Vesicoureteral reflux severity is not associated with unplanned urinary catheterization or length of hospital stay after ureteroneocystostomy.

INTRODUCTION: Vesicoureteral reflux (VUR) is a common urologic condition affecting approximately 1% of all children. Surgical success often depends on the grade of VUR, as patients with grades 4 or 5 have been have a greater risk for postoperative complications. Unplanned urinary catheter placement (UCP) postoperatively and prolonged length of hospital stay (LOS) are indicative of unexpected complications. The association between VUR severity and such metrics remain unclear. OBJECTIVE: The study's objective is to determine if the severity of VUR is associated with higher rates of UCP or prolonged LOS after ureteroneocystostomy (UNC). STUDY DESIGN: The 2020 National Surgical Quality Improvement Program Pediatric database was analyzed for patients with VUR. A total of 1742 patients were initially evaluated with 1373 meeting exclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC) severity: VCUG Grade 1 or RNC Grade 1 (Group A), VCUG Grade 2 or 3 or RNC Grade 2 (Group B), and VCUG Grade 4 or 5 or RNC Grade 3 (Group C). Basic statistical analysis was performed, and logistic regression was performed with both UCP and LOS as dependent variables. RESULTS: Among the 1373 patients, 2.9% were included in Group A, 32.5% were in Group B, and 64.6% were in Group C. Significant differences were found among the groups for mean age, gender, inpatient status, rate of congenital malformation, ureteral stents, and ASA classification. Regarding surgical treatment, differences were also found comparing mean operative time, LOS, laterality and type of procedure, urine culture results, rates of UTI, surgical site infections, postoperative returns to the emergency department, and unplanned procedures and catheterization. Multivariate analysis demonstrated no significant association between the rate of UCP and VUR severity, while postoperative UTI and unplanned procedure were both independent factors associated with UCP postoperatively. Additionally, postoperative UTI, ASA classification, mean operation time, ureteral stent placement, unplanned procedure, and UCP were independent factors found to contribute to LOS. CONCLUSION: Greater VUR severity does not appear to increase the need for catheterization or prolong hospital stay, while the development of a UTI postoperatively or having an additional unplanned procedure are associated with an increased likelihood of both. The postoperative course after UNC also appears to be influenced more so by other factors such as the operative approach and whether complications arise.

Preoperative and Intraoperative Urine Cultures and Its Association With Postoperative Infection After Ureteroneocystostomy.

OBJECTIVE: To unveil this association, we hypothesize that preoperative and intraoperative urinary tract infection (UTI) will be correlated with postoperative UTI and sepsis occurrence. PATIENTS AND METHODS: The 2020 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data was analyzed for patients undergoing ureteroneocystostomy (UNC) for vesicoureteral reflux (VUR). Patients that underwent UNC for treatment of VUR with urine culture obtained within 2weeks preoperatively or on the day of surgery were identified. The patients were divided into 3 groups: no bacterial growth, bacterial growth with UTI, and bacterial growth polymicrobial growth. Patient demographics and preoperative variables were evaluated. RESULTS: The postoperative urinary tract infection rate of the three groups were 2.0%, 9.2%, and 9.9% for group A, B, C, respectively (P < .001). Postoperative sepsis was noted to be 0.5%, 1.3%, and 3.6% for group A, B, C (P < .01). Additionally, there was a difference between mean operative time (P < .001), mean length of stay (P = .03), and mean days from operation to discharge (P < .01). On adjusted analysis, both groups B and C had higher rates of UTI compared to group A. Group C was also seen to have greater rates of sepsis on adjusted analysis. CONCLUSION: The association found between preoperative UTI with less than 2 species of microorganisms (group B) and postoperative UTI indicates that UTI treatment and antibiotic prophylaxis should be considered when undergoing UNC for VUR. The results of this study may lead to more careful consideration of the use of preoperative and intraoperative urine culture as well as treatment of UTI in pediatric patients with VUR undergoing UNC.

Transvesical robotic excision of a Müllerian duct remnant.

Müllerian duct remnants are rare and found in patients with disorders of sexual development. Presenting symptoms vary and many parents opt for surgical management. Literature on robotic repair is limited to small series, single case reports and all were approached extravesically. We present our case of a unique transvesical approach. Perioperative parameters were favorable with no complications, suggesting robotic repair is a safe and effective treatment strategy for these unique patients.

