Survey of COVID-19 impact on pediatric urology services.

INTRODUCTION: To better understand how the COVID-19 pandemic has forced rapid operational changes in the global healthcare industry, changes implemented on an individual, institutional basis must be considered. There currently is not adequate literature about the overall impact COVID-19 has had on pediatric urology services worldwide. We believe that they have dramatically decreased during the COVID-19 crisis, but have adapted to accommodate changes. We hypothesize that patient care was widely variant due to inadequate standardized recommendations or crisis planning. MATERIALS AND METHODS: A web-based survey was deployed to 377 pediatric urologists globally via email to analyze COVID-19's impact on various types of pediatric urology practices. Key categories included impacts on elective services, telemedicine use, finances, and recovery operations. A total of 114 responses were collected between April 29th - May 22nd, 2020. RESULTS: The widespread cancellation of elective surgical procedures caused significant disturbances in the field. There was a uniform, significant increase (75%) in telemedicine use across practices. The pandemic has created many changes in care provision for physicians, institutions, and patients themselves. Furthermore, the sudden economic burden on healthcare facilities could lead to cost-cutting measures, creating further strain within institutions. Though telemedicine has its limitations, it is a very viable option when traditional services are unavailable. CONCLUSIONS: Immediate steps should be taken to ensure that the recovery phases of pediatric urology practices are as efficient as possible. Institutions should develop task forces to develop critical workflow processes in the event of health crises, while still maintaining patient-centered care. This will be essential in maximizing appropriate care allocation.

Hydronephrosis From Ureteropelvic Junction Obstruction Discovered on Point-of-Care Ultrasound in Patients With Trauma.

We present 2 cases of patients with abdominal trauma who were found to have hydronephrosis on point-of-care ultrasound secondary to previously undiagnosed ureteropelvic junction obstructions. We review the ultrasound findings, technique, and relevant literature regarding renal point-of-care ultrasound and ureteropelvic junction obstruction.

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.

The Clavien-Dindo Classification of Surgical Complications is Not a Statistically Reliable System for Grading Morbidity in Pediatric Urology.

PURPOSE: Although the Clavien-Dindo classification of surgical complications has been evaluated using adult surgical patients, it is being applied to pediatric populations. We hypothesized that this instrument is not well suited to children and sought to determine the reliability of the tool in a pediatric urological population. MATERIALS AND METHODS: We replaced adult surgical cases in the "Survey to Assess Acceptability and Reproducibility of the Classification" from the original Clavien-Dindo study with pediatric urology cases and mimicked original study methods. The survey was distributed with the REDCap (Research Electronic Data Capture) tool, and Krippendorff α coefficients of reliability were calculated from the responses. RESULTS: There were 51 respondents and 40 complete responses. The Krippendorff α coefficient of reliability for the Clavien-Dindo classification (α = 0.487) did not achieve the minimum level of acceptable agreement (α = 0.667) with the pediatric urological cases, even when the disability suffix (α = 0.266) was excluded from the analysis (α = 0.632). The accuracy of the grading system with the pediatric urological surgical cases when excluding the disability suffix (410 of 550, 75%) was significantly less than the accuracy had been with the original adult cases (1,816 of 2,016, 90%, p <0.0001). While 89% of respondents (32 of 36) thought the system was appropriate for adults, only 49% (17 of 35) found it appropriate for children (p <0.001). CONCLUSIONS: The Clavien-Dindo classification of surgical complications is not a reliable tool for use in pediatric urology, where its accuracy is significantly decreased compared to adult surgical cases. Further study is needed to determine if findings are similar across all pediatric surgical groups.

24-Hour Urinary Parameters in Overweight and Obese Children with Urolithiasis.

PURPOSE: The increasing incidence of pediatric nephrolithiasis is a growing concern and its association with obesity continues to be an area of debate. We present data on urine chemistries of overweight/obese children compared to those with a normal body mass index and history of urolithiasis treated at a single institution in the United States, and assess risk factors. MATERIALS AND METHODS: We retrospectively identified 110 stone forming patients who underwent 24-hour urine collection and stratified them according to the Centers for Disease Control and Prevention definitions of overweight/obese (body mass index above 85th/95th percentile). Absolute urine collection quantities were compared between groups. Stone risk factors were analyzed according to Litholink® specified reference ranges. RESULTS: Compared to patients with low or normal body mass index, overweight and obese patients had lower body surface area adjusted citrate (242 mg/1.73 m(2) vs 315 mg/1.73 m(2), p = 0.03), lower urine phosphate (12 mg/kg vs 14 mg/kg, p = 0.04), lower urine magnesium (1.2 mg/kg vs 1.6 mg/kg, p = 0.01) and increased incidence of hypercalciuria (31% vs 11%, p = 0.02). Differences in urine citrate, phosphate and magnesium were not apparent when analyzing stone risk factors. There was no association between body mass index and urine pH. CONCLUSIONS: Overweight and obese stone forming children have decreased levels of urine citrate, phosphate and magnesium compared to patients with normal body mass index. The incidence of hypercalciuria is increased in overweight/obese patients. In contrast to findings in adults, there is no association between urine pH and body mass index.

