Expert Consensus on Pediatric Urodynamics Reporting Using Modified Delphi Technique.

PURPOSE: Urodynamic testing (UDS) is an important tool in the management of pediatric lower urinary tract conditions. There have been notable efforts to standardize pediatric UDS nomenclature and technique, but no formal guidelines exist on essential elements to include in a clinical report. We sought to identify ideal structure and elements of a pediatric UDS assessment based on expert consensus. MATERIALS AND METHODS: Pediatric urologists regularly performing UDS were queried using a Delphi process. Participants were invited representing varied geographic, experience, and societal involvement. Participants underwent 3 rounds of questionnaires between November 2022 and August 2023 focusing on report organization, elements, definitions, and automated electronic health record clinical decision support. Professional billing requirements were also considered. Consensus was defined as 80% agreeing either in favor of or against a topic. Elements without consensus were discussed in subsequent rounds. RESULTS: A diverse sample of 30 providers, representing 27 institutions across 21 US states; Washington, District of Columbia; and Canada completed the study. Participants reported interpreting an average number of 5 UDS reports per week (range 1-22). The finalized consensus report identifies 93 elements that should be included in a pediatric UDS report based on applicable study conditions and findings. CONCLUSIONS: This consensus report details the key elements and structure agreed upon by an expert panel of pediatric urologists. Further standardization of documentation should aid collaboration and research for patients undergoing UDS. Based on this information, development of a standardized UDS report template using electronic health record implementation principles is underway, which will be openly available for pediatric urologists.

Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study.

INTRODUCTION/BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE: We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN: Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS: A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION: The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS: ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

Evaluating the role for regional analgesia in children with spina bifida: a retrospective observational study comparing the efficacy of regional versus systemic analgesia protocols following major urological surgery.

INTRODUCTION: Regional techniques are a key component of multimodal analgesia and help decrease opioid use perioperatively, but some techniques may not be suitable for all patients, such as those with spina bifida. We hypothesized peripheral regional catheters would reduce postoperative opioid use compared with no regional analgesia without increasing pain scores in pediatric patients with spina bifida undergoing major urological surgery. METHODS: A retrospective review of a multicenter database established for the study of enhanced recovery after surgery was performed of patients from 2009 to 2021 who underwent bladder augmentation or creation of catheterizable channels. Patients without spina bifida and those receiving epidural analgesia were excluded. Opioids were converted into morphine equivalents and normalized to patient weight. RESULTS: 158 patients with pediatric spina bifida from 7 centers were included, including 87 with and 71 without regional catheters. There were no differences in baseline patient factors. Anesthesia setup increased from median 40 min (IQR 34-51) for no regional to 64 min (IQR 40-97) for regional catheters (p<0.01). The regional catheter group had lower median intraoperative opioid usage (0.24 vs 0.80 mg/kg morphine equivalents, p<0.01) as well as lower in-hospital postoperative opioid usage (0.05 vs 0.23 mg/kg/day morphine equivalents, p<0.01). Pain scores were not higher in the regional catheters group. DISCUSSION: Continuous regional analgesia following major urological surgery in children with spina bifida was associated with a 70% intraoperative and 78% postoperative reduction in opioids without higher pain scores. This approach should be considered for similar surgical interventions in this population. TRIAL REGISTRATION NUMBER: NCT03245242.

Design and development of the Pediatric Urology Recovery After Surgery Endeavor (PURSUE) multicentre pilot and exploratory study.

INTRODUCTION: Lower urinary tract reconstruction in paediatric urology represents a physiologically stressful event that is associated with high complication rates, including readmissions and emergency room visits. Enhanced recovery after surgery (ERAS) protocol is a set of multidisciplinary, perioperative strategies designed to expedite surgical recovery without adversely impacting readmission or reoperation rates. Early paediatric urology data demonstrated ERAS reduced complications in this population. METHODS AND ANALYSIS: In 2016, a working group of paediatric urologists and anaesthesiologists convened to develop an ERAS protocol suitable for patients undergoing lower urinary tract reconstruction and define study process measures, patient-reported outcomes and clinically relevant outcomes in paediatric and adolescent/young adult patients. A multicentre, prospective, propensity-matched, case-control study design was chosen. Each centre will enrol five pilot patients to verify implementation. Subsequent enrolled patients will be propensity matched to historical controls. Eligible patients must be aged 4-25 years and undergoing planned operations (bladder augmentation, continent ileovesicostomy or appendicovesicostomy, or urinary diversion). 64 ERAS patients and 128 controls will be needed to detect a decrease in mean length of stay by 2 days. Pilot phase outcomes include attainment of ≥70% mean protocol adherence per patient and reasons for protocol deviations. Exploratory phase primary outcome is ERAS protocol adherence, with secondary outcomes including length of stay, readmissions, reoperations, emergency room visits, 90-day complications, pain scores, opioid usage and differences in Quality of Recovery 9 scores. ETHICS AND DISSEMINATION: This study has been registered with authors' respective institution review boards and will be published in peer-reviewed journals. It will provide robust insight into the feasibility of ERAS in paediatric urology, determine patient outcomes and allow for iteration of ERAS implementations as new best practices and evidence for paediatric surgical care arise. We anticipate this study will take 4 years to fully accrue with completed follow-up. TRIAL REGISTRATION NUMBER: NCT03245242; Pre-results.

