High Infertility Rates and Pregnancy Complications in Female Physicians Indicate a Need for Culture Change.

OBJECTIVE: This survey study aims to determine the prevalence of pregnancy complications and infertility in female physicians in comparison to the general population. Risk factors, workplace environment, and education are also examined. BACKGROUND: Physicians undertake long training and have stressful work environments during optimal childbearing years. While growing literature indicates increased rates of pregnancy complications and infertility in female surgeons, the prevalence in female physicians of all specialties is unknown. METHODS: An anonymous, voluntary survey was distributed to female physicians via private physician social media groups. It queried pregnancy demographics and complications, infertility diagnosis and treatment, workplace environment, and prior education on these topics. Results were compared with general population data, between medical and surgical subspecialties, and between physicians who were and were not educated on the risks of delaying pregnancy. RESULTS: A total of 4533 female physicians completed the survey. Compared with the general population, female physicians were older at first pregnancy, more often underwent infertility evaluation and treatment, and had higher rates of miscarriage and preterm birth. During training, only 8% of those surveyed received education on the risks of delaying pregnancy. Those who were educated were significantly less likely to experience miscarriage or seek infertility evaluation or treatment. Compared with physicians in nonsurgical specialties, surgeons had fewer children, were older at first pregnancy, had more preterm births and fetal growth problems, and were more likely to be discouraged from starting a family during training and practice. CONCLUSIONS: Female physicians, particularly surgeons, have a significantly greater incidence of miscarriage, infertility, and pregnancy complications compared with the general population. The culture of medicine and surgery must continue to evolve to better support women with family planning during their training and careers.

Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study.

PURPOSE: A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. MATERIALS AND METHODS: This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy Δ%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy Δ%StO2 to diagnose testis torsion was described with ROC curves. RESULTS: Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy Δ%StO2 in the 36 patients with torsion was 2.0 (IQR -4.2 to 9.8) vs -1.7 (IQR -8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55-0.78). Near infrared spectroscopy Δ%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3-5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86-1.0) and 0.80 (95% CI 0.62-0.99), respectively. CONCLUSIONS: In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3-5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.

Bowel preparation prior to reconstructive urologic surgery in pediatric myelomeningocele patients.

INTRODUCTION: Mechanical bowel preparation (MBP) has historically been the standard of care for patients undergoing reconstructive urologic surgery, including urinary diversion. To date, several studies have examined the role of mechanical bowel preparation in postoperative outcomes in pediatric patients undergoing augmentation cystoplasty. However, these patient populations have been heterogeneous in nature, with no studies dedicated to examining the role of MBP prior to reconstructive urologic surgery in pediatric patients with myelomenginoceles. Thus, our objective was to retrospectively assess perioperative measures and postoperative complications after reconstructive urologic surgery with or without mechanical bowel preparation in pediatric myelomeningocele patients. MATERIALS AND METHODS: From 2008 to 2013, 80 patients with myelomeningocele underwent reconstructive urologic surgery involving the use of bowel. Seventy patients underwent a preoperative MBP while 10 did not. Perioperative measures and postoperative complications for these two cohorts were assessed. RESULTS: Eighty patients with myelomeningocele were identified; 70 patients underwent MBP while 10 patients did not. There were no statistically significant differences in demographics or operative time. There were no statistically significant differences in postoperative outcomes including time to first bowel movement and time to tolerating diet. There was also no significant difference in overall complication rate; patients with MBP had 31/70 (44%) complications while 2/10 (20%) of those without MBP had complications (p = 0.18). CONCLUSION: There was no significant difference in perioperative measures and postoperative complications for patients who did not receive a mechanical bowel preparation. Our findings indicate that it is safe and warranted to perform a prospective, randomized study to better characterize the risks and benefits of preoperative bowel preparation for patients with myelomeningocele.

Perioperative and Short-Term Outcomes of Robotic vs Open Bladder Neck Procedures for Neurogenic Incontinence.

