Impact of COVID-19 pandemic on the presentation, management and outcome of testicular torsion in the pediatric population - an analysis of a large pediatric center.

INTRODUCTION To examine the impact of COVID-19 pandemic on the presentation, management and outcome of testicular torsion at our institution. MATERIALS AND METHODS: A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤ 18 years of age evaluated in our emergency room between 3/11/2020 to 10/1/2020 (during-COVID-19) and the same period in 2018 and 2019 (pre-COVID-19) with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant. RESULTS: A total of 82 torsions were included in the study; 55 pre-COVID-19 and 27 during-COVID-19. The incidence of testicular torsion remained the same; 3.93 cases/month pre-COVID-19 versus 3.86 cases/month during-COVID-19 (p = 0.791). However, there were significantly fewer delayed (> 24 hours) presentations (11.1% versus 45.5% , p = 0.003), shorter time from onset of symptoms to presentation (median 15.5 hours versus 8 hours, p = 0.001), and a lower but not statistically significant overall orchiectomy rate (33.3% versus 50.9% p = 0.1608) during-COVID-19. Among those presenting acutely with torsion (< 24 hours from onset), no statistical differences were found in the median time from US diagnosis to OR, from ED to OR, referral rate, or orchiectomy rate between the two groups. Lastly, SARS-CoV2 testing did not delay median time from ED to OR. CONCLUSIONS: There was a notably less delayed presentation of testicular torsion and shorter ischemia time on presentation during-COVID, however, no significant change of time to OR or orchiectomy rate in those with acute testicular torsion were observed.

Discrepant Rates of Hypospadias Surgical Complications: A Comparison of U.S. News & World Report and Pediatric Health Information System® Data and Published Literature.

PURPOSE: Complication rates of 5% to 10% and 12% to 23% have been observed following distal and proximal hypospadias repair, respectively. However, these rates may be overreported. We hypothesized that data from the Pediatric Health Information System would corroborate the complication rates reported in the literature and refute the rates established by U.S. News & World Report as quality metrics. MATERIALS AND METHODS: The Pediatric Health Information System database was interrogated for hypospadias and revision CPT® codes. To evaluate the appropriateness of the U.S. News & World Report code list to identify revisions, 3 CPT groups were defined. Group A included codes sought by U.S. News & World Report, group B included group A plus codes for acquired urethrocutaneous fistula in males and group C included group B plus any revision codes associated with the index procedures. To evaluate the appropriateness of U.S. News & World Report followup interval, we assessed revision rates with ever increasing followup intervals out to 7 years. Yearly revision rates were summarized by median and quantile to correlate whether median revision rates changed significantly depending on whether increased followup or enhanced code lists were used. RESULTS: Average complication rates for group A were 3.32% (range 0.48% to 7.36%) and 12.29% (3.48% to 36.36%) for distal and proximal repairs, respectively. Revision rates increased significantly from group A (median 3.32%) by inclusion of a more expansive list of CPT codes associated with revision procedures (group B, 4.26%, p <0.001 and group C, 6.37%, p <0.001) in distal hypospadias. Among proximal hypospadias cases this difference was not significant when comparing group A (12.29%) to group B (12.53%, p=0.813), but was significant when comparing group A to group C (22.14%, p <0.001). Median revision rates for distal and proximal hypospadias increased with longer followup for all 3 groups, although the upward trend was not statistically significant. CONCLUSIONS: Depending on how one defines hypospadias revision, no hospital within the Pediatric Health Information System data set meets the U.S. News & World Report definition of perfection, a finding that is supported by recent reports from some of the largest, most prolific and most highly regarded pediatric urology programs. We posit that the U.S. News & World Report quality metrics do not accurately reflect the nature of hypospadias surgery complication rates.

Prediction of Clinical Outcomes in Prenatal Hydronephrosis: Importance of Gravity Assisted Drainage.

