Robot-Assisted Laparoscopic Ureteral Reimplantation in Pre-Toilet Trained Children with Vesicoureteral Reflux.

OBJECTIVES: To evaluate the outcomes of pre-toilet trained children undergoing RALUR for the treatment of primary VUR at our institution and compare these to an older cohort. MATERIALS AND METHODS: This retrospective study analyzed data from a single institution's registry, comparing outcomes between pre-toilet trained and toilet trained children who underwent RALUR for primary VUR. Preoperative parameters, surgical details, and postoperative outcomes were evaluated. RESULTS: The study included 158 patients, with 24 in the pre-toilet trained group and 134 in the toilet trained group. Both cohorts exhibited similar demographics and preoperative characteristics. Operative times, complication rates, and surgical outcomes were comparable between the groups, despite the pre-toilet trained group presenting with more severe VUR grades. Incidence of febrile UTI after surgery and need for further intervention did not significantly differ between the cohorts. CONCLUSION: The current study demonstrates the feasibility, success, and safety of RALUR in pre-toilet trained compared to toilet-trained children and thus support the stance that it is a viable alternative to open surgery.

Ureteroscopy for stone disease in pediatric patients with neurogenic bladder: A single institution case-control study.

INTRODUCTION: Ureteroscopy (URS) for urolithiasis in pediatric patients may be particularly challenging for patients with co-morbidities that increase the risk for stone formation and recurrence. Patients with neurogenic bladders (NGB) and/or patients that are non-ambulatory are reported to have higher rates of additional comorbidities and a particularly increased risk of developing urolithiasis, and higher rates of infections and post-operative complications. OBJECTIVE: To report outcomes of URS for stone disease in pediatric patients with NGB and/or non-ambulatory status and compare these outcomes to patients without these co-morbidities. METHODS: An IRB-approved prospective single institutional registry was used to retrospectively identify all patients under 18 years of age who underwent URS for stone disease between July 2012 and July 2021, excluding bladder stones. Patients were categorized in two groups: patient with NGB with or without non-ambulatory status versus all other patients (control). Baseline demographics, pre-operative radiologic imaging, intra-operative details, and post-operative outcomes including 30-day complications were aggregated and compared between the two groups. RESULTS: 275 URS in 198 patients were performed during the study period, and 49 (18 %) of these were performed on patients with NGB. Pre-operative imaging showed significantly higher number of stones (3 vs 2, p = 0.003) and larger total stone burden in patients with NGB than those without NGB (15 mm vs 9 mm, p = 0.009). Patients with NGB had a significantly longer length of procedure (86 vs 60 min, p = 0.002), increased need for staged procedures, increased length of stay (1 vs 0 days, p < 0.001), and increased use of an extended duration of antibiotics prior to the procedure (<0.001). There was no difference in need for passive dilation, stent placement, or other intra-operative parameters. There was no statistical difference in the incidence of 30-day complications between the two groups post-operatively. However, there was a higher incidence of febrile UTIs (8.2 % vs 1.3 %, p = 0.021) in patients with NGB and a lower incidence of pain related complications (0 % vs 9.3 %, p = 0.032). Patients with NGB had a higher incidence of requiring ipsilateral URS for recurrent stone disease within a year of surgery (34.6 % vs 18.9 %, p = 0.01). CONCLUSION: The results show that URS for urolithiasis can be done safely and effectively in pediatric patients with neurogenic bladders. The increased risk of infectious complications within 30 days of surgery warrants careful pre- and post-operative antibiotic care plan for this patient population.

Think before you pop: Outcomes of non-operative management of ureteroceles.

