Correlation between surgical booking by a PA and surgical procedure performed.

OBJECTIVE: This study evaluated the concordance between clinical evaluation and diagnosis by a physician associate/assistant (PA) and the preoperative and intraoperative evaluations by a pediatric urologic surgeon. METHODS: A retrospective chart review was performed for patients independently evaluated and scheduled for surgery by a single PA between 2017 and 2020. Concordance was measured by comparing the PA's office note with the surgeon's preoperative note and operative report. RESULTS: Of the 242 patients scheduled for surgery, 11 underwent an operative report procedure change and 11 others underwent a preoperative note procedure change. Concordance increased from 89.09% in 2017 to 92.31% in 2020; this was not statistically significant ( P = .230). Urologic conditions evaluated demonstrated an increase in the variety and complexity of conditions. CONCLUSIONS: A supervisory/collaborative model involving a well-trained PA yields excellent outcomes in terms of concordance with surgical scheduling and procedure performed.

Magnetic resonance imaging of Müllerian anomalies in girls: concepts and controversies.

Female Müllerian anomalies are the result of failure of formation, fusion or resorption of the Müllerian ducts and are relatively common, with a prevalence of 5.5-7.0% in the general population. While some of these anomalies are asymptomatic, those presenting with obstruction require accurate identification for optimal clinical management including potential surgical treatment. MRI is a useful adjunct to sonography in the evaluation of Müllerian anomalies, typically allowing a more complete characterization of the malformation. Technical aspects, embryologic concepts and controversies regarding classification systems are highlighted in this review. Several Müllerian anomalies are discussed and illustrated in more detail utilizing various cases with pelvic MRI studies.

Experience and outcomes for PAs in a neonatal circumcision clinic.

OBJECTIVE: To evaluate the outcomes of neonatal circumcision performed by a PA in pediatric urology. METHODS: A retrospective review was performed of infants evaluated for neonatal circumcision by a single PA in pediatric urology over 30 months. Technique, age and weight at circumcision, presence or absence of genital anomalies, and complications were gathered. RESULTS: Of the 371 male infants evaluated for neonatal circumcision, 276 underwent the procedure. Complications included retained Plastibell (2.1%), penile adhesions (1.1%), swelling (1.8%), and cosmetic concerns (0.73%). Eighteen unanticipated postprocedure visits occurred-four in the ED and 14 in the outpatient clinic. No acute procedural complications occurred. One patient (0.3%) underwent lysis of penile adhesions at age 19 months. CONCLUSION: Neonatal circumcisions are commonly performed by nonsurgeons with variable formal circumcision training. These data support that well-trained PAs can perform neonatal circumcisions with low complication rates.

Testicular Torsion: Current Evaluation and Management.

Testicular torsion is a urologic emergency, requiring prompt identification and management. Understanding the risk factors, presentation, and management is essential to decrease delays in diagnosis and intervention. This review discusses the prevalence, pathophysiology, management, and outcomes of testicular torsion.

Peyronie's Disease: Overview and Recent Treatment Advances.

Peyronie's disease is a chronic condition affecting approximately 3% to 9% of adult males and is associated with significant negative effects on physical and psychosocial well-being and quality of life. Historically, treatment has been limited by a lack of understanding of the pathophysiology. Recent advances have led to the first FDA-approved therapy for the treatment of Peyronie's disease. Evaluation, treatment, and management of patients with this condition, including use of an algorithm and pre-/post-treatment questionnaire, will be discussed.

Undescended Testes: A Clinical and Surgical Review.

Undescended testes are a common congenital disorder with potential sequelae that include infertility and malignancy. This article addresses a contemporary perspective on the pathophysiology of the undescended testis, impact on testicular function and risk of testicular cancer. Surgical management and current guidelines regarding optimal timing of surgery will also be presented.

Onabotulinum toxin A: a therapeutic option for refractory neurogenic detrusor overactivity and idiopathic overactive bladder.

