Randomized controlled trial of NSAID prior to cystoscopic ureteral stent removal in a pediatric population.

INTRODUCTION: Ureteral spasm, common with ureteral stents, is partially mediated by prostaglandins and may be suppressed by cyclooxygenase inhibitors like non-steroidal anti-inflammatory (NSAIDs). Practices currently vary widely for pain management in patients with ureteral stents, sometimes including opioids. OBJECTIVE: We aimed to determine if NSAID given prior to stent removal would reduce postoperative pain. We hypothesized there would be at least a 75% reduction in postoperative severe pain (pain score ≥7) in patients receiving ibuprofen compared to placebo. STUDY DESIGN: We performed a double-blind, placebo-controlled randomized controlled trial on pediatric urology patients with an indwelling ureteral stent undergoing removal in the operating room from 2014 to 2019. 20 patients in each arm were needed to achieve 80% power to detect a 75% reduction in the estimated 55% incidence of severe postoperative pain (α = 0.05). Patients ≥4 years old who had a unilateral stent placed after treatment of urolithiasis or ureteropelvic junction obstruction were randomized to NSAID or placebo in a 1:1 ratio at least 15 min prior to scheduled stent removal. Patients estimated pain using Faces Pain Scale-Revised (FPS-R) or visual analogue scale (VAS) prior to and 24 h after stent removal. RESULTS: 254 patients undergoing stent removal were assessed for eligibility, and 44 randomized patients were analyzed using intention to treat analysis. The cohorts were demographically similar and received similar anesthesia treatment. There was no significant difference in maximum post anesthesia care unit pain score (p = 0.269) or use of in-hospital opioids (p = 0.626) between the two groups. No difference was seen in the incidence of severe postoperative pain (p = 1.0), thus rejecting the hypothesis. Significant worsened postoperative pain (pain score increases of ≥2 between time points) decreased from 22.7% to 13.6% between placebo and NSAID, but this did not reach significance (p = 0.410). DISCUSSION: There was no difference in postoperative pain for patients undergoing ureteral stent removal given preoperative NSAID versus placebo. The incidence of severe pain before and after stent removal was low, ranging from 4.5 to 9.1%. CONCLUSION: Research to understand the etiology of pain after stent removal and techniques to minimize or prevent discomfort should continue in order to optimize patient outcomes.

A Contemporary Analysis of Pediatric Urology Surgical Volume at a Tertiary Care Center.

OBJECTIVE: To describe the annual volume of pediatric urology cases in an academic, tertiary care setting. METHODS: A retrospective review was performed of all patients operated on by 4 pediatric urologists (total of 2.5 full-time equivalents) at an academic, tertiary care center with a free-standing children's hospital from 2016 to 2017 (24 months). Basic case information was collected from operative reports. Descriptive statistics are reported using nonparametric methods. "Uncommon" was defined a priori as occurring <10% of the time. RESULTS: During the entire study period, 2718 patients underwent 4580 procedures. This equated to 1088 patients and 1832 procedures per full-time equivalent. Median age at surgery was 3.2 years (IQR 0.8-10) and 757 (16.5%) of patients were female. Most procedures were elective (4406, 96.2%) and did not require postoperative admission (3842, 83.9%). Urgent and emergent cases were uncommon (174, 3.8%). Most cases were classified as general pediatric urology (3894, 85%) with 319 (7%) classified as major reconstruction, 275 (6%) as laparoscopy/endourology and 92 (2%) as oncology. The most common cases involved the groin/scrotum (1415, 30.9%), prepuce (809, 17.7%), phallus (802, 17.5%), and endoscopy (652, 14.2%). All other case types were uncommon. CONCLUSION: This description of an academic pediatric urology practice at a tertiary care center with a free-standing children's hospital noted a high volume of elective, outpatient procedures that are largely general pediatric urology. Uncommon cases include urgent/emergent interventions, major reconstruction, laparoscopy/endourology, and oncology procedures.

Patients with disorders of sex development and proximal hypospadias are at high risk for reoperation.

