Impact of Social Disparities on 5-Year Survival Rates in Pediatric Hematologic Malignancies.

BACKGROUND: Socioeconomic disparities exist in pediatric patients with hematologic malignancies, leading to suboptimal survival rates. Social determinants of health impact health outcomes, and in children, they may not only lead to worse survival outcomes but carry over into late effects in adult life. The social deprivation index (SDI) is a composite score using geographic county data to measure social determinants of health. Using the SDI, the purpose of the present study is to stratify survival outcomes in pediatric patients with hematologic malignancies based on area deprivation. METHODS: A retrospective cohort study was performed using the national Surveillance, Epidemiology, and End Results oncology registry in the USA from 1975 to 2016 based on county-level data. Pediatric patients (≤18 y old) with a diagnosis of leukemia or lymphoma based on the International Classification for Oncology, third edition (ICD-O-3) were used for inclusion criteria. Patients were grouped by cancer subtype for leukemia into acute lymphoblastic leukemia (ALL) and acute myeloid leukemia while for lymphoma into non-Hodgkin's lymphoma and Hodgkin's lymphoma. SDI scores were calculated for each patient and divided into quartiles, with Q1 being the lowest area of deprivation and Q4 being the highest, respectively. RESULTS: A total of 38,318 leukemia and lymphoma patients were included. Quartile data demonstrated stratification in survival based on area deprivation for ALL, with no survival differences in the other cancer subtypes. Patients with ALL from the most deprived area had a roughly 3% difference in both overall and cancer-specific morality at 5 years compared with the least deprived area. CONCLUSION: Disparities in pediatric patients with ALL represent a significant area for quality improvement. Social programs may have value in improving survival outcomes and could rely on metrics such as SDI.

Surgeon, and Institution Characteristics Associated Surgical Preferences in the Pediatric KIDney Stone Care Improvement Network.

OBJECTIVE: To reveal barriers and opportunities to implement evidence for the management of pediatric kidney stone disease, we determined surgeon and institutional factors associated with preferences for the type of surgical intervention for kidney and ureteral stones. METHODS: We conducted a cross-sectional study of urologists participating in the Pediatric KIDney Stone Care Improvement Network (PKIDS) trial. Questionnaires ascertained strengths of urologists' preferences for types of surgery as well as characteristics of participating urologists and institutions. The outcome was the strength of preferences for ureteroscopy, shockwave lithotripsy, and percutaneous nephrolithotomy for four scenarios for which two alternative procedures are recommended by the AUA guidelines: (1) 2 cm kidney stone, (2) 9 mm proximal ureteral stone, (3) 1.5 cm lower pole kidney stone, (4) 1 cm nonlower pole kidney stone. Principal component analysis was performed to identify unique clusters of factors that explain surgical preferences. RESULTS: One hundred forty-eight urologists at 29 sites completed surveys. Stated preferences were highly skewed except for the choice between ureteroscopy and percutaneous nephrolithotomy for a 1.5 cm kidney stone. Shockwave lithotripsy ownership and local practice patterns most frequently associated with the strength of surgeons' preferences for the type of surgery. Principal component analysis revealed that three clusters of stone, patient, and heterogenous characteristics explained 30% of the variance in preferences. CONCLUSION: There is wide variation in the strengths of preferences for surgical interventions supported by current guidelines that are partially explained by surgeon and institutional characteristics. These results reveal opportunities to develop strategies for guidelines that consider real-world drivers of care.