PURPOSE: In infants with SFU (Society for Fetal Urology) grade 3-4 congenital hydronephrosis, 99mTc-mercaptoacetyltriglycine diuretic renography assesses differential function and drainage half-time. We routinely also include the percent of radiotracer drained after 30 minutes of diuresis as well as after 15 minutes with the patient in the upright position. We investigated whether any 1 or more of these parameters on initial diuretic renography predicts persistent or worsening drainage parameters. MATERIALS AND METHODS: Infants 6 months or younger with grade 3-4 congenital hydronephrosis who presented between January 2009 and December 2014 were identified from billing data and included in analysis if they underwent at least 1 baseline diuretic renography. Those with structural anomalies were excluded from study. Baseline and followup differential function, diuresis half-time, clearance at 30 minutes and clearance with the patient upright were abstracted and comparisons were made between those with initially indeterminate diuresis half-time who underwent pyeloplasty vs those showing spontaneous improvement. RESULTS: A total of 74 patients (82 renal units) with presumed ureteropelvic junction obstruction met inclusion/exclusion criteria. All 10 renal units with initial diuresis half-time less than 5 minutes resolved spontaneously and all 25 renal units with initial diuresis half-time greater than 75 minutes underwent pyeloplasty. Therefore, we defined the indeterminate group as the 47 renal units with initial half-time between 5 and 75 minutes. Of those 47 renal units with indeterminate initial diuresis half-time 23 (47%) underwent pyeloplasty and 25 (53%) resolved spontaneously. Indications for pyeloplasty included worsening in 17 cases, persistent obstruction in 4 and urinary tract infection in 1. Among renal units with indeterminate drainage clearance while upright and clearance at 30 minutes were the only variables that differed significantly between surgical cases and those that resolved spontaneously. CONCLUSIONS: Radiotracer clearance with the patient upright and clearance at 30 minutes are more predictive of surgical management than diuresis half-time or differential function for renal units with indeterminate drainage. They should be included in the standard assessment of ureteropelvic junction obstruction.

Vesicoureteral Reflux and Antibiotic Prophylaxis: Why Cohorts and Methodologies Matter.

PURPOSE: Published cohorts of children with vesicoureteral reflux placed on antibiotic prophylaxis differ in baseline characteristics and methodology. These data have been combined in meta-analyses to derive treatment recommendations. We analyzed these cohorts in an attempt to understand the disparate outcomes reported. MATERIALS AND METHODS: A total of 18 studies were identified from 1987 to 2013. These series retrospectively or prospectively evaluated children with vesicoureteral reflux who were on long-term antibiotic prophylaxis. Presenting demographic data, criteria and methods of evaluation were tabulated. Outcomes were compared, specifically recurrent urinary infections and renal scarring. RESULTS: Significant differences identified in baseline characteristics included gender, circumcision status and reflux grade, and differences in methodology included evaluation of bowel and bladder dysfunction, method of urine collection, definition of urinary infection, measurement of compliance and means of identifying renal scarring. Cohorts with larger numbers of uncircumcised boys had more breakthrough urinary infections. Infection and renal scarring rates were higher in series with higher grades of reflux. Bagged urine specimens were allowed in 6 series, rendering the data suspect. Children with bowel and bladder dysfunction were excluded from 3 cohorts, and bowel and bladder dysfunction was correlated with outcome in only 1 cohort. Compliance was monitored in only 6 studies. CONCLUSIONS: Subpopulations and methodologies vary significantly in published series of children with vesicoureteral reflux on antibiotic prophylaxis. It is inappropriate to combine outcomes data from these series in a meta-analysis, which would serve to blur distinctions between these subpopulations. Broad recommendations or guidelines based on meta-analyses should be viewed with caution.

Risk Factors for Catheter Associated Urinary Tract Infections in a Pediatric Institution.