The Role of the Intestine in the Pathogenesis of Primary Sclerosing Cholangitis: Evidence and Therapeutic Implications.

The pathogenesis of primary sclerosing cholangitis (PSC), a progressive biliary tract disease without approved medical therapy, is not well understood. The relationship between PSC and inflammatory bowel disease has inspired theories that intestinal factors may contribute to the development and progression of hepatobiliary fibrosis in PSC. There is evidence from both fecal and mucosa-associated microbial studies that patients with PSC harbor an abnormal enteric microbiome. These organisms are thought to produce toxic byproducts that stimulate immune-mediated damage of hepatocytes and the biliary tree. The link between these mechanisms may be related to altered intestinal permeability leading to migration of bacteria or associated toxins to the liver through the portal circulation. In support of these concepts, early trials have demonstrated improved biochemical parameters and symptoms of PSC with oral antibiotics, ostensibly through manipulation of the enteric microbiota. This article reviews the published literature for evidence as well as gaps in knowledge regarding these mechanisms by which intestinal aberrations might drive the development of PSC. We also identify areas of future research that are needed to link and verify these pathways to enhance diagnostic and therapeutic approaches.

Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study.

BACKGROUND: The American Academy of Pediatrics (AAP) Task Force on Circumcision has called for the development of standards of trainee proficiency in regards to evaluation and technique for neonatal clamp circumcision (NCC). At the present time, there is no standardized or general consensus on patient selection for NCC. An improved method to evaluate newborns for NCC is an important first step in this process. Therefore, the authors collaborated to identify criteria useful in the evaluation of newborns for suitability for NCC, and for assessment of success after NCC and have named it "Checklist Assessment for Neonatal Clamp Circumcision Suitability." METHODS: A national multi-institutional collaboration was created to obtain consensus on objective criteria for use in determining patient suitability for NCC, and for assessing post-circumcision success outcomes. Criteria included elements from detailed medical history, bedside physical examination, and post-circumcision follow-up. Patients desiring NCC were enrolled consecutively and prospectively. The Checklist was followed to determine which newborns were suited to NCC, and NCC was done in those cases. The patients' caretakers were given post-circumcision care instructions and a follow-up appointment. Post circumcision, the Checklist was followed to determine if the procedure resulted in a successful circumcision or if there were complications. RESULTS: A total of 193 cases were enrolled prospectively and consecutively from January 2014 through October 2014. The mean age was 15 days (1-30 days). Of those 193 patients, 129 (67%) were deemed suitable for circumcision and underwent NCC. Post-circumcision assessment showed a 100% success rate with no complications. A total of 64 (23%) cases were deemed unsuitable for NCC because at least one checklist criterion was not satisfied, most commonly: penile torsion (n = 25), chordee (n = 19), and penoscrotal webbing (n = 19). DISCUSSION: Use of the Checklist in the present study has demonstrated a method of patient screening resulting in a 100% success rate with no complications. A high proportion of patients (33%) was identified as unsuited for NCC; however, the patient population consisted of newborn males referred to pediatric urology, and thus does not represent the general population, which is expected to have a lower proportion of unsuited patients. Regardless, the Checklist has the potential to enhance the decision-making process for both urologic and non-urologic care providers. CONCLUSIONS: The use of the "Checklist Assessment for Neonatal Clamp Circumcision Suitability" assessment tool improves identification of patients unsuited for NCC and thereby potentially decreases the likelihood of circumcision-related complications.

Updates in the management of the overactive bladder in patients with myelomeningocele.

Overactive bladder secondary to myelomeningocele provides a unique management problem to the health care provider. A randomized prospective trial has called into question the standard postnatal treatment closure of myelomeningocele, with antenatal closure acting as an acceptable alternative, although caution for maternal and fetal risks must be further delineated. While traditional techniques such as the Mitrofanoff procedure have become standard of care in allowing patient independence from care providers, modifications of the technique in addition to assimilation of minimally invasive approaches have further improved quality-of-life measurements for this patient population. Intravesical botulinum-toxin injection therapy has provided acceptable outcomes, albeit transiently, in terms of improving bladder compliance and decreasing bladder pressures. Bladder neck revision, both endoscopically and surgically, have shown promise with minimal upper tract deterioration. Nerve rerouting for neurogenic bladder is a novel, albeit unproven, approach, its use remaining experimental at this point. Utilization of the multitude of emerging techniques will serve to optimize treatment in this otherwise complicated patient population, although consideration of the long-term consequence of each therapy has yet to be elucidated.