Antenatal Presentation of Wilms' Tumor.

Tumors discovered antenatally are rare and the prognosis is generally poor. We present a case of a fetal left renal mass, initially discovered via routine prenatal ultrasound. The mother was an otherwise healthy gravida 4 para one 30-year-old female with 2 previous miscarriages, reportedly secondary to septate uterus. Further imaging and subsequent genetic testing was consistent with an antenatal Wilms' tumor with a mutation in the NPHP1 gene. The newborn received chemotherapy and had no evidence of recurrence at 3 months follow-up.

Genetic Testing Proves Crucial in Case of Ambiguous Genitalia and Renal Masses.

OBJECTIVE: The Denys-Drash syndrome consists of a triad of ambiguous genitalia, Wilm's tumor and nephrotic syndrome. METHODS: We present a diagnostically challenging case of an XY patient with female appearance and Müllerian structures with a WT1 mutation. RESULTS: These genetic findings resulted in gonadal dysgenesis, end-stage renal disease, and precursor changes to Wilm's tumor in both kidneys. Genetic testing proved critical in this case, helping to solidify a diagnosis and guiding our decision to proceed with bilateral nephrectomy and bilateral gonadectomy. CONCLUSIONS: Denys-Drash syndrome can present quite dramatically. WT1 testing should be considered early in the workup for patients with differences of sexual development, particularly those with 46XY karyotype.

Lower Urinary Tract Dysfunction and Associated Pons Volume in Patients with Wolfram Syndrome.

PURPOSE: Wolfram syndrome is a neurodegenerative disorder characterized by childhood onset diabetes mellitus, optic nerve atrophy, diabetes insipidus, hearing impairment, and commonly bladder and bowel dysfunction. We hypothesized that there is an association between a smaller pons, which contains the pontine micturition center, and abnormal lower urinary tract function. MATERIALS AND METHODS: Patients with genetically confirmed Wolfram syndrome attended an annual multidisciplinary research clinic. Subjects underwent noninvasive urodynamic testing and brain magnetic resonance imaging, and completed validated patient reported outcome measures. Bowel and bladder diaries were completed before visits. Age and gender corrected linear and logistic mixed effects models were used to correlate pons volume, corrected for whole brain size, to urodynamic and patient reported outcomes. RESULTS: A total of 36 patients attended 142 visits between 2010 and 2016. Mean age was 16.9 years (range 7 to 30) and 64% of patients were female. Functional bladder capacity was decreased in 31% of the patients, normal in 54% and increased in 14%. Of the patients 44% and 54% had abnormal uroflowmetry and post-void residual, respectively, on at least 1 occasion. There was no increase through time in incidence of lower urinary tract dysfunction. Decreased pons volume was associated with increased post-void residual (p = 0.048) and higher PinQ (Pediatric Incontinence Questionnaire) score (p = 0.011), indicating lower quality of life and higher levels of dysfunction. CONCLUSIONS: A significant number of children, adolescents and young adults with Wolfram syndrome have objective evidence of lower urinary tract dysfunction. Decreased pons volume is associated with more abnormal urinary function and lower quality of life in patients with Wolfram syndrome.

Extra-adrenal Pheochromocytoma Associated With Segmental Renal Artery Compression and Pseudostenosis.

Classically, pheochromocytomas and paragangliomas result in hypertension secondary to an excess release of catecholamines. However, when the tumor arises near the renal hilum, hypertension may also be secondary to renal artery stenosis, which can occur via several purported mechanisms. We describe an unusual case of a hereditary, extra-adrenal pheochromocytoma causing right lower pole renal artery pseudostenosis, pertinent radiologic signs, relevant surgical findings, and subsequent resolution after extirpative surgery.