PURPOSE: Catheter associated urinary tract infections are an essential measure for health care quality improvement that affects reimbursement through hospital acquired condition reduction programs in adult patients. With the mounting importance of preventing such infections we evaluated risk factors for acquiring catheter associated urinary tract infections in pediatric patients. MATERIALS AND METHODS: All catheter associated urinary tract infections were identified at 1 pediatric institution from September 2010 to August 2014 from a prospective database maintained by the infection control office. To identify risk factors patients with a catheter associated urinary tract infection were individually matched to control patients with a urinary catheter but without infection by age, gender, date and the hospital location of the infection in 1:2 fashion. RESULTS: A total of 50 patients with catheter associated urinary tract infection were identified and matched to 100 control patients. Compared to controls the patients with infection were more likely to have a catheter in place for longer (2.9 days, OR 1.08, 95% CI 1.01, 1.15, p = 0.02). They were also more likely to be on contact precautions (OR 4.00, 95% CI 1.73, 9.26, p = 0.001), and have concurrent infections (OR 3.04, 95% CI 1.39, 6.28, p = 0.005) and a history of catheterization (OR 3.24, 95% CI 1.55, 6.77, p = 0.002). Using a conditional multivariate regression model the 3 most predictive variables were duration of catheter drainage, contact isolation status and history of catheterization. CONCLUSIONS: Longer duration of urinary catheter drainage, positive contact precautions status and a history of catheterization appear to be associated with a higher risk of catheter associated urinary tract infection in hospitalized pediatric patients. Physicians should attempt to decrease the duration of catheterization, especially in patients who meet these criteria, to minimize the risk of catheter associated urinary tract infection.

The prevalence of bell clapper anomaly in the solitary testis in cases of prior perinatal torsion.

PURPOSE: Bell clapper anomaly is associated with an increased risk of intravaginal testicular torsion. However, perinatal torsion is thought to be secondary to an extravaginal process. We quantified the contralateral prevalence of bell clapper anomaly in children found to have atrophic testicular nubbins secondary to presumed torsion during gestation to better define the subsequent risk of metachronous testicular torsion. MATERIALS AND METHODS: Inspection results for the presence of contralateral bell clapper anomaly was recorded by a single surgeon in 50 consecutive cases in which exploration for nonpalpable testes revealed a testicular nubbin. For comparison data were collected in 27 consecutive cases of acute testicular torsion. Anatomy of the normal contralateral testis was compared between the 2 groups. RESULTS: Average age at surgery in the perinatal torsion group was 15 months vs 12.7 years in the acute torsion group. One case of partial contralateral bell clapper anomaly was discovered in the perinatal torsion group but no complete anomaly was found. In contrast, in older boys with acute testicular torsion complete bell clapper anomaly was found in 21 of the 27 contralateral testes (78%). CONCLUSIONS: In older boys with acute testicular torsion contralateral bell clapper anomaly is highly prevalent, supporting the standard practice of contralateral testicular fixation in this clinical situation. However, the prevalence of contralateral bell clapper anomaly is exceedingly small in cases of monorchism after perinatal torsion, substantiating an insufficient risk of subsequent torsion to justify routine fixation of the solitary testis.

Evaluation of prenatal hydronephrosis: novel criteria for predicting vesicoureteral reflux on ultrasonography.

PURPOSE: Radiographic evaluation for prenatal hydronephrosis often includes voiding cystourethrography to ascertain whether vesicoureteral reflux is present. We sought to determine whether use of voiding cystourethrography could be limited to those patients at greatest risk for vesicoureteral reflux. We hypothesized that vesicoureteral reflux could be predicted by findings on renal/bladder ultrasonography of hydroureter, renal dysmorphia and/or duplication. MATERIALS AND METHODS: We reviewed the records of patients with prenatal hydronephrosis who underwent initial postnatal ultrasonography and voiding cystourethrography during a 3-year period. The presence of vesicoureteral reflux on voiding cystourethrogram was correlated to ultrasound findings, including hydronephrosis grade, presence of hydroureter, renal dysmorphia or duplication, with ultrasound considered positive for any of the latter 3 findings. RESULTS: Of 262 patients 47 (18%) had vesicoureteral reflux. Ultrasound was positive in 24 of 29 patients (83%) with high grade reflux and 12 of 18 (67%) with low grade reflux. If ultrasonography showed any of the 3 positive findings, the odds ratio of detecting vesicoureteral reflux was 8.07 (95% CI 3.86, 16.87). Using these criteria, among all cases of prenatal hydronephrosis 5 (2%) with high grade vesicoureteral reflux and 6 (2%) with low grade reflux would have been missed. Among the 47 cases of reflux overall 5 of 29 high grade (17%) and 6 of 18 low grade cases (33%) would have been missed. CONCLUSIONS: By using ultrasonography criteria of hydroureter, duplication and renal dysmorphia for patients with prenatal hydronephrosis, vesicoureteral reflux can be detected more specifically. Using our criteria, 165 of 262 voiding cystourethrograms (63%) could have been avoided in patients with prenatal hydronephrosis during a 3-year period. Reducing these evaluations may decrease risks regarding radiation exposure, family anxiety and health care costs.