Comparison of musculoskeletal anatomic relationships, determined by magnetic resonance imaging, in postpubertal female patients with and without classic bladder exstrophy.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Several studies in the paediatric literature have characterized the pelvic musculoskeletal anatomy of infants and children with bladder exstrophy using MRI and three-dimensional CT. The pelvic floor anatomy of female patients with bladder exstrophy who have undergone somatic growth and puberty is less well described. This study uses MRI to characterize comprehensively the pelvic anatomy of postpubertal females with classic bladder exstrophy by measuring 15 pelvic floor variables previously described in younger children with bladder exstrophy. OBJECTIVE: To characterize pelvic musculoskeletal anatomy in postpubertal females with classic bladder exstrophy, and to compare this with females without bladder exstrophy. PATIENTS AND METHODS: The authors reviewed the medical records of all females in our institutional review board-approved bladder exstrophy database of 1078 patients and identified those with classic bladder exstrophy who underwent pelvic magnetic resonance imaging (MRI) after the age of 12 years. Indications for MRI included haematuria, adnexal lesion, perineal fistula, non-pelvic cancer staging, abdominal wall hernia and vaginal stenosis. Age- and race-matched female patients without exstrophy who underwent MRI evaluation for similar indications were included for comparison. The MRI protocol included axial, sagittal and coronal T1- and/or T2-weighted imaging. RESULTS: The study included 30 patients with a median (range) age of 22.5 (12-55) years at time of MRI. Ten patients had bladder exstrophy while 20 control patients did not. A smaller percentage of levator ani was located in the anterior compartment of the pelvis in patients with bladder exstrophy compared with controls. The iliac wing angle, puborectalis angle, ileococcygeous angle, levator ani width, symphyseal diastasis, erectile body diastasis, posterior bladder neck distance and posterior anal distance was greater in patients with bladder exstrophy than in those without. The ischial angle and obturator internus angle were narrower in patients with bladder exstrophy than in those without, and there was no significant difference between levator ani surface area, sacral anal angle, sacral bladder neck angle and bladder neck erectile body distance between the two patient groups. CONCLUSIONS: In postpubertal females with bladder exstrophy, significant deviations from normal pelvimetry exist, including posterior location of the majority of the levator ani muscle, a wider ileococcygeous angle and a wider symphyseal diastasis. These differences are similar to those described in previous comparisons of younger children with bladder exstrophy and control children.

Using a serosal trough for fashioning a continent catheterizable stoma: technique and outcomes.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Continent urinary diversion with bladder augmentation is an established method of providing urinary continence in children with bladder exstrophy, who are not suitable candidates or have a failed bladder neck reconstruction. Sub-mucosal implantation of the tubularized catheterizable stoma (usually the appendix) into the reservoir, with backing typically provided by either the bladder musculature or colonic taenia, is safe and highly effective in these children. In some cases of classic bladder exstrophy and in the majority of patients with cloacal exstrophy, the ileum is used for enterocystoplasty and therefore there is no taenia to back the implanted catheterizable channel. This study describes the steps for providing a reliable flap-valve mechanism for the continent catheterizable channel using the serosal trough technique. OBJECTIVES: To evaluate the efficacy and potential complications of the serosal-trough (ST) technique for the implantation of a continent catheterizable stoma (CCS) during enterocystoplasty. To describe the surgical technique and provide detailed illustrations. PATIENTS AND METHODS: Using an institutional review board-approved departmental database, children with bladder exstrophy, born after 1990, were selected, and patients who had undergone urinary diversion with a CCS created using the ST technique were identified. Demographic and technical characteristics, as well as the eventual clinical outcomes, were retrospectively reviewed. RESULTS: A total of 135 patients with urinary diversion were identified, of whom 26 (13 males) had undergone CCS implantation using the ST technique. Patients included 14 classic exstrophies, 10 cloacal exstrophies, and two epispadias. The appendix and tapered ileum were used for the creation of a CCS in 11 and 15 patients, respectively. The median (range) age at creation of a CCS was 10.7 (4.4-17.4) years. At the time of CCS creation, 21 patients underwent initial enterocystoplasty, four had repeat augmentations, and one had a CCS on a previously augmented bladder. Ileum (mean length 18 cm) was used in 24/25 augmentations and was selected owing to lack of redundant sigmoid in 52% of patients and intraoperative surgeon preference in the remaining cases. In one case of cloacal exstrophy, a hindgut remnant was used. In 24 (92%) cases, initial CCS resulted in complete continence of the catheterizable channel. After a median (range) of 2.5 (0.2-7.5) years' follow-up all patients were dry via intermittent catheterization. The CCS failed at postoperative months 6 and 21 and required complete revision in two cases. CONCLUSIONS: Using a ST to provide a strong backing for a catheterizable channel is an excellent option when a channel must be placed in the ileum, hindgut, or in an area of augmentation where muscular backing is not available. The ST technique provides a reliably catheterizable tunnel, durable continence mechanism and a good success rate when creating a CCS in combination with a urinary diversion.

Open versus minimally invasive ureteroneocystostomy: trends and outcomes in a NSQIP-P cohort.

