Endoscopic treatment of primary obstructive megaureter with high pressure balloon dilation in infants.

INTRODUCTION AND OBJECTIVE: Ureteral reimplantation of the dilated ureter in infants is challenging; however, some patients with primary obstructive megaureter (POM) in this age group require intervention due to clinical or radiological progression. We sought to determine if high pressure balloon dilation (HPBD) can serve as a definitive treatment for POM in children under one year of age, or as a temporizing measure until later reimplantation. MATERIALS AND METHODS: All patients from a single institution who underwent HPBD between October 2009 and May 2022 were retrospectively reviewed. Patients were excluded if older than 12 months or diagnosed with neurogenic bladder, posterior urethral valves, or obstructed refluxing megaureter. Patients with prior surgical intervention at the ureterovesical junction were excluded. Indications for surgery included progressive hydroureteronephrosis or urinary tract infection (UTI). Balloon dilation was performed via cystoscopy with fluoroscopic guidance, followed by placement of two temporary ureteral stents. Primary outcomes were improvement or resolution of megaureter and rates of subsequent reimplantation. Secondary outcomes included total number of anesthetics and postoperative UTIs. RESULTS: Fifteen infants with median age of 7.6 months (IQR 3.8-9.7) underwent HPBD. Twelve (80%) patients were detected prenatally and 3 (20%) after a UTI. Indication for surgery was progressive hydroureteronephrosis in 10 patients (67%) and UTI in five (33%). All had SFU grade 3 or 4 hydronephrosis on preoperative ultrasound and median distal ureteral diameter was 13 mm. Median follow up was 2.9 years. Twelve (80%) succeeded with endoscopic treatment: 7 patients had an undetectable distal ureter on ultrasound at last follow-up, 5 were improved with median distal ureteral diameter of 7 mm. Three patients (20%) required ureteral reimplantation due to progressive dilation, all with grade 4 hydronephrosis and distal ureteral diameters were 11, 15, and 21 mm. Six patients (40%) required two anesthetics to complete endoscopic treatment. Among those, 4 patients required initial stent placement for passive dilation followed by a second anesthetic for HPBD weeks later. Two patients underwent repeat HPBD following postoperative proximal migration of the ureteral stents. All 15 patients had an additional anesthetic for removal of stents. Five patients (33%) were treated for a symptomatic UTI (4 febrile, 1 afebrile) with the stents indwelling but there were no UTIs in the group following stent removal. CONCLUSION: Balloon dilation is a practical option for treatment of POM in infants, and in most cases (80%) avoids subsequent open surgery (over median 2.9 years of follow-up).

The double-face onlay-tube-onlay transverse preputial flap: An advantageous alternative to the two-stage hypospadias repair?

OBJECTIVE: To compare the surgical outcomes and complications of boys who underwent double-face onlay-tube-onlay transverse preputial island flap (DFOTO) one-stage repair vs. two-stage repair for proximal hypospadias. STUDY DESIGN: Males with proximal hypospadias who underwent DFOTO or two-stage repair at a single institution from 2008 to 2021 were identified. Patients who had prior hypospadias surgery were excluded. Outcomes were surgical complications, number of surgical procedures, operative time, and post-operative uroflowmetry results. RESULTS: Fifty-three males who underwent DFOTO and 39 who underwent two-stage repair were included. Median age at surgery was 1.1 years (IQR 0.83-1.6) and median follow-up was 3.0 years (IQR 1.2-6.8). Although not statistically significant, the DFOTO group had higher rates of urethrocutaneous fistula (30% vs. 15%, p = 0.10), urethral stricture (15% vs. 3%, p = 0.07) and urethral diverticulum (8% vs. 3%, p = 0.39). Although the unplanned re-operation rate was higher in DFOTO (58% vs. 33%, p = 0.02), the mean number of procedures and median total surgical time were lower in DFOTO (1.8 ± 0.9 vs. 2.4 ± 0.8, p = 0.0004; 337 min [IQR 278-460] vs. 468 min [IQR 400-563], p = 0.008). There were no significant differences between groups for mean peak flow rates and post void residuals. CONCLUSIONS: In males who underwent DFOTO, 42% achieved completion of their proximal hypospadias repair with one operation, while the remainder had largely minor complications. Accounting for reoperation rates, the mean number of procedures per patient was lower in the DFOTO group. Comparable results can be achieved with both techniques; the risks of higher unplanned operation rates in the DFOTO group should be considered with the benefit of fewer total procedures.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network.