Most infants with dilating vesicoureteral reflux can be treated nonoperatively.

PURPOSE: Dilating vesicoureteral reflux provokes concern for physicians and parents that often leads to corrective surgery in young children. Since there are limited data describing the natural history of dilating vesicoureteral reflux in infants, we identified factors predictive of resolution/improvement in infants initially treated nonoperatively. MATERIALS AND METHODS: We reviewed the medical records of 90 infants 6 months old or younger from 2004 to 2010 who were referred for prenatal hydronephrosis or initial febrile urinary tract infection and found to have dilating vesicoureteral reflux (grade 3 or greater). Variables of interest included presentation, dimercapto-succinic acid results, sex, breakthrough febrile urinary tract infections, reflux grade and bilateral reflux. Cox regression analysis was performed to determine predictors of spontaneous resolution and/or improvement to reflux grade less than 3 as well as predictors of surgical intervention. RESULTS: Included in final analysis were 80 infants (113 renal units). Of the patients 51 (64%) experienced spontaneous resolution/improvement with a mean followup of 29 months before resolution, discharge home and/or end of followup. Only 20 patients (25%) underwent surgery. Cox regression analysis revealed that a normal initial dimercapto-succinic acid scan, initial reflux grade less than 5 and absent breakthrough febrile urinary tract infections were predictive of reflux resolution/improvement (p <0.05). Dimercapto-succinic acid scan abnormalities, prenatal hydronephrosis and breakthrough febrile urinary tract infections were significant predictors of surgery (p <0.05). CONCLUSIONS: Dilating vesicoureteral reflux in infancy often resolves/improves spontaneously. Therefore, surgery should be directed toward patients unlikely to experience resolution, ie those with an abnormal initial dimercapto-succinic acid scan, grade 5 vesicoureteral reflux and breakthrough febrile urinary tract infections.

The birth of pediatric urology in the United States: From pioneers to subcertification.

INTRODUCTION: Pediatric urology is a subspecialty of urology that emerged from a culture in which children with urological disorders were cared for by general urologists and general pediatric surgeons. The development of pediatric urology as a subspecialty was years in the making, highlighted by individuals who recognized that children with urological conditions were not just "small adults," but required special experience and training. Subspecialization was initiated by persistent visionaries who recognized the need for a trained cadre of experts to provide better care for children. It took the coordinated effort of all subgroups and leaderships in pediatric urology to push these efforts over the goal line. The focus of this review is to highlight certain individuals who played major roles in this vision and to document the efforts of many to coordinate the pathways to sub-specialization. METHODS: The careers of Meredith F. Campbell and Frank B. Bicknell were researched to identify their rationale and roles in developing pediatric urology as a distinct medical specialty in the United States. In addition, the minutes of the meetings of the Pediatric Urology Advisory Council (PUAC) with the American Board of Urology (ABU) were reviewed. The origins of the Society for Pediatric Urology (SPU) and the American Academy of Pediatrics Section of Urology (AAP-SOU) were researched. The contributions of each to the certification of pediatric urology as a distinct subspecialty was delineated. RESULTS: Campbell was Chair of Urology at the New York University (NYU) School of Medicine and wrote prolifically about pediatric urology. He published one of the first practical textbooks in pediatric urology, almost completely self-written, in 1937. Bicknell, a general urologist in Michigan on the faculty at Wayne State University School of Medicine, led the initiative to create the Society for Pediatric Urology (SPU) that first met at the 1951 annual American Urological Association (AUA) meeting in Chicago and included nine attendees. Subsequently, John Lattimer (College of Physicians and Surgeons at Columbia University) organized a well-attended meeting of urologists interested in pediatrics at the 1964 annual AAP meeting in New York City. This led to the formation of the AAP Section on Urology. Integral to the justification for the development of a subspecialty was evidence of a published corpus of content. In addition to published textbooks devoted exclusively to pediatric urology, this was further fulfilled by the AAP Section on Urology Pediatric Supplement to the Journal of Urology, first published in 1986, and later with the Journal of Pediatric Urology in 2005. The SPU and the AAP Section on Urology came together to form the Pediatric Urology Advisory Council (PUAC) in 2000, which worked with the ABU to create subspecialty certification in pediatric urology with an independent exam, first administered in 2008 to 176 applicants. CONCLUSION: The metaphor "We have stood on the shoulders of giants" is apt for pediatric urology: Meredith Campbell, Frank Bicknell, David Innes Williams (Hospital for Sick Children, London), and J. Herbert Johnston (Alder Hay Hospital, Liverpool) come to mind among the first generation of pediatric urology pioneers, and others among their colleagues also had significant impact. Clearly this is a story of persistence and attention to detail on the part of those giants and those who followed. Pediatric urology became a distinct discipline after the SPU and AAP-SOU came together to create a robust cohort of pediatric urologists who through education and negotiation were able to help the ABU and the American Board of Medical Specialties (ABMS) recognize that subspecialization would lead to better care for children with urologic disorders. This benchmark set a high bar for future subspecialization in urology and other fields.