Although surgical intervention has commonly been performed using an open approach for vesicoureteral reflux (VUR), this is rapidly changing due to adoption of minimally invasive surgery (MIS). Success rates with MIS are similar to open for re-implantation (> 90%); however, open ureteral re-implantation is still widely considered the gold standard. Using national surgical quality improvement program-pediatric (NSQIP-P) data, this manuscript evaluates recent large population trends of open versus robotic-assisted and laparoscopic ureteroneocystostomy for complications and factors associated with worse outcomes. Cases were identified in the 2012-2019 NSQIP-P database using the ureteroneocystostomy operative codes and vesicoureteral reflux post-operative diagnosis codes. A 1:1 propensity score match (PSM) analysis was performed comparing surgical outcomes while matching patients with similar characteristics to reduce bias. A total of 4183 patients were included; 621 patients with MIS and 3562 with open approach. Patients in the MIS approach tended to be older (67 months vs. 53 months) and non-Caucasian (12.9% vs. 6.3%) with no differences in other demographics. After 1:1 PSM, 30-day complications after ureteroneocystostomy showed no significant differences in readmission, reoperation, or extended hospital stay. A multivariate analysis found patients with CNS structural abnormalities (such as spina bifida) had 4.5 times greater odds of experiencing a reoperation (p value < 0.05). Similarly, patients with an ASA above two had 2.0 times greater odds of an UTI (p value < 0.05). The cohorts undergoing open and MIS approaches are well matched overall, without profound differences in outcomes overall.

Effect of social disparities on 10 year survival in pediatric patients with Wilms' tumor.

BACKGROUND: To stratify 10-year survival outcomes by degree of social disparities in pediatric Wilms' tumor patients. We applied the Social Deprivation Index (SDI) to survival outcomes from the national SEER database to elucidate the effects of lower socioeconomics on cancer survival. METHODS: A retrospective cohort study was performed using the national Surveillance, Epidemiology, and End Results (SEER) oncology registry from 1975 to 2016 based on county-level data. Pediatric patients (<18 years old) with a diagnosis of WT (C64.9) and confirmed based on histology codes (8960/8963) were included. SDI scores were calculated for each patient and initially divided into quintiles. Patients were delineated into high-risk (>60th percentile/more deprived) or low-risk (<60th percentile/less deprived) groups. Statistics were assessed using Fisher's exact test, Student's t-test, and Kaplan-Meier assessed survival differences with log-rank test for trend. RESULTS: A total of 3406 patients were included with 1366 patients reported in the high-risk group and 2040 patients in the low-risk group. Quintile data demonstrated a stratification in survival based on socioeconomic status. Patients in more socially deprived counties were significantly (p = 0.035) more likely to have worse overall survival compared with those living in less deprived areas at 10-year (87.3% vs 89.3%) follow-up. CONCLUSIONS: 10-year overall and cancer-specific survival data for patients with Wilms' tumor stratify by socioeconomic lines. This represents an area that needs to be addressed in this pediatric oncologic population. Patients from more socially deprived areas have significantly worse 10-year overall survival rates and noticeably different 10-year cancer-specific survival rates.

Impact of social disparities on 10 year survival rates in paediatric cancers: a cohort study.

Background: Studies reporting on the impact of social determinants of health on childhood cancer are limited. The current study aimed to examine the relationship between health disparities, as measured by the social deprivation index, and mortality in paediatric oncology patients using a population-based national database. Methods: In this cohort study of children across all paediatric cancers, survival rates were determined using the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. The social deprivation index was used to measure and assess healthcare disparities and specifically the impact on both overall and cancer-specific survival. Hazard ratios were used to assess the association of area deprivation. Findings: The study cohort was composed of 99,542 patients with paediatric cancer. Patients had a median age of 10 years old (IQR: 3-16) with 46,109 (46.3%) of female sex. Based on race, 79,984 (80.4%) of patients were identified as white while 10,801 (10.9%) were identified as Black. Patients from socially deprived areas had significantly higher hazard of death overall for both non-metastatic [1.27 (95% CI: 1.19-1.36)] and metastatic presentations [1.09 (95% CI: 1.05-1.15)] compared to in more socially affluent areas. Interpretation: Patients from the most socially deprived areas had lower rates of overall and cancer-specific survival compared to patients from socially affluent areas. With an increase in childhood cancer survivors, implementation of social determinant indices, such as the social deprivation index, might aid improvement in healthcare outcomes for the most vulnerable patients. Funding: There was no study sponsor or extramural funding.

Delayed primary repair of bladder exstrophy: ultimate effect on growth.

