. We recorded demographics, procedure, time required for placement of the SA, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA, and perioperative complications. RESULTS: SA was attempted in 105 consecutive children (104 boys, 1 girl) with a mean age of 7.4 ± 4.3 months (range 19 days-24 months) and mean weight of 8.3 ± 1.7 kg (range 3.5-13.7). Placement of the SA was successful in 93/105 children (89%). Inability to achieve lumbar puncture (cerebrospinal fluid was not obtained) meant that SA was abandoned in seven (7%) patients and GA was administered. In five patients in whom SA was successful and surgery was begun, 5/93 (5%) required conversion to GA: two because of evisceration of intestine through large hernia defects related to coughing and abdominal irritation, two because of lack of motor blockade despite an adequate sensory block, and one because of an inability to place an intravenous catheter in the lower extremities (required per SA protocol). If necessary, an intravenous catheter can be placed in the upper extremity, but this must be weighed against the fact that the block has already been placed and is of limited duration. Overall, SA was successful (SA was placed and surgery was completed without conversion to GA) in 88/105 children (84%). No additional sedation and no systemic anesthetic agents were required in 75/88 children (85%). The average time required to place the SA was 3.8 ± 2.7 min (range 1-12). The average time for the surgical procedure was 38.3 ± 23.1 min (range 10-122). No patient required conversion to GA because of recession of block. There were no surgical complications. DISCUSSION/CONCLUSIONS: SA is a safe and efficacious technique for routine pediatric urological procedures. SA should be considered for cases such as neonatal torsion or patients with significant cardiac or pulmonary comorbidities when the risks of GA are often weighed against the risks of non-intervention.

Uroepithelial thickening improves detection of vesicoureteral reflux in infants with prenatal hydronephrosis.

INTRODUCTION: Postnatal evaluation of prenatal hydronephrosis (PNH) often includes a voiding cystourethrogram (VCUG) for VUR assessment. Despite limited supporting data, VCUG is currently recommended if postnatal renal and bladder ultrasound (RBUS) reveals moderate/severe hydronephrosis (HN) or hydroureter (HU). Recent studies have shown VUR is more accurately diagnosed by using certain sonographic findings as criteria for obtaining VCUG. Uroepithelial thickening (UET) of the renal pelvis is a finding associated with high-grade vesicoureteral reflux (HGVUR); however, the clinical significance of UET with PNH has not been studied. OBJECTIVE: We sought to determine if the presence of UET implies increased risk for VUR, and to investigate whether UET can improve the test characteristics of RBUS for VUR. STUDY DESIGN: We retrospectively analyzed postnatal RBUS and VCUG findings in infants ≤30 days undergoing evaluation for "prenatal hydronephrosis" over an 11-year period. We used logistic regression to identify factors associated with VUR. Test characteristics of RBUS for HGVUR were compared based on the presence of UET and two criteria sets to define abnormal RBUS. Criteria set 1 consisted of HN SFU grade 3-4 and/or HU; criteria set 2 was defined by the presence of two of following: UET, HU, duplication, and/or renal dysmorphia. RESULTS: Of 135 patients, 39 (29%) had VUR, of whom 16 (41%) had HGVUR. UET was significantly associated with VUR (p < 0.001), and the sensitivity for HGVUR based on UET alone was 94%. On multivariable analysis, UET, HU, duplication, and renal dysmorphia remained significant independent predictors of HGVUR. Compared to criteria 1, using criteria 2 resulted in 43 fewer VCUGs, and significant improvement in sensitivity and specificity for HGVUR (Table). DISCUSSION: Consistent with previous studies, HN alone on postnatal RBUS has little value in predicting the presence or severity of VUR. This study is the largest known series to evaluate UET in the setting of PNH, and our results demonstrate that UET, as well as HU, duplication and renal dysmorphia, are independent sonographic findings predicting HGVUR. Using our proposed criteria, the probability of HGVUR is fourfold more than the prevalence described in the literature, and importantly, when compared to the criteria recommended by the SFU and AUA, would have resulted in 53% fewer VCUGs while missing zero cases of HGVUR. CONCLUSION: In infants with PNH, the sonographic findings of UET, HU, duplication and renal dysmorphia independently indicate greater risk of HGVUR, and the sensitivity and specificity of RBUS for HGVUR is markedly improved when at least two of the four are present.

Preoperative risk assessment in children undergoing major urologic surgery.

