Semen parameters in adolescents with varicocele: association with testis volume differential and total testis volume.

PURPOSE: We evaluated the relationship between testicular volume differential, total testis volume and total motile sperm count in adolescents with varicocele. Prior reports have been inconclusive regarding the association of testis volume with semen analysis parameters. MATERIALS AND METHODS: We retrospectively reviewed a single institution database of Tanner 5 adolescents with nonoperated left varicocele with at least 1 semen analysis available. Patients were included in analysis if they had clinical left varicocele, ultrasound measurement of testis volume and no prior inguinal or scrotal surgery. RESULTS: We analyzed the records of 100 patients. Mean ± SD age at presentation was 15.2 ± 3.5 years. The mean testicular volume differential was 8% ± 23% and 31 patients (31%) had a greater than 20% testicular volume differential. Mean total testis volume was 30.4 ± 13.3 cc. Varicocele was grade 3 in 39 patients, grade 2 in 50, grade 1 in 8 and ungraded in 3. Median total motile sperm count in the cohort was 42.0 (IQR 9.2, 105.8). ROC analysis with the Youden index indicated an optimal total testis volume cutoff of 30 cc to predict the total motile sperm count. In a multivariable logistic model accounting for age and varicocele grade a testicular volume differential of greater than 20% was associated with twice the odds of a total motile sperm count of less than 20 million per cc (OR 2.1, 95% CI 1.02-4.12, p = 0.04). Total testis volume less than 30 cc more than quadrupled the odds of a total motile sperm count of less than 20 million per cc (OR 4.2, 95% CI 1.8-9.7, p <0.001). CONCLUSIONS: Total testis volume and the testicular volume differential are associated with semen analysis outcomes in adolescents with varicocele. A testicular volume differential of greater than 20% doubles the odds of a low total motile sperm count. A total testis volume of less than 30 cc quadruples the odds of a low total motile sperm count.

Evaluation of a mobile voiding diary for pediatric patients with voiding dysfunction: a prospective comparative study.

PURPOSE: One potential strategy for improving voiding diary completion rates and data quality is use of a mobile electronic format. We evaluated the acceptability and feasibility of mobile voiding diaries for patients with nonneurogenic lower urinary tract dysfunction, and compared mobile and paper voiding diaries. MATERIALS AND METHODS: We prospectively enrolled children presenting with daytime symptoms of lower urinary tract dysfunction between July 2012 and April 2013. We enrolled an initial cohort of patients who were provided a paper voiding diary and a subsequent cohort who were provided a mobile voiding diary. We conducted in person interviews and assessed completion rates and quality, comparing paper and mobile voiding diary groups. RESULTS: We enrolled 45 patients who received a paper voiding diary and 38 who received a mobile voiding diary. Completion rates were 78% for paper voiding diaries and 61% for mobile voiding diaries (p = 0.10). Data quality measures for patients completing paper vs mobile voiding diaries revealed a larger proportion (63% vs 52%) providing a full 5 days of data and a smaller proportion (20% vs 65%) with data gaps. However, the paper voiding diary also demonstrated a lower proportion (80% vs 100%) that was completely legible and a lower proportion (40% vs 65%) with completely prospective data entry. CONCLUSIONS: The use of a mobile voiding diary was acceptable and feasible for our patients with lower urinary tract dysfunction, although completion rates were somewhat lower compared to paper voiding diaries. Data quality was not clearly better for either version. The mobile voiding diary format may offer data quality advantages for select groups but it did not display significant superiority when provided universally.

Use of buccal mucosa grafts for urethral reconstruction in children: a retrospective cohort study.

BACKGROUND: The use of buccal mucosa grafts (BMG) for urethral reconstruction has increased in popularity over the last several decades. Our aim was to describe our institutional experience with and outcomes after BMG urethroplasty. METHODS: We conducted a retrospective cohort study of boys undergoing BMG urethral reconstruction. Preoperative and perioperative characteristics and postoperative outcomes were evaluated. RESULTS: Twenty-nine patients (median age 8.2 years) underwent BMG urethroplasty from 1995-2012. Of the 10 patients undergoing 1-stage repairs, 6 had tubularized grafts, the last of which was performed in 2000 due to an unacceptably high revision rate (100%). A 2-stage approach was elected for 19 patients (median follow-up 21.3 months). Complications including stricture, fistula, or chordee were seen in 60% of patients completing both stages and 32% required ≥1 revision. However, 71% of 2-stage patients were free of significant problems at last follow-up. CONCLUSIONS: We found BMG to be a reasonable option for use in complex pediatric urethral reconstruction. Tubularized grafts had poor results, and we no longer use them. We favor a 2-stage approach for all patients except those with "simple" non-hypospadiac strictures. Although revision procedures were not uncommon, the majority of patients were ultimately free of long-term problems.

Sensitivity to violence measured by ratings of severity increases after nonviolence training.