BACKGROUND: Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. OBJECTIVE: With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. STUDY DESIGN: A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. RESULTS: Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. CONCLUSION: Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Telemedicine and patient satisfaction during the COVID-19 pandemic: A case-control study of outpatient pediatric urology patients.

Telemedicine has increased during the coronavirus disease 2019 pandemic. Our objective was to determine if patient satisfaction with telemedicine differed from in-person visits in an academic pediatric urology clinic. Following outpatient telemedicine and in-person pediatric urology visits, the validated NRC Health© Patient Survey was used to assess patient experience. Patient satisfaction was assessed on a 10-point scale with scores of 9-10 considered "satisfied" and 1-8 considered "not satisfied." Satisfaction scores between telemedicine and in-person groups were compared using McNemar's test, Wilcoxon signed rank test, and conditional logistic regression. Fifty-one patients had urology telemedicine visits during April-August 2020 and completed the NRC Health© Patient Survey. Propensity score matching was used to identify 102 in-person controls between January 2019 and March 2020. Ninety-two percent of telemedicine patients were satisfied compared to 87% of in-person patients (OR 1.7 95% CI [0.53-5.6]). Regression analysis adjusting for matching variables demonstrated that patient satisfaction was higher for telemedicine compared to in-person visits but was not statistically significant (OR 1.5 95% CI [0.43-5.6]). Patient satisfaction with telemedicine was similar to in-person visits in the pediatric urology clinic. Reduced waiting time and convenience associated with telemedicine visits provide an opportunity for telemedicine as a useful modality for pediatric urology.

Recurrent ventral curvature after corporoplasty with tunica vaginalis flap.

INTRODUCTION AND OBJECTIVE: Optimal means to correct ventral curvature (VC) is debated. Our preferred technique for curvature greater than 45° is corporoplasty using tunica vaginalis flap (TVF). We describe our complications with TVF for ventral lengthening. METHODS: Forty-four boys who underwent ventral lengthening with a corporoplasty with TVF were identified in a prospective database for proximal hypospadias repair by a single surgeon from 2008 to 2021. Corporotomy was performed by incising the tunica albuginea of the corpora cavernosa transversely at the point of maximum curvature. Harvested TVF was tailored to the size of the corporotomy and anastomosed to the edges of the tunica albuginea and on laid to the corporal defect with the mesothelial side of the TVF abutting the erectile tissue. RESULTS: Median age at surgery was 1.0 years (IQR 0.72-1.82). Median follow-up time was 4.9 years (IQR 2.6-8.0). Thirteen patients (27%) were older than 10 years of age at last follow up (median 13.3, range 10-20). Twenty-two boys (50%) received preoperative testosterone. The most common location of the meatus after degloving was penoscrotal (41%). Median VC after degloving was 90° (IQR 80-100). The urethral plate was transected in 43/44 (98%) of boys, improving median VC to 60° (IQR 40-60). After corporotomy, the median longitudinal distracted distance was 15 mm (IQR 12-17). Urethral reconstruction was most commonly achieved with the transverse island preputial flap technique or its modifications (39/44; 89%). Erections were reported in 42 boys (95%). None developed corporal diverticula, and two patients (4.5%) had ascended testis associated with TVF harvest. Seven percent of boys had recurrent ventral curvature (RVC; 3/44). Median RVC was 30° (IQR 30-45). One patient had RVC at the penoscrotal junction (not at site of prior corporoplasty) identified 11 years post operatively at age 15, and underwent dorsal plication. The other 2 patients were diagnosed less than 1 year post operatively. Both patients received testosterone due to small glans size, had double-face tubularized transverse island preputial flap as urethral and ventral skin coverage, and had endocrine and genetic consultation. Both had scarring of the preputial flap and of the corporoplasty. Scar excision and superficial transverse incisions on the tunica albuginea corrected RVC. CONCLUSIONS: The five-year outcome of ventral penile lengthening using TVF for corporoplasty is favorable with 7% of boys with RVC, and 4.5% with ascended testes associated with TVF harvest. None developed corporal diverticula.