Adult hypospadias: urethral and penile reconstruction.

PURPOSE OF REVIEW: This article provides a subjective, concise review of contemporary advances in reconstructive urology as it pertains to adult hypospadias repair. Herein, we highlight the most important and interesting articles among the many published within the past 12 months. RECENT FINDINGS: The main themes in the recent literature covered herein, include management of postoperative complications, long-term follow-up, and penile cosmesis. SUMMARY: Recent literature would suggest beauty is in the eye of the beholder when it comes to cosmesis after hypospadias repair. Long-term data are reassuring regarding uroflow improvement through puberty and into adulthood for common distal shaft hypospadias repairs.

Retrograde robotic radical prostatectomy: description of a new technique and early perioperative outcomes.

Objectives. This research was conducted to describe a novel technique for performing robotic-assisted laparoscopic prostatectomy (RALP) using a retrograde approach that mimics the classic open surgical technique. Methods. From June 2009 to March 2011, we performed 18 nonconsecutive RALPs using a novel retrograde approach. Patients were initially selected with D'Amico low to intermediate risk disease. Pre-, intra-, and postoperative data were analyzed in all patients. Results. All 18 patients had successful surgery without any intraoperative complications. Mean preoperative PSA was 6.0 ng/mL. Nine patients had biopsy Gleason score (GS) 6, seven patients had GS 7, and two patients had GS 8. Fourteen patients had clinical stage T1c and four patients had stage T2a. Mean operative time was 198 minutes, with a mean robotic console time of 168 minutes. Fifteen patients had T2 disease on the final pathology and three had T3 disease. With a median follow-up of 11 months, 10 patients had an undetectable PSA. Conclusions. Our early experience with retrograde robotic-assisted laparoscopic prostatectomy demonstrates the feasibility of this approach with early outcomes comparable to the contemporary antegrade approach. Long-term study with a greater number of patients will be necessary to fully evaluate the oncologic and functional outcomes using this technique.

Long-term efficacy and durability of botulinum-A toxin for refractory dysfunctional voiding in children.

PURPOSE: We evaluated our long-term experience with intrasphincteric botulinum toxin A injection in children with dysfunctional voiding. MATERIALS AND METHODS: From January 2006 through July 2012 we saw 2,172 neurologically normal children due to dysfunctional voiding. Of patients who presented to these visits we retrospectively identified the charts of 12 with dysfunctional voiding (8 females) in whom urotherapy and medical management failed and who underwent botulinum toxin A injection to the external urinary sphincter. Mean patient age at surgery was 10.5 years (range 4 to 19). Average followup was 45 months (range 20 to 71). Preoperatively and postoperatively all children were evaluated with history and physical examination, voiding diary, renal and pelvic ultrasound with post-void residual volume measurement and uroflowmetry. RESULTS: Eight of the 12 children (67%) experienced significant improvement in voiding parameters. Before vs after treatment mean ± SD post-void residual urine volume was 115 ± 83 vs 57 ± 61 ml (p = 0.016) and the mean maximum flow rate was 11.8 ± 8.1 vs 20.4 ± 7.9 ml per second. Half of the cohort required a second injection an average of 15 months later. Three of the 4 patients who failed to show improvement had neuropsychiatric problems and 1 had evidence of bladder underactivity. CONCLUSIONS: Our results demonstrate reasonable efficacy and durability of intrasphincteric botulinum toxin A injection in children with refractory dysfunctional voiding. Neuropsychiatric issues appear to negatively influence the success rate. Long-term followup is vital to identify patients in whom repeat injection may be necessary.

The true risk of blood transfusion after nephrectomy for renal masses: a population-based study.

