Testicular Torsion Presentation Trends before and after Pediatric Urology Subspecialty Certification.

PURPOSE: We examined testicular torsion presentation and referral trends at our institution before and after pediatric urology subspecialty certification. MATERIALS AND METHODS: We reviewed patients with testicular torsion presenting directly to our pediatric hospital emergency department ("direct") or transferred urgently from an outside institution ("referred") who underwent detorsion and orchiopexy or orchiectomy between 2005 and 2015. Presentations were considered acute (less than 24 hours) or delayed (24 hours or greater) based on time from symptom onset. Primary outcomes were case volume and presentation trends through time. Secondary outcomes were effect of presenting location and transport variables on orchiectomy rate. RESULTS: Incidence of testicular torsion increased from 15 cases in 2005 to 32 in 2015. Annual incidence of direct cases increased slightly during the study period from 12 to 17, whereas incidence of referred cases increased from 3 in 2005 to 15 in 2015. Proportion of referred acute cases markedly increased from precertification (4 of 63, 6.3%) to postcertification period (42 of 155, 27.1%; p <0.01). The majority of referred cases (59 of 83, 71.1%) presented during weekday nights or weekends compared to a minority of direct cases (59 of 135, 43.7%; p <0.01). Orchiectomy rates were similar between direct and referred cases across all study periods and were not significantly impacted by presentation location, transport distance or transport modality (all p >0.05). CONCLUSIONS: Patients with testicular torsion have been increasingly referred to our institution, with the majority presenting on weekday nights and weekends. Our data do not support routinely transferring these patients to dedicated pediatric hospitals.

Factors Associated with Delayed Presentation and Misdiagnosis of Testicular Torsion: A Case-Control Study.

We identified factors associated with delay in presentation and misdiagnosis of testicular torsion. Compared with acute cases, delayed presentations were more likely to report isolated abdominal pain, developmental disorders, and history of recent genital trauma. Failure to perform a genitourinary examination or scrotal imaging was associated with misdiagnosis.

Do healthcare disparities play a role in pediatric testicular torsion? - Analysis of a single large pediatric center.

INTRODUCTION: Healthcare disparities have been shown to impact outcomes of various acute pediatric conditions. We sought to examine the impact of race, ethnicity and insurance status on the presentation, management and outcome of testicular torsion. MATERIALS AND METHODS: A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤18 years of age evaluated in our pediatric institution's emergency room between April 2016-April 2020 with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant. RESULTS: A total of 206 patients were included. 114 (56.2%) were Black or African American (Black/AA), 43 were (21.2%) Hispanic/Latino, 22 (10.8%) were Caucasian, and 24 (11.8%) were designated as Other races. Ninety-eight (48.3%) patients had Medicaid, 90 (44.3%) had private insurance, and 15 (7.4%) patients were uninsured. Sixty-eight (33.0%) presented in a delayed fashion (>24 h). Compared to the Caucasian patients, Black/AA patients were 2.1 years (95% CI: 0.5, 3.8; P = 0.010) older at the time of presentation. When compared to those with Medicaid insurance, uninsured patients had 6.26 times (95% CI: 1.58, 41.88; P = 0.021) higher odds to be referred from an outside hospital for management. In those patients presenting acutely (<24 h, N = 138), there were no significant differences in the odds of orchiectomy for Black/AA or Hispanic/Latino patients when compared to Caucasian patients, however, the odds of orchiectomy in Other races (non-Caucasian, non-Black/AA, non-Hispanic/Latino) was significantly higher (OR: 10.38; 95% CI: 1.13, 246.96; P = 0.049). While the mean time in minutes from ED to OR was longer in those with Medicaid insurance (141 vs 125.4 private vs 115 uninsured, p = 0.042), this did not impact orchiectomy rate (39.8% vs 40.9% vs 46.7%, p = 0.88). CONCLUSIONS: We found no differences in the orchiectomy rates by race with the exception of a higher rate in the diverse and heterogeneous Other race (non-Caucasian, non-Black/AA, non-Hispanic/Latino) group. Those uninsured had a higher referral rate highlighting the potential existence of disparities for those uninsured and the need for further investigation.

Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned?

Diuresis renography (DR) is widely used in the evaluation of hydronephrosis and hydroureter in infants and children. The goal of this provocative nuclear imaging examination should be to detect the hydronephrotic kidneys at risk for loss of function and development of pain, hematuria, and urinary tract infection. The reliability of DR is dependent on the acquisition and processing of the data as well as interpretation and utilization of the results. In this review, the key concepts of standardized DR and pitfalls to avoid are highlighted.

Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion.