Timely orchiopexy by 18 months of age: Are we meeting the standards defined by the 2014 AUA guidelines?

BACKGROUND: Cryptorchidism is one of the most common reasons for pediatric urology referral and one of the few pediatric urologic conditions in which there are established AUA guidelines that recommend orchiopexy be performed before 18 months of age. While access to timely orchiopexy has been studied previously, there is no current study with data from a national clinical database evaluating timely orchiopexy after the AUA guidelines were published. Additionally, prior studies on delayed orchiopexy may have included patients with an ascended testis, which is a distinct population from those with true undescended testicles. OBJECTIVES: To evaluate in a national, clinical database if timely orchiopexy improved after the AUA guidelines were published in 2014. In particular, we aim to evaluate a younger group of patients, 0-5 years of age, in an effort to account for potential ascending testes. STUDY DESIGN: Using Cerner Real-World Data™, a national, de-identified database of 153 million individuals, we analyzed pediatric patients undergoing orchiopexy in the United States from 2000 to 2021. We included males 0-18 years old and further focused on the subset 0-5 years. Primary outcome was timely orchiopexy, defined as age at orchiopexy less than 18 months. Predictor variables included race, ethnicity and insurance status. Statistical analyses were performed using logistic regression. RESULTS: Of the total 17,012 individuals identified as undergoing orchiopexy, 9274 were ages 0-5 at the time of surgery. Comparing time periods pre and post AUA guidelines (2000-2014 versus 2015-2021), we found a significant difference in the proportion of timely orchiopexy (51% versus 56%, respectively; p < 0.0001) (Figure). In multivariable analyses, Hispanic (OR = 0.65, p < 0.0001), African American (OR = 0.74, p < 0.0001), and Native American males (OR = 0.66, p = 0.008) were less likely to have timely orchiopexy compared to non-Hispanic White males. Individuals without insurance (OR = 0.81, p = 0.03) or with public insurance (OR = 0.88, p = 0.02) were less likely to have timely orchiopexy as compared to those with private insurance. CONCLUSIONS: Nearly a decade after publication of the AUA cryptorchidism guidelines, a large proportion of patients are still not undergoing orchiopexy by 18 months of age. This is the first study to show that timely orchiopexy has improved among patients 0-5 years, but the majority of patients are still not undergoing timely orchiopexy. Health disparities were apparent among Hispanic, African American, Native American, and uninsured males, highlighting the need for further progress in access to pediatric surgical care.

Home bladder pressure measurements correlate with urodynamic storage pressures and high-grade hydronephrosis in children with spina bifida.