INTRODUCTION/BACKGROUND: Ureteroceles are often diagnosed antenatally and incidentally and treated in a minimally invasive fashion with endoscopic puncture. Recent literature suggests that observation, or non-operative management, is an effective and viable management option in select patients with ureteroceles and certain radiologic findings, however there is no consensus on how to best select patients for non-operative management. OBJECTIVE: To 1) determine if pediatric ureteroceles managed non-operatively require less or sooner secondary surgical intervention than those managed with up-front incision, 2) describe characteristics of success and failure in pediatric ureteroceles managed non-operatively, and 3) identify risk factors associated with receiving intervention and time to intervention. RESULTS: Of 287 ureteroceles, 65 (23%) were managed non-operatively and underwent secondary surgical intervention less frequently (9% vs. 34%, P < 0.01) and later (median age 40 vs. 20 months) than those managed with puncture. Successful non-operative management was associated with fewer comorbidities, smaller ureterocele size, absence of vesicoureteral reflux (VUR) and high-grade VUR, single collecting system, lesser degree of hydronephrosis, ipsilateral MCDK and intravesical location. For all ureteroceles, high-grade VUR, duplex system, and female sex were associated with shorter time to secondary intervention (intervention after initial management). DISCUSSION: In the largest retrospective review of ureterocele management, smaller ureterocele size, absence of high-grade VUR, single system, ipsilateral MCDK and minimal hydronephrosis were factors that increased the efficacy of non-operative management of select pediatric ureteroceles. Furthermore, time to event analysis showed that non-operative management did not predispose patients to sooner secondary intervention (Figure). Lack of a standardized protocol for ureterocele management is a limitation of this single institution retrospective study as it introduces selection bias to the results, however few patients with low risk characteristics underwent puncture and no high risk patients were observed. CONCLUSION: Smaller ureterocele size, absence of high-grade VUR, single system, ipsilateral MCDK and minimal hydronephrosis are factors that may increase the efficacy of non-operative management of select pediatric ureteroceles, which may delay or avoid secondary surgical intervention.

Is robot-assisted appendicovesicostomy equivalent to the current gold standard open procedure? A comparative analysis.

INTRODUCTION: Robot-assisted Laparoscopic Appendicovesicostomy (RALAPV) is increasingly performed as a minimally invasive alternative to the open appendicovesicostomy (OPAV), but questions remain regarding the efficacy of the RALAPV compared to OPAV. OBJECTIVE: To assess and compare outcomes for non-augmented RALAPV to the open surgical approach. MATERIALS AND METHODS: An IRB approved prospective registry was retrospectively examined to abstract all patients who underwent APV without augment between 2012 and 2023. Baseline demographics, intra and post-operative characteristics, and long-term outcomes were aggregated and compared. P-values were two sided and a p-value <0.05 was considered statistically significant. RESULTS: 52 children were identified, 19 (36.5%) OAPV and 33 (63.5%) RALAPV. The median age at surgery was 8.5 years for OAPV and 9.3 years for RALAPV (p = 0.29). Longer operative time was noted in the RALPAV group (346 min vs 289 min, p = 0.04), with a lower estimated blood loss (5 cc vs 30 cc, p = 0.003), shorter median length of hospital stay (4 days vs 5 days, p = 0.07), and lower IV morphine administration (0.04 mg/kg/d vs 0.09 mg/kg/d, p = 0.01). Similar surgical reintervention rate was seen in both cohorts (42% OAPV vs 36% RALAPV, p = 0.77). At the end of follow-up, continence was achieved in 18 (95%) OAPV and 33 (100%) RALAPV patients (p = 0.37) CONCLUSIONS: RALAPV shows comparable success to patients who underwent OPAV procedures. The longer follow-up interval for OPAV highlights minimally invasive surgery as a recent adoption.

Does socioeconomic opportunity impact distal hypospadias surgical outcomes or post-operative care?

INTRODUCTION: Complications following hypospadias repair are common and several risk factors have been implicated such as penile biometrics and surgeon experience. Less well understood is that impact that social determinants of health have on hypospadias outcomes. OBJECTIVE: Anatomic and technical factors have been identified that contribute to complications; however, the impact that social determinants of health have on outcomes remains unclear. We hypothesized that the development of complications following distal hypospadias repair in children is negatively associated with the presence of resources and conditions necessary for development. METHODS: A retrospective analysis of children ≤18 years who underwent distal hypospadias repair from January 2016 to December 2022 was performed. Patients with <30 days follow-up were excluded from the primary analysis. The COI (Childhood Opportunity Index), calculated from residential address, was used as a measure of the resources and conditions present in a community necessary for healthy child development. The primary outcome was the presence of post-operative complications and the association of complications with COI. The secondary outcome was the association of COI and race with loss of follow-up (defined as no follow-up after 30 days post-operatively). Univariate and multivariable logistic regression analyses were used to assess the association of complications with COI, insurance status, anatomic, and technical factors. RESULTS: 938 patients were identified, of which 166 were lost to follow-up. The overall complication rate was 14.1%. There was no significant difference in COI, insurance type, race, or primary language between patients with and without complications (p > 0.05). Glans width, degree of chordee, and repair type were associated with complications on univariate regression analysis (p < 0.01) and glans width and degree of chordee were significant on multivariate analysis (p < 0.01). COI was not significant on univariate or multivariate analysis. Lower COI, non-white race, and government insurance were associated with lack of follow-up (p < 0.01) (Summary figure). DISCUSSION: Socioeconomic opportunity is not an independent risk factor for complications after distal hypospadias repair; complications are impacted by anatomic factors and repair type. However, children with a lower COI were more likely to be lost to follow-up, and thus complications in this group may be underreported. CONCLUSION: While socioeconomic opportunity does not appear to be a risk factor in the development of complications after distal hypospadias repair, non-white children and those with lower COI were more likely to be lost to follow-up and without proper follow-up this group has an unknown true complication rate.