BACKGROUND: Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. OBJECTIVE: We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. STUDY DESIGN: Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control. RESULTS: Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137-249 min) to 127 min (IQR 100-148 min; P < 0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P = NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. DISCUSSION: In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. CONCLUSIONS: The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected.

Technetium-99m-DMSA renal cortical scintigraphy to detect experimental acute pyelonephritis in piglets: comparison of planar (pinhole) and SPECT imaging.

UNLABELLED: The purpose of this study was to directly compare the sensitivity and specificity of SPECT and pinhole imaging for the detection of acute pyelonephritis using histology as the standard of reference. METHODS: Bilateral vesicoureteral reflux of infected urine was induced in 16 piglets (32 kidneys) by unroofing the intravesical ureter and subsequently instilling a broth culture of E. coli into the bladder. DMSA scans were obtained by both pinhole and SPECT techniques at 24 hr (4 piglets), 48 hr (5 piglets), 72 hr (4 piglets) and 10 days (3 piglets) after instillation of bacteria into the bladder. Kidneys were harvested immediately after scintigraphy for histopathologic examination. Results of the SPECT images, pinhole images and histologic findings were interpreted independently in a blinded fashion. The images of each kidney were classified as positive or negative for pyelonephritis regardless of the severity and number of lesions. To evaluate accuracy of SPECT and pinhole imaging for the detection of individual lesions, each kidney was arbitrarily divided into three zones (upper, middle and lower). Image findings were then compared with the pathology results for the presence or absence of pyelonephritis in each zone. RESULTS: Histopathology revealed pyelonephritis in 24 of 32 kidneys (58 of 96 zones). The sensitivity of the DMSA scan for detection of affected kidneys was 92% for SPECT and 83% for pinhole; overall accuracy was 88% for both. The sensitivity of SPECT for the detection of affected renal zones was slightly better than pinhole imaging (91% compared with 86%), but its specificity was lower (82% compared with 95%) resulting in a similar accuracy. Excluding four piglets where scans were obtained within 24 hr after instillation of bacteria into the bladder, the sensitivity of SPECT and pinhole for the detection of affected kidneys were 95% and 90%, respectively. Their overall accuracy were 96% and 92%. In this subgroup, the sensitivity, specificity and accuracy of SPECT for the detection of involved zones were 96%, 95% and 96%, respectively. The corresponding values for pinhole imaging were 90%, 95% and 92%, respectively. CONCLUSION: Although the sensitivity of SPECT for the detection of acute pyelonephritis is slightly better than pinhole DMSA scan, the overall accuracy of these two imaging techniques is essentially the same.

Renal cortical scintigraphy in the diagnosis of acute pyelonephritis.

Comparative clinical studies have shown renal cortical scintigraphy, using technetium-99m (99mTc)-labeled glucoheptonate or dimercaptosuccinic acid (DMSA), to be significantly more sensitive than either intravenous pyelography or renal sonography in the diagnosis of acute pyelonephritis. However, due to uncertainties about the diagnostic accuracy of the clinical and laboratory parameters used in these studies, true sensitivity of renal cortical scintigraphy was unknown. Therefore, we evaluated the accuracy of [99mTc]DMSA scintigraphy in the diagnosis of experimentally induced acute pyelonephritis in piglets using strict histopathologic criteria as the standard of reference. The sensitivity and specificity of the DMSA scan for the diagnosis of acute pyelonephritis were 91% and 99%, respectively, with an overall 97% agreement between the scintigraphic and histopathologic findings. Based on the results of this experimental study, we used the [99mTc]DMSA scan as the standard of reference for the diagnosis of acute pyelonephritis, and conducted a prospective clinical study of 94 children hospitalized with the diagnosis of acute febrile urinary tract infection (UTI). The aims of this study were (1) to determine the relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, acute pyelonephritis, and renal scarring, and (2) to evaluate the diagnostic reliability of the clinical and laboratory parameters commonly used in the diagnosis of acute pyelonephritis. We documented acute pyelonephritis in 62 (66%) of 94 patients. Vesicoureteral reflux was demonstrated in 29 (31%) of the total group and in only 23 (37%) of 62 patients with acute pyelonephritis. The prevalence of P-fimbriae in the E coli isolates was 64% in the patients with acute pyelonephritis and 78% in those with a normal DMSA scan. Even in patients without reflux, P-fimbriae were found in 71% of isolates from the patients with acute pyelonephritis and in 75% of those with a normal renal scan. Follow-up DMSA scans were obtained in 33 patients with acute pyelonephritis in 38 kidneys. We found complete resolution of the acute inflammatory changes in 58% of the involved kidneys and renal scarring in the remaining 42%, including 40% of the kidneys associated with reflux and 43% of those without reflux.(ABSTRACT TRUNCATED AT 400 WORDS)

Escherichia coli virulence factors and 99mTc-dimercaptosuccinic acid renal scan in children with febrile urinary tract infection.