PURPOSE: Late referrals or unsuitable bladder templates often require delayed primary repair of bladder exstrophy. We investigated longitudinal bladder growth rates and eventual outcomes following this approach. MATERIALS AND METHODS: After institutional review board approval, we reviewed the medical records of patients with classic bladder exstrophy who underwent neonatal or delayed (more than 30 days) primary closure at our institution between 1970 and 2006. Clinical characteristics and annual cystographic bladder capacity before the continence procedure were compared. Failed primary exstrophy repairs were excluded. RESULTS: A total of 33 patients with available bladder capacity measurements underwent delayed exstrophy closure due to small bladder template in 18 (88% male) and late referral in 15 (80% male) at respective median ages of 305 days (range 86 to 981) and 172 days (31 to 676). They were compared to 82 patients (71% male) undergoing neonatal closure at a median of 2 days of life (range 0 to 27). Pelvic osteotomy was performed in 32 of 33 delayed closures. Longitudinal analysis of the bladder capacities demonstrated that, compared to neonatally closed cases, bladder capacities were on average 36 ml smaller in those with delayed repair due to small templates (p = 0.01) and 29 ml smaller in those with late referrals (p = 0.13). However, the rate of bladder growth did not differ significantly among the 3 groups. CONCLUSIONS: Delayed primary repair of exstrophy does not compromise the rate of bladder growth. However, children born with smaller templates will have overall smaller capacities and are less likely to undergo bladder neck reconstruction.

Initial characterization of exstrophy bladder smooth muscle cells in culture.

PURPOSE: Previous studies have suggested that exstrophic bladder smooth muscle cells grown in culture show contractility similar to that of normal bladder smooth muscle cells. Despite this similar contractility, other cellular characteristics may vary between exstrophic and normal bladder smooth muscle cells. MATERIALS AND METHODS: Primary cultures of bladder smooth muscle cells were established from patients with bladder exstrophy (14) and vesicoureteral reflux as a control (10). Expression of smooth muscle specific α-actin and heavy chain myosin was determined with immunohistochemistry. Response of smooth muscle cells to high potassium Krebs solution or acetylcholine (0.1 mM) was assessed using a calcium sensitive fluorescent dye. Intracellular calcium concentration was measured after 48 hours in basal media. Cell migration in basal media during 24 hours was determined using transwell assays. Baseline proliferation and response to 10% fetal bovine serum were assessed with bromodeoxyuridine incorporation assays. RESULTS: More than 95% of exstrophy and control smooth muscle cells stained positive for actin and myosin. Functional integrity was verified in each exstrophy and control cell line by response to high potassium Krebs solution or acetylcholine. The intracellular calcium concentration was lower in exstrophy smooth muscle cells than in control smooth muscle cells (71 vs 136 nM, p <0.001). More exstrophy cells migrated than control cells (37% vs 18%, p = 0.004). There was no statistically significant difference in proliferation between exstrophy and control smooth muscle cells in basal or growth media. CONCLUSIONS: Cultured exstrophy smooth muscle cells demonstrate some differences in baseline characteristics compared to control cells. Differences in migration and intracellular calcium may have implications for in vivo detrusor function and tissue engineering.

Transforming growth factor-ß1 mediates migration in cultured human control and exstrophy bladder smooth muscle cells.

PURPOSE: Transforming growth factor-ß1 regulates extracellular matrix composition, and impacts function and proliferation in multiple cell types, including bladder smooth muscle cells. In this study we evaluated the response to transforming growth factor-ß1 in cultured exstrophy and control bladder smooth muscle cells. MATERIALS AND METHODS: Primary bladder smooth muscle cell cultures were established from patients with bladder exstrophy or vesicoureteral reflux. Smooth muscle specific α-actin and heavy chain myosin expression was determined using immunohistochemistry. Cell migration, intracellular calcium concentration and proliferation were determined after incubation for 24 to 48 hours in basal media, with or without transforming growth factor-ß1 (0.001 to 3 nM) or transforming growth factor-ß1 receptor inhibitor SB 431542 (10 µM). RESULTS: Cultured exstrophy and control smooth muscle cells stained positive for α-actin and heavy chain myosin. Exstrophy smooth muscle cells demonstrated increased migration compared to control smooth muscle cells at baseline (38% vs 20%, p = 0.01). Transforming growth factor-ß1 increased control smooth muscle cell migration while SB 431542 decreased exstrophy smooth muscle cell migration. Control cells had a higher intracellular calcium concentration, which decreased significantly when exposed to SB 431542. Transforming growth factor-ß1 did not cause significant changes in intracellular calcium concentration. Inhibition of transforming growth factor-ß1 receptors decreased proliferation in exstrophy and control smooth muscle cells, but exogenous transforming growth factor-ß1 did not impact proliferation. CONCLUSIONS: Our results suggest that there are distinct differences in bladder smooth muscle cell function between control and exstrophy cases which persist in culture. Although resting intracellular calcium concentration was higher in control cells, proliferation rates were similar in both cell types, indicating that lower intracellular calcium concentration did not impact growth potential. In contrast, enhanced migration was observed in exstrophy cells, possibly due to excess transforming growth factor-ß1 signaling, but seemingly independent of increases in intracellular calcium concentration.

