Analysis of Factors Associated with Patient or Caregiver Regret following Surgery for Fecal Incontinence.

PURPOSE: Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence. MATERIALS AND METHODS: We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications. RESULTS: A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1-18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0-6.4 for age 13 years; OR 2.9, 95% CI 1.1-7.8 for age 14 years; OR 3.1, 95% CI 1.1-8.8 for age 15 years). CONCLUSIONS: This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued.

A cross sectional single institution study of quality of life in adult patients with spina bifida.

OBJECTIVE: To describe and compare differences in perception of independence, urinary continence, and quality of life in an adult spina bifida (SB) population. METHODS: We collected data on adult neurogenic bladder patients which included demographics, relevant procedures, and quality of life (QoL) questionnaires. QoL and functional outcomes were assessed using spinal cord independence measure (SCIM) and SF-8 health questionnaire. International consultation of incontinence questionnaire (ICIQ) was used to assess incontinence. Comparisons were drawn between patients who underwent surgical reconstruction and those who did not. Student t-tests were used for comparisons and a P-value <0.05 was considered statistically significant. RESULTS: Fifty-four patients with SB were included. A total of 43% underwent bladder augmentation (BA) and 30% underwent antegrade continence enema (ACE). Patients with BA scored 49 ± 25 on the SCIM survey while those without had higher scores of 68 ± 19 with a P-value of 0.016. This difference remained evident when patients with ACE were excluded. When comparing ICIQ and SF-8, no statistically significant differences were found between those who underwent surgical procedures and those who did not. CONCLUSIONS: Assessing QoL in congenital NGB patients is a complex task. In our cohort, patients who underwent BA and ACE were shown to have decreased SCIM scores. SCIM scores for BA patients were significantly higher in patients who did not receive a BA independent of ACE status. SF-8 and ICIQ scores did not show any statistically significant difference in quality of life survey scores in those who underwent procedures versus those who did not.

Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study.

INTRODUCTION/BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE: We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN: Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS: A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION: The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS: ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

Application of the decisional regret scale (DRS) in men undergoing anti-incontinence procedures for stress urinary incontinence.

Background: Decisional regret (DR) has previously been applied to other urologic issues (hypospadias, prostate cancer). The present study seeks to evaluate certain patient factors that directly correlate to high DR scores in anti-incontinence procedures. Methods: Medical records for 119 patients undergoing anti-incontinence procedures between 2009 and 2020 were retrospectively reviewed. Forty-one patients were accessible for telephone follow-up and provided a Decisional Regret Scale (DRS) questionnaire. If patients had both a sling and an artificial urinary sphincter (AUS) placed, questionnaires were administered for each. DRS score was quantified in accordance with prior literature, with scores ranging 0-100. We subdivided patients based on demographics and surgical data, correlating this with DRS score. Results: In 41 patients, 46 procedures (13 slings, 33 AUS) were performed. Thirty-nine (95.1%) men underwent robotic-assisted laparoscopic prostatectomy, and 11 (26.8%) men reported prior pelvic radiation. Post-procedural continence, irrespective of procedure, yielded an average 2±1.56 pads per day (PPD). Mean DRS score across the cohort was 29.78. DRS score was subdivided into mild, moderate, and severe, with majority noting "none to mild" regret (63%), 15.2% reporting moderate and 21.7% severe. Predictors of higher regret included history of radiation (P=0.056), choice of anti-incontinence procedure (P=0.011), and need for surgical revision (P=0.00042). DR was unrelated to race, complete continence, and time to follow-up. Conclusions: DRS has recently been applied to anti-incontinence procedures for male stress incontinence; our study highlights novel findings not previously assessed. Majority of men had minimal regret with a subset that had significant regret-history of radiation, multiple revisions/explant, and those who elected for sling upfront. These results highlight the importance of patient selection and pre-operative counselling.

Supernumerary Testis Discovered Upon Workup of a Paratesticular Mass.

A supernumerary testis is a rare finding with limited description in the literature. Presentations of supernumerary testes vary and often involve initial discovery intraoperatively or in association with a separate condition. In this case report, we describe our experience of a patient with ultrasound imaging concerning for a left paratesticular mass. The patient was taken to the operating room where the mass was found to be an atrophic, supernumerary testis. We also address the specific anatomy encountered in our case and discuss both the intraoperative and post-operative management that resulted, in addition to reviewing relevant literature.

Referrals for Cryptorchidism: Analyzing for Quality from a Pre-COVID Dataset.

OBJECTIVE: To identify risk factors associated with an inaccurate diagnosis, delayed referral, and/or inappropriate ultrasound in consecutive referrals for an undescended testicle (UDT). METHODS: This study was approved by the institutional review board. Data was prospectively collected for all children referred to University of Oklahoma's pediatric urology service from August 2019 to February 2020. The data was imported into SAS vs 9.4 for analysis. We categorized the "quality" of referral by a point system using 3 factors (no previous ultrasound, ≤18 months, correct location). An optimal referral had an accurate testicular examination, was referred by 18 months of age, and no diagnostic ultrasound. RESULTS: We collected 75 referrals. Thirty-nine (52.0%) had confirmed UDT, requiring surgery. Twenty-seven (69.2%) had an accurate initial examination. Forty-one (54.7%) were outside the optimal age. Thirty-four were considered low quality (0-1 qualities) and 41 were high quality (2-3 qualities). Seven (9.3%) were optimal (3/3 qualities). Referrals that needed intervention were statistically more likely to be higher quality. CONCLUSION: Increased quality of UDT referrals directly correlated with the likelihood for treatment. This study reveals a need for more education on UDT referral in the community. By improving referring provider knowledge and skills, we can minimize unnecessary referrals.