Overactive bladder syndrome affects up to 17% of the American population and adversely impacts quality of life. Antimuscarinic agents have been the primary treatment of neurogenic detrusor overactivity and overactive bladder, but they are often ineffective or poorly tolerated. Onabotulinum toxin A for refractory cases provides an important therapeutic alternative. Indications, use, efficacy and safety data for intradetrusor injection of onabotulinum toxin A will be reviewed.

Contemporary Approach To Diagnosis, Management, And Treatment of Varicocele In the Adolescent.

Varicocele is the most common inguinoscrotal pathology among adolescents. It is of concern due to the potential effect on fertility. A review of the literature focusing on current guidelines regarding diagnosis, evaluation, and management of adolescent varicocele was conducted. An algorithm is provided as one method for approaching the adolescent varicocele.

Decreasing suprapubic tube-related injuries: results of case series and comprehensive literature review.

Bowel-related injuries are known complications of suprapubic tube (SPT) catheterization placement. A literature review was conducted to determine identifiable risk factors for bowel injury. Results on the analysis of 25 cases are presented along with a proposed algorithm to aid in choosing between open, percutaneous, and image-guided methods of placement.

A case report and review of transitional cell carcinoma in children.

Transitional cell carcinoma (TCC) is a rare cause of hematuria in children. This type of urothelial bladder tumor is typically low grade and carries a good prognosis. In this article, a case report is presented along with a review of the literature on TCC in children.

Emerging therapies for overactive bladder: preclinical, phase I and phase II studies.

INTRODUCTION: Overactive bladder syndrome is a common chronic condition with a significant impact on quality of life and economic burden. Persistence with pharmacologic therapy has been limited by efficacy and side effects. A greater understanding of the pathophysiology of overactive bladder has led to the initial evaluation of several drugs affecting ion channels, the autonomic nervous system, and enzymes which may provide useful alternatives for the management of overactive bladder. AREAS COVERED: A comprehensive review was performed using PubMed and Cochrane databases as well as reviewing clinical trials in the United States. The current standard of care for overactive bladder will be discussed, but this paper focuses on investigational drugs currently in preclinical studies and phase I and II clinical trials. EXPERT OPINION: Current therapies for overactive bladder have limitations in efficacy and side effects. A greater understanding of the pathophysiology of overactive bladder has identified the role(s) of other pathways in the overactive bladder syndrome. Targeting alternative pathways including ion channels and enzymes may provide alternative therapies of overactive bladder and a more tailored approach to the management of overactive bladder.

Inguinal Polyorchidism Found Incidentally During Orchiopexy in 9-Year-Old Male: A Case Report and Review of Orchiopexy of Nonscrotal Supernumerary Testes.

Polyorchidism, the presence of more than two testes, usually presents as a painless scrotal mass or is diagnosed incidentally during the management of another condition.1 It is a rare congenital abnormality with approximately 200 reported cases in the literature. Most cases are found on the left side within the scrotum. We report a case of right-sided polyorchidism in a 9-year-old patient found incidentally during inguinal orchiopexy. As there is debate on the management of polyorchidism, a careful approach is required as the surgeon must decide between either scrotal fixation or the removal of the supernumerary testis. This case report will discuss the anatomical and clinical considerations when making this decision.

A large urachal cyst presenting with lower urinary tract symptoms and a falsely elevated post-void residual on bladder scan.

The urachus is an embryologic remnant that connects the bladder to the umbilicus and typically obliterates during gestation. Urachal cysts are one of the most common congenital urachal anomalies. Urachal cysts may be found incidentally on imaging or present as a palpable mass with abdominal pain and fever. We present a case of a young male with a urachal cyst who presented with lower urinary tract symptoms and a falsely elevated post void residual (PVR) volume on bladder scan. This case illustrates an atypical presentation of a large urachal cyst and highlights the limitations of bladder scanner post-void residual determination.