Is pelvic osteotomy associated with lower risk of pelvic organ prolapse in postpubertal females with classic bladder exstrophy?

PURPOSE: Bladder exstrophy is a major congenital anomaly involving defects in the genitourinary tract and pelvic musculoskeletal system. It appears intuitive that closure of the pelvic ring using osteotomy would be associated with a decreased risk of pelvic organ prolapse. We investigated whether osteotomy is associated with a decreased risk of pelvic organ prolapse in females with classic bladder exstrophy. MATERIALS AND METHODS: We searched our institutional review board approved exstrophy database of 1,078 patients and identified 335 females. We excluded patients who were younger than 13 years, had cloacal exstrophy or epispadias and did not have postpubertal imaging for measurement of pubic diastasis available. Our final study population consisted of 67 females. Univariate analysis was performed using t test or rank sum test for continuous variables and chi-square test for categorical variables. Logistic regression was used for multivariate analysis. RESULTS: Median patient age was 23 years (range 13 to 60). A total of 20 patients (29.9%) had pelvic organ prolapse at a median age of 20 years (range 11 to 43). Of the 67 patients 25 (37.3%) had undergone osteotomy at a median age of 6 months (range birth to 10 years). Seven patients had at least 1 pregnancy (range 1 to 3), and 24 patients had undergone vaginoplasty. On univariate analysis only diastasis was associated with pelvic organ prolapse, with smaller diastasis associated with a decreased risk of prolapse. On multivariate analysis including diastasis and osteotomy only diastasis was statistically significant. CONCLUSIONS: Osteotomy does not decrease the risk of pelvic organ prolapse in patients with classic bladder exstrophy. Rather, degree of diastasis is significantly associated with pelvic organ prolapse.

Evaluation of pelvic floor muscular redistribution after primary closure of classic bladder exstrophy by 3-dimensional magnetic resonance imaging.

PURPOSE: We used 3-dimensional magnetic resonance imaging reconstruction to generate models of the pelvic floor musculature in classic bladder exstrophy, allowing for statistical analysis of changes seen in the anatomy after primary closure. MATERIALS AND METHODS: Patients with classic bladder exstrophy underwent pelvic magnetic resonance imaging before and after primary closure. Contours of the levator ani were mapped and measured in 3-dimensional space. In addition, 2-dimensional angles and measurements were used to make a quantitative and qualitative analysis of the pelvic floor before and after closure. RESULTS: A total of 19 cases of classic bladder exstrophy were included in the study, with 12 closed as newborns without osteotomy and 7 closed later with osteotomy. In both groups the pre-closure exstrophy pelvic floor in the axial plane was box-like and after closure it had a more inward rotation. The steepness and angulation of the levator ani muscle remained relatively unchanged in both groups. The levator ani muscle group, with and without osteotomy, was redistributed into the anterior compartment of the pelvis after closure. Postoperatively a successfully closed exstrophy had the bladder positioned deeply within the pelvis. After closure the levator ani muscle regained the expected smooth contoured shape. CONCLUSIONS: Primary closure of bladder exstrophy 1) reshapes the pelvis from a box-like configuration to a more inwardly rotated hammock, 2) redistributes a significant portion of the levator ani muscle into the anterior compartment and 3) facilitates a smooth uniform contouring to the pelvic floor. Closing the bony pelvic ring by pubic reapproximation in the newborn or by osteotomy in an infant produces similar changes in the pelvic floor.

An evaluation of perioperative surgical procedures and complications in classic bladder exstrophy patients Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P).