A Rare Case of T-Cell Lymphoma Presenting With Bilateral Nephrolithiasis and Acute Renal Failure.

We present the rare case of a young boy who was found to have T-cell lymphoma after presenting with flank pain and bilateral nephrolithiasis. He initially underwent bilateral ureteral stent placement but returned with oliguria and acute renal failure. His subsequent workup revealed lymphoma involving both kidneys. He was started on chemotherapy for his lymphoma and dialysis for his renal failure. His stones ultimately dissolved with aggressive hydration and correction of serum uric acid levels. In this report, we discuss the identification and management of this rare condition.

Genetic Testing Proves Crucial in Case of Ambiguous Genitalia and Renal Masses.

OBJECTIVE: The Denys-Drash syndrome consists of a triad of ambiguous genitalia, Wilm's tumor and nephrotic syndrome. METHODS: We present a diagnostically challenging case of an XY patient with female appearance and Müllerian structures with a WT1 mutation. RESULTS: These genetic findings resulted in gonadal dysgenesis, end-stage renal disease, and precursor changes to Wilm's tumor in both kidneys. Genetic testing proved critical in this case, helping to solidify a diagnosis and guiding our decision to proceed with bilateral nephrectomy and bilateral gonadectomy. CONCLUSIONS: Denys-Drash syndrome can present quite dramatically. WT1 testing should be considered early in the workup for patients with differences of sexual development, particularly those with 46XY karyotype.

Antenatal Presentation of Wilms' Tumor.

Tumors discovered antenatally are rare and the prognosis is generally poor. We present a case of a fetal left renal mass, initially discovered via routine prenatal ultrasound. The mother was an otherwise healthy gravida 4 para one 30-year-old female with 2 previous miscarriages, reportedly secondary to septate uterus. Further imaging and subsequent genetic testing was consistent with an antenatal Wilms' tumor with a mutation in the NPHP1 gene. The newborn received chemotherapy and had no evidence of recurrence at 3 months follow-up.

Penile Fracture Following a Fall in a 7-Year-Old Male.

We report a rare case of isolated penile fracture in a prepubescent male caused by an accidental fall. The patient presented with swelling and ecchymosis on the base of the penis and along the penile shaft. A flexible cystoscopy was performed, which did not reveal any concomitant urethral injury. The penis was degloved and the corporal tear was closed with absorbable suture. Due to the location of the injury, ventral mobilization of the urethra was required. The pathophysiology of penile fracture as well as the diagnosis and management of this rare injury are discussed in this report.

Percutaneous Stone Removal in an Adult with a Continent Cutaneous Reservoir: Case Report and Review of the Literature.

Stone formation is a known long-term complications of continent urinary reservoirs. We present a rare case of a large stone in a continent cutaneous reservoir in a 56-year-old male managed with percutaneous cystolithotomy. The patient presented with recurrent urinary tract infections and stomal incontinence. CT revealed an 8-cm stone occupying the entire lumen of his reservoir. Rather than removing this large stone through an open approach, the pouch was accessed percutaneously and lithotripsy was performed. In this report, we demonstrate our operative technique and that percutaneous cystolithalopaxy may be a safe and effective alternative for the management of large stones within continent cutaneous reservoirs.

"Watering Can" Ureterocele Puncture Technique Leads to Decreased Rates of De Novo Vesicoureteral Reflux and Subsequent Surgery With Durable Results.

OBJECTIVE: To assess the outcomes of "watering can" ureterocele puncture (WCP), a technique previously associated with decreased incidence of de novo vesicoureteral reflux (VUR), as a durable option for management of ureteroceles and to determine the need for subsequent surgery for VUR following watering can puncture. MATERIALS AND METHODS: We retrospectively reviewed records of 55 consecutive endoscopic ureterocele procedures performed at our institution from 1999 to 2015. The WCP was performed using a holmium laser fiber to make 10-20 puncture holes through the ureterocele. Follow-up data were collected on infection, de novo VUR in the affected renal moiety and the need for further treatment and surgery. RESULTS: Of 55 patients who underwent endoscopic ureterocele management, 34 underwent WCP and 21 patients underwent either incision or puncture. Median follow-up was 3.4 and 2.8 years in the incision and puncture groups, respectively. Both groups had similar rates of ureterocele decompression (88% vs 90%; P >.05) and improvement in hydronephrosis (82% vs 81%; P >.05). The WCP group had a significantly decreased rate of de novo VUR (32% vs 67%; P <.05) and of subsequent surgery due to de novo VUR (38% vs 71%; P <.05). The average grade of de novo VUR was lower in the WCP group (1.4 vs 2.8; P <.05). CONCLUSION: Our study shows that the endoscopic WCP successfully decompresses the obstructing ureterocele and results in a decreased incidence of de novo VUR and ultimately in fewer invasive procedures for the patient. This update demonstrates the durable outcomes of this novel technique.