Evaluation of differential renal function and renographic patterns in patients with dietl crisis.

PURPOSE: We analyzed preoperative and postoperative differential renal function and characterized the renographic findings in patients with ureteropelvic junction obstruction associated with Dietl crisis. MATERIALS AND METHODS: Patients with Dietl crisis who underwent pyeloplasty between January 2004 and December 2010 were classified by renographic presentation. Patients in group 1 were diagnosed with cortical retention, those in group 2 had an initial obstructed scan (T1/2 of 20 minutes or more and no cortical retention) and those in group 3 had an initial nondiagnostic scan (T1/2 of less than 20 minutes and no cortical retention). Renographic parameters were used to analyze each group. RESULTS: A total of 59 patients met criteria for study inclusion. The 13 patients in group 1 demonstrated the most significant recovery of function after pyeloplasty (mean differential renal function change 13.59%). The 38 patients in group 2 exhibited a mean differential renal function change of 43.06% (range 20% to 54.6%) and mean preoperative T1/2 of 64.31 minutes. Pyeloplasty was performed in all 8 patients in group 3 based on subsequent diagnostic scan (4 patients) or increased hydronephrosis on other imaging associated with further symptomatic episodes (4). Initial renographic patterns noted in group 3 included biphasic curves, diminished clearance after 15 minutes upright or symptoms despite nonobstructive drainage. CONCLUSIONS: Interpretation of diuretic renography requires the assimilation of multiple parameters since patients with Dietl crisis can exhibit variability in renographic patterns due to the intermittent nature of ureteropelvic junction obstruction. Cortical retention represents a specific and pathognomic finding of acute ureteropelvic junction obstruction. With appropriate evaluation of these parameters, obstruction can be reliably diagnosed and appropriate surgical candidates chosen.

Initial observational management of hydronephrosis in infants with reduced differential renal function and non-obstructive drainage parameters.

