Patterns of care in testicular torsion: influence of hospital transfer on testicular outcomes.

OBJECTIVE: To investigate patterns of care for testicular torsion and influence of hospital transfers on testicular outcomes. Hospital transfer may be a source of treatment delay in a condition where delays increase likelihood of orchiectomy. METHODS: We used a retrospective cohort of Californian males with ICD-9/CPT-defined torsion from inpatient, emergency department (ED), and ambulatory surgery center (ASC) data. Logistic regression assessed predictors of orchiectomy. RESULTS: Predictors of orchiectomy were ages <1 year (OR 19.2, 95% CI 6.3-58.9), 1-9 years (OR 2.7, 95% CI 1.4-5.2), and ≥40 years (OR 6.6, 95% CI 3.1-13.9) (vs. masked age). Treatment at mid-volume (vs. high-volume) facilities was associated with lower odds of orchiectomy (OR 0.5, 95% CI 0.3-0.7). Rural location, non-private insurance, and hospital transfer were associated with orchiectomy on univariate but not multivariate analysis. During 2008-2010, 2794 subjects experienced torsion (average incidence 5.08 per 100,000 males yearly). Encounters occurred in ASCs (55%), inpatient facilities (36%), and EDs (9%). 60% of subjects were privately insured, 2% experienced hospital transfer, and 31% underwent orchiectomy. CONCLUSION: Our census found that most cases of testicular torsion were treated in outpatient settings. Hospital transfer was not associated with orchiectomy.

Timing of orchiopexy in the United States: a quality-of-care indicator.

OBJECTIVE: To investigate whether orchiopexies are occurring later than recommended by American Academy of Pediatrics 1996 guidelines (around age 1). Adherence to guidelines is poorly studied. METHODS: The main cohort consisted of 4103 boys insured from birth (Innovus i3, insurance claims database). The complementary cohort consisted of 17 010 insured and noninsured boys (Pediatric Health Information System, PHIS). The inclusion criteria was age ≤ 5 years at time of International Classification of Disease, 9th revision-defined cryptorchidism diagnosis. The primary outcome was timely surgery (orchiopexy by age 18 months). RESULTS: In Innovus, 87% of boys who underwent an orchiopexy had a timely orchiopexy. Of those who did not undergo surgery (n = 2738), 90% had at least 1 subsequent well-care visit. Those who underwent timely surgery were referred to a surgeon at a younger age compared with those who underwent late surgery (4.1 vs 16.1 months, P < .00005). Predictors of timely surgery were number of well-care visits (odds ratio 1.5, 95% confidence interval 1.3-1.7), continuity of primary care (odds ratio 1.9, 95% confidence interval 1.3-2.7), and use of laparoscopy (odds ratio 4.5, 95% confidence interval 1.4-14.9). Family/internal medicine as referring provider was predictive of delayed surgery (odds ratio 0.5, 95% confidence interval 0.3-0.8). In the Pediatric Health Information System, 61% of those with private insurance had timely surgery compared with 54% of those without private insurance (P < .0001). CONCLUSION: We found an unexpectedly high adherence to guidelines in our continuously insured since birth Innovus population. Primary care continuity and well-care visits were associated with timely surgery. Further studies can confirm these findings in nonprivately insured patients with the ultimate goal of instituting quality improvement initiatives.

Prospective blinded laboratory assessment of prophylactic antibiotic compliance in a pediatric outpatient setting.

PURPOSE: Prophylactic antibiotics are commonly used to prevent urinary tract infections in children with conditions such as vesicoureteral reflux. Patient compliance with antibiotics is salient, given the effects that noncompliance can have on development of antibiotic resistance and outcomes of clinical trials. Prior series have shown variable compliance (17% to 70%). However, no study has used objective methods. We hypothesized that direct measurement of urine antibiotic levels can reveal poor compliance. MATERIALS AND METHODS: During a pediatric urology clinic visit patients 0 to 18 years old taking trimethoprim prophylaxis for any urological diagnosis were invited to participate in the study. They were unaware of any potential urine testing before the visit. Urine was sent for chromatography to quantify trimethoprim levels. Parents also completed a compliance self-assessment. RESULTS: Of patients invited to participate 97% consented (54 patients). Of the patients 91% were compliant based on urine levels. Factors not associated with compliance included age, gender, self-report of compliance, duration of time on antibiotics, insurance status and history of breakthrough infection, surgery, pyelonephritis or hospitalization. CONCLUSIONS: This study demonstrates the highest compliance reported for children taking prophylactic antibiotics to prevent urinary tract infection. We attribute this unexpected result to the discussion by specialists of 1 problem for the duration of an office visit. All education in this study was part of clinical care. Thus, our results should be generalizable to nonstudy environments. Future studies should confirm whether this high level of compliance can be achieved by nephrologists and pediatricians. If such compliance cannot be achieved at nonsurgical clinics, then early referral to a pediatric urologist may be warranted.