Outcomes of robot-assisted laparoscopic pyeloplasty among pediatric patients with complex renal anatomy: A retrospective comparative study.

INTRODUCTION: Robot-assisted laparoscopic pyeloplasty (RALP) has been increasingly utilized in the treatment of pediatric ureteropelvic junction obstruction (UPJO) with reported success rates of >95%. Complex renal anatomy can make some cases challenging to reconstruct. OBJECTIVE: To evaluate outcomes of children undergoing RALP with aberrant renal anatomy and compare it to those with simple renal anatomy. METHODS: An IRB approved prospective registry was queried to retrospectively identify all patients who underwent robotic pyeloplasty at our institution from 2012 to 2022. Patients undergoing re-do pyeloplasty were excluded. Complex anatomy was defined as horseshoe kidney, ectopic/pelvic kidney, duplex collecting system, fully bifid renal pelvis and severe malrotation (≥180°). A comparative analysis of baseline demographics, pre-operative clinical/radiological characteristics, intra and post-operative details, and long-term success was performed between those patients with complex anatomy and those without. RESULTS: Of 405 total robotic pyeloplasty's, 375 patients (378 total pyeloplasty; 353 simple, 22 complex) met inclusion criteria. 27 re-do were excluded from analysis. The complex pyeloplasty cohort included 9 horseshoe kidneys, 8 duplex collecting systems, 3 ectopic/pelvic kidneys and 2 kidneys with severe malrotation. There was no difference in age (58 vs 31 months; p = 0.38), procedure time (203 vs 207 min; p = 0.06), length of stay (1.4 vs 1.3 days; p = 0.99), or success (91.6% vs 100%; p = 0.24) between the simple and complex groups. Etiology of obstruction differed significantly between groups - high insertion was more common (3.9% vs 18.2%, p = 0.02) and intrinsic narrowing was less common (60.1% vs 36.4%, p = 0.04) in patients with complex anatomy. A multivariate logistic regression was adjusted for age, gender, etiology of obstruction, preoperative differential renal function and post-operative complications and found no difference in success between complex and simple RALP. DISCUSSION: The findings showed no significant differences in age, procedure time, length of hospital stay, or success rates between the two groups. Specifically, the success rates were 91.6% for the complex group and 100% for the simple group (p = 0.24), indicating comparable efficacy. However, the etiology of obstruction varied significantly, with high ureteral insertion more common in the complex anatomy group (18.2% vs. 3.9%, p = 0.02) and intrinsic narrowing less common (36.4% vs. 60.1%, p = 0.04). Despite these differences, multivariate logistic regression, adjusted for confounders, confirmed no difference in success rates between the groups. CONCLUSION: RALP is a safe and efficacious approach in patients with complex anatomy with success rates comparable to index patients. High ureteral insertion does appear to be more common in patients with complex anatomy undergoing pyeloplasty.

The missed crossing vessel during open pyeloplasty: a potential advantage of the robot-assisted approach in children.

OBJECTIVE: To investigate whether the panoramic view offered by robot-assisted laparoscopic pyeloplasty (RALP) reduces the likelihood of missing a crossing vessel compared to open pyeloplasty in cases where initial pyeloplasty fails. METHODS: A single institution redo-pyeloplasty database was reviewed for children treated between January 2012 to July 2023. Clinical history, imaging and operative details were reviewed to identify the etiology for the redo procedure. RESULTS: Cohort consisted of 45 patients undergoing a redo RALP during the study period. 29 of 45 patients had an initial open surgical approach, whereas 16 had an initial RALP. 10 patients were noted to have a missed crossing vessel on redo pyeloplasty - 9 had an initial open approach whereas 1 had an initial RALP (p<0.0001). CONCLUSIONS: RALP may reduce the risk of missing a crossing vessel due to the panoramic view of the surgical field intrinsic to an intraperitoneal RALP approach.