PURPOSE: Surgical repair for proximal hypospadias has been associated with long-term success rates of 32-68%. In a prior study, outcomes for proximal hypospadias in patients with a diagnosis of disorders of sex development (DSD) were no different than those of patients without DSD. The objective of our study is to report our experience with proximal hypospadias repair in patients with and without DSD. METHODS: We retrospectively reviewed patients who underwent repair of proximal hypospadias between 2005 and 2016. Data collected included patient and disease characteristics, operative details, complications, and follow-up. The primary outcome was unplanned reoperation. RESULTS: Sixty seven patients were identified; 30 (44.8%) with DSD and 37 (55.2%) without DSD. Median follow-up was 28.3 months (IQR 18.9-45.7). 41 patients (61.2%) underwent at least one unplanned reoperation, median time to unplanned reoperation 10.3 months. More patients with DSD needed an unplanned reoperation (80 vs. 45.9%, p = 0.024). During the first 12 months after initial repair, there was no difference in unplanned reoperation rates (40 vs. 32.4%, p = 0.611), but there was a difference in the first 24 months post-operatively (76.7 vs. 43.2%, p = 0.007). On multivariate logistic regression, older age at initial repair (OR 1.144) and two stage repair (OR 7.644) were positively associated with unplanned reoperation in the first 2 years after repair. CONCLUSIONS: Proximal hypospadias repair is associated with an overall 61.2% reoperation rate regardless of associated DSD diagnosis. Patients with DSD are more likely to undergo an unplanned reoperation in the first 2 years after repair.

Incidence and risk factors for positive urine culture at the time of pediatric urologic surgery.

PURPOSE: Urinary tract infections are relatively common in pediatric patients. Unrecognized bacteriuria at the time of urologic surgery puts patients at increased risk for perioperative complications. Many pediatric urologists obtain preoperative or intraoperative urine cultures prior to surgery, but data are lacking regarding rates and risk factors for positive intraoperative urine cultures. We conducted a retrospective cohort study of patients undergoing pediatric urologic surgery to examine factors associated with positive intraoperative urine cultures. MATERIALS AND METHODS: Charts of patients of age 0-18 years from a single pediatric urologist with associated intraoperative urine culture results between 2008 and 2013 were retrospectively reviewed. Demographics, prior culture results, and information regarding possible risk factors of interest-history of constipation, hydronephrosis, neurogenic bladder, posterior urethral valves, ureterocele, UPJ obstruction, urolithiasis, vesicoureteral reflux, and circumcision status-were collected and analyzed. RESULTS: Seven hundred and fifty procedure encounters with associated intraoperative urine culture results were reviewed. Overall positive urine culture rate was 13.5%. Factors associated with increased odds of positive intraoperative urine culture included neurogenic bladder (odds ratio 26.3, p < 0.001), prior positive culture (OR 5.4, p < 0.001), female sex (OR 2.1, p 0.007), constipation (OR 2.9, p < 0.001), and urolithiasis (OR 1.58, p = 0.04). Patients without any of these risk factors had no positive intraoperative cultures (p = 0.03). CONCLUSIONS: Patients with neurogenic bladder, prior positive urine culture, constipation, female gender, and urolithiasis were at increased risk for positive intraoperative urine culture. This may aid in decision-making regarding obtaining preoperative or intraoperative urine cultures in pediatric urology patients.

Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know.

Pediatric blunt scrotal trauma is most often the consequence of sports injury and presents a diagnostic challenge because swelling and pain make a scrotal physical exam difficult. US with color flow and duplex Doppler is the first-line imaging modality with the goal of accurate and timely diagnosis of injury requiring surgery to preserve fertility and hormonal function. US imaging findings following blunt scrotal trauma include hydrocele, hematocele, testicular hematoma, testicular fracture, testicular rupture, compromised perfusion/testicular torsion and testicular dislocation. Importantly, several of these findings may coexist. Our goal is to present the pertinent intrascrotal anatomy, US imaging findings for each testicular injury, and contemporary management for each, with emphasis on what our pediatric urology colleagues need to know for optimal patient care.

Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system).

OBJECTIVE: Urinary tract (UT) dilation is sonographically identified in 1-2% of fetuses and reflects a spectrum of possible uropathies. There is significant variability in the clinical management of individuals with prenatal UT dilation that stems from a paucity of evidence-based information correlating the severity of prenatal UT dilation to postnatal urological pathologies. The lack of correlation between prenatal and postnatal US findings and final urologic diagnosis has been problematic, in large measure because of a lack of consensus and uniformity in defining and classifying UT dilation. Consequently, there is a need for a unified classification system with an accepted standard terminology for the diagnosis and management of prenatal and postnatal UT dilation. METHODS: A consensus meeting was convened on March 14-15, 2014, in Linthicum, Maryland, USA to propose: 1) a unified description of UT dilation that could be applied both prenatally and postnatally; and 2) a standardized scheme for the perinatal evaluation of these patients based on sonographic criteria (i.e. the classification system). The participating societies included American College of Radiology, the American Institute of Ultrasound in Medicine, the American Society of Pediatric Nephrology, the Society for Fetal Urology, the Society for Maternal-Fetal Medicine, the Society for Pediatric Urology, the Society for Pediatric Radiology and the Society of Radiologists in Ultrasounds. RESULTS: The recommendations proposed in this consensus statement are based on a detailed analysis of the current literature and expert opinion representing common clinical practice. The proposed UTD Classification System (and hence the severity of the UT dilation) is based on six categories in US findings: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. The classification system is stratified based on gestational age and whether the UT dilation is detected prenatally or postnatally. The panel also proposed a follow-up scheme based on the UTD classification. CONCLUSION: The proposed grading classification system will require extensive evaluation to assess its utility in predicting clinical outcomes. Currently, the grading system is correlated with the risk of postnatal uropathies. Future research will help to further refine the classification system to one that correlates with other clinical outcomes such as the need for surgical intervention or renal function.

Discovery of hypospadias during newborn circumcision should not preclude completion of the procedure.

OBJECTIVE: To test the hypothesis that completion of newborn circumcision does not complicate hypospadias repair, and that circumcision will minimize future operations. STUDY DESIGN: Children referred for distal hypospadias over a 5-year period were grouped by presentation. Children with an aborted circumcision owing to concerns for hypospadias were subdivided into patients who underwent hypospadias repair (group 1a) and those who underwent circumcision (group 1b). Group 2 consisted of patients with a completed circumcision who underwent hypospadias repair. Children with traditionally recognized distal hypospadias served as controls. RESULTS: A total of 93 newborns had an aborted newborn circumcision. Of these, 28 underwent hypospadias repair (group 1a), and 47 underwent circumcision completion under general anesthesia (group 1b). The remaining 18 either deferred surgery or underwent in-office circumcision. Ten patients with hypospadias and an intact prepuce had a completed circumcision and subsequently underwent repair (group 2). The control group comprised 151 patients. No patients with a completed circumcision experienced complications after hypospadias repair, whereas the control group had a 5.3% rate of complications. CONCLUSION: Performing circumcision in newborns with hypospadias and an intact prepuce did not affect repair or the risk of complications. These findings, along with previous results, demonstrate that newborn circumcision can be safely completed in children with an intact prepuce. Furthermore, aborting a newborn circumcision after dorsal slit will expose a substantial number of children to additional procedures under general anesthesia.

Variations in management of mild prenatal hydronephrosis among maternal-fetal medicine obstetricians, and pediatric urologists and radiologists.