INTRODUCTION: Hydronephrosis secondary to ureteropelvic junction (UPJ) obstruction is a common finding in infants with prenatally-diagnosed hydronephrosis and often results in pyeloplasty due to obstructive drainage parameters and/or renal function compromise. However, little is known regarding the natural history of hydronephrosis with reduced differential renal function (DRF) but non-obstructive drainage. OBJECTIVE: We sought to explore our experience with initial observational management of these patients. STUDY DESIGN: A retrospective review of our institutional database of all diuretic MAG-3 renal scans obtained between 2000 and 2016 was performed. We included patients with antenatally-detected unilateral hydronephrosis ≥ SFU grade 2, first MAG-3 scan prior to 18months of age, DRF <40% and post-furosemide half-time (T1/2) <20 min. Exclusion criteria were: hydroureter, VUR, solitary kidney, duplication anomalies. Outcomes of interest were a progression of T1/2 ≥ 20 min and/or further decline in DRF >5%. RESULTS: Of 704 patients with unilateral hydronephrosis, 91 had DRF≤40%, of which 29 (18 boys, 11 girls) met our inclusion criteria and were followed for a mean of 2.8 years (1.4 months-6.6 years). Mean age at first sonogram was 2.3 months. 2 patients had SFU grade 2, 16 had grade 3, and 9 had grade 4 hydronephrosis, and 2 unknown grade. Median half-time on initial MAG-3 scan across all patients was 10 min (3-20 min). Initial MAG3 scan was performed at a median of 2.3 months of age (0.3-17 months). 22/29 patients had >1 MAG3 scan. Of the 7 remaining, 5 were lost to follow-up and 2 demonstrated improvement in hydronephrosis. Worsening drainage occurred in 10/22(45%), median final T1/2 was 45.5 min 8 of these underwent pyeloplasty and 2 were lost to follow up. 4/22 patients (18%) had progressive decline in DRF (mean 8.3%, range 6-10%). 3/4 maintained non-obstructive drainage patterns and stable/improved hydronephrosis, and 1 underwent pyeloplasty. 13/18 remaining patients had stable DRF and 5 had improvement in DRF. 7(39%) of these underwent surgery for worsening drainage (Summary Figure). Overall, 7/29(24%) patients had sufficient resolution of hydronephrosis to be discharged from our care, 8(28%) are under continued observation, 9(31%) underwent pyeloplasty, and 5(17%) were lost to follow-up. In the observational group [median follow-up 4.5 years (3.7-6.6 years)], all 8 demonstrated improved non-obstructive drainage (T1/2 <20 minutes) and/or improvement in hydronephrosis. 4/10(40%) with DRF <35% underwent pyeloplasty versus 5/19(26%) with DRF 35-40%(p=0.67). CONCLUSION: Initial observational management of unilateral hydronephrosis with reduced DRF and nonobstructive drainage is recommended as most kidneys maintain nonobstructive drainage and do not demonstrate further decline in DRF. Even when DRF decreases, the majority remain non-obstructive. Worsening drainage over time more often leads to the decision for pyeloplasty rather than change in DRF.

Parental preferences in the management of vesicoureteral reflux.

PURPOSE: Considering that there are few absolute indications for the timing and type of surgical correction of vesicoureteral reflux, we objectively measured parental choice in how the child's vesicoureteral reflux should be managed. MATERIALS AND METHODS: We prospectively identified patients 0 to 18 years old with any grade of newly diagnosed vesicoureteral reflux. All races and genders were included, and non-English speakers were excluded from analysis. Parents were shown a video presented by a professional actor that objectively described vesicoureteral reflux and the 3 treatment modalities of antibiotic prophylaxis, open ureteral reimplantation and endoscopic treatment. Then they completed a questionnaire regarding their preference for initial management, and at hypothetical followup points of 18, 36 and 54 months. Consultation followed with the pediatric urologist who was blinded to the questionnaire results. RESULTS: A total of 86 girls and 15 boys (150 refluxing units) were enrolled in the study. Mean patient age was 2.6 years old. Preferences for initial treatment were antibiotic prophylaxis in 36, endoscopic surgery in 26, open surgery in 11, unsure in 26 and no response in 2. Among those initially selecting antibiotic prophylaxis, after 18 months the preference was for endoscopic treatment, but after 36 and 54 months preferences trended toward open surgery. After consultation with the pediatric urologist 68 parents chose antibiotic prophylaxis. CONCLUSIONS: Our data show that antibiotic prophylaxis is preferred as the initial therapy for vesicoureteral reflux by 35.6% of parents. However, given persistent vesicoureteral reflux, preferences shifted toward surgery. With time the preference for open surgery increased and the preference for endoscopic surgery decreased.

Vesicoureteral reflux associated renal damage: congenital reflux nephropathy and acquired renal scarring.