Unmasking Ureteral Polyps: Insights From a Case Series.

Fibroepithelial polyps in the urinary tract are a rare cause of obstructive uropathy with fewer than 130 cases reported in the literature. In our series, we describe polyps that were missed on preoperative imaging and later found in the operating room during pyeloplasty. It is critical for urologists to be aware of polyps as a potential source of obstruction as they can increase the complexity of a reconstruction and, if missed, may result in a failed repair and persistent obstruction. We hypothesize that performing a retrograde pyelogram prior to ureteric reconstruction will facilitate diagnosis prior to surgical repair.

Multi-Institutional Bladder Exstrophy Consortium After 8 Years: The Short- and Intermediate-Term Outcomes.

PURPOSE: Bladder exstrophy (BE) poses challenges both during the surgical repair and throughout follow-up. In 2013, a multi-institutional BE consortium was initiated, which included utilization of unified surgical principles for the complete primary repair of exstrophy (CPRE), real-time coaching, ongoing video capture and review of video footage, prospective data collection, and routine patient data analysis, with the goal of optimizing the surgical procedure to minimize devastating complications such as glans ischemia and bladder dehiscence while maximizing the rate of volitional voiding with continence and long-term protection of the upper tracts. This study reports on our short-term complications and intermediate-term continence outcomes. MATERIALS AND METHODS: A single prospective database for all patients undergoing surgery with a BE epispadias complex diagnosis at 3 institutions since February 2013 was used. For this study, data for children with a diagnosis of classic BE who underwent primary CPRE from February 2013 to February 2021 were collected. Data recorded included sex, age at CPRE, adjunct surgeries including ureteral reimplantations and hernia repairs at the time of CPRE, osteotomies, and immobilization techniques, and subsequent surgeries. Data on short-term postoperative outcomes, defined as those occurring within the first 90 days after surgery, were abstracted. In addition, intermediate-term outcomes were obtained for patients operated on between February 2013 and February 2017 to maintain a minimum follow-up of 4 years. Outcomes included upper tract dilation on renal and bladder ultrasound, presence of vesicoureteral reflux, cortical defects on nuclear scintigraphy, and continence status. Bladder emptying was assessed with respect to spontaneous voiding ability, need for clean intermittent catheterization, and duration of dry intervals. All operating room encounters that occurred subsequent to initial CPRE were recorded. RESULTS: CPRE was performed in 92 classic BE patients in the first 8 years of the collaboration (62 boys), including 46 (29 boys) during the first 4 years. In the complete cohort, the median (interquartile range) age at CPRE was 79 (50.3) days. Bilateral iliac osteotomies were performed in 89 (97%) patients (42 anterior and 47 posterior). Of those undergoing osteotomies 84 were immobilized in a spica cast (including the 3 patients who did not have an osteotomy), 6 in modified Bryant's traction, and 2 in external fixation with Buck's traction. Sixteen (17%) patients underwent bilateral ureteral reimplantations at the time of CPRE. Nineteen (21%) underwent hernia repair at the time of CPRE, 6 of which were associated with orchiopexy. Short-term complications within 90 days occurred in 31 (34%), and there were 13 subsequent surgeries within the first 90 days. Intermediate-term outcomes were available for 40 of the 46 patients, who have between 4 and 8 years of follow-up, at a median of 5.7 year old. Thirty-three patients void volitionally, with variable dry intervals. CONCLUSIONS: Cumulative efforts of prospective data collection have provided granular data for evaluation. Short-term outcomes demonstrate no devastating complications, that is, penile injury or bladder dehiscence, but there were other significant complications requiring further surgeries. Intermediate-term data show that boys in particular show encouraging spontaneous voiding and continence status post CPRE, while girls have required modification of the surgical technique over time to address concerns with urinary retention. Overall, 40% of children with at least 4 years of follow-up are voiding with dry intervals of > 1 hour.

Male epispadias repair: Outcomes at three sites prior to the establishment of a multi-institutional collaboration.