PURPOSE: There are no current guidelines for diagnosing and managing mild prenatal hydronephrosis. Variations in physician approach make it difficult to analyze outcomes and establish optimal management. We determined the variability of diagnostic approach and management regarding prenatal hydronephrosis among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. MATERIALS AND METHODS: Online surveys were sent to mailing lists for national societies for each specialty. Participants were surveyed regarding criteria for diagnosing mild prenatal hydronephrosis and recommendations for postnatal management, including use of antibiotic prophylaxis, followup scheduling and type of followup imaging. RESULTS: A total of 308 maternal-fetal medicine obstetricians, 126 pediatric urologists and 112 pediatric radiologists responded. Pediatric urologists and radiologists were divided between Society for Fetal Urology criteria and use of anteroposterior pelvic diameter for diagnosis, while maternal-fetal medicine obstetricians preferred using the latter. For postnatal evaluation radiologists preferred using personal criteria, while urologists preferred using anteroposterior pelvic diameter or Society for Fetal Urology grading system. There was wide variation in the use of antibiotic prophylaxis among pediatric urologists. Regarding the use of voiding cystourethrography/radionuclide cystography in patients with prenatal hydronephrosis, neither urologists nor radiologists were consistent in their recommendations. Finally, there was no agreement on length of followup for mild prenatal hydronephrosis. CONCLUSIONS: We observed a lack of uniformity regarding grading criteria in diagnosing hydronephrosis prenatally and postnatally among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. There was also a lack of agreement on the management of mild intermittent prenatal hydronephrosis, resulting in these cases being managed inconsistently. A unified set of guidelines for diagnosis, evaluation and management of mild intermittent prenatal hydronephrosis would allow more effective evaluation of outcomes.

Ventriculoperitoneal shunt infections after bladder surgery: is mechanical bowel preparation necessary?

PURPOSE: We investigated whether children with a ventriculoperitoneal shunt who undergo mechanical bowel preparation before bladder reconstruction with bowel have a lower rate of infection than children who do not undergo preoperative bowel preparation. MATERIALS AND METHODS: We performed an institutional review board approved, retrospective chart review of the incidence of ventriculoperitoneal shunt infections after bladder reconstruction using bowel and compared infection rates using Fisher's exact test. Mean ± SD followup was 2.9 ± 2.3 years. RESULTS: Between 2003 and 2009, 31 patients with a ventriculoperitoneal shunt underwent bladder reconstruction using bowel, of whom 19 (61%) and 12 (39%) did and did not undergo mechanical bowel preparation, respectively. There was no significant difference in gender or age at surgery between the 2 groups. Infection developed in 3 children (9.6%) within 2 months postoperatively, including 2 (10.5%) with and 1 (8.3%) without bowel preparation (2-tailed p = 1.0). CONCLUSIONS: There was no significant difference in the shunt infection rate between patients with a ventriculoperitoneal shunt who did and did not undergo preoperative bowel preparation. Our results add to the current literature suggesting that bowel preparation is unnecessary even in patients with a ventriculoperitoneal shunt.

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

Endoscopic treatment of symptomatic refluxing renal transplant ureteroneocystostomies in children.

To present a multi-center experience with the use of Dx/HA copolymer for treatment of symptomatic refluxing renal transplant UNC in children. A multi-center, retrospective chart review was performed. Eleven patients with a mean age of eight yr underwent renal transplantation with an anti-refluxing UNC. Data were collected to determine the safety and effectiveness of the procedure and to identify possible predictors of success. Endoscopic treatment was successful in one of five males and five of six females, for an overall success rate of 54.5%. The etiology of renal failure was associated with success of treatment, with 4/6 (67%) patients with upper tract pathology demonstrating resolution of the VUR, as compared with one of three (33%) patients with lower tract pathology. Male patients had a higher incidence of lower tract pathology. No complications were associated with the endoscopic procedure. Endoscopic injection of Dx/HA remains a safe option for the treatment of symptomatic refluxing transplant UNC in children. Although the success rate is lower than that seen in the treatment of primary VUR, the minimally invasive nature and safety of this technique may offer advantages over open reconstruction of the refluxing transplant ureter.

Operative versus nonoperative management of ureteropelvic junction obstruction in children.

