Trends in Emergency Department Admissions Due to Renal Colic in the Pediatric Population: A Multicenter Study.

BACKGROUND: Pediatric urolithiasis is relatively uncommon and is generally associated with predisposing anatomic or metabolic abnormalities. In the adult population, emergency department (ED) admissions have been associated with an increase in ambient temperature. The same association has not been evaluated in the pediatric population. OBJECTIVES: To analyze trends in ED admissions due to renal colic in a pediatric population (≤ 18 years old) and to assess the possible effect of climate on ED admissions. METHODS: We conducted a retrospective, multicenter cohort study, based on a computerized database of all ED visits due to renal colic in pediatric patients. The study cohort presented with urolithiasis on imaging during their ED admission. Exact climate data was acquired through the Israeli Meteorological Service (IMS). RESULTS: Between January 2010 and December 2020, 609 patients, ≤ 18 years, were admitted to EDs in five medical centers with renal colic: 318 males (52%), 291 females (48%). The median age was 17 years (IQR 9-16). ED visits oscillated through the years, peaking in 2012 and 2018. A 6% downward trend in ED admissions was noted between 2010 and 2020. The number of ED admissions in the different seasons was 179 in autumn (30%), 134 in winter (22%), 152 in spring (25%), and 144 in summer (23%) (P = 0.8). Logistic regression multivariable analysis associated with ED visits did not find any correlation between climate parameters and ED admissions due to renal colic in the pediatric population. CONCLUSIONS: ED admissions oscillated during the period investigated and had a downward trend. Unlike in the adult population, rates of renal colic ED admissions in the pediatric population were not affected by seasonal changes or rise in maximum ambient temperature.

Association between Hidradenitis Suppurativa and Abnormalities in Semen Parameters and Sexual Function: A Pilot Study.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease affecting patients of reproductive age. Although HS shares risk factors with male infertility, only 1 epidemiological study has evaluated this association. To further evaluate this potential association, findings on semen and hormonal analysis, testicular ultrasound, and the International Index of Erectile Function (IIEF-15) were compared between 28 men attending a tertiary HS clinic during the period April 2019 to April 2021, and 44 healthy controls, spouses of infertile women undergoing semen evaluation before in vitro fertilization. Patients with HS were divided based on the absence or presence of gluteal and genital lesions. Patients with HS were younger than controls (median 27 vs 34 years, p < 0.0004) and had a higher proportion of smokers (86% vs 33%, p < 0.0001). Semen parameters in patients with gluteal-genital lesions, specifically those with severe scrotal involvement necessitating surgery, were lower than the WHO reference values and significantly lower than in patients without gluteal-genital lesions and controls. Erectile dysfunction was reported by 93% of patients with HS. These findings suggest that spermatogenesis and sexual function may be impaired in young men with HS. Therefore, multidisciplinary management of HS should include their evaluation to identify patients who might benefit from semen cryopreservation and sexual treatment.

Pediatric Age-Related Distribution of Calcium Oxalate Monohydrate and Calcium Oxalate Dihydrate in Urinary Tract Stones: Metabolic, Gender, and Ethnic Correlates.

Introduction: Previous studies of pediatric urolithiasis have suggested possible associations between the relative proportions of calcium oxalate dihydrate (COD) and calcium oxalate monohydrate (COM) stones with age, gender, and ethnicity. This study aimed to investigate the composition and distribution of calcium oxalate (CaOx) stones according to these clinical factors and the metabolic correlates of the different subtypes in pediatric stone formers (PSFs). Patients and Methods: We retrospectively reviewed the database of all first-time stone formers between 2014 and 2019. Infrared spectrometry was used to determine stone composition. Stones were categorized by their highest relative component and reported as a percentage of occurrences in the cohort as a whole and by patient gender, age (divided into three age groups: 1-5, 6-12, and 13-18 years), and ethnicity. Clinical and metabolic correlates were analyzed. Results: Of 2479 consecutive stones submitted to our chemical stone laboratory, 220 first-time PSFs were identified. COD stones were the predominant subtype in the youngest group, and COM stones in the oldest group (odds ratio 0.39, 95% confidence interval: 0.18-0.86, p = 0.036). In the intermediate-age group (6-12 years), COM stones were more prevalent in Arab boys, and COD stones in girls of either ethnicity. COD stones were associated with hypercalciuria (p < 0.0001), and COM stones with hyperoxaluria (p = 0.0024). Hypercalciuria and hypocitraturia were the most prevalent abnormalities at ages 1 to 5 and 13 to 18 years, respectively. Conclusions: Analysis of CaOx stone subtypes and their metabolic correlates in stone formers has significant clinical relevance, specifically in children. In the present study, COD stones and hypercalciuria were more common in younger children, and COM stones and hypocitraturia in adolescents. These findings suggest unique complex interactions driving stone formations in children that may guide a more practical, limited, and cost-effective approach to metabolic evaluations, choice of treatment, and preventive measures, particularly in first-time CaOx PSFs.