Correlation of virulence factors of Escherichia coli with renal inflammation documented by 99mTc-dimercaptosuccinic acid renal scan was undertaken in 59 children with febrile urinary tract infections to identify more accurately the role of bacterial virulence factors in the development of pyelonephritis. P fimbriae were present in 63% of isolates from the positive scan group and 83% of those from the negative scan group (P = 0.126). Multivariate regression analysis showed no significant role for established E. coli virulence factors in the development of pyelonephritis. The pap genome was independently associated with negative scan (P less than 0.007) and with the absence of reflux (P = 0.031). E. coli pyelonephritogenic clone O16:K1:H6 was isolated from negative scan patients and did not produce hemolysin. We conclude that P fimbriae are important in the development of febrile urinary tract infection regardless of the level of infection. Virulent E. coli clones described in prior Scandinavian urinary tract infection studies were not common causes of pyelonephritis in our patient population.

Wetting and functional voiding disorders.

Wetting and voiding dysfunction in children represent a wide spectrum of disorders ranging from uncomplicated nocturnal enuresis, which is not associated with significant uropathology, to more complicated functional voiding dysfunction, which, in the worst of cases, can result in severe deterioration of both bladder and renal function. A complete understanding and thorough evaluation of these clinical entities allow a classification that lends itself to rational and tailored therapy. Optimal response rates can be achieved only with a disciplined and well-defined approach to the evaluation and management of these children.

Diagnosis and management of teratomas and epidermoid cysts.

One can strongly suspect a benign lesion in a prepubertal child on the basis of preoperative sonographic, biochemical, and clinical evaluation; however, when considering a testis-sparing enucleation, the definitive diagnosis must be established by pathologic frozen section of the tumor. The high incidence of benign testicular lesions in the prepubertal patient, the absence of associated carcinoma in situ in prepubertal germ cell tumors, and the universally benign behavior of the specific tumors described in this article are supportive evidence for testis-sparing surgery versus orchiectomy, for these benign lesions.

Testis-sparing surgery for benign lesions of the prepubertal testis.

Testis tumors in children are more likely to be benign that those in adults, and those tumors that are malignant are associated with a much lower incidence of metastases. As a result, a less-aggressive surgical approach to pediatric lesions has evolved. A testis-sparing operation in appropriate cases has potential psychological and cosmetic advantages for the developing child, and there may be functional advantages for fertility when the child matures.

Urinary tract infections in children. Epidemiology, evaluation, and management.

Accurate documentation of UTIs in children is essential for proper evaluation and management. Urine cultures with multiple organisms or colony counts less than 50,000 to 100,000 CFU/ml should be considered suspect and require confirmation, particularly with clean-catch specimens. Children with well-documented UTIs should be evaluated based on their age and presenting symptoms. Infants and young children require imaging, usually with a cystogram and sonogram of the kidneys and bladder. Older girls with febrile UTIs and boys at any age should also be considered for urinary tract imaging. Renal cortical scintigraphy with 99mTc-DMSA has emerged as the imaging study of choice for acute pyelonephritis and renal scarring in children with UTIs. Treatment of UTIs in children ideally commences with culture-specific antimicrobial therapy, although treatment may be started in sick children before culture results are available. Short-course treatment (3-5 days) is sufficient for children with acute uncomplicated lower UTIs. Children with acute pyelonephritis require 10 to 14 days of antibiotics, which can be administered on an outpatient basis in older infants and children who are not toxic, as long as good compliance is expected. Patients with first-time UTIs who require imaging should be maintained on low-dose antibiotic prophylaxis until their workup is completed. Treatment of ABU does not seem necessary if the urinary tract is otherwise normal. Long-term antibiotic prophylaxis is indicated for children with frequent symptomatic recurrences of UTI and for those with known VUR. Diagnosis and treatment of underlying voiding dysfunction and constipation is an essential component of the successful management of UTIs in children.

Reflux uropathy.