Management trends in prenatally detected hydronephrosis: national survey of pediatrician practice patterns and antibiotic use.

OBJECTIVE: To assess the practice patterns of general pediatricians in the management of prenatally detected hydronephrosis. Hydronephrosis is the most common abnormality found on prenatal ultrasonography. The utility of prophylactic antibiotics in the postnatal management of this condition is controversial. No study has assessed the practice patterns of general pediatricians in the management of prenatally detected hydronephrosis. METHODS: An 18-question survey was sent to a random cross-section national sample of pediatricians from the American Medical Association Masterfile. The participants answered questions regarding practice location and type, practice experience, frequency of cases seen, familiarity with the published data, use of antibiotics, workup of hydronephrosis, and specialist referral. Multivariate logistic regression analysis was used to identify the factors associated with prescribing antibiotics. RESULTS: Of the 461 pediatricians, 244 (53%) responded. Of the respondents, 56% routinely prescribed antibiotics for prenatally detected hydronephrosis, and 57% performed the postnatal workup themselves. Of these, 98% routinely ordered ultrasound scans and ∼40% routinely ordered voiding cystourethrograms. Of the respondents, 94% always had specialists readily available; however, only 41% always referred to a specialist. On multivariate logistic regression analysis, those who believe prophylactic antibiotics to be beneficial were significantly more likely to prescribe antibiotics than those who had not read the published data (odds ratio 6.1, 95% confidence interval 2-15). Those without specialist consultation readily available had an increased odds of starting prophylactic antibiotics compared with those who had consultation available (odds ratio 7.2, 95% confidence interval 1.3-39). CONCLUSION: Most pediatricians initiate postnatal management of prenatally detected hydronephrosis; therefore, pediatricians truly are the gatekeepers for children with this condition. Knowledge of the practice patterns is crucial for the dissemination of evidence-based information to the appropriate providers and will enable us to learn more about the utility of antibiotic prophylaxis in future studies.

Ovarian pathology for the pediatric urologist.

OBJECTIVES: To report the breadth of ovarian conditions that pediatric urologists may encounter through diverse referral patterns. METHODS: Two regional pediatric centers reviewed cases from 2000 to 2010, yielding 13 females with gonad-related conditions. RESULTS: Six of 13 patients (46%) were referred for a presumed urological condition that was later discovered to be of ovarian origin or were already known to the urology clinic for a congenital urological anomaly. Six patients had tumor markers drawn, all of which were normal. Median age was 11.2 years. The most common presenting symptoms were pain (6/13), emesis (5/13), and precocious puberty (2/13). Median mass diameter was 7.5 cm with 2 patients having masses greater than 20 cm. Histologic diagnosis was mature teratoma (4/13), streak gonad (3/13), and hemorrhagic cyst (2/13). Two patients had potentially malignant tumors (immature teratoma and juvenile granulosa cell tumor). CONCLUSIONS: At our centers, an ovarian condition is encountered an average of 1.3 times per year. As management of pediatric ovarian cysts and masses is controversial, pediatric urologists should be familiar with the diagnosis and treatment of such conditions.

Preoperative magnetic resonance angiography detection of septocutaneous perforators in fibula free flap transfer.

OBJECTIVE: To investigate whether preoperative magnetic resonance angiography (MRA) is predictive of surgical findings in fibula free flap surgery for head and neck reconstruction. METHODS: Retrospective review (April 2004 until September 2009) of 123 patients who underwent preoperative MRA as part of surgical planning for fibula free flap tissue transfer for head and neck reconstruction. Each MRA was reviewed by a board-certified radiologist masked to the intraoperative findings and to the number of septocutaneous perforators documented. Operative notes were reviewed and the number of septocutaneous perforators found during the operation was recorded. A κ interrater agreement statistic was calculated to compare these values. RESULTS: Two vascular anomalies found during the operation were undetected by MRA. Analysis of the entire cohort demonstrated that agreement between the number of perforators documented on MRA and the number found intraoperatively approached zero (unweighted κ = -0.088, P = .04). The agreement between the 2 values was 17.9% and the average percentage correctly classified was 10.9%. CONCLUSIONS: Contrary to previous reports, preoperative MRA does not accurately predict the presence and/or number of skin perforators found intraoperatively for a fibula free flap operation. The surgeon should not be dissuaded from planning a fibula free flap operation if skin perforators appear unfavorable on preoperative MRA because intraoperative observation is definitive. The surgeon should prepare for anomalous cases in which perforators may arise from the posterior tibial system. Further investigation is needed to achieve more accurate imaging modalities for evaluating septocutaneous perforators prior to free fibula flap transfer.