PURPOSE: Complex urological reconstruction may be facilitated by the improved magnification and dexterity provided by a robotic approach. Minimally invasive surgery also has the potential advantages of decreased length of stay and improved convalescence. We reviewed perioperative and short-term outcomes between robot-assisted and open bladder neck sling/repair with catheterizable channel in patients with neurogenic bladder. MATERIALS AND METHODS: We performed an institutional review board approved retrospective chart review of all patients who underwent open or robotic bladder neck reconstruction without augmentation cystoplasty for refractory urinary incontinence between 2010 and 2014. Age at surgery, operative time, length of stay, complications within 30 days of surgery and future continence procedures (injection of bladder neck/catheterizable channel, additional bladder neck surgery, botulinum toxin A injection) were compared between the groups. RESULTS: A total of 45 patients underwent bladder neck reconstruction (open in 26, robotic in 19) with a mean follow up of 2.8 years. There was no difference in preoperative urodynamics, age at surgery or length of stay (median 4 days in each group, p >0.9). Operative time was significantly longer in the robotic group (8.2 vs 4.5 hours, p <0.001). Three patients (16%) undergoing robotic and 3 (12%) undergoing open surgery had a complication within 30 days (p >0.9). Of patients undergoing open repair 14 (56%) underwent 23 subsequent surgeries for incontinence. By comparison, 8 patients undergoing robotic repair (42%) underwent 12 additional procedures (p = 0.5). CONCLUSIONS: Although a robotic approach may take longer to perform, it does not result in increased complications or length of stay, or worsened continence outcomes.

Long-Term Outcomes of Bladder Neck Reconstruction without Augmentation Cystoplasty in Children.

PURPOSE: Bladder outlet procedures without augmentation cystoplasty remain controversial. We hypothesized that bladder outlet procedures without augmentation cystoplasty may lead to unfavorable bladder dynamics, upper tract changes and/or continued incontinence. We reviewed long-term urodynamic, upper tract and continence outcomes following bladder outlet procedures without augmentation cystoplasty. MATERIALS AND METHODS: We retrospectively reviewed all patients who underwent bladder neck reconstruction/closure/sling without augmentation cystoplasty between 2000 and 2014. Because of variation in length of followup, we calculated the cumulative incidence and proportion of cases of upper tract and urodynamic changes, augmentation cystoplasty and subsequent continence procedures. Preoperative factors were compared between patients with and without adverse outcomes. RESULTS: A total of 109 patients underwent bladder outlet procedures without augmentation cystoplasty at a mean age of 8.5 years. At a mean of 4.9 years of followup 59 patients (54%) had undergone additional continence surgery, 20 (18%) had undergone augmentation cystoplasty, 50 (46%) manifested vesicoureteral reflux or hydronephrosis and 23 (21%) had newly diagnosed or worsening renal scarring. At augmentation cystoplasty 13 of 18 patients (72%) had upper tract changes, 15 (83%) had continued incontinence and 11 (61%) had an end fill pressure of greater than 40 cm H2O. All patients had resolution of these changes after augmentation cystoplasty. Patients who had previously undergone vesicostomy or surgery for vesicoureteral reflux were significantly more likely to undergo a subsequent augmentation cystoplasty or to show upper tract changes. CONCLUSIONS: Following bladder outlet procedures without augmentation cystoplasty the estimated 10-year cumulative incidence of augmentation cystoplasty is 30%, continence procedures 70%, upper tract changes greater than 50% and chronic kidney disease 20%. Because of these risks, careful patient selection and close followup are essential if considering a bladder outlet procedure without augmentation cystoplasty.

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score.

PURPOSE: The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. MATERIALS AND METHODS: Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST. RESULTS: Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%). CONCLUSIONS: TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

Comparison of Complications of Robot-Assisted Laparoscopic and Open Appendicovesicostomy in Children.