INTRODUCTION: Epispadias, which occurs on the more mild end of the Bladder Exstrophy Epispadias Complex (BEEC) spectrum, presents still with a wide range of severity in boys, from mild glanular epispadias to penopubic epispadias with severe urethral and bladder neck defects. Surgical management ranges from isolated epispadias repair to epispadias repair with bladder neck reconstruction (BNR) with or without pelvic osteotomies. OBJECTIVES: We aimed to evaluate outcomes in epispadias treated at three institutions prior to formation of a formal collaboration. In addition, we sought to delineate outcomes based on anatomic severity at time of diagnosis, and initial procedure performed in cases of penopubic epispadias. METHODS: IRB approved databases were retrospectively queried at three institutions for patients who underwent repair of epispadias between 1/1993 and 1/2013. Degree of epispadias, age and technique at initial repair, and self-reported continence status at last follow-up were recorded. Continence was categorized as: wet, intermediate (dry 2-3 h), or dry, while also distinguishing those who void and those who require clean intermittent catheterization (CIC). Those not seen since 1/1/2015, younger than 10 years at last follow up, or in whom continence data were not recorded were excluded. RESULTS: A total of 48 boys were identified; 36 met inclusion criteria. The epispadias cohort consisted of 8 glanular epispadias (GE) (22%); 8 penile epispadias (PE) (22%), and 20 penopubic epispadias (PPE) (56%) with a median follow-up of 11.3 years (3.2-26.2 years). Overall, 33 of 36 (92%) boys void per urethra. Within the group that voids, 19/33 (58%) are completely dry, while 6/33 (18%) are wet. Among patients who underwent initial epispadias repair without concurrent or subsequent bladder neck reconstruction, continence rates were: GE 63% (5/8); PE 75% (6/8); PPE 71% (5/7). Among the 9 boys with PPE who underwent initial epispadias repair with concurrent BNR, 22% (2/9) were dry with no further surgeries. Overall, 8/20 (40%) of boys with PPE void with complete dryness. DISCUSSION: This multi-center retrospective review of continence in epispadias demonstrates that even some boys with glanular and penile epispadias can have challenges with continence, and boys with penopubic epispadias may remain wet despite careful preoperative assessment of bladder neck functionality and concurrent BNR. CONCLUSION: Continence outcomes in boys with all degrees of epispadias can be variable. Even boys with more distal defects may have significant bladder neck deficiency. And those with the most severe form of epispadias may require bladder neck reconstruction to achieve continence.

Prenatal Presentation of a Covered Cloacal Exstrophy Variant; Early Diagnostic Challenges Within the Broad Spectrum of the Exstrophy-Epispadias Complex.

There is a broad range of variant phenotypes that can occur within the bladder exstrophy and epispadias complex spectrum. Accurate prenatal detection helps prepare families and to coordinate subspecialty resources. Here, we present the case of a patient with prenatally diagnosed patient with covered cloacal exstrophy variant along with four additional cases illustrating the nonlinear spectrum from isolated epispadias to cloacal exstrophy. Given the rarity of these variants overall and of each subtype within the spectrum, there is a need for long-term multi-institutional outcomes data to improve detection, characterization, and prognostication for these patients.

Pelvic Ectopic Kidney Prevalence and Pressure Changes During Cloacal Exstrophy (Omphalocele-Exstrophy-Imperforate Anus-Spinal Defects Syndrome) Closure.

OBJECTIVES: To assess the prevalence of pelvic ectopic kidneys (PEK) and compare renal parameters of the PEK to the orthotopic kidney following pubic bone approximation. METHODS: In four Omphalocele-Exstrophy-Imperforate Anus-Spinal Defects Syndrome (OEIS) patients undergoing second-stage repair with known pelvic and orthotopic kidneys, changes in the renal pelvis pressure (RPP), peak systolic velocity (PSV), and resistive index (RI) were measured in the pelvic and orthotopic kidneys following pubic bone approximation. A paired t-test was performed for analysis. Prevalence was tabulated using a multi-institutional retrospective review. RESULTS: Mean rise in RPP was +26.0 mmHg in the PEK and +10.3 mmHg in the orthotopic kidney (P = .55). One patient had immediate increase in RPP of 66 mmHg in the PEK (7 mmHg in the orthotopic kidney) which decreased to +17 mmHg in the PEK upon release of the pubic approximation stitch. Mean change in PSV was +67.7 cm/s in the PEK compared to - 25.7 cm/s in the orthotopic kidney (P = .09). Mean change in renal RI was + 0.06 in PEK compared to - 0.01 in the orthotopic kidney (P = .29). Among 80 OEIS patients, 24 (30%) had a PEK. 3 (4%) had a solitary PEK. CONCLUSION: During second-stage OEIS closure, we witnessed patterns of higher change in RPP, PSV, and RI of the PEK compared to the orthotopic kidney. Furthermore, PEKs were found in nearly a third of our OEIS patients. Real-time RPP monitoring, especially those with solitary PEK, may aid in the management of OEIS patients during the perioperative period.