PURPOSE: The pathophysiology, evaluation, description and clinical implications of renal damage associated with vesicoureteral reflux remain controversial. We summarized the current understanding of this important aspect of clinical vesicoureteral reflux. MATERIALS AND METHODS: We performed a detailed review of the literature on clinical, pathological and experimental data related to congenital vesicoureteral reflux and bladder dynamics. We also reviewed the clinical context and imaging evaluation with underlying experimental data related to post-infectious reflux nephropathy. RESULTS: Congenital reflux nephropathy is a pattern of impaired renal function and development with renal dysplasia as the most severe but not the only form. Mechanisms of developmental disruption are potentially related to vesicoureteral reflux dynamics during gestation and associated bladder dynamics, which may continue into postnatal life. Acquired renal injury associated with infection is related to particular bacterial and host factors that determine infection virulence, host inflammatory response and tissue recovery. As best seen on dimercapto-succinic acid scan, acute changes may resolve but may also persist as permanent renal scarring. Specific risk factors for acute pyelonephritis and renal scarring in patients with vesicoureteral reflux include higher reflux grade, dysfunctional voiding/elimination, recurrent pyelonephritic episodes and delayed initiation of antibiotic therapy. Low pressure sterile reflux is not a cause of reflux nephropathy. CONCLUSIONS: Renal damage associated with vesicoureteral reflux may be congenital or acquired and the respective pathophysiological mechanisms are likely different. Congenital damage is often dysplasia, which may be a result of disordered renal development secondary to significant alterations in bladder dynamics. These processes may continue into the newborn period while kidney maturation continues. Recognizing the clinical potential for ongoing effects on renal function and the role of bladder development are important for clinical care. Post-pyelonephritic acquired damage is the result of a complex interaction of host and bacterial factors that leads to acute alterations in renal function, and may lead to permanent renal scarring. Strategies for timely intervention as well as prevention are essential to limit the risk of permanent renal injury, which may predispose to hypertension and renal insufficiency in some patients.

High incidence of abnormal imaging findings in circumcised boys diagnosed with urinary tract infections.

BACKGROUND: The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI. METHODS: A retrospective review was performed of all urine cultures from the Emergency Department at our institution between 2006 and 2015. Males under 18 years of age with ≥50,000 CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch, catheterized and suprapubic aspiration specimens were included. Bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. Statistical analysis was performed with Stata software, version 15.1 MP (Stata Corporation, College Station, Texas, USA). RESULTS: We reviewed 1585 urine cultures, of which 812 met eligibility criteria including 619 (76.2%) E. coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 29 (3.6%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age was six months (2.4-36 months IQR). After adjusting for age, ethnicity and bacterial species, the prevalence of dilating vesicoureteral reflux (VUR, defined as grades III-V) was 5.3 times higher in circumcised males compared to uncircumcised males (95% CI: 2.4-11.4, p = 0.001). Circumcised males had a 3.1 times increased prevalence of high-grade hydronephrosis (defined as SFU grades 3 and 4) compared to uncircumcised males (prevalence ratio: 3.1, 95% CI: 1.0-10.0, p = 0.05). Among bacterial pathogens, no patients with Proteus UTI had high-grade hydronephrosis or dilating VUR. In contrast, Staphylococcal infections were associated significantly with dilating VUR (prevalence ratio 10.1, 95% CI: 2.3, 44.8; p = 0.002) and high-grade hydronephrosis (prevalence ratio 8.1, 95% CI: 1.7, 39.7; p = 0.010). CONCLUSIONS: Circumcision status is an independent predictor of structural urinary anomalies of the bladder and upper tracts in pediatric males with UTI, therefore circumcised males should be considered for early imaging, including VCUG, after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high-grade hydronephrosis and dilating VUR and therefore warrant early investigation with VCUG. In contrast, none of the Proteus infections, which were seen almost exclusively in uncircumcised males, were associated with dilating VUR or hydronephrosis, making initial observation more appropriate in these patients.

Febrile urinary tract infections in children with an early negative voiding cystourethrogram after treatment of vesicoureteral reflux with dextranomer/hyaluronic acid.