OBJECTIVES: To describe and validate our strategy for treating patients with ureteropelvic junction obstruction operatively or nonoperatively according to ultrasonography and nuclear renal scan findings. METHODS: A retrospective analysis of 243 patients from 1999 to 2006 with grade 3-4 hydronephrosis was performed. Depending on the grade of hydronephrosis with parenchymal thinning on ultrasonography and renal function on the nuclear renal scan, patients were treated with immediate pyeloplasty, pyeloplasty after a period of observation, or observation only. RESULTS: Of 243 patients, 116 were found to have UPJO as determined by a half-life >20 minutes. The mean follow-up was 24.0 months (range 3-69). Immediate pyeloplasty was performed in 32 children, and 84 were treated conservatively. Crossover from observation to surgery occurred in 47 children. In the immediate pyeloplasty group, the mean pre- and postoperative differential function was 30.4% and 38.8%, respectively (P < .0001). In the observation-only group (n = 37), the initial mean renal function was 41.4% and stayed stable throughout the follow-up period, at a mean of 43.2% (P = .2764). In the delayed pyeloplasty group (n = 47), the initial mean renal function was 35.9% and increased to a mean of 41.6% after intervention (P = .0003). The median improvement of hydronephrosis on ultrasonography for those who underwent immediate surgery from before to after the intervention was from grade 4 to grade 3 (P < .0001). For those not undergoing surgery, it improved from grade 4 to grade 2.25 (P = .0026) and for those who underwent delayed surgery, from grade 4 to 3 (P = .0003). CONCLUSIONS: According to our findings, the serial ultrasonography findings and initial renal function on nuclear renal scan are better indicators than the half-life alone for determining whether pyeloplasty is indicated.

A favorable outcome following 32 vesicocentesis and amnioinfusion procedures in a fetus with severe prune belly syndrome.

Patients with severe prune belly syndrome rarely survive beyond the first days of life. We present a case of prune belly syndrome that initially presented with severe oligohydramnios, megacystis and associated poor urine biochemistries. Due to an anteriorly located placenta the patient was referred to three major centers, but was turned down because of the unfavorable prognostic findings. Therefore, fetal intervention was performed with 32 vesicocentesis and amnioinfusion procedures. Despite the unfavorable prenatal findings, and having undergone numerous fetal interventions, the birth resulted in a viable infant.

Radiographic changes following excisional tapering and reimplantation of megaureters in childhood: long-term outcome in 46 renal units.

PURPOSE: Despite the routine use of renal ultrasonography to document progressive improvement in hydronephrosis following ureteral tailoring and reimplantation of megaureters, there have been few reports characterizing the serial radiographic changes to be expected following this procedure. We evaluated the radiographic outcomes following surgical repair of megaureters at single institution, and assessed potential preoperative factors for predicting outcome. MATERIALS AND METHODS: We conducted a retrospective analysis of all patients who underwent surgical correction of clinically significant megaureters at our center between 1996 and 2003. Demographic data, indications for surgery, and preoperative and postoperative radiographic imaging data were recorded. RESULTS: A total of 46 megaureters (39 patients) were tapered and reimplanted. Average patient age at surgery was 4.0 years (range 5 months to 19 years). Indications for surgery included recurrent or breakthrough urinary tract infections, decreased renal function and increased hydroureteronephrosis. Mean followup was 3.9 years (range 4 months to 7 years). Postoperative voiding studies showed vesicoureteral reflux in 3 reimplanted ureters (7%). There was no evidence of obstruction on postoperative nuclear renal scans in any patient. Renal ultrasonography revealed improvement or resolution of hydroureteronephrosis in 29 reimplanted units (63%). In general, male patients, those operated on at a younger age and those with a lower preoperative grade of hydronephrosis were most likely to demonstrate improvement or resolution of hydronephrosis. The best results were seen in ectopic megaureters, followed in decreasing order by refluxing megaureters, megaureters associated with ureteroceles and primary obstructive megaureters. CONCLUSIONS: Despite functional improvement on postoperative radiographic imaging, it is not uncommon to see persistent hydroureteronephrosis following excisional tapering and reimplantation of megaureters in childhood.

Inguinal herniation of the bladder in an infant.

Inguinal herniation of the bladder is an uncommon finding with fewer than 200 cases reported in the literature. It is found most commonly in older, obese men with lower urinary tract symptoms. We report a case of inguinal herniation of the bladder in a premature infant.