Single-Dose Post-Office Fulguration Mitomycin C Instillation Appears to Improve Recurrence-Free Survival in Patients With Low-Grade Noninvasive Bladder Cancer.

INTRODUCTION: Perioperative instillation of mitomycin-C (MMC) has shown effectiveness in reducing the recurrence of low-grade non-muscle invasive bladder cancer (NMIBC). Data is lacking about the impact of single-dose MMC following office fulguration of low-grade urothelial carcinoma. We compared the outcomes of small-volume low-grade recurrent NMIBC in patients treated with office-fulguration - with and without an immediate single-dose instillation of MMC. PATIENTS AND METHODS: A retrospective analysis of medical records of patients with recurrent small-volume (≤1 cm) low-grade papillary urothelial cancer who underwent fulguration in a single institution between January 2017 and April 2021 either with or without instillation of post-fulguration MMC (40mg/50 mL). The primary outcome was recurrence-free survival (RFS). RESULTS: Of 108 patients (27% women) who underwent fulguration, 41% received intravesical MMC. The treatment and control groups had similar sex ratio, mean age, mass size, tumor multifocality and or tumor grade. Median RFS was 20 months (95% CI 4-36) in the MMC group and 9 months (95% CI 5-13) in the control group (P = .038). Multivariate Cox regression analysis showed that MMC instillation was associated with longer RFS (OR = 0.552, 95% CI 0.320-0.955, P = .034) and multifocality was associated with shorter RFS (OR = 1.866, 1.078-3.229, P = .026). A higher rate of grade 1-2 adverse events was observed in the MMC group (18.2%) vs. the control (6.8%, P = .048). No complications grade 3 or higher were observed. CONCLUSION: A single dose of MMC instilled after office fulguration is associated with longer RFS compared to patients who did not receive MMC after the procedure, with no associated high-grade complications.

Retrograde intrarenal surgery for lower pole stones utilizing stone displacement technique yields excellent results.

Objective: To evaluate the long-term stone-free rate (SFR) of retrograde intra-renal surgery (RIRS) in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free status. Methods: All consecutive patients undergoing RIRS lower pole renal calculi at a single high-volume tertiary center were analyzed retrospectively. Lower pole stones were relocated to the upper pole, where laser lithotripsy was performed. All patients were followed up in the clinic following the surgery and yearly thereafter. The stone-free status was assessed with a combination of an abdominal ultrasound and abdominal X-ray, or an abdominal non-contrast computed tomography if the stones were known to be radiolucent. Results: A total of 480 consecutive patients who underwent RIRS for treatment of lower pole renal calculi, between January 2012 and December 2018, were analyzed from a prospectively maintained database of 3000 ureteroscopies. With a median follow-up time of 18.6 months, the mean SFR was 94.8%. The procedures were unsuccessful in 26 (5.4%) patients due to unreachable stones. The median stone size of the unreachable stones was 12 mm (range 10-30 mm). Multivariable logistic regression analysis revealed two predictors of SFR for lower pole stones: a small cumulative stone burden (odds ratio [OR]: 0.903, 95% confidence interval [CI]: 0.867-0.941, p<0.0001) and preoperative ureteral stent insertion (OR: 0.515, 95% CI: 0.318-0.835, p=0.007). Conclusion: The long-term SFR of RIRS for the treatment of lower pole stones with basket displacement with appropriate patient selection is high.

Post-operative pain following percutaneous nephrolithotripsy- clinical correlates.