INTRODUCTION: Classic bladder exstrophy (CBE) repair report wide variation in success. Given the complexity of CBE care, benefit would be derived from validation of reported outcomes. Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data, this manuscript evaluates surgical complications for bladder closure and advanced urologic reconstruction in CBE patients. AIM: The primary aim of this study was to determine complication rates in the CBE population for bladder closure and advanced urologic reconstruction in national studies compared to single-institutional studies. STUDY DESIGN: Pediatric cases and complications were identified in the 2012-2019 NSQIP-P database in CBE patients who had either bladder closure or advanced urologic reconstruction. Bladder closure was further defined as early (<7 days) or delayed (>7 days). Differences were assessed using Fisher's exact test and analysis was conducted using SPSS with significance defined as p-value <0.05. RESULTS: 302 patients were included; 152 patients underwent bladder closure, and 150 patients underwent advanced urologic reconstruction. The 30-day complication rate for bladder closure is 30.3% and for advanced urologic reconstruction is 24.0% in the CBC cohort. No differences were found in the rates of NSQIP complications between early and delayed bladder closure, though significant differences (p < 0.001) were found in the rates of blood transfusion (17.9 vs 65.3%). This may be due to the different rates of osteotomy (25.0 vs 48.3%) between early and delayed bladder closure. Rates of readmission are 14.7% and rates of reoperation are 8.0% for advanced urologic reconstruction procedures. Both bladder closure and advanced urologic reconstruction had infectious issues in greater than 10% of the population. DISCUSSION: CBE surgeries nationally carry a higher risk of complications than is reported in most institutional studies. Infectious complications occur greater than 10% of the time in both bladder closure and advanced urologic reconstruction, which should be the source of additional study given the inverse relationship infections pose to surgical success in BE patients. A limitation of this study is that the data is derived from Children's hospitals that elect to participate and includes only data from 30 days after a procedure. CONCLUSION: CBE complication data for both bladder closure and advanced urologic reconstruction may be underrepresented in the literature.

Does Moses technology improve the efficiency and outcomes of standard holmium laser lithotripsy? A systematic review and meta-analysis.

Introduction: Retrograde ureteroscopy with holmium laser lithotripsy (HLL) is a standard treatment for urolithiasis. Moses technology has been shown to improve fragmentation efficiency in vitro; however, it is still unclear how it performs clinically compared to standard HLL. We performed a systematic review and meta-analysis evaluating the differences in efficiency and outcomes between Moses mode and standard HLL. Material and methods: We searched the MEDLINE, EMBASE, and CENTRAL databases for randomized clinical trials and cohort studies comparing Moses mode and standard HLL in adults with urolithiasis. Outcomes of interest included operative (operation, fragmentation, and lasing times; total energy used; and ablation speed) and perioperative parameters (stone-free rate and overall complication rate). Results: The search identified six studies eligible for analysis. Compared to standard HLL, Moses was associated with significantly shorter average lasing time (mean difference [MD] -0.95, 95% confidence interval [CI] -1.22 to -0.69 minutes), faster stone ablation speed (MD 30.45, 95% CI 11.56-49.33 mm3/min), and higher energy used (MD 1.04, 95% CI 0.33-1.76 kJ). Moses and standard HLL were not significantly different in terms of operation (MD -9.89, 95% CI -25.14 to 5.37 minutes) and fragmentation times (MD -1.71, 95% CI -11.81 to 8.38 minutes), as well as stone-free (odds ratio [OR] 1.04, 95% CI 0.73-1.49) and overall complication rates (OR 0.68, 95% CI 0.39-1.17). Conclusions: While perioperative outcomes were equivalent between Moses and standard HLL, Moses was associated with faster lasing time and stone ablation speeds at the expense of higher energy usage.

Complete primary repair of bladder exstrophy: a single institution referral experience.