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.

Contemporary Series of Robotic-Assisted Distal Ureteral Reconstruction Utilizing Side Docking Position.

PURPOSE: The robot-assisted approach to distal ureteral reconstruction is increasingly utilized. Traditionally, the robot is docked between the legs in lithotomy position resulting in limited bladder access for stent placement. We examined the use of side docking of the daVinci robot® to perform distal ureteral reconstruction. MATERIALS AND METHODS: A retrospective review of distal ureteral reconstruction (ureteral reimplantation and uretero-ureterostomy) executed robotically was performed at a single institution by a single surgeon. The daVinci robotic® Si surgical platform was positioned at the right side of the patient facing towards the head of the patient, i.e. side docking. RESULTS: A total of 14 cases were identified from 2011-2013. Nine patients underwent ureteral reimplantation for ureteral injury, two for vesicoureteral reflux, one for ureteral stricture, and one for megaureter. One patient had an uretero-ureterostomy for a distal stricture. Three patients required a Boari flap due to extensive ureteral injury. Mean operative time was 286 minutes (189-364), mean estimated blood loss was 40cc (10-200), and mean length of stay was 2.3 days (1-4). Follow-up renal ultrasound was available for review in 10/14 patients and revealed no long-term complications in any patient. Mean follow-up was 20.7 months (0.1-59.3). CONCLUSION: Robot-assisted laparoscopic distal ureteral reconstruction is safe and effective. Side docking of the robot allows ready access to the perineum and acceptable placement of the robot to successfully complete ureteral repair.

Timing and predictors for urinary drainage in children with expectantly managed grade IV renal trauma.

PURPOSE: We determined which children sustaining blunt grade IV renal trauma are at greatest risk for failing nonoperative management and in what time frame they will likely present. MATERIALS AND METHODS: We retrospectively reviewed children presenting with nonvascular grade IV blunt renal trauma between 2003 and 2012. We compared characteristics on computerized tomography, reasons for intervention, type and timing of surgery, length of hospital stay and need for readmission between children undergoing early intervention (less than 72 hours after admission) and those managed conservatively (with any subsequent intervention undertaken more than 72 hours after admission). RESULTS: A total of 26 children were identified with nonvascular grade IV blunt renal trauma. Conservative management was attempted in 16 cases (62%). Seven of these patients (44%) required intervention (ureteral stent and/or percutaneous drain placement), with a mean time to intervention of 11 days. Collecting system clot and larger urinoma (1.45 cm in cases with successful and 4.29 cm in those with failed conservative management) significantly predicted failure of conservative management (p<0.05). Presence of dissociated renal fragments (57% vs 11%) and interpolar contrast extravasation (57% vs 0%) were increased in the early intervention group compared to the conservatively managed group (p>0.05), as was rehospitalization (43% vs 0%), mean length of stay (7.9 vs 5.4 days) and transfusion (14% vs 0%, p>0.05). CONCLUSIONS: Collecting system hematoma and urinoma size significantly predicted failure of conservative management, with a mean time to intervention of 11 days. Children with failed conservative management had a greater incidence of dissociated renal fragments and interpolar extravasation. Early identification of these patients may decrease hospital readmissions, length of stay and prolonged morbidity.

Pelvic Neuroblastoma of the Pediatric Prostate.

Neuroblastoma accounts for a significant portion of childhood tumors and can present in a variety of ways. Pelvic neuroblastoma has been reported but few cases exist of neuroblastoma invading or originating from the bladder or prostate. We present a 4-year-old patient with pelvic neuroblastoma arising from the prostate and describe the medical and surgical management of this challenging case. While pelvic neuroblastoma may have an improved prognosis, this case demonstrates the challenging surgical decisions that accompany these patients to maintain quality of life while balancing oncologic efficacy of treatment.