PURPOSE: Robot-assisted laparoscopic appendicovesicostomy in children has become increasingly popular. However, the literature on this technique mainly consists of small case series with only 1 small comparison to an open cohort. We compared the number of complications and surgical revisions required with open and robotic surgery in children undergoing appendicovesicostomy at our institution. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent appendicovesicostomy by 3 surgeons between July 2002 and September 2013. Acute complications and surgical revisions were recorded and compared between groups with t-tests for continuous variables and Fisher exact test for categorical variables. RESULTS: A total of 28 open and 39 robotic appendicovesicostomies were included. At a mean followup of 2.7 years there was no difference in number of complications or reoperations (p = 0.788 and p = 0.791, respectively) between groups. Time to first reoperation was shorter in the robotic group. However, there was no significant difference between groups regarding number of patients who underwent reoperation within the first 12 months postoperatively (p = 0.346). CONCLUSIONS: Comparison of robotic and open appendicovesicostomy revealed no significant difference in the number of acute complications or reoperations between groups. However, the nature and timing of complications differed between groups.

Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation.

PURPOSE: We performed a multi-institutional assessment of the outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux in children. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation as done by 1 of 5 surgeons at Children's Medical Center, Dallas, Texas, or Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, from 2010 to 2013. Procedure failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram and/or the need for reoperation. Multivariate logistic regression was done to identify possible risk factors for failure using STATA®, version 11. RESULTS: A total of 61 patients (93 ureters) with a mean age of 6.7 years (range 0.6 to 18.0) underwent a procedure, of which 32 (52%) were bilateral. Ten patients (16%) underwent previous subureteral injection for vesicoureteral reflux. At a mean followup of 11.7 months the procedure was successful in 44 of 61 patients (72%). There were 14 cases of persistent vesicoureteral reflux (23%), 6 complications (10%) and 9 reoperations (11%). Multivariate logistic regression identified no factor that increased the risk of failure (p = 0.737). CONCLUSIONS: Compared to the literature we found a notably lower success rate for robot-assisted laparoscopic extravesical ureteral reimplantation in the hands of 5 fellowship trained, robotically experienced pediatric urologists. More than 10% of patients required at least 1 reoperation for persistent vesicoureteral reflux or a surgical complication. Our experience suggests a higher complication rate and a lower success rate for robot-assisted laparoscopic ureteral reimplantation compared to the gold standard of open reimplantation.

DNA copy number variations in patients with 46,XY disorders of sex development.

PURPOSE: Less than 50% of cases of 46,XY disorders of sex development are genetically defined after karyotyping and/or sequencing of known causal genes. Since copy number variations are often missed by karyotyping and sequencing, we assessed patients with unexplained 46,XY disorders of sex development using array comparative genomic hybridization for possible disease causing genomic variants. MATERIALS AND METHODS: DNA from unexplained cases of 46,XY disorders of sex development were tested by whole genome array comparative genomic hybridization. In cases where novel copy number variations were detected parental testing was performed to identify whether copy number variations were de novo or inherited. RESULTS: Of the 12 patients who underwent array comparative genomic hybridization testing 2 had possible copy number variations causing disorders of sex development, both maternally inherited microdeletions. One case, with a maternal history of premature ovarian failure, had a cosegregating microdeletion on 9q33.3 involving NR5A1. The other case, with a maternal family history of congenital heart disease, had a cosegregating microdeletion on 8p23.1 upstream of GATA4. CONCLUSIONS: In this cohort copy number variations involving or adjacent to known causal genes led to 46,XY disorders of sex development in 2 of 12 previously unexplained cases (17%). Copy number variation testing is clinically indicated for unexplained cases of 46,XY disorders of sex development to aid in genetic counseling for family planning.

Demographics of pediatric renal trauma.

PURPOSE: There is a lack of national data describing the demographics and nature of pediatric renal trauma. We used the National Trauma Data Bank to analyze mechanisms and grades of injury, demographics and treatment characteristics of pediatric renal trauma cases. MATERIALS AND METHODS: Renal injuries were identified by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Patients were stratified by age (0 to 1, 2 to 4, 5 to 14 and 15 to 18 years) for more specific analyses of mechanisms and grades of injury. Data reviewed included mechanisms and grades of renal injury, demographics, and setting and type of treatment. RESULTS: A total of 2,213 pediatric renal injuries were converted to American Association for the Surgery of Trauma grade. Mean ± SD age at injury was 13.7 ± 4.4 years, with 2,089 patients (94%) being 5 to 18 years old. Of the injuries 79% were grade I, II or III. Penetrating injury accounted for less than 10% of all pediatric renal injuries. A majority of patients (57%) were admitted to university hospitals with a dedicated trauma service (73%) and only 12% of patients were admitted to a pediatric hospital. A total of 122 nephrectomies (5.5%) were performed. CONCLUSIONS: Most renal trauma in children is low grade, is blunt in nature and occurs after age 5 years. The majority of these cases are managed at adult hospitals. Although most patients are treated conservatively, the rate of nephrectomy is 3 times higher at adult hospitals than at pediatric centers.