Although much remains to be learned, most pediatric nephrologists and urologists are now in comfortable agreement with the following assumptions: (1) Most reflux (primary reflux) is due to a congenital anatomic abnormality of the bladder trigone. (2) In many instances this anomaly improves with growth and development of the child so that the reflux may cease spontaneously. In low-grade (I-II) reflux with undilated ureters, approximately 75 to 85 per cent will stop refluxing. In higher grades (III-V) with dilated ureters, the cessation rate is in the range of only 25-30 per cent. (3) Although radiologic grading is helpful in predicting the likelihood of spontaneous cessation, it is possible to improve that predictability by cystoscopic evaluation of the size, configuration, and position of the ureteral orifice plus the length of the submucosal tunnel. (4) Reflux in combination with bacteriuria can and does lead to renal scarring. (5) Renal scarring probably does not occur in patients with primary reflux and normal voiding pressures in the absence of bacteriuria. (6) Renal growth may proceed normally despite sterile reflux. (7) A few refluxing patients, perhaps 10 per cent, will have bacteriuria despite continuous antimicrobials, and these "breakthrough" infections may cause renal scars. (8) Other patients prove either unwilling or unable to comply with continuous medications and are also vulnerable to scars. (9) A successful antireflux operation may not change the recurrence rate of urinary tract infections per se, but it almost eliminates the likelihood of pyelonephritic episodes and the necessity for further continuous antibiotics. Unfortunately, in patients with intermediate grades of reflux, it is not presently known whether an early surgical correction might be more effective in allowing normal renal growth, in avoiding renal scars, and in preventing eventual hypertension, which is present as a late complication in almost 20 per cent of the patients. The data to answer this important question should ultimately be forthcoming from the current International Collaborative Reflux Study.

Older pharmacologic therapy for nocturnal enuresis.

Since the early 1960s, a number of pharmacologic agents have been used to treat children with enuresis. Success has been reported with tricyclic antidepressants (imipramine), anticholinergics (oxybutynin), and desmopressin acetate (DDAVP). Sedatives, stimulants, or sympathomimetic agents have not proved beneficial. Because treatment with medication may be effective even in children with an organic problem such as infection or neuropathy, patients should always be evaluated carefully before drug therapy is started. Of the tricyclic antidepressants, imipramine has been investigated and used the most extensively. Oxybutynin is beneficial for children with small bladder capacity and daytime enuresis. DDAVP, introduced in the 1990s, has response rates similar to those of imipramine but with fewer side effects.

Evaluation of the enuretic child.

Nocturnal enuresis is a symptom of environmental, physical, and psychosocial factors. In addition to a physical examination, the initial workup of the enuretic child should include a careful voiding, psychosocial, and family history. Studies have shown that the parents of enuretic children often have a history of enuresis. An increased incidence of enuresis has also been demonstrated in children from large families and lower socioeconomic groups. Daytime voiding symptoms (e.g., frequency, urgency, or enuresis) suggest the possibility of underlying voiding dysfunction. A complete urinalysis and urine culture also should be performed to exclude urinary infection and certain metabolic or nephrologic disorders. Finally, it is important that the treating physician understand the attitudes of both the child and the family concerning enuresis. Parents who feel that the child is at fault need to be educated and reassured. A careful, complete evaluation will allow the physician to tailor treatment to the individual child and family.

Split prepuce in situ onlay hypospadias repair: 17 years of experience.

PURPOSE: We report our 17-year experience using split prepuce in situ onlay hypospadias repair, including long-term followup of the first 100 patients initially reported on in 1998. MATERIALS AND METHODS: We identified 421 patients who underwent in situ onlay repair. Charts were retrospectively reviewed to determine preoperative management, intraoperative details and complications. RESULTS: In situ onlay repair was used to repair glanular hypospadias in 22 cases (5.2%), coronal hypospadias in 184 (43.7%), distal shaft hypospadias in 152 (36.1%), mid shaft hypospadias in 51 (12.1%), proximal shaft hypospadias in 7 (1.6%) and hypospadias in the penoscrotal region in 5 (1.2%). Repair was successful with 1 procedure in 376 patients (89.4%), which increased to 99.8% after a second procedure. Complications were defined as any problem that gave the surgeon or family reason for concern. Functional complications requiring reoperation occurred in 45 patients (10.6%). Minor complications requiring simple procedures or early postoperative evaluation occurred in 17 patients (4%). Concerns not requiring intervention occurred in 27 patients (6.4%). There were no urethral strictures. Three patients (0.7%) were lost to followup. Repair is pending in 1 patient. CONCLUSIONS: In situ onlay repair preserves the urethral plate and allows the formation of a well vascularized flap with adequate tissue to completely cover the neourethra, resulting in a low rate of major complications. With longer followup, inclusion of more mid shaft repairs and expansion to more proximal degrees of hypospadias our complication rates are higher than previously reported but there have been no urethral strictures in 17 years of experience. Since complications present at a median of 158 days (mean 570) after the procedure, long-term followup is indicated.

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center.

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.