Does Preoperative Testosterone Administration Decrease Complications in Distal Hypospadias Repair With Urethroplasty?

PURPOSE: Testosterone administration prior to hypospadias repair is common practice among pediatric urologists; however, its impact on surgical outcomes remains controversial. We hypothesize that testosterone administration prior to distal hypospadias repair with urethroplasty significantly decreases postoperative complications. MATERIALS AND METHODS: We queried our hypospadias database for primary distal hypospadias repairs with urethroplasty from 2015 to 2021. Patients undergoing repair without urethroplasty were excluded. We collected information on patient age, procedure type, testosterone administration status, initial visit and intraoperative glans width, urethroplasty length, and postoperative complications. To determine the role of testosterone administration on incidence of complications, a logistic regression adjusting for initial visit glans width, urethroplasty length, and age was performed. RESULTS: A total of 368 patients underwent distal hypospadias repair with urethroplasty. One hundred thirty-three patients received testosterone and 235 did not. Initial visit glans width was significantly larger in the no-testosterone vs testosterone group (14.5 mm vs 13.1 mm, P = .001). Testosterone patients had significantly larger glans width at the time of surgery (17.1 mm vs 14.6 mm [no-testosterone group], P = .001). On multivariable logistic regression analysis after controlling for age at surgery, preoperative glans width, testosterone status, and urethroplasty length, testosterone administration did show significant association with reduced odds of postoperative complications (OR 0.4, P = .039). CONCLUSIONS: This retrospective review of patients shows that on multivariable analysis there is significant association between testosterone administration and decreased incidence of complications in patients undergoing distal hypospadias repair with urethroplasty. Future studies on testosterone administration should focus on specific cohorts of patients with hypospadias as benefits of testosterone may be more evident in some subgroups than others.

Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair.

INTRODUCTION: The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups. OBJECTIVE: Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications. STUDY DESIGN: We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days. RESULTS: Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days. DISCUSSION: Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period. CONCLUSIONS: After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE: The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events. METHODS: A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed. RESULTS: 1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter. DISCUSSION: The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution. CONCLUSIONS: The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Prenatal Diagnosis of Bladder Exstrophy and OEIS over 20 Years.

OBJECTIVE: To examine the prenatal diagnosis rates of bladder exstrophy (BE) and Omphalocele-Exstrophy-Imperforate anus-Spinal Defect Syndrome (OEIS) in a large cohort of patients over a 20-year period. We hypothesized that prenatal diagnosis rates improved over time due to evolving techniques in fetal imaging. METHODS: A multi-institutional database was queried to identify BE or OEIS patients who underwent primary closure between 2000 and 2020. We retrospectively determined prenatal or postnatal diagnosis. Those with unknown prenatal history were excluded. Multivariable logistic regression was used to investigate temporal pattern in rate of prenatal diagnosis while adjusting for sex and treating institution. RESULTS: Among 197 BE and 52 OEIS patients, 155 BE and 45 OEIS patients had known prenatal history. Overall prenatal diagnosis rates of BE and OEIS were 47.1% (73/155) and 82.2% (37/45), respectively. Prenatal diagnosis rate was significantly lower in BE compared to OEIS (P <.0001). The prenatal diagnosis rate for BE significantly increased over time (OR 1.10; [95%CI: 1.03-1.17]; P = .003). Between 2000 and 2005, the prenatal diagnosis rate of BE was 30.3% (10/33). Between 2015 and 2020, prenatal diagnosis rate of BE was 61.1% (33/54). Prenatal diagnosis rate for OEIS did not change over time. Rates of prenatal diagnosis did not differ by sex or treating institution. CONCLUSION: Rates of prenatal diagnosis of BE and OEIS are higher than previously reported. Prenatal diagnosis rate of BE doubled in the last 5 years compared to the first 5 years of the study period. Nonetheless, a significant proportion of both BE and OEIS patients remain undiagnosed prior to delivery.