The use of autologous buccal mucosa grafts in vaginal reconstruction.

Vaginal reconstruction can be challenging when there is a paucity of tissue, as the ideal donor source has yet to be determined. Many of the existing and commonly used techniques, such as vaginal replacement with skin grafts or bowel segments, have both advantages and disadvantages. A novel technique for vaginal replacement and reconstruction is with autologous buccal mucosa, an epithelium which is an excellent tissue match to the vagina. As urologists often have extensive experience with the use of oral mucosa for urethral reconstruction, it is fitting to apply these techniques to procedures where native vaginal tissue is lacking. This review presents the existing literature as well as the author's own experience with the use of autologous buccal mucosa for a variety of vaginal reconstructive procedures.

Autologous buccal mucosa graft for repair of recurrent rectovaginal fistula.

Post-operative pediatric rectovaginal fistulas are rare, can be challenging to repair, and often recur. The versatility, ease of accessibility, vascularization, and likeness to native vaginal tissues make autologous buccal mucosal grafts a novel tissue substitute for the repair of a recurrent rectovaginal fistula after the surgical repair of anorectal malformations.

Greater Obstetric Barriers for Female Urologists Compared to Peer-Physicians.

OBJECTIVE: To determine the prevalence of pregnancy complications, infertility, and maternal support for female urologists in comparison to the general population and other female physicians. METHODS: An anonymous, voluntary survey was distributed to female physicians via private physician social media groups from June to August 2021. The survey queried pregnancy demographics and complications, infertility diagnosis and treatment, workplace environment, and prior education on these topics. Results were compared between urologists and the general population and other female physicians with Fisher exact test, chi-square with Yates's correction, or Student's t tests as indicated. RESULTS: Four thousand six hundred twelve female physicians completed the survey including 241 (5%) urologists. Compared with the general population, urologists were more likely to have a miscarriage or preterm birth, have children later in life, and undergo infertility evaluation or infertility treatment (all P < .0001). 42% of urologists reported experiencing a pregnancy complication and only 9% of those surveyed received education on the risks of delaying pregnancy. Despite being educated more often regarding the risks of delaying pregnancy compared to other physicians, urologists were less likely to have children, had fewer children, and were more likely to be discouraged from starting a family during training and practice (all P < .0001). Additionally, urologists reported shorter parental leave, worked more hours per week while pregnant, and were less likely to receive lactation accommodations compared to other female physicians (all P < .001). CONCLUSION: Education for trainees on family planning and fostering a culture of support are deficits identified in overcoming obstetric barriers in urologists.

Risk factors for mortality in children with hemorrhagic cystitis after hematopoietic transplant.