Feasibility of a femoral nerve motor branch for transfer to the pudendal nerve for restoring continence: a cadaveric study.

OBJECT: Nerve transfers are an effective means of restoring control to paralyzed somatic muscle groups and, recently, even denervated detrusor muscle. The authors performed a cadaveric pilot project to examine the feasibility of restoring control to the urethral and anal sphincters using a femoral motor nerve branch to reinnervate the pudendal nerve through a perineal approach. METHODS: Eleven cadavers were dissected bilaterally to expose the pudendal and femoral nerve branches. Pertinent landmarks and distances that could be used to locate these nerves were assessed and measured, as were nerve cross-sectional areas. RESULTS: A long motor branch of the femoral nerve was followed into the distal vastus medialis muscle for a distance of 17.4 ± 0.8 cm, split off from the main femoral nerve trunk, and transferred medially and superiorly to the pudendal nerve in the Alcock canal, a distance of 13.7 ± 0.71 cm. This was performed via a perineal approach. The cross-sectional area of the pudendal nerve was 5.64 ± 0.49 mm(2), and the femoral nerve motor branch at the suggested transection site was 4.40 ± 0.41 mm(2). CONCLUSIONS: The use of a femoral nerve motor branch to the vastus medialis muscle for heterotopic nerve transfer to the pudendal nerve is surgically feasible, based on anatomical location and cross-sectional areas.

Outpatient perineal sling in adolescent boys with neurogenic incontinence.

PURPOSE: Management for urinary incontinence in boys with sphincteric incompetence secondary to a neurogenic etiology is a challenge. Minimally invasive approaches have inconsistent efficacy and may require multiple treatments. Open bladder neck reconstruction requires inpatient hospitalizations and can be associated with a high complication rate. To overcome some of these shortcomings we placed a polypropylene male perineal sling in male adolescents with neurogenic sphincteric incontinence. We retrospectively reviewed the outcome in our initial 6 patients. MATERIALS AND METHODS: Six patients 14 to 20 years old underwent placement of a polypropylene male perineal sling on an outpatient basis. Followup was 27 to 39 months (median 33). All patients had a history of myelomeningocele and underwent urodynamics showing normal compliance, adequate capacity and sphincteric incompetence. A suburethral sling was placed on an outpatient basis through a small perineal incision. Sling tension was adjusted for maximal urethral compression while still permitting uncomplicated urethral catheter passage. RESULTS: All 6 patients reported immediate complete continence after sling placement. Two slings were removed after local infection developed and 1 was replaced. Another sling required revision secondary to incomplete bone anchor fixation. No patients had urethral erosion. All 5 patients with a sling currently in place were fully continent on intermittent catheterization every 3 hours and they reported excellent satisfaction with the procedure. CONCLUSIONS: Our retrospective study suggests that the male urethral sling may be an outpatient option for neurogenic incontinence secondary to sphincteric incompetence. Long-term followup in our initial 6 patients shows encouraging durability. Continued study is required to determine strategies that might decrease the complication rate of this approach.

Outcomes of urinary diversion in children with spinal cord injuries.

PURPOSE: To gain a better understanding of the outcomes of the Mitrofanoff procedure for urinary diversion in children with spinal cord injury (SCI). DESIGN: Descriptive retrospective. PARTICIPANTS/METHODS: Individuals 6 to 27 years of age with SCI with at least 1 year follow-up after the Mitrofanoff procedure. Objective data collected via retrospective chart review include general demographics and medical/surgical history. Data collected via structured telephone interview include history of adverse urological events, bladder management, bladder management independence scores, patient satisfaction, and quality of life. RESULTS: Sixteen subjects (13 female, 3 male) with a mean age of 19 years (range 6-27 y) who underwent the Mitrofanoff procedure were interviewed. Length of postoperative follow-up ranged from 1 to 8 years (mean 4.25 y). Complications included stomal stenosis 25% (n=4) with a mean of 19 months to first occurrence of stenosis; urethral incontinence 75% (n=12); renal/bladder calculi 19% (n = 3); and stomal leakage 44% (n=7). Independence scores for bladder management after the Mitrofanoff procedure improved in 84% of subjects with tetraplegia and 25% of subjects with paraplegia. Eighty-eight percent (n 14) were satisfied with the procedure, while 12% (n=2) were somewhat satisfied. A thematic analysis of quality of life revealed that freedom (35%) and independence (35%) were most commonly cited. CONCLUSION: While some subjects experienced complications, satisfaction was relatively high and level of independence in bladder management was greatly improved. This study demonstrates that the Mitrofanoff procedure is a beneficial option to improve independence and ease of bladder management in children with SCI.

