Pelvic Neuroblastoma of the Pediatric Prostate.

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

Survey of COVID-19 impact on pediatric urology services.

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

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

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

Urologic Phenotype and Patterns of Care in Patients With Megacystis Microcolon Intestinal Hypoperistalsis Syndrome Presenting to a Major Pediatric Transplantation Center.

OBJECTIVE: To describe the phenotype, referral pattern, and trends of urologic management for children with megacystis microcolon intestinal hypoperistalsis syndrome. MATERIALS AND METHODS: We performed a retrospective review of all patients with megacystis microcolon intestinal hypoperistalsis syndrome treated at a large tertiary children's medical center over a 14-year period. Our primary outcomes included the rate of urology referral, urodynamic characteristics of bladder function, and the proportion of patients managed with clean intermittent catheterization. RESULTS: Twenty-six patients were evaluated at our institution with a median age at presentation of 1.3 years (73% female, 19 of 26). Most patients presented for intestinal transplantation evaluation and were dependent on parenteral nutrition. Megacystis was diagnosed prenatally in 15 patients and postnatally in 11 patients. Twenty patients (77%, 20 of 26) were evaluated by a pediatric urologist. Six patients (23%, 6 of 26) had varying degrees of vesicoureteral reflux. Early bladder management consisted of clean intermittent catheterization in 13 patients and vesicostomy in 8 patients. CONCLUSION: Megacystis microcolon intestinal hypoperistalsis syndrome is a severe form of intestinal failure and bladder atony with substantial urologic morbidity. Parents should be counseled accordingly and prompt urologic consultation should be included in the multidisciplinary approach to these complex patients.

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

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

Pediatric Ureteroscopy.

In recent years, the incidence of nephrolithiasis in the pediatric population appears to be increasing. 1 This has placed a new emphasis on surgical management of stones in children. In the past, extracorporeal shockwave lithotripsy was the preferred management technique for stones in children. 2 More recently, though, advances in endoscopy have allowed ureteroscopy to be adapted to the pediatric population and this approach has become more frequently utilized not just for lower ureteral calculi but also for proximal ureteral and renal stones.

Trends in Urologic Indications for Pediatric Renal Transplantation Over a 27-Year-period United Network for Organ Sharing (UNOS) Database.

OBJECTIVE: To elucidate the trends in urologic causes for renal transplant in the pediatric population using a national database. Little is known about the specific pediatric urologic conditions and resultant trends that precede renal transplantation. MATERIAL AND METHODS: We reviewed the United Network for Organ Sharing (UNOS) database for pediatric patients (<18 years old) who underwent renal transplantation from January 1988 to September 2015. We included those patients who received a renal transplant because of a urologic condition. RESULTS: Over 27 years, 7291 of 20,213 children (36%) underwent renal transplant secondary to a urologic condition. The 2 most common indications were hypoplasia/dysplasia/dysgenesis/agenesis (HDDA, 35.1%) and congenital obstructive uropathy (COU, 25.7%). The incidence of COU has increased from 18% to 30%, and the incidence of Wilms tumor has remained relatively consistent at 1.8% per year. In addition, 68% of all urologic renal transplants were performed in men compared with women. However, a higher percentage of women required transplantation because of Wilms tumor (3.1% vs 1.2%) and chronic pyelonephritis (17.6% vs 7.9%). Overall, the majority of patients (61.5%) who underwent renal transplantation were white, 18.8% Hispanic, and 15.3% black. CONCLUSION: HDDA and COU consistently have been the most common urologic indications for renal transplantation. Both are the leading causes in men, whereas HDDA and chronic pyelonephritis are predominant in women. Higher rate of renal transplant during the ages of 11-17 years is suggestive of increased burden on poorly functioning kidneys during times of adolescent growth.

Bowel preparation prior to reconstructive urologic surgery in pediatric myelomeningocele patients.