INTRODUCTION: Hemorrhagic cystitis (HC) is a devastating complication of bone marrow (BMT) and stem cell transplant (SCT). Much of the literature has focused on exclusively adult patient populations, with limited evidence regarding risk factors for mortality and morbidity among pediatric HC patients. OBJECTIVE: To examine factors associated with all-cause mortality in children with HC after BMT/SCT. METHODS: The Pediatric Health Information System database was queried for patients with ICD-9/10 codes for hematopoietic transplant and gross hematuria, hematuria unspecified, or cystitis with hematuria. Multivariable logistic regression examined association of medical and surgical interventions frequently employed for hemorrhagic cystitis with mortality and genitourinary morbidity, defined as having received instillation of any bladder medication or having undergone any genitourinary procedure. RESULTS: A total of 811 patients, mean age of 12.4 years and 62% male, were included. Primary diagnosis included 388 (49%) leukemia/lymphoma, 182 (22%) blood dyscrasia, 99 (12%) solid organ tumor, 27 (3%) metabolic disease, 115 (14%) unknown. Transplant type included 377 (46%) bone marrow, 329 (41%) stem cell, 105, and (13%) unknown. Performing any bladder instillation (p < 0.0001) or any type of GU procedure (p < 0.0001) was significantly associated with mortality. On multivariate analysis, dialysis (OR = 10.7, 95% CI = 5.7-20.2), genitourinary morbidity (OR = 4, 95% CI = 2.2-6.8) and intravenous cidofovir (OR = 2.0, 95% CI = 1.2-3.3) were significantly associated with all cause mortality. Having an underlying diagnosis of blood dyscrasia was protective against mortality (OR = 0.425, CI = 0.205-0.88). DISCUSSION: In this large retrospective study evaluating factors associated with mortality in children with HC, all cause mortality was found to be 11%. This is probably an underrepresentation of true mortality in this population, as many patients discharged from the hospital likely die outside the hospital at home or hospice care. This study supports the current literature that invasive GU procedures are not associated with increased survival in patients with severe HC. This study is limited by retrospective use of a billing database that has the potential for errors in data entry and missing data. Patients who were discharged from the hospital were not captured by the PHIS which only collects data from inpatient stays. CONCLUSIONS: Patients with HC who received dialysis, intravenous cidofovir, or underwent GU intervention had significantly higher all-cause mortality. High grade HC is a marker of disease severity and efforts should be made by urologists and oncologists to maximize quality of life and limit futile treatments in this patient population.

Prevalence of and factors associated with burnout in pediatric urology fellows.

INTRODUCTION: The 2016 AUA census found 39% of practicing urologists experienced burnout. Burnout is a syndrome of emotional exhaustion, depersonalization, and decreased feelings of personal accomplishment due to workplace stress. Despite the demands of training, little is known about the prevalence of burnout in pediatric urology fellows. OBJECTIVE: To determine the prevalence of burnout in pediatric urology fellows and factors associated with higher levels of burnout. STUDY DESIGN: The Maslach Burnout Inventory (MBI) and an anonymous survey of personal and training characteristics were distributed electronically to pediatric urology fellows in April 2023. The MBI is a standardized and validated 22-item questionnaire used to quantify burnout and is comprised of three subscales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). As per prior literature, higher scores in EE (>27) or DP (>10) were defined as high burnout. Demographic and training characteristics were compared between fellows with high and low to moderate levels of burnout with t tests and Fischer's exact tests. RESULTS: The survey response rate was 85% (29/34); 48% clinical fellows, 52% research fellows. Mean age of respondents was 31.4 years (SD 2.6), 59% female, 70% married, and 37% a parent. Mean scores for EE, DP, and PA were 15 (SD 10.2), 4 (SD 4.0), and 39 (SD 10.3), respectively, with no significant difference between year in fellowship. Nineteen percent of fellows met criteria for high burnout and 41% met criteria for moderate to high burnout based on EE or DP scores. Factors significantly associated with high burnout included number nights of call per month and number of projects required to complete in fellowship. Strategies fellows used most to combat burnout included quality time with family and friends, sleep, exercise, and watching TV/movies. DISCUSSION: Nearly 20% of pediatric urology fellows scored for high levels of burnout and over 40% scored for moderate to high levels of burnout. There appears to be an association with increased call and project workload requirements with increased levels of burnout, and efforts to combat burnout could specifically address these factors. Fellows with more children at home had lower levels of burnout, and many trainees described quality time with family and friends as their preferred strategy to prevent burnout. CONCLUSION: This survey-based study identifies risk factors for burnout in pediatric urology fellows. Fellows can use the information presented to consider personalized strategies to prevent burnout through training and into their careers.

Comparison of midurethral sling outcomes with and without prolapse repair.