PURPOSE: The reasons for referral and treatment strategies in patients who underwent complete primary repair of bladder exstrophy elsewhere in the newborn period were evaluated. MATERIALS AND METHODS: An institutionally approved database identified patients who underwent complete primary repair of exstrophy and were subsequently referred for continued care. RESULTS: A total of 10 females and 55 males were referred for treatment between 1996 and 2010. Six females and 23 males were referred for complications following initial complete primary repair of exstrophy. Female complications included dehiscence (3 patients), prolapse (2) and stricture (1). Male complications included dehiscence (10 patients), prolapse (9), pubic separation (1) and stricture (3). Nine males had posterior urethral loss and 13 had major penile soft tissue injuries. Grade V vesicoureteral reflux and severe hydronephrosis were seen in the 4 patients with urethral strictures. Patients with dehiscence or prolapse underwent successful reclosure with osteotomy. Cases with posterior urethral loss or strictures were repaired with grafts. Four females and 32 males were referred for incontinence. Nine of these patients had poor bladder capacity, of whom 5 underwent bladder augmentation with continent stoma and 4 are awaiting further bladder growth. A total of 27 patients underwent bladder neck repair, with 15 (56%) subsequently continent, 5 (19%) daytime continent with nocturnal incontinence and 7 (26%) continuously incontinent. At initial closure osteotomy had been performed in all patients who were continent following bladder neck reconstruction and in 4 of 5 who were daytime continent. CONCLUSIONS: Complications of complete primary repair of bladder exstrophy can result in undesired upper urinary tract changes and penile soft tissue loss. Surgical reconstruction of such complications and acceptable continence are attainable in select cases.

Open renal biopsy: comorbidities and complications in a contemporary series.

STUDY TYPE: Therapy (case series) Level of Evidence 4. OBJECTIVE: To report the indications and outcomes of a contemporary series of patients with contraindications to percutaneous renal biopsies (PRBs) who had an operative RB (ORB), as although ORB is a relatively infrequent procedure, it remains an important and underreported operation. PATIENTS AND METHODS: In a retrospective review of patients who had an ORB we examined comorbidities, indications, and 30-day morbidity and mortality. Preoperative comorbidities were stratified according to the Charlson comorbidity index. RESULTS: In all, 115 patients had ORB between 1991 and 2006 (mean age 48 years, range 18-83); 60% of the patients were American Society of Anesthesiologists class >or=3. The median Charlson comorbidity index score was 3, with a score of 0 in 20.9%, 1-2 in 27.8%, 3-4 in 30.4% and >or=5 in 20.9% of patients. Indications for an ORB included morbid obesity, failed PRB, coagulopathy, and solitary kidney. In all, 47.8% of patients had a serum creatinine level of <3.0 mg/dL, 34.8% of >3.0 mg/dL and 17.4% were dialysis-dependent. There were 43 complications in 36 patients. The mortality rate after surgery was 0.8%. There were eight major complications in seven patients (6.1%) including cardiac arrest, stroke, sepsis, reoperation and re-intubation. There were minor complications 34 times in 31 patients (27%), the most common being wound infection, pneumonia, intraoperative transfusion of >2 units, arrhythmia, postoperative retroperitoneal bleed, and seep vein thrombosis. CONCLUSIONS: This study shows that there are significant comorbidities in patients referred to urologists for an ORB. With a mortality rate of 0.8% and major and minor complication rates of 6.1% and 27%, respectively, the ORB, while infrequent, carries a significant risk in this population that should be included in preoperative decision making and used for patient counselling.

Volumetric and acetabular changes in the bony pelvis associated with primary closure of classic bladder exstrophy.

INTRODUCTION: Repair of classic bladder exstrophy (CBE) is known to alter dimensions of the bony pelvic ring. Pelvic volume and acetabular configuration are additional metrics which merit analysis in the reconstruction process. Advances in magnetic resonance imaging (MRI) allow for precise elucidation of such anatomy in pediatric patients, providing enhanced knowledge of how primary reconstruction may impact factors in pelvic health. METHODS: An IRB-approved exstrophy-epispadias database of 1337 patients was reviewed for patients with CBE who had pelvic MRI performed before and after repair. Pelvic MRIs were analyzed by a pediatric radiologist, and three-dimensional volumetric renderings of the true pelvis were calculated. Pre- and post-closure imaging were compared, in addition to imaging from age-matched controls without pelvic pathology. Cartilaginous acetabular index and version angles were also calculated and compared between groups. RESULTS: Eighteen patients with post-closure imaging, 14 of whom also had pre-closure imaging, and 23 control patients (ages 0-365 days) were included. The median ages at pre- and post-closure scan were 2 and 178 days, respectively. Osteotomy was performed in 6 (33%) of the closures. The median segmented pelvic volumes were 89 cm3 in the pre-closure group, 105 cm3 in the post-closure group, and 72 cm3 in the control group. At a given age, patients with CBE pre-closure had the largest pelvic volume, and those without bladder exstrophy demonstrated the smallest pelvic volumes (Summary Figure). CBE patients' pelvic volumes were overall lower following repair, relative to age (p = 0.007). Cartilaginous acetabular version angle increased following closure, with acetabular orientation converting from retroversion to anteversion in all cases. However, only acetabular version angles were significantly different between groups. DISCUSSION: This study found that pelvic volume significantly decreased relative to age following primary repair of CBE, but that it did not correct to control levels. Similarly, acetabular retroversion that is naturally seen in exstrophy patients was converted to anteversion post-closure but did not become completely normal. Knowledge of these persistent anatomical anomalies may be useful in treatment of future concerns related to exstrophy, such as continence achievement, pelvic organ prolapse, and potential gait disturbances. Lack of significant differences between study groups regarding acetabular index angles can give assurance to providers that hip dysplasia is neither a natural concern nor iatrogenically inflicted through reconstruction. CONCLUSIONS: The primary closure of exstrophy results in pelvic volumes and anteverted acetabula that more closely resemble those without bladder exstrophy, compared to pre-closure findings.