Use of internal stent, external transanastomotic stent or no stent during pediatric pyeloplasty: a decision tree cost-effectiveness analysis.

PURPOSE: Copious studies exist regarding the use of stents in pediatric pyeloplasty. Most surgeons use either no stent, an internal (Double-J®) stent or an external transanastomotic pyeloureteral stent. We propose the first known study to compare all 3 methods using a decision tree model that incorporates success rates, complications, patient discomfort and costs. MATERIALS AND METHODS: We created a deterministic decision tree model. We conducted a literature search querying urinary diversion in pediatric pyeloplasty. We used the largest studies for base inputs and remaining studies for sensitivity analysis. Direct costs from actual patients seen at the University of California San Francisco populated cost inputs. RESULTS: Total quality adjusted life-years during a 16-year period for no stents was 12.70851 with a total cost of $6,122. Total quality adjusted life-years for external stents was 12.71098 at a total cost of $5,702. Internal stents resulted in total quality adjusted life-years of 12.69983 and cost of $8,421. Thus, external stents dominated no stents and internal stents, while no stents dominated internal stents. On sensitivity analysis even decreasing complication and failure rates of internal stents to zero did not make them cost effective due to the costs associated with stent removal. In contrast, decreasing complication and pyeloplasty rates of no stents by 20% resulted in an incremental cost-effectiveness ratio of $5,475 per quality adjusted life-year gained compared to external stents. CONCLUSIONS: External and no stents are superior to internal stents. Given high overall success rates of pyeloplasty regardless of stent method, perhaps more attention should be given to cost from a health policy standpoint.

Environmental factors in genitourinary development.

PURPOSE: In the last century the world has experienced an increase in the use of industrial chemicals as well as possible increases in the prevalence of hypospadias and cryptorchidism. Because hormones regulate the fetal development of many organs, numerous investigations have explored the role of environmental factors in genitourinary growth. We summarize the data regarding endocrine disruptors in human genitourinary development. MATERIALS AND METHODS: A PubMed literature search was performed for human studies from 2004 to 2009. RESULTS: Few data exist on environmental influences on the kidneys, ureters or bladder. Studies on the influence of pesticides, vegetarian diets, diethylstilbestrol, oral contraceptives and corticosteroids on hypospadias have yielded varied conclusions. Phthalates appear to increase the odds of hypospadias and anogenital distance. The testicular dysgenesis syndrome postulates that cryptorchidism, hypospadias, poor semen quality and testicular cancer share a common environmental origin. In utero exposure to diethylstilbestrol has been shown to increase the risk of testicular dysgenesis syndrome. However, to our knowledge no other environmental factor has been shown to cause testicular dysgenesis syndrome. Some industrial chemicals as well as the pesticide dichloro-diphenyl-trichloroethane have detrimental effects on semen quality. In cases of documented industrial accidents, chemical exposure has also decreased the male-to-female birth ratio. CONCLUSIONS: Data on chemical exposure are largely mixed and inconclusive. Studies of populations with high exposure rates due to industrial accidents or in utero exposure to diethylstilbestrol suggest that endocrine disruptors adversely affect genitourinary development.

A diagnostic algorithm for urachal anomalies.

OBJECTIVE: Urachal anomalies are rare. Variable presentations can be a diagnostic challenge. We combine our series with a review of literature to delineate the most common presentations, highest yield diagnostic studies and a diagnostic algorithm. METHODS: We reviewed records of 22 boys and 15 girls with the diagnosis of a urachal anomaly from 2000 through 2005. This revealed 19 cysts, seven patent urachuses, five sinuses, four patients with unspecified "urachal anomalies," and two patients with no urachal anomaly by surgical exploration. Ultrasound was the most common diagnostic study, followed by computed tomography (CT), voiding cystourethrogram and sinogram. Thirty-five of 37 patients underwent surgery. RESULTS: Clinical presentation included periumbilical leakage in 54%, pain in 30%, periumbilical mass in 22% and irritative voiding symptoms in 14%. In many patients diagnosis was made on clinical examination alone. When an ultrasound was used it was diagnostic for 82% of cysts, 100% of sinuses and 100% of patent urachuses. A voiding cystourethrogram was diagnostic for 100% of patent urachuses, but less successful in the other anomalies. CT scans correctly diagnosed 71% of cysts. Overall complication rate was 9%, all wound infections. CONCLUSION: Reviewing the results of this and four other large series showed that the most common anomaly is the urachal cyst followed by urachal sinus and patent urachus. Periumbilical drainage is the most common presentation. Physical exam alone can be diagnostic. When this is not possible ultrasound is our recommended initial study, followed by a CT scan if unsuccessful.