PURPOSE: Children in whom nonsurgical management for vesicoureteral reflux fails are considered candidates for surgical intervention. An option is endoscopic treatment with Deflux(R). We reviewed our experience with febrile urinary tract infections in children following initial successful treatment of vesicoureteral reflux with Deflux and identified factors predictive of post-Deflux urinary tract infections. We also analyzed the incidence of delayed vesicoureteral reflux recurrence in these patients. MATERIALS AND METHODS: We performed a retrospective chart review of all children from 2002 to 2006 diagnosed with grades I to IV vesicoureteral reflux who were treated with Deflux and who had a negative initial followup voiding cystourethrogram at 2 to 5 months. Patients were categorized into post-Deflux infection and infection-free groups. Predictive factors, including the number of preoperative febrile urinary tract infections, dysfunctional elimination and renal cortical defects on dimercapto-succinic acid scan, were analyzed and compared. RESULTS: Of the patients 45 met all study inclusion and exclusion criteria. A total of 12 patients (27%) who were diagnosed with a culture documented febrile urinary tract infection were categorized into the infection group. Of 12 children in the post-Deflux infection group 11 (92%) had multiple predictors compared to 14 of 33 (42%) who remained infection-free (p = 0.005). Ten of these 12 patients (92%) were found to have evidence of vesicoureteral reflux when evaluated with voiding cystourethrogram/radionuclide cystogram after infection. CONCLUSIONS: This study demonstrates that up to 27% of patients treated endoscopically may have a febrile urinary tract infection after an initial negative postoperative voiding cystourethrogram/radionuclide cystogram at 2 to 5 months and up to 92% of those will demonstrate delayed vesicoureteral reflux recurrence. Children with a history of 2 or more predictive factors, including multiple febrile urinary tract infections, dysfunctional elimination and/or renal cortical defects on dimercapto-succinic acid scan, may not be optimal candidates for Deflux. If endoscopic treatment is chosen, these patients require more vigilant followup, including late voiding cystourethrogram.

In pursuit of the perfect penis: Hypospadias repair outcomes.

Hypospadias is commonly assessed and repaired by pediatric urologists. Mild, distal hypospadias is generally more a cosmetic problem than a functional one and is more frequently encountered than severe, proximal hypospadias. Outcomes following repair, especially of mild phenotypes, are important to understand, but range widely in timing and measurability. Surgical complications, postoperative satisfaction of parents, patients, surgeons and even lay observers, urinary function, sexual function, and quality of life all may be considered as relevant outcomes of hypospadias repair. Existing studies examining these outcomes are diverse in their conclusions, but are important to understand when counseling parents and patients prior to any surgical intervention.

Sonographic appearance of the epididymis in pediatric testicular torsion.

OBJECTIVE: The purpose of this study was to determine the frequency of an enlarged epididymis in pediatric patients with testicular torsion and to determine whether an altered epididymis might be a helpful ancillary sonographic sign of testicular torsion. MATERIALS AND METHODS: The sonograms of 50 pediatric patients (age range, neonate-17 years) with testicular torsion were retrospectively reviewed for the size, appearance, and blood flow of the epididymis. Medical records were reviewed for surgical and pathologic findings and to determine whether testicular salvage had been possible. RESULTS: The epididymis was enlarged (maximum dimension, 5.5 cm) in 47 of the 50 patients with acute or late phase torsion and after manual or spontaneous detorsion. The average difference in volume between the ipsilateral epididymis and the contralateral epididymis was 30 cm3, highly significant (p < 0.0001). The shape of the epididymis was altered in 92% of the cases (globular, bilobular, or multilobular). Seventy-three percent showed increased echogenicity and 27% appeared isoechoic. Of those with active torsion, 93% of the epididymides were avascular; 2%, hypovascular; and 5%, hypervascular. After detorsion, 100% of the epididymides (10/10) had blood flow. In patients with testicular loss due to infarction, pathology showed engorgement and enlargement of the epididymis with hemorrhagic infarction. In one patient with a hypervascular epididymis, surgery showed inflammation and erythema of the epididymis. Testicular loss occurred in each type of epididymal flow pattern. CONCLUSION: A markedly enlarged, echogenic, and avascular or hypovascular epididymis is an ancillary sonographic sign in pediatric patients with testicular torsion. A hypervascular enlarged epididymis infrequently occurs (5% of cases) and should not be mistaken for epididymitis. In addition, the return of epididymal blood flow is an ancillary sign of successful testicular detorsion.