INTRODUCTION: Mechanical bowel preparation (MBP) has historically been the standard of care for patients undergoing reconstructive urologic surgery, including urinary diversion. To date, several studies have examined the role of mechanical bowel preparation in postoperative outcomes in pediatric patients undergoing augmentation cystoplasty. However, these patient populations have been heterogeneous in nature, with no studies dedicated to examining the role of MBP prior to reconstructive urologic surgery in pediatric patients with myelomenginoceles. Thus, our objective was to retrospectively assess perioperative measures and postoperative complications after reconstructive urologic surgery with or without mechanical bowel preparation in pediatric myelomeningocele patients. MATERIALS AND METHODS: From 2008 to 2013, 80 patients with myelomeningocele underwent reconstructive urologic surgery involving the use of bowel. Seventy patients underwent a preoperative MBP while 10 did not. Perioperative measures and postoperative complications for these two cohorts were assessed. RESULTS: Eighty patients with myelomeningocele were identified; 70 patients underwent MBP while 10 patients did not. There were no statistically significant differences in demographics or operative time. There were no statistically significant differences in postoperative outcomes including time to first bowel movement and time to tolerating diet. There was also no significant difference in overall complication rate; patients with MBP had 31/70 (44%) complications while 2/10 (20%) of those without MBP had complications (p = 0.18). CONCLUSION: There was no significant difference in perioperative measures and postoperative complications for patients who did not receive a mechanical bowel preparation. Our findings indicate that it is safe and warranted to perform a prospective, randomized study to better characterize the risks and benefits of preoperative bowel preparation for patients with myelomeningocele.

The use of intraoperative cell salvage in urologic oncology.

Intraoperative cell salvage (IOCS) has been used in urologic surgery for over 20 years to manage intraoperative blood loss and effectively minimize the need for allogenic blood transfusion. Concerns about viability of transfused erythrocytes and potential dissemination of malignant cells have been addressed in the urologic literature. We present a comprehensive review of the use of IOCS in urologic oncologic surgery. IOCS has been shown to preserve the integrity of erythrocytes during processing and effectively provides cell filtration to mitigate the risk of tumor dissemination. Its use is associated with reduction in the overall need for allogenic blood transfusion, which clinically reduces the risk of hypersensitivity reactions and disease transmission, and may have important implications on overall oncologic outcomes. In the context of a variety of urologic malignancies, including prostate, urothelial, and renal cancer, the use of IOCS appears to be safe, without risk of tumor spread leading to metastatic disease or differences in cancer-specific and overall survival. IOCS has been shown to be an effective intraoperative blood management strategy that appears safe for use in urologic oncology surgery. The ability to reduce the need for additional allogenic blood transfusion may have significant impact on immune-mediated oncologic outcomes.

Combination of Extracorporeal Shockwave Lithotripsy and Ureteroscopy for Large Staghorn Calculi in a Pediatric Patient: Case Report.

Background: Extracorporeal shockwave lithotripsy (SWL) is a procedure commonly performed to treat nephrolithiasis, with promising results in pediatric patients. However, increasing renal calculi size is directly related to worsening stone-free rates. There are few reports in the literature of >2-cm staghorn calculi that expound on the exact mechanism of treatment in the pediatric population. Case Presentation: We present a case report of a 3-year-old boy who presented with a large 3-cm staghorn calculi effectively treated with one session of SWL followed by a planned staged ureteroscopy for definitive treatment. Conclusion: Despite the numerous studies limiting the use of SWL to treat stones <2 cm, if used in softer composition stones, coupled with the larger focal volume involved with smaller patients, SWL when used in combination with adjunctive ureteroscopy is a safe and effective treatment option.

Optimal Length of Follow-up for the Detection of Unsuccessful Pediatric Pyeloplasty: A Single-Center Experience.