OBJECTIVE: To examine blood transfusion rates after nephrectomy for renal masses at the population-level. PATIENTS AND METHODS: We performed a population-based, retrospective observational study using a national discharge abstract database. The study cohort consisted of 10,902 patients who were treated by radical nephrectomy (RN) or partial nephrectomy (PN) for a renal mass between 1 April 2003 and 31 March 2008. The association between blood transfusion and various explanatory variables was examined using the chi-squared test and multivariable logistic regression. RESULTS: The overall blood transfusion rate was 18.1%. Transfusions occurred after 28.2%, 12.7%, 9.2% and 8.6% of open RN, open PN, laparoscopic RN and laparoscopic PN, respectively (P < 0.001). Transfusion rates were found to be strongly associated with age and comorbidity, such that patients aged <50 years with Charlson scores of 0 were transfused 11.2% and 14.5% of the time compared to 28.2% and 40.7% in patients aged ≥80 years with Charlson scores of ≥3, respectively (P < 0.001). On multivariable logistic regression, age (P < 0.001), Charlson score (P < 0.001), procedure type (P < 0.001), surgeon (P < 0.001) and hospital volume quartile (P < 0.001) were all found to be associated with the rate of blood transfusions, whereas year of surgery, sex and income quintile were not. CONCLUSIONS: The transfusion rate after nephrectomy in general clinical practice is higher than that reported in the urological literature. Patient and provider factors appear to contribute to the considerable variability that exists in the observed transfusion rate. A more detailed understanding of these factors may help with respect to preoperative patient counselling and informed consent.

Endoscopic snare resection of bladder tumors: evaluation of an alternative technique for bladder tumor resection.

Transurethral resection of bladder tumor (TURBT) is the standard of care for initial bladder tumor management. In response to its shortcomings, we propose an alternative technique for tumor resection and retrieval: The endoscopic snare resection of bladder tumor (ESRBT). Eleven tumors managed by ESRBT were reviewed retrospectively. Via cystoscopy, tumors were resected en bloc with an electrosurgical polypectomy snare and retrieved transurethrally. Safety and efficacy were assessed by clinical and pathologic outcomes. ESRBT was highly effective for appropriate tumors. Tumor size and location varied: Two small, six medium, three large; six lateral wall, two dome, two trigone, one posterior wall. Half of initial urothelial carcinoma specimens contained muscle. There were no intraoperative or postoperative complications (mean follow-up: 17 mos; range 10-25 mos). ESRBT is a feasible technique for the resection of pedunculated bladder tumors. It offers evident and theoretical advantages over TURBT and may augment bladder tumor management. Further study is needed.

Contrast-induced nephropathy and nephrogenic systemic fibrosis: minimizing the risk.

INTRODUCTION: Contrast-enhanced cross-sectional imaging is essential to the urologist's practice. Traditionally, patients with impaired renal function could not be imaged with a computed tomography (CT) scan with contrast due to the risk of contrast-induced nephropathy (CIN). These patients could alternatively be imaged by magnetic resonance imaging (MRI) with gadolinium. However, the recent identification of the association between nephrogenic systemic fibrosis (NSF) and gadolinium administration has created significant challenges for urologists and radiologists when faced with the need for evaluation with contrast-enhanced cross-sectional imaging. In this review, we summarize the most comprehensive articles discussing both NSF and CIN and present a straightforward, evidence-based algorithm to determine the appropriate approach to cross-sectional imaging for all patients, as well as future directions regarding cross-sectional imaging. MATERIALS AND METHODS: A MEDLINE literature search for review articles from 1966 to August 2009 was performed. Selected additional articles for specific topics were also reviewed. This search yielded a total of 25 articles for NSF and 28 for CIN that were reviewed. RESULTS: The pathophysiology and risk factors of NSF and CIN are discussed, as well as potential interventions to decrease either morbidity or incidence. A multidisciplinary (urologist, nephrologist, radiologist) evidence-based algorithm is introduced for managing patients in need of cross-sectional imaging. CONCLUSIONS: The associated risks of contrast-enhanced, cross-sectional imaging has created significant challenges for urologic evaluation. We propose an evidence-based approach to guide patient therapy, which can minimize patient risk and physician anxiety, while simplifying the decision-making process.

Does size really matter? The impact of prostate volume on the efficacy and safety of GreenLight HPS™ laser photoselective vaporization of the prostate.