BACKGROUND: Preoperative risk assessment is standard in adult surgery, but often these risk assessments cannot be applied to children. Previous studies emphasize the differences between pediatric and adult populations and variability by surgical procedure types. OBJECTIVE: We investigated preoperative risk factors for several outcomes in children undergoing major urologic surgery using the National Surgical Quality Improvement Program (NSQIP) Pediatric. STUDY DESIGN: A cohort of 2-18-year-old children who underwent major urologic surgery was identified by Current Procedure Terminology (CPT) codes in the 2012-2013 NSQIP-Pediatric. The NSQIP-Pediatric prospectively collects standardized and validated data from 61 sites on preoperative, operative, and 30-day postoperative variables. Urologic surgeries involving dissection of the peritoneal or extraperitoneal space were included. Patients undergoing pure genitourinary surgery were analyzed separately from those with bowel involvement to improve homogeneity. Postoperative outcomes including hospital length of stay and 30-day infective complications, non-infective complications, unplanned reoperation and readmissions were evaluated by fitting multivariable logistic regression models. RESULTS: A total of 2601 patients were identified, of whom 399 (15.3%) underwent bowel-involved surgery and 2202 (84.7%) underwent pure genitourinary surgery. Patients in the bowel-involved group were significantly older with more comorbidity. Postoperative complications, unplanned return to operating room, hospital length of stay and readmission rates were all significantly worse in the bowel-involved group. In the pure genitourinary group, older age and white race improved some outcomes, while American Society of Anesthesia (ASA) class ≥ 3, total operation time, obesity, pulmonary risk factors, preoperative renal disease, developmental delay, structural central nervous system abnormality, and supplemental nutrition independently predicted at least one negative outcome (Table). DISCUSSION: Consistent with previous research on reconstructive surgery, we identified a significant difference in patient age, surgery details, comorbidity, and increased complications for patients undergoing urologic surgery with bowel involvement compared with pure genitourinary surgery. Focusing solely on pure genitourinary surgery, we identified predictors of outcomes. Identification of these factors in pediatric urology is novel and only recently possible with the availability of the NSQIP-Pediatric. CONCLUSION: Using the NSQIP-Pediatric, we confirmed differences in complication rates for major urologic surgeries, with and without bowel involvement in a national sample. Preoperative risk characteristics were also identified for patients undergoing pure genitourinary surgery. Further investigation into these relationships is necessary to better elucidate their clinical significance with the goal of improving surgical planning, postoperative care, and family counseling.

Uroepithelial Thickening on Sonography Improves Detection of Vesicoureteral Reflux in Children with First Febrile Urinary Tract Infection.

PURPOSE: The 2011 American Academy of Pediatrics clinical practice guideline for childhood febrile urinary tract infection recommends voiding cystourethrography if renal and bladder ultrasound reveals hydronephrosis, scarring or "other findings" that suggest high grade vesicoureteral reflux. We sought to determine if the finding of uroepithelial thickening indicates greater risk of high grade vesicoureteral reflux and whether uroepithelial thickening improves the screening value of renal and bladder ultrasound. MATERIALS AND METHODS: We retrospectively analyzed renal and bladder ultrasound and voiding cystourethrogram findings in children 2 to 24 months old with first febrile urinary tract infection during an 11-year period. Patients with uroepithelial thickening were compared to an age and gender matched sample without uroepithelial thickening. Logistic regression was used to identify factors associated with high grade vesicoureteral reflux. Test characteristics of renal and bladder ultrasound for high grade reflux were compared based on different criteria to define an abnormal renal and bladder ultrasound. RESULTS: Of 226 patients 143 (63%) had vesicoureteral reflux, of whom 37 (26%) had high grade reflux. On multivariable analysis uroepithelial thickening was a significant independent predictor of high grade vesicoureteral reflux (OR 5.41, 95% CI 1.74-16.79, p = 0.004). When hydronephrosis and hydroureter were considered the only abnormal renal and bladder ultrasound findings warranting voiding cystourethrography, sensitivity of renal and bladder ultrasound for high grade reflux was 84%, and 6 children with high grade and 82 with low grade reflux would have been missed. When uroepithelial thickening was also considered an abnormal finding, the sensitivity increased to 97%, and only 1 child with high grade and 57 with low grade reflux would have been missed. CONCLUSIONS: Uroepithelial thickening is associated with an increased risk of high grade vesicoureteral reflux and is an abnormal finding warranting voiding cystourethrography. Sensitivity of renal and bladder ultrasound as a screening test for high grade vesicoureteral reflux is markedly improved when uroepithelial thickening is considered.

Utilization and costs associated with robotic surgery in children.

BACKGROUND: To evaluate utilization and costs associated with robotic surgery in children. MATERIALS AND METHODS: We identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. RESULTS: The number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. CONCLUSIONS: Use of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Double-V scrotoplasty for repair of congenital penoscrotal webbing: a hidden scar technique.

OBJECTIVE: Penoscrotal webbing (PSW) is a common reason for deferral of neonatal circumcision. Reports of successful procedures and outcomes in the literature are sparse. We have performed double-V scrotoplasty (DVS), a modification of a V-Y technique, in 138 patients with excellent results. PATIENTS AND METHODS: We retrospectively reviewed the charts of boys who had undergone DVS for PSW since January 2009 by a single surgeon (S.A.A.). The indications, intraoperative findings, concomitant procedures, outcomes, and complications were recorded. RESULTS: A total of 138 DVSs were performed. Concomitant genital surgeries included 81 hidden penis repairs and 10 other (hernia, hypospadias, chordee, orchidopexy). The median age at the time of surgery was 9.6 months (6.1 months-9.8 years). Patients were evaluated about 1 month postoperatively. In seven cases (5%), minor skin separation occurred at the penoscrotal junction but all healed completely. Superficial skin infection occurred in one patient. None required reoperation and cosmetic results were subjectively excellent. CONCLUSIONS: PSW has been corrected in 138 patients without significant complications and with excellent results. This is the largest known peer-reviewed series evaluating a surgical technique for congenital PSW repair. We believe our technique is simple, reproducible, and, with no diverging suture lines lateral to the median raphe, improves cosmesis.