BACKGROUND: Patients with spina bifida are at risk for developing bladder and renal deterioration secondary to increased bladder storage pressures. OBJECTIVES: To determine the association of home bladder volume and pressure measurements (home manometry) to: 1) detrusor storage pressures on urodynamics (UDS); and 2) the presence of Society of Fetal Urology (SFU) grades 3-4 hydronephrosis on renal bladder ultrasound in patients with spina bifida. METHODS: Data were prospectively collected on patients with spina bifida and neurogenic bladder requiring clean intermittent catheterization. Patients used a ruler and typical catheterization equipment to measure bladder pressures and volumes at home. Home measurements were compared to UDS detrusor pressures and SFU hydronephrosis grade. Detrusor pressure <20 cm H2O at 50% maximal cystometric capacity (MCC) on UDS was used as a measure of safe storage pressures on UDS; conversely, detrusor pressure >20 cm H2O was used a measure to capture both unsafe storage pressures and those with potential for unsafe storage pressures. Receiver-operator characteristic curves and area under curve (AUC) were calculated to depict the association between home manometry variables with detrusor pressures on UDS and SFU grades 3-4 hydronephrosis. RESULTS: Included were 52 patients with a median age of 10.3 years (interquartile range 6.3-14.4 years). Three home manometry measurements (maximum bladder pressure, bladder pressure at maximum catheterized volume, and mean bladder pressure) > 20 cm H2O were sensitive for Pdet >20 cm H2O at 50% MCC. Maximal bladder pressure >20 cm H2O was the most sensitive among home manometry measures (sensitivity 100%, specificity 70%, AUC 0.92 for Pdet >20 cm H2O at 50% MCC on UDS; sensitivity 100%, specificity 62%, AUC 0.89 for SFU grade 3-4 hydronephrosis). None of the patients who had maximum home bladder pressure <20 cm H2O had SFU grades 3-4 hydronephrosis; conversely, individuals with maximal home bladder pressure >20 cm had a wide range of hydronephrosis grades. CONCLUSION: None of the patients with maximal home bladder pressure <20 cm H2O had grade 3-4 hydronephrosis. Home measurements of maximal bladder pressure, bladder pressure at maximum catheterized volume and mean bladder pressure of >20 cm H2O were all sensitive for Pdet >20 cm H2O at 50% MCC on UDS. Home manometry is an inexpensive and simple technique to identify patients at risk for and to monitor individuals at high risk of upper tract dilation, without incurring significant cost or morbidity.

Single-Layer Acellular Porcine Bladder Matrix as Graft in Corporoplasty for Ventral Curvature in Pediatric Proximal Hypospadias Repair: An Initial Experience.

BACKGROUND: Single-layer ACell Cytal matrix (ACell Inc, Columbia, MD) is a commercially available, acellular scaffold derived from porcine bladder epithelial basement membrane and tunica propria. We describe our initial experience using Cytal as corporal graft in pediatric patients who underwent correction of ventral curvature in proximal hypospadias repair. METHODS: A retrospective review of a single-institution, 4 surgeon hypospadias database was performed between January 2020 and December 2021. Outcomes assessed were postoperative recurrent ventral curvature, corporal diverticulum, scarring on corporoplasty site on physical exam, and parental reports of atypical adverse effects. RESULTS: Ten males underwent correction of ventral curvature with Cytal as corporal graft for correction of ventral curvature were identified. All completed planned operations. Median age was 18.6 months (IQR 14.6-27.0). Median follow up was 14.1 months (IQR 8.9-16.5). Mean ventral curvature after degloving was 80 ± 50 degrees. All patients had straight erections. Nine of the 10 patients had straight erections verified at a subsequent artificial erection test at least 6 months from the corporoplasty (90%). The remaining patient underwent a double face onlay-tube-onlay transverse island preputial flap as a single-stage hypospadias repair and did not require any additional procedures. He had straight erections per parental history. None developed corporal diverticulum or demonstrated induration at site of corporoplasty on physical exam. There were no parental reports of atypical adverse systemic effects. CONCLUSION: In the short term, single-layer Cytal is effective as corporal graft for correction of ventral curvature in proximal hypospadias repairs without incurring additional donor site morbidity.

Continuous antibiotic prophylaxis in isolated prenatal hydronephrosis.