INTRODUCTION: To compare the outcome of single incision and retropubic midurethral slings when performed with and without concomitant repair of pelvic organ prolapse (POP). MATERIALS AND METHODS: A retrospective chart review was conducted of all midurethral slings performed with and without concomitant POP repair by a single provider from September 2008 to April 2010. Prolapse was repaired transvaginally with light-weight polypropylene mesh or robotically via sacrocolpopexy based on the nature of the prolapse and surgeon preference. Success of the sling procedure was defined as complete resolution of leakage or great improvement of leakage based on the Patient Global Impression of Improvement score. RESULTS: Eighty-nine patients underwent a midurethral sling procedure. Forty-five patients received a single incision sling, 18 of which had concomitant POP repair. Forty-four received a retropubic sling, 16 of which had concomitant POP repair. Successful treatment of SUI in the single incision sling group was 89% (24/27) which was not significantly different from the retropubic only sling group 93% (26/28), p = 0.61. However, a significant difference was seen in the successful treatment of SUI in the single incision sling plus prolapse repair group 67% (12/18) versus the retropubic sling plus prolapse repair group 94% (15/16), p = 0.05. CONCLUSION: We found a higher incidence of single incision mid-urethral sling failure when done at the same time as repair of pelvic organ prolapse in comparison to sling placement alone. There is no difference in the success of retropubic slings when done with or without concomitant prolapse repair.

Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway.

INTRODUCTION/BACKGROUND: Urolithiasis is an increasingly common condition seen in children with an annual incidence of 2-3% in children under 18, and up to 10% in adolescents. Treatment of stones varies including observation, IV hydration, pain management, medical expulsive therapy (MET), or surgery. Though well-studied and often used in adults, MET (alpha-adrenergic antagonists to facilitate passage of ureteral stones), is not routinely prescribed in pediatric patients. OBJECTIVE: The goals of this study were to review a quaternary children's hospital's emergency room frequency of MET utilization for ureterolithiasis as well as evaluate the clinical outcomes of children who were prescribed MET compared to those treated with pain control alone. STUDY DESIGN: A retrospective review was performed of children 2 months to 18 years with ureterolithiasis who presented to a quaternary children's hospital ED from 2011 to 2017. The primary outcome was the frequency of MET prescribed. Secondary outcomes included the following comparisons in patients who received MET and analgesics with those who received analgesics alone: hospital admission rate, length of hospitalization, emergency room re-presentation rate, surgical intervention, spontaneous stone passage, urology consultation, how the urology consult affected MET utilization, referral to outpatient urology and nephrology clinics, and CT utilization in the ED. Comparisons were performed utilizing Fischer's exact and t-tests. RESULTS: 139 patients were included with a mean age of 14 years (SD 4.14), 42% male. There was no difference between age, gender, stone size, return to the ED, serum creatinine, or length of hospitalization (if admitted) between patients who were and were not placed on MET. The rate of stone passage was significantly higher for those placed on MET (45%) versus not (20%) (p = 0.0022). Urology was consulted for 93% of the cases where children were prescribed MET, compared with only 52% of cases where MET was not prescribed (p = <0.0001). DISCUSSION: In our experience MET was significantly underutilized in patients where urology was not involved. This is similar to a study by Itano et al. which found urology consultation in the ED significantly increased use of tamsulosin for ureterolithiasis in adults. Children with ureterolithiasis placed on MET had a significantly higher rate of stone passage compared to children managed by pain control alone. CONCLUSION: Given the benefits of MET to increase the rate of spontaneous stone passage it may be considered first line therapy for treatment of children with ureterolithiasis.

Lack of Medicaid Coverage of Routine Newborn Circumcision Leads to Increased Operative Circumcisions, Chordee Procedures, and Balanitis.