It was hypothesized that training in nonviolence would increase participants' sensitivity to violence because such training emphasizes both the harm and the avoidability of many kinds of violence. This research built upon earlier studies, which had proposed that ratings of the severity of violent behaviors (e.g., murder, bullying, cursing) can be interpreted as measuring sensitivity to violence. Two quasi-experiments examined changes in ratings of severity obtained before and after nonviolence training. In Study 1, 28 college-age traffic offenders who received nonviolence training judged stimulus behaviors ranging from life-threatening physical harm to verbal disrespect as more violent after their training. An untrained comparison group did not show this change. In Study 2, 30 student teachers who received instruction in nonviolence also rated behaviors as more violent after training; an untrained comparison group did not. Results are interpreted as showing increased sensitivity to violence following exposure to nonviolence.

Imaging and surgical utilization for pediatric cystinuria patients: A single-institution cohort study.

OBJECTIVE: Although cystinuria is rare, its clinical manifestations are life-long. Little is known about healthcare utilization in this population. STUDY DESIGN: Through billing records and chart review, we identified pediatric patients with cystinuria treated at our institution. Variables included demographics, gender, race, comorbidities, location of presentation, presenting symptoms, initial laboratory data, and stone characteristics. Outcomes included the number and type of imaging tests and procedures performed. Descriptive statistics were performed. Median annual frequencies of procedures and imaging were calculated. RESULTS: Twenty-three patients who presented between 1995 and 2011 were identified. The median age at presentation was 12 years, 48% of our patients were male, and 91% were Caucasian. Median follow-up was 4.6 years. Over half were diagnosed in clinic (13/23), while 30% (7/23) presented to the ED. Pain was the most common presenting symptom (13/23), followed by nausea/vomiting (6/23), gross hematuria (5/23), and fevers (5/23). Only one patient presented with acute renal failure. Five patients were discovered by sibling screening. The median number of stones at presentation was two and median size of the largest stone was 9 mm, with three staghorn calculi. During follow-up, a total of 110 stone procedures were performed in 15 patients. Five patients underwent 13 PCNLs, 11 patients underwent 44 ureteroscopy procedures, and nine underwent open or robotic surgery, including one nephrectomy. Among patients identified by sibling screening, most (4/5) were managed with medical therapy alone. A total of 390 imaging procedures were performed. Radiation-associated imaging comprised half of all imaging tests. DISCUSSION: The high rates of imaging and surgical utilization among pediatric cystinuria patients reflect the morbidity of this condition and the need for preventative management. By practicing the ALARA principle during urologic procedures, urologists can reduce radiation exposure. Multiple procedures are often required to render patients stone-free. URS/LL and PCNL are likely to be more effective than ESWL. In complex cases, robotic-assist lithotomy provides the advantage of a minimally invasive approach. Both sibling screening and transitional care represent long-term strategies with the potential to reduce life-long morbidity. The limitations of this study include its small sample size, retrospective nature, and single-center experience. CONCLUSIONS: Our study demonstrates that the clinical impact of disease among pediatric patients presenting with cystinuria at our institution is considerable, with most requiring surgery. Our population also generates heavy utilization of diagnostic imaging. Given the lifelong nature of this disease, research on improved preventive therapies is urgently needed.

Self-cathing experience journal: Enhancing the patient and family experience in clean intermittent catheterization.

OBJECTIVE: This pilot study evaluated the safety, feasibility, and usefulness of the Self-Cathing Experience Journal (SC-EJ), an online resource for patients and families to address issues and stigma surrounding clean intermittent catheterization (CIC). Modeled after previous assessments of the Cardiac and Depression Experience Journals (EJs), this project uniquely included patients and caregivers. We explored whether patients and caregivers would find the SC-EJ helpful in increasing their understanding of CIC, accepting the medical benefits of self-catheterization, improving hopefulness, and diminishing social isolation. METHODS: Patients seen in a tertiary urology clinic were asked to view the SC-EJ for 30 min and rate its safety and efficacy. The cross-sectional sample included 25 families: 17 surveys were completed by the patient and their caregiver, five by the patient only, and three by the caregiver only. Mean patient age was 15.7 ± 5.8 years (range 7-29 years). The patients were 64% female, and 72% used CIC due to neurological diagnoses. RESULTS: Mean overall patient satisfaction with the SC-EJ was moderately high (mean = 5, out of a 7-point Likert scale from 1 = not at all to 7 = extremely). Mean overall caregiver satisfaction was high (mean = 5.55) and was similar to caregiver satisfaction scores recorded in caregivers with children with congenital heart disease and depression (mean = 5.7 and mean = 5.75, respectively). No significant differences were noted in satisfaction between CIC patients and CIC caregivers or among caregivers of the three populations surveyed (CIC, Cardiac, and Depression). CIC patients and caregivers reported that SC-EJ viewing gave them a strong sense that others are facing similar issues (patient mean = 6.15, caregiver mean = 6.21) and that it was helpful to read about other families' CIC experiences (patient mean = 6, caregiver mean = 5.89). DISCUSSION: The SC-EJ appears to be safe, feasible, and useful to patients and families using CIC. Ratings from caregivers of CIC patients were similar to other cohorts of caregivers facing chronic childhood conditions. Despite beliefs that the EJ format best targets adults, high satisfaction ratings among patients suggest that the SC-EJ is acceptable and beneficial to children and adolescents. This web-based intervention can be a helpful clinical supplement in promoting healthy coping skills and a decreased sense of isolation among patients and families facing CIC. The unique integration of real patient and family experiences with accurate and vetted medical knowledge has the potential to enhance resiliency among viewers who use CIC.