BACKGROUND: Prenatal hydronephrosis (PNH) is one of the most common congenital anomalies and can increase the risk of developing a urinary tract infection (UTI) in the first two years of life. Continuous antibiotic prophylaxis (CAP) has been recommended empirically to prevent UTI in children with PNH, but its use has been controversial. OBJECTIVE: We describe the incidence of UTI in children with isolated PNH of the renal pelvis without ureteral dilation. Our objective was to compare patients receiving and not receiving CAP and determine whether CAP is beneficial at preventing UTI in children with isolated PNH. STUDY DESIGN: Children with confirmed PNH were enrolled between 2008 and 2020 into the Society for Fetal Urology Hydronephrosis Registry. Children with isolated dilation of the renal pelvis without ureteral or bladder abnormality were included. The primary outcome was development of a UTI, comparing patients who were prescribed and not prescribed CAP. RESULTS: In this cohort of 801 children, 76% were male, and 35% had high grade hydronephrosis (SFU grades 3-4). CAP was prescribed in 34% of children. The UTI rate among all children with isolated PNH was 4.2%. Independent predictors of UTI were female sex (HR = 13, 95% CI: 3.8-40, p = 0.0001), intact prepuce (HR = 5.1, 95% CI: 1.4-18, p = 0.01) and high grade hydronephrosis (HR = 2.0, 95% CI: 0.99-4.0, p = 0.05; Table) on multivariable analysis. For patients on CAP, the UTI rate was 4.0% compared to 4.3% without CAP (p = 0.76). The risk of UTI during follow-up was not significantly different between patients who received CAP and patients who were not exposed to CAP; adjusting for sex, circumcision status and hydronephrosis grade (HR = 0.72, 95% CI: 0.34-1.5, p = 0.38). In sub-group analysis of patients at higher risk of UTI (uncircumcised males, females and high grade hydronephrosis), CAP use was not associated with a statistically significant reduction in UTI. CONCLUSIONS: The overall UTI rate in children with isolated PNH is very low at 4.2%. In the overall population of patients with isolated PNH, CAP was not associated with reduction in UTI risk, although the limitations in our study make characterizing CAP effectiveness difficult. Clinicians should consider risk factors prior to placing all patients with isolated PNH on CAP.

Taking "Trans-ano-rectal" out of ASTRA: An anterior sagittal approach without splitting the rectum.

The anterior sagittal trans-ano-rectal approach (ASTRA) provides excellent exposure to the urethra and vagina for partial or total urogenital sinus mobilization and subsequent reconstruction for patients with urogenital sinus anomalies. It is a frequent approach to reconstruction for children with a high confluence. However, the division of the anterior anal external sphincter and the rectal wall in the ASTRA incurs morbidity, which include fecal incontinence if one veers from the midline, and increased risk of wound infection due to fecal soilage. We demonstrate a modified technique to the ASTRA without dividing the anterior anal sphincter and rectal wall, with achievement of comparable exposure and excellent vaginal mobilization and length.

Risk of urinary tract infection in patients with hydroureter: An analysis from the Society of Fetal Urology Prenatal Hydronephrosis Registry.

BACKGROUND: Prenatal hydronephrosis is one of the most common anomalies detected on prenatal ultrasonography. Patients with prenatal hydronephrosis and ureteral dilation are at increased risk of urinary tract infection (UTI) and continuous antibiotic prophylaxis (CAP) is recommended. However, current guidelines do not define the minimum ureteral diameter that would be considered a dilated ureter in these patients. OBJECTIVE: We evaluate the definition of clinically relevant hydroureter, its association with UTI, and the impact of CAP. STUDY DESIGN: Patients with prenatal hydronephrosis from seven centers were enrolled into the Society for Fetal Urology Prenatal Hydronephrosis Registry from 2008 to 2020. Patients with ureteral measurement on ultrasound were included. Patients with ureterocele, ectopic ureter, neurogenic bladder, posterior urethral valves, horseshoe or solitary kidney, known ureteropelvic junction obstruction, or follow-up less than one month were excluded. Primary outcome was UTI. Analyses were performed using Cox regression. RESULTS: Of the 1406 patients enrolled in the registry, 237 were included. Seventy-six percent were male, ureteral diameter ranged from 1 to 34 mm, and median follow-up was 2.2 years. Patients with ureters 7 mm or greater had nearly three times the risk of UTI adjusting for sex, circumcision status, antibiotic prophylaxis and hydronephrosis grade (HR = 2.7, 95% CI: 1.1-6.5, p = 0.03; Figure). In patients who underwent voiding cystourethrogram (VCUG; 200/237), ureteral dilation of 7 mm or more identified patients at increased UTI risk controlling for sex, circumcision status, vesicoureteral reflux and hydronephrosis grade (HR = 2.3, 95% CI: 0.97-5.6, p = 0.06). CAP was significantly protective against UTI (HR = 0.50 (95% CI: 0.28-0.87), p = 0.01). Among patients who underwent VCUG and did not have vesicoureteral reflux, ureteral dilation 7 mm or greater corresponded with higher UTI risk compared to ureteral diameter less than 7 mm on multivariable analysis (HR = 4.6, 95% CI: 1.1-19.5, p = 0.04). CONCLUSIONS: This is the first prospectively collected, multicenter study to demonstrate that hydroureter 7 mm or greater identifies a high-risk group for UTI who benefit from antibiotic prophylaxis. In contrast, patients with prenatal hydronephrosis and non-refluxing hydroureter less than 7 mm may be managed more conservatively.