PURPOSE: To evaluate the efficacy and safety of GreenLight HPS™ laser photoselective vaporization of the prostate (PVP) for the treatment of benign prostatic hyperplasia (BPH) in patients with different prostate volumes. PATIENTS AND METHODS: Between July 2006 and February 2011, 207 consecutive patients were identified from a prospectively maintained urologic database. Based on preoperative prostate volume measured by transrectal ultrasonography, patients were stratified into two groups: ≥ 80 cc (group 1, n=57) and < 80 cc (group 2, n=150). Transurethral PVP was performed using a 120W GreenLight HPS side-firing laser system. American Urological Association Symptom Score (AUASS), quality-of-life (QoL) score, maximum flow rate (Qmax), and postvoid residual (PVR) volume were measured preoperatively and at 1 and 4 weeks and 3, 6, 12, 18, 24, and 36 months postoperatively. RESULTS: Among the preoperative parameters evaluated, there were significant differences (P<0.05) in the incidence of preoperative urinary retention (1: 24.6%; 2: 7.3%), serum prostate-specific antigen level (1: 4.5 ± 2.7; 2: 1.8 ± 1.9 ng/mL), QoL (1: 4.2 ± 1.1; 2: 4.7 ± 0.9), and mean prostate volume (1: 118.1 ± 37.9; 2: 48.5 ± 15.5 cc), while AUASS, Qmax, and PVR were similar (P>0.05) between groups. Significant differences (P<0.05) in laser use (1: 22.8 ± 13.3; 2: 10.4 ± 6.4 minutes) and energy usage (1: 152.7 ± 90.6; 2: 70.9 ± 44.8 kJ) were also noted. Clinical outcomes (AUASS, QoL, Qmax, and PVR) showed immediate and stable improvement from baseline (P<0.05) within each group, but no significant differences between the two groups were observed during the follow-up period (P>0.05). The incidence of adverse events was low and similar in both cohorts. CONCLUSIONS: These results suggest that prostate volume has little effect on the efficacy and safety of GreenLight HPS laser PVP, and that this technique remains a viable surgical option for BPH, irrespective of preoperative prostate volume.

Conversion from pure laparoscopy to hand-assisted laparoscopy for control of bleeding in renal surgery: an attractive alternative to open conversion.

PURPOSE: To assess the safety and efficacy of conversion from pure laparoscopy to hand-assisted laparoscopy to control mild-to-moderate bleeding during renal surgery. PATIENTS AND METHODS: Between August 2006 and August 2008, we performed 94 laparoscopic nephrectomies (44 partial and 50 radical). A total of three radical nephrectomies were converted from pure to hand-assisted laparoscopy for control of bleeding. The first patient was a 44-year-old man with a 14-cm cystic renal mass. The second patient was a 52-year-old man with a 3.8-cm renal mass, and the third patient was an 86-year-old woman with a 7-cm renal mass. RESULTS: In all three procedures, the indication for conversion was bleeding from the renal hilum or the kidney parenchyma during dissection. The bleeding was difficult to control using pure laparoscopy, and therefore a hand port was inserted. Time for conversion and placement of the hand port averaged less than 7 minutes. Total estimated blood loss for the three patients was 800 mL, 2000 mL, and 650 mL, respectively. One patient needed a transfusion with three units of packed red blood cells. The postoperative course was uneventful in all patients, except for one patient who had prolonged ileus and stayed in the hospital for 6 days. The remaining two patients were discharged on postoperative days 2 and 3. CONCLUSIONS: Conversion from pure to hand-assisted laparoscopy for bleeding control is feasible and effective. It adds minimal morbidity while maximizing cosmesis, and it should be considered as an alternative to open conversion in cases of mild-to-moderate bleeding.

Percutaneous cryoablation of renal masses: impact of patient selection and treatment parameters on outcomes.

OBJECTIVES: To evaluate whether the trend in patient selection or perioperative parameters were associated with treatment outcomes after percutaneous cryoablation (PCA) of renal masses. METHODS: We retrospectively analyzed our urological oncology database and identified 52 patients treated for a total of 54 renal masses. Univariate analysis was performed to evaluate whether the variables of age, gender, tumor size, number of probes used, total freezing time, preoperative creatinine, American Society of Anesthesia class, body mass index, or age-adjusted Charlson comorbidity index (CCI) score had an impact on the outcomes of treatment failure or the complication rate. RESULTS: During a mean follow-up of 21 months, recurrence-free, overall, and disease-specific (based on radiographic follow-up and biopsy) survival were 96.2%, 98.1% and 100%, respectively. The mean age-adjusted CCI score for patients with postoperative complications was 6.5, compared with a mean score of 3.0 in patients without postoperative complications (P = .02). The complication rate was also significantly higher when a greater number of cryoprobes were used during PCA (P < .005). None of the variables analyzed were predictive of treatment failure. CONCLUSIONS: Of the pre- and intraoperative variables studied, age-adjusted CCI score and number of cryoprobes used were the only variables with predictive value for outcomes in regard to treatment failure or complications. As investigators continue using cryoablation to treat renal masses, it is important to be able to completely and honestly counsel patients regarding the likelihood of complications and need for subsequent therapy in the setting of treatment failure.