Cost analysis of pediatric robot-assisted and laparoscopic pyeloplasty.

PURPOSE: An increasing percentage of pediatric pyeloplasties are being performed with assistance of the da Vinci® Surgical System. A review of the recent literature shows decreased operative times and length of hospital stays when robotic procedures are performed, although there are few published data comparing the cost of pediatric robotic and pure laparoscopic pyeloplasty. We reviewed a representative sample of pyeloplasties performed at our institution and performed a cost analysis. MATERIALS AND METHODS: We retrospectively identified 23 robot-assisted and 23 laparoscopic pyeloplasties performed at our institution between August 2008 and April 2012. Total cost was calculated from direct and indirect costs provided by our billing department. RESULTS: Robotic procedures were shorter than pure laparoscopic procedures (200 vs 265 minutes, p <0.001) but there was no significant difference in the total cost of the 2 procedures ($15,337 vs $16,067, p <0.46). When compared to laparoscopic cases, subgroup analysis demonstrated decreased operative times (140 vs 265 minutes, p <0.00001) and total cost ($11,949 vs $16,067, p <0.0001) in robotic cases where stents were placed in an antegrade fashion. CONCLUSIONS: With widespread use the cost of robotic instrumentation may decrease, and experience may further shorten operative times. However, it currently remains to be seen whether robotic technology will become a cost-effective replacement for pure laparoscopy in the management of pediatric ureteropelvic junction obstruction.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in infants.

PURPOSE: Laparoscopic pyeloplasty and open pyeloplasty have comparable efficacy for ureteropelvic junction obstruction in pediatric patients. The role of laparoscopic pyeloplasty in infants is less well defined. We present our updated experience with laparoscopic pyeloplasty in children younger than 1 year. MATERIALS AND METHODS: We retrospectively reviewed the records of all 29 infants treated with transperitoneal laparoscopic pyeloplasty for symptomatic and/or radiographic ureteropelvic junction obstruction from May 2005 to February 2012. Patients were followed with renal ultrasound at regular intervals. Treatment failure was defined as the inability to complete the intended procedure, persistent radiographic evidence of obstruction and/or the need for definitive adjunctive procedures. RESULTS: Transperitoneal laparoscopic pyeloplasty was performed in 29 infants 2 to 11 months old (mean age 6.0 months) weighing 4.1 to 10.9 kg (mean ± SD 7.9 ± 1.6). Followup was available in all except 5 patients (median 13.9 months, IQR 7.7-23.8). Mean operative time was 245 ± 44 minutes. All cases were completed laparoscopically. Three postoperative complications were reported, including ileus, superficial wound infection and pyelonephritis. Two patients had persistent symptomatic and/or radiographic evidence of obstruction, and required reoperative pyeloplasty. The overall success rate was 92%. CONCLUSIONS: Laparoscopic pyeloplasty in infants remains a technically challenging procedure limited to select centers. Our early experience revealed a success rate comparable to that of other treatment modalities with minimal morbidity.

Incidentally discovered capillary hemangioma of the prostate.

We present the case of a 69-year-old male with incidentally discovered capillary hemangiomas at radical prostatectomy. Hemangiomas of genitourinary origin are extremely rare, typically benign vascular tumors. This finding represents the first reported hemangioma within a radical prostatectomy specimen.

Prenatally Diagnosed Testicular Torsion: A Rare Condition That Causes Dilemma in Management.

BACKGROUND: Prenatal testicular torsion (PTT) is exceedingly rare in intrauterine development, often diagnosed at the time of birth and very rarely diagnosed in utero during routine gestational ultrasound. As a result, incidence is unknown, and there exists no consensus regarding the pathophysiology of this phenomenon nor universally recognized algorithms and guidelines regarding its diagnosis and management. Case Presentation. We present the case of an antenatally diagnosed torsion and our subsequent management which included ipsilateral orchiectomy and prophylactic contralateral orchiopexy via a scrotal approach. CONCLUSION: While controversy regarding surgical intervention in patients with unilateral PTT exists due to poor salvage rates-estimated to be less than 1%-the risk of anorchia is higher in affected patients due to limitations in the accuracy of detecting bilateral testicular involvement. Risk of misdiagnosis of bilaterality may lead to lasting sequelae such as infertility and devastating psychological consequences for affected patients, supporting the need for surgical exploration, as was performed in our case.