Management of urachal anomalies in pediatric patients: A comparison of treatment strategies between pediatric urology and general surgery.

INTRODUCTION: Persistence of embryonic urachal structures due to a failure of the urachus to involute into the median umbilical ligament is known as a urachal anomaly (UA). UAs may remain asymptomatic or lead to abdominal pain and recurrent infections. Management of UAs in pediatric patients has historically lacked a clear consensus between conservative and surgical management. While both urologists and general surgeons manage this pathology, a comparison of management style and outcomes between these specialties has not been published to our knowledge. OBJECTIVE: To (1) evaluate trends in management of UAs among pediatric urologists and general surgeons across three tertiary care children's hospitals and (2) identify factors that place patients at higher risk for requiring surgery. STUDY DESIGN: All patients diagnosed with a UA from 2016 to 2020 at our multi-site institution were identified by ICD-10 code Q64.4 "malformation of the urachus" and retrospectively reviewed. Patient demographics, treatment specialty, remnant subtype, and management strategy were recorded. Data was dichotomized between both urology and general surgery as well as between surgical and nonsurgical intervention to identify and compare management strategies. RESULTS: Overall, 143 patients diagnosed with UAs were identified. Of these patients, 74 were treated by urology and 69 were treated by general surgery. Patients who were treated by urology were significantly more likely to receive conservative treatment (66.2% treated conservatively vs. 33.8% treated surgically), while patients treated by general surgery were significantly more likely to undergo surgery (84.1% treated surgically vs. 15.9% treated conservatively, p < .0001). Though, urology was more likely to treat patients who presented incidentally (p < .01), and general surgery was more likely to treat patients who presented with an infected remnant (p < .01). Patients of male sex were more likely overall to receive surgery compared to female patients (p < .01). DISCUSSION: Management of UAs by urologists was more conservative than general surgeons. However, both specialties treat distinctly different patient presentations, with urology managing more incidental remnants and general surgery operating on more emergent, infected urachi. Limitations of the study included its retrospective nature and the insufficient reporting of urachal remnant subtypes and presence of infection among patients. CONCLUSIONS: Management strategies of UAs differ among urology and general surgery, but surgical and conservative treatments are necessary to appropriately treat their distinct patient populations. This study provides valuable insight into current practices of UA management and may help to inform future treatment.

Long-term followup of primary nonrefluxing megaureter.

PURPOSE: We evaluated outcomes of nonoperative management of primary nonrefluxing megaureter at long-term followup to identify clinical predictors of spontaneous resolution. MATERIALS AND METHODS: A total of 75 patients (88 primary megaureters) were diagnosed between 1990 and 2005 and followed for more than 6 months. Of the patients 63 (74 primary megaureters) were included in the main study population. Indications for surgery were obstructive hydroureteronephrosis, functional impairment and persistent symptoms. RESULTS: Of the 74 primary megaureters 20 (27%) required surgery up to 7 years after diagnosis. Surgery was not indicated in 82% of primary megaureters with grade I or II hydronephrosis vs 62.9% of those with grade III or higher hydronephrosis (difference not significant), nor in 76.5% of types I and II primary megaureters vs 33.3% of type III primary megaureters (p = 0.040), 78.7% of renal units with differential function 40% or greater vs 0% with differential function less than 40% (p = 0.027), 80% of primary megaureters with a nonobstructive washout pattern vs 44.4% with an intermediate/obstructive pattern (p = 0.032), 67.9% of patients with perinatal presentation vs 25% with postneonatal presentation (p = 0.008) or 63.2% of patients presenting with symptoms vs 76.4% of those who were asymptomatic (difference not significant). On multivariate analysis age at presentation and washout pattern were significant predictors of spontaneous resolution. CONCLUSIONS: Most cases of primary megaureter resolve spontaneously or improve without loss of function or development of symptoms. Careful observation allows surgery to be delayed beyond the neonatal period in most patients. Long-term followup is recommended because symptoms can develop years later. Washout pattern and age at presentation are statistically significant predictors of spontaneous resolution.