OBJECTIVES: To assess the optimal length of follow-up for patients undergoing both open and minimally invasive pyeloplasties to ensure prompt detection of a recurrent obstruction. There are no standard guidelines on ideal follow-up and imaging post-pediatric pyeloplasty currently. METHODS: A retrospective chart review identified 264 patients (<18 years old) who underwent pyeloplasty for ureteropelvic junction obstruction between April 2002 and December 2014. Ultrasound was obtained every 3-4 months for the first year following pyeloplasty and thereafter at discretion of treating physician. Patient characteristics including symptoms and imaging were reviewed. RESULTS: Of the 264 patients, 72% were male with mean age of 51 months and follow-up of 26.8 months. Approximately 73% followed up to 3 years. Fourteen patients (5.3%) had a recurrent obstruction. Among the failures, 85% were diagnosed and underwent successful redo pyeloplasty within 3 years. Six infants had a recurrence (43% of all unsuccessful surgeries) and were diagnosed within 3 years of the initial surgery. Patients undergoing a minimally invasive procedure were less likely to be followed for more than 3 years compared to an open procedure (p < 0.001). Patients with severe hydronephrosis preoperatively were followed longer (p = 0.031). Age at surgery and type of surgical approach (p < 0.01) were significant predictors of length of follow-up in a negative binomial regression. CONCLUSION: Based on the results, a minimum of 3 years of follow-up is necessary to detect the majority of recurrent obstructions. Those patients who have higher than average lengths of follow-up tend to be younger and/or underwent an open surgical approach.

Percutaneous Stone Surgery in Spina Bifida Patients--Are Stone-Free Rates Worth the Risk?

PURPOSE: Percutaneous stone surgery can be challenging in spina bifida (SB) patients due to their body habitus and spinal cord anomalies. A safe surgical approach may necessitate acceptance of lower stone-free (SF) rates. We seek to determine if anatomic complexity, as measured by spinal cord curvature and torso length, is associated with SF rates after percutaneous stone surgery in SB patients. We hypothesize that increasing anatomic complexity is associated with lower SF rates following percutaneous stone surgery. METHODS: We retrospectively reviewed all cases of percutaneous nephrolithotomy (PCNL) and percutaneous cystolitholapaxy (PC) in patients with SB at our institution. We calculated individual Cobb angles for scoliosis and kyphosis and measured torso lengths to serve as surrogates of anatomic complexity. These parameters were used to test for associations between anatomic complexity and SF rates. RESULTS: A total of 32 procedures were analyzed (15 PCNL, 17 PC). SF rates for PCNL and PC were 60% and 71%, respectively. For both the PCNL and PC cohorts, there was no difference in age, preoperative stone burden, body mass index, operative time, or estimate blood loss between patients deemed SF or not stone free (NSF) after a single procedure. In the PCNL cohort, worsening scoliosis (higher Cobb angle) and lower SF rates trended toward statistical significance (43° vs. 24°, p = 0.058). In the PC cohort, increasing torso length was associated with lower SF rates (34.1 vs. 28.5 cm, p = 0.02). CONCLUSIONS: Overall SF rates were modest in this population. Cobb angle measurements of scoliosis and kyphosis as well as torso length are novel tools for objectively defining anatomic complexity in the SB population and may help predict success following stone surgery.

Clinical and Radiological Risk Factors Predicting Open Surgical Repair in Pediatric Patients With Dilating Vesicoureteral Reflux.

OBJECTIVE: To study the individual patient-related risk factors in those undergoing open corrective vesicoureteral reflux (VUR) surgery in a contemporary series. The management of VUR remains controversial, and the indications for open surgery has evolved from that of surgeon and patient preference to criteria involving breakthrough urinary tract infections and grade of VUR. MATERIALS AND METHODS: A retrospective study was performed, and patients undergoing open surgical repair for dilating VUR (grade III-V) from 2005 to 2014 were included. Characteristics of patients were determined to identify predictors of operative intervention. Statistical analysis including Fisher's exact test and multivariable logistic regression of patient demographics and independent predictors of surgery was performed using the Stata (College Station, TX) version 13 software package. RESULTS: Of the 469 patients, 351 (74.8%) underwent open intravesical ureteroneocystostomy and 118 (25.2%) were managed conservatively. Based on the multivariable analysis, age, female sex, number of febrile urinary tract infections, maximum grade of reflux, prenatal hydronephrosis, ureteral dilatation, and persistence of VUR on voiding phase of voiding cystourethrogram were strong predictors of eventual surgery. Female sex (odds ratio [OR]: 19.8), ureteral dilatation (OR: 6.2), and persistence of VUR on voiding phase (OR: 5.03) were among the strongest predictors of surgical intervention. CONCLUSION: Female sex and higher grades of VUR were the strongest predictors of eventual surgical intervention. VCUG characteristics of ureteral dilatation >7 mm and persistence of VUR on the voiding phase were also very strong predictors of eventual surgical intervention.