Antegrade and retrograde endoscopic dextranomer/hyaluronic Acid bladder neck bulking for pediatric incontinence.

PURPOSE: Endoscopic bladder neck bulking techniques offer the potential for a relatively noninvasive cure for a difficult clinical problem. We review our experience using antegrade and retrograde approaches. MATERIALS AND METHODS: A total of 34 children (18 boys and 16 girls, mean age 11.7 years) have been treated since March 2003. Of the patients 28 (82%) had neurogenic bladder and 6 had nonneurogenic sphincteric incontinence. Urodynamics confirmed low detrusor leak point pressures and adequate bladder capacity. Patients were treated with either a retrograde or an antegrade approach. In 82% of patients an antegrade approach was used and a posttreatment suprapubic tube was placed. RESULTS: Mean followup was 11.7 months (range 3 to 31). Patients averaged 1.47 injections (range 1 to 5). Detailed followup of 19 patients revealed significant improvement in continence in 78% (mean 1.6 injections), with an average followup of approximately 1 year. CONCLUSIONS: Our 31 months of experience with antegrade/retrograde bladder neck bulking demonstrates that it is a viable therapy for this group of children. While some patients have experienced prolonged success, re-treatment can be beneficial. The antegrade approach offers several advantages, including intraoperative leak point pressures, improved visualization and placement of a suprapubic tube to limit post-procedural remodeling.

Refinement in the management of the denervated canine urinary bladder using an abdominal vesicostomy.

Treatment of the neurogenic bladder in canine models of spinal cord injury presents challenges in ensuring bladder drainage. While vesicostomy is routine for humans, the procedure is not common in canines. Our study of bladder reinnervation involved transection of the nerve roots that mediate bladder contraction in 34 canines. An abdominal vesicostomy was created by fixing the everted mucosa to the skin incision. After euthanasia, we assessed the contractility of in vitro bladder muscle strips in response to muscarinic receptor stimulation. There were a total of 11 complications in 9 of the 34 animals. In two animals, the vesicostomy narrowed such that it could not be catheterized and in two other animals the vesicostomy closed to between 5 and 10 mm diameter. Another animal removed the stitches prior to complete healing, requiring further surgical procedures. In fi ve animals, partial prolapse of the bladder through the vesicostomy required surgical repair, and in one animal the bladder became infected and required antibiotic treatment. In the few animals in which irritation resulted from the constant contact of urine with the skin, daily topical application of petrolatum ointment alleviated this symptom. Gross inspection of the bladder at euthanasia and in vitro contractility of bladder muscle strips from these animals revealed no evidence of changes associated with bladder hypertrophy. This study demonstrated that permanent cutaneous vesicostomy is an optimal refinement method for management of the neurogenic bladder in canines. The procedure avoids the distress as well as potential bladder hypertrophy induced by multiple daily interventions to empty the bladder by either catheterization or manual compression.

The extended use of deflux (dextranomer/hyaluronic acid) in pediatric urology.

The use of injectable bulking agents into the submucosal layer of the pediatric urinary tract continues to grow. Treatment strategies for vesicoureteral reflux and urinary incontinence have changed with the introduction of dextranomer/hyaluronic acid as a minimally invasive option. Socially and medically debilitating conditions requiring major surgical reconstruction and hospitalization in the past have now been replaced by outpatient endoscopic procedures. As experience has been gained, broader uses of this agent have been applied to more complex etiologies of reflux and incontinence.

Glandular hypospadias repair.

Glandular hypospadias represents approximately 15% of the hypospadias variants seen. This article will examine common surgical approaches applicable to the child with glandular hypospadias. Hypospadias repairs discussed in this article will include urethromeatoplasty, MAGPI, the GAP procedure, MIV glans plasty, urethral advancement procedure, and parameatal based flap variants, including the Mathieu and Barcat procedures. Because these anomalies are cosmetically less aberrant than more proximal variants, only those surgical techniques which assure a normal-appearing penis should be undertaken.