Use of a mechanical thrombectomy catheter for percutaneous extraction of renal fungal bezoars in a premature infant.

Fungal urinary tract infections are commonly encountered in the hospitalized neonate. Although these infections most commonly take the form of cystitis, the infection may be complicated by the formation of fungal bezoars, with subsequent urinary tract obstruction. In certain cases, endosurgical debulking or extraction of the fungal bezoar may be necessary. This is particularly challenging in neonates due to their often-compromised physiologic state and small size. We report a case of a premature infant with bilateral obstructing renal fungal bezoars in whom a percutaneous catheter-based thrombectomy system was used successfully to debulk the fungal burden.

Complications associated with clean intermittent catheterization in children with spina bifida.

PURPOSE: Clean intermittent catheterization (CIC) is commonly used in the management of voiding dysfunction associated with neurospinal dysraphism. We determined the incidence of genitourinary complications associated with this technique in a population of children with spina bifida. MATERIALS AND METHODS: The charts of all children younger than 13 years attending a multi-disciplinary spina bifida clinic between 1987 and 2002 were reviewed. Children in whom CIC had been performed for a minimum of 5 years were identified. Catheterization was performed with a polyvinyl chloride catheter and a water-based lubricant. All genitourinary complications that had occurred in this group were recorded. The caregiver of each patient was then contacted by telephone to confirm the accuracy of our data. RESULTS: There were 32 females and 27 males identified in whom CIC had been performed for a minimum of 5 years. Mean duration of CIC was 10.5 years (range 5 to 15). Of the patients 45 (76%) learned to perform CIC independently at a mean age of 8 years (range 4.7 to 15.3). Two complications were gross hematuria and a false passage in the bulbar urethra. Both complications occurred in males early in the course of CIC, and while being performed by a caregiver. Neither complication was associated with long-term sequelae. CONCLUSIONS: The incidence of genitourinary complications associated with CIC in children with spina bifida is low. We identified 2 complications during a period of 570 patient-years for an incidence of 3.5 complications/1000 patient-years (95% confidence interval -1.3, 8.3) of observation.

Laparoscopic versus open adrenalectomy for surgical adrenal disease.

OBJECTIVE: To compare the intraoperative and postoperative outcomes of laparoscopic versus open adrenalectomy for surgical adrenal disease. MATERIALS AND METHODS: Prospectively collected data from 22 consecutive laparoscopic adrenalectomies, performed by one surgeon (MGH) over a period of 18 months at the Royal Alexandra Hospital, Edmonton, Alberta, were reviewed. Laparoscopic adrenalectomy was performed by both the transperitoneal and retroperitoneal approaches. In addition, a retrospective chart review was performed for all open adrenalectomies, performed at the same institution, over a 6 year period. Exclusion criteria were locally invasive lesions and masses greater than 8 cm in diameter. Adrenal pheochromocytomas were included in both groups. The two groups were evaluated with respect to intraoperative and postoperative outcomes. RESULTS: Twenty-two laparoscopic and 19 open adrenalectomies were reviewed. Both groups were similar with regard to gender, age, body mass index, and ASA class. Two laparoscopic cases, both with a history of prior ipsilateral adrenal surgery, were converted to the open approach. The laparoscopic group had a longer mean operative time (171 minutes versus 104 minutes), yet had a lower estimated blood loss (146 cc versus 455 cc), blood transfusion rate (0% versus 16%), and intraoperative complication rate (5% versus 16%). Both groups were similar with regard to specimen size and pathology. The laparoscopic group required less post-operative analgesia (44 mg morphine versus 478 mg morphine), resumed a regular diet sooner (1.1 days versus 3.7 days), and had a shorter hospital stay (2.2 days versus 5.4 days). CONCLUSIONS: In our experience, prior ipsilateral adrenal surgery greatly increases the risk of open conversion. This study is consistent with the findings of a number of previously reported studies, supporting the emergence of laparoscopic adrenalectomy as the standard of care for surgical management of benign adrenal disease.