Reducing costs of referrals for non-neonatal circumcision in Florida Medicaid population.

INTRODUCTION: Florida Medicaid will only cover a non-neonatal circumcision if it meets the specified Medicaid medical indications or the patient is 3 years or older and has failed a 6-week trial of topical steroid therapy (TST). Referral of children who do not meet guideline criteria results in unnecessary costs. OBJECTIVE: We sought to evaluate the cost savings if the initial evaluation and management were performed by the primary care provider (PCP) with referral to a pediatric urologist of only those males meeting the guidelines. STUDY DESIGN: An institutional review board-approved retrospective chart review of all male pediatric patients ≥3 years of age presenting for phimosis/circumcision from September 2016 to September 2019 at our institution was performed. Data extracted included (1) presence of phimosis, (2) presence of medical indication for circumcision on presentation, (3) circumcision performed without meeting criteria, (4) use of topical steroid therapy prior to referral. The population was stratified into 2 groups based on whether criteria were met at the time of referral. Those with a defined medical indication on presentation were excluded from cost analysis. Cost savings were based on costs incurred for PCP visit(s) versus initial referral to a urologist using estimated Medicaid reimbursement rates. RESULTS: Of the 763 males, 76.1% (581) did not meet Medicaid criteria for circumcision on presentation. Of these, 67 had a retractable foreskin with no medical indication, 514 had phimosis with no documented topical steroid therapy (TST) failure. A savings of $95,704.16 would have been incurred if the PCP initiated the evaluation and management and referred only those who met the criteria (Table 2). DISCUSSION: These savings would only be feasible if there were proper education of PCPs in the evaluation of phimosis and the role of TST. Limitations are assuming cost savings in the setting of well-educated pediatricians for clinical exam and believing they are aware of and comply with the guidelines. CONCLUSIONS: Education of PCPs on the role of TST in phimosis and current Medicaid guidelines may reduce unnecessary office visits, health care costs, and family burden. The most impactful method to reduce the cost of non-neonatal circumcision would be for states that do not currently cover neonatal circumcision to acknowledge affirmative policies from the American Academy of Pediatrics regarding circumcision and realize the cost savings associated with providing coverage for neonatal circumcision and reducing significantly the number of more expensive non-neonatal circumcisions.

Solitary Intrascrotal Plexiform Neurofibroma in a 10-Year-Old Male.

Intrascrotal neurofibromas are extensive tumors that grow from peripheral nerves within the scrotum and are exceedingly rare among the benign extratesticular tumors. Though the risk is low, potential for malignancy and patient discomfort make diagnosis and surgical evaluation imperative. Pediatric neurofibromas are typically only associated with neurofibromatosis type 1. However, herein, we describe a rare case of a benign, intrascrotal plexiform neurofibroma in a 10-year-old male who lacks any stigmata associated with this genetic disorder. Diagnostic and surgical challenges as well as histopathological findings are discussed.

To circ or not: a reappraisal.

Routine circumcision remains a topic of controversy. The most recent male circumcision policy from the American Academy of Pediatrics argued that data were insufficient to recommend routine circumcision. Recent trials in Africa evaluating male circumcision for the prevention of sexually transmitted diseases have, however, revived the circumcision controversy.

Overview of current approaches to the evaluation and management of male infertility.

Infertility, the inability to conceive after one year of regular, unprotected intercourse, is secondary to male-only factors in 20% and a combination of male and female factors in 30% to 40% of cases. Advances in the identification and management of male factor infertility have provided new and often successful options for paternity.

Effects of analgesic and anesthetic medications on lower urinary tract function.

Analgesic and anesthetic medications may affect lower urinary tract function via a variety of mechanisms. This article reviews the more commonly used medications and their effects on lower urinary tract function.