OBJECTIVE: To compare proportions of newborn circumcisions, operative circumcisions, chordee procedures, and cases of balanitis in states where Medicaid covers newborn circumcision (covered states) versus states that do not (noncovered states) using the pediatric health information system database. METHODS: A retrospective review of pediatric health information system data was conducted from 2011 to 2020. The proportions and median ages of newborn circumcision current procedural terminology (CPT 54,150, 54,160), operative circumcision (CPT 54,161), chordee (CPT 54,360), and balanitis (ICD-9 607.1, ICD-10 N48.1, N47.6) were compared in covered versus noncovered states. RESULTS: A total of 118,530 circumcisions were reviewed. Covered states had significantly higher proportions of circumcision overall (9.7% vs 7.1%, P < 0.0001). Noncovered states had significantly higher proportions of Medicaid-covered operative circumcisions (54.9% vs 47.7%, P < 0.0001). Compared to covered states, noncovered states had significantly higher median ages of all types of circumcisions. Noncovered states also had higher numbers of balanitis cases and double the incidence of balanitis compared with covered states. The median age of chordee (1.07 vs 0.79 years, P < 0.0001) and proportion of chordee repairs (15.2% vs 12.9%, P < 0.0001) were also significantly higher in noncovered states. CONCLUSION: The lack of Medicaid coverage of circumcision increases the number of foreskin procedures done in the operating room. In addition, in states without Medicaid coverage of circumcision, there is an increased burden of disease related to the foreskin. These findings represent a need to further investigate the costs of healthcare associated with Medicaid coverage of circumcision or the lack thereof.

Bladder capacity on preoperative urodynamics may impact outcomes on transobturator male slings.

AIMS: Stress incontinence is frequently seen after prostate surgery. We sought to evaluate preoperative urodynamic (UDS) parameters on functional outcomes after transobturator male sling placement. METHODS: 49 male patients with stress urinary incontinence (SUI) after radical prostatectomy or transurethral resection of the prostate underwent transobturator sling (TOS) placement from December 2008 through June 2011 (AdVance® and Virtue®). A retrospective review was performed of those patients who underwent preoperative UDS and had a minimum of 6 weeks of follow up. In total 38 patients were identified. There were 28 patients considered a success and 10 patients considered a failure. We then evaluated the preoperative UDS parameters between these two groups to identify potential adverse parameters. RESULTS: Overall success rate was 74% (28/38) with an average follow up of 3 months. Comparing the success and failure groups there was no difference between the pre-operative parameters. On pre-operative UDS, only bladder capacity was found to be significantly lower in those who failed TOS. Univariate comparisons of sling outcomes stratified by bladder capacity tertiles was performed. These values were chosen as they represented the 25th, 50th, and 75th percentiles, respectively. All patients (10/10) with bladder capacities in the top tertile experienced success with the sling, compared to only 62% and 50% of patients in the 50th and 25th tertiles, respectively; these differences were significant (Fisher's exact P-value = 0.044). CONCLUSION: TOS is an effective therapy for men with SUI. Bladder capacity based on pre-operative UDS may impact the success of the procedure.

Early outcomes of the transobturator male sling based on body mass index.

INTRODUCTION: Little is known regarding factors that contribute to the long term success or failure of the transobturator male sling for stress urinary incontinence. The objective of this study was to compare the outcomes of the transobturator male sling for stress urinary incontinence based on body mass index (BMI). MATERIALS AND METHODS: A retrospective review was performed of 31 transobturator male slings placed at a single institution from 2008 to 2010. Success of the procedure was defined as resolution of leakage or great improvement of leakage by the Patient Global Impression of Improvement scale and lack of urinary leakage on postoperative physical exam. Patients were divided into one of three groups: ideal weight (BMI 18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (> 30 kg/m(2)). Outcomes and complications were compared between groups. RESULTS: Etiology of urinary incontinence was radical prostatectomy in 28 patients and a transurethral procedure for infection or benign prostatic hypertrophy (BPH) in 3 patients. Successful treatment of incontinence was significantly higher in the ideal weight (7/8 or 88%) and overweight group (13/14 or 93%) in comparison to the obese group (4/9 or 44%), (p = 0.019). Postoperative complications were similar between groups. CONCLUSIONS: Obese patients had lower success rates after transobturator sling in comparison to ideal and overweight patients. We feel this may be due to increased intra-abdominal pressure transmission to the bladder, urethra, and sling itself. These patients may be better candidates for an artificial urinary sphincter or should be counseled to undergo pre-preoperative weight loss to improve sling outcomes.