OBJECTIVES: Management of postoperative pain following percutaneous nephrolithotripsy (PCNL) is a significant goal. We sought to identify risk factors and clinical correlates of postoperative pain in order to improve perioperative management and patient satisfaction. MATERIALS AND METHODS: A single-center, retrospective analysis, from a prospectively maintained database, of all consecutive patients who underwent PCNL for renal calculi between January 2011 and August 2018. Postoperative pain was assessed using the visual analog scale (VAS) and analgesic use. We considered VAS score above 4 as meaningful. Pain management was standardized according to patirnt reported VAS scores. Multivariable logistic regression was performed to identify risk factors and clinical correlates. RESULTS: A total of 496 patients were analyzed. Younger age was associated with VAS above 4 on the operative day and the first postoperative following PCNL (p = 0.003 and p < 0.001, respectively). Female gender was associated with VAS above 4 in the first 2 days following the operation (p < 0.001). CONCLUSIONS: Younger age and female gender would most likely benefit from pre-emptive improved pain management protocols following PCNL.

Fascial dehiscence after radical cystectomy: Is abdominal exploration mandatory?

BACKGROUND: Fascial dehiscence after radical cystectomy may have serious clinical implications. To optimize its management, we sought to describe accompanying intraabdominal findings of post-cystectomy dehiscence repair and determine whether a thorough intraabdominal exploration during its operation is mandatory. METHODS: We retrospectively reviewed a multi-institutional cohort of patients who underwent open radical cystectomy between 2005 and 2020. Patients who underwent exploratory surgery due to fascial dehiscence within 30 days post-cystectomy were included in the analysis. Data collected included demographic characteristics, the clinical presentation of dehiscence, associated laboratory findings, imaging results, surgical parameters, operative findings, and clinical implications. Potential predictors of accompanying intraabdominal complications were investigated. RESULTS: Of 1301 consecutive patients that underwent cystectomy, 27 (2%) had dehiscence repair during a median of 7 days post-surgery. Seven patients (26%) had accompanying intraabdominal pathologies, including urine leaks, a fecal leak, and an internal hernia in 5 (19%), 1 (4%), and 1 (4%) patients, respectively. Accompanying intraabdominal findings were associated with longer hospital stay [20 (IQR 17, 23) vs. 41 (IQR 29, 47) days, P = 0.03] and later dehiscence identification (postoperative day 7 [IQR 5, 9] vs. 10 [IQR 6, 15], P = 0.03). However, the rate of post-exploration complications was similar in both groups. A history of ischemic heart disease was the only predictor for accompanying intraabdominal pathologies (67% vs. 24%; P = 0.02). CONCLUSIONS: A substantial proportion of patients undergoing post-cystectomy fascial dehiscence repair may have unrecognized accompanying surgical complications without prior clinical suspicion. While cardiovascular disease is a risk factor for accompanying findings, meticulous abdominal inspection is imperative in all patients during dehiscence repair. Identification and repair during the surgical intervention may prevent further adverse, possibly life-threatening consequences with minimal risk for iatrogenic injury.

Diagnostic Needle Biopsies in Renal Masses: Patient and Physician Perspectives.

BACKGROUND: The utility of renal mass biopsies (RMB) in the diagnosis of kidney tumors remains debatable. OBJECTIVE: To assess patient and urologist preferences regarding the utilization of RMB. DESIGN, SETTING, AND PARTICIPANTS: Seventy-three patients diagnosed with renal tumors and 59 board-certified urologists were asked to participate in an interview-based study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using the standard gamble method we determined the minimal accepted accuracy at which RMB would be favored as part of the diagnostic process. Clinical and demographic data with potential to affect participants' preferences were analyzed. RESULTS AND LIMITATIONS: At the time of the study interview, 56 patients (77%) were referred for kidney surgery and 17 (23%) opted for surveillance. Overall, 59% of the patients accepted some level of inaccuracy (1-20%), whereas 27% refuted a biopsy. Anxiety associated with the possibility of missing cancer was the primary determinant (82%) for declining RMB among patients referred for surgery, while fear of complications was the primary reason (58%) among those undergoing surveillance. Having an academic degree was associated with a lower accuracy threshold (p=0.03). Of the 59 participating urologists, 39% were reluctant to recommend RMB, primarily because of its inexorable nondiagnostic rate. CONCLUSIONS: Most patients and urologists would favor RMB to facilitate their definitive treatment decision. Diagnostic accuracy of 95% was acceptable by the majority of study participants. The utility of RMB as part of the diagnostic algorithm for renal tumors should be discussed with patients, emphasizing its potential benefits and limitations. PATIENT SUMMARY: Although needle biopsy seems to be an effective tool to differentiate benign from malignant kidney lesions, it is not commonly used. Our study shows that most patients would opt for a biopsy before definitive treatment decision despite its imperfect accuracy. Hence, the option of undergoing renal biopsy should be discussed with all patients diagnosed with small renal tumors.