Orchiopexy for intra-abdominal testes: factors predicting success.

PURPOSE: Intra-abdominal testes can be treated with several surgical procedures. We evaluated factors influencing the outcome of orchiopexy for intra-abdominal testis. MATERIALS AND METHODS: We retrospectively reviewed 156 consecutive orchiopexies performed for intra-abdominal testis, defined as a nonpalpable testis on examination and located in the abdomen at surgery. All surgical approaches were included in the study. Primary outcome was the overall success rate and secondary outcomes were success based on surgical approach, age and a patent processus vaginalis. Success was considered a testis with normal texture and size compared to the contralateral testis at followup. Multivariate analysis was performed to determine factors predictive of success. RESULTS: The overall success rate of all orchiopexies was 79.5%. Median patient age at orchiopexy was 12 months and mean followup was 16 months. Of the patients 117 had a patent processus vaginalis at surgery. One-stage abdominal orchiopexy was performed in 92 testes with 89.1% success. Of these cases 32 were performed laparoscopically with 96.9% success. One-stage Fowler-Stephens orchiopexy was performed in 27 testes and 2-stage Fowler-Stephens orchiopexy was performed in 37 with success in 63.0% and 67.6%, respectively. Multivariate analysis revealed that 1-stage orchiopexy without vessel division had more successful outcomes than 1 and 2-stage Fowler-Stephens orchiopexy (OR 0.24, p = 0.007 and 0.29, p = 0.19, respectively). Neither age at surgery nor an open internal ring was significant (p = 0.49 and 0.12, respectively). CONCLUSIONS: The overall success of orchiopexy for intra-abdominal testis is 79.5%. While patient selection remains a critical factor, 1-stage orchiopexy without vessel division was significantly more successful and a laparoscopic approach was associated with the fewest failures for intra-abdominal testes.

Prognostic factors in T3b renal cell carcinoma.

OBJECTIVES: We reviewed our patients with pathologic T3b renal cell carcinoma (RCC) to determine which factors influenced survival in this high risk patient group. METHODS: From April 1988 to August 2006, 722 patients underwent nephrectomy for RCC at Vanderbilt University. 128 patients (17%) had T3b disease by 2002 AJCC TNM staging criteria. 31 (24%) of these patients had known metastases at the time of nephrectomy. Patient demographics, clinical, and pathological characteristics were collected. RESULTS: There were 95 men (74%) and 33 women (26%) whose median age was 64 years (range 35-87). Median follow-up was 25.2 months (0-124). Median follow-up among those still alive at last follow up was 45.8 months (2.4-114). For overall survival (OS), disease specific survival (DSS), and recurrence free survival (RFS), non-clear cell histology, grade, presence of sarcomatoid features, LN positive disease, presence of necrosis, positive margins, and metastasis present at the time of nephrectomy were all associated with worse outcomes. Race, gender, ASA class, age, and inferior vena cava (IVC) involvement were not associated with outcome. On multivariate analysis, metastasis at the time of nephrectomy, margin involvement, and the presence of necrosis were independently associated with decreased OS and DSS. The presence of necrosis and lymph node involvement were independent predictors of worse RFS. CONCLUSIONS: Our data suggests that in patients with T3b RCC, the presence or absence of macroscopic necrosis should be included as part of the pathology report to help guide prognosis in this high risk patient group.