A multicenter study of acute testicular torsion in the time of COVID-19.

BACKGROUND: Testicular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure. OBJECTIVE: To assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period. STUDY DESIGN: Patients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal-Wallis tests, Chi-square tests, and logistic regression. RESULTS: A total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5-48.0) and 7.5 h (IQR 4.0-28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04). DISCUSSION: We found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group. CONCLUSIONS: In a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

Retractable foreskin reduces urinary tract infections in infant boys with vesicoureteral reflux.

BACKGROUND: Uncircumcised males are at higher risk of urinary tract infection (UTI) in the first year of life and circumcision is recommended as an option for males with vesicoureteral reflux (VUR). Uncircumcised males treated successfully with topical corticosteroid cream have decreased risk of UTI but the role of preputial management has not been explored previously in males with VUR. OBJECTIVE: We hypothesized that among uncircumcised boys with VUR, those with retractable foreskin would be at reduced risk of UTI compared to those with non-retractable foreskin. STUDY DESIGN: Males less than one year of age with primary VUR were prospectively enrolled. Patients with concomitant urologic diagnoses or less than one month of follow-up were excluded. Phimosis severity was graded on a 0-5 scale. Primary outcome was UTI during follow-up. Patients were divided into three groups for analysis: circumcised, low grade phimosis (grades 0-3) and high grade phimosis (grades 4-5). Multivariable Cox proportional hazards regression was used to estimate UTI risk adjusting for risk factors. RESULTS: One-hundred and five boys (24 circumcised and 81 uncircumcised) with VUR were included. Median age at enrollment was 4.4 months (IQR 2.2-6.6) and median follow-up was 1.1 years (IQR 0.53-2.9). Males with phimosis grades 4-5 had a higher UTI rate (29%) compared to phimosis grade 0-3 (4%). Based on Kaplan-Meier curves, boys with initial phimosis grades 4-5 were significantly more likely to develop a UTI than boys who were circumcised or had phimosis grades 0-3 (p = 0.005). On multivariable analysis, boys with phimosis grades 4-5 were significantly more likely to develop UTI when compared to boys with grades 0-3 phimosis (HR = 8.4, 95% CI: 1.1-64, p = 0.04). DISCUSSION: Males with a retractable prepuce had a lower UTI risk compared to males with non-retractable prepuce (high grade phimosis) and this remained significant on multivariable analysis. This is concordant with prior studies demonstrating that a retractable prepuce is associated with decreased UTI risk. Limitations of our study include using phimosis grade at time of study enrollment and heterogenous prophylactic antibiotic use in our population. CONCLUSIONS: Retractable foreskin reduces UTI risk in uncircumcised boys less than one year of age with VUR. Medical phimosis treatment to achieve a retractable prepuce offers an alternative and less invasive modality to reduce UTI risk in males with VUR.

Keys to improving patient satisfaction in the pediatric urology clinic: A starting point.

BACKGROUND: Recent developments in healthcare have placed increased focus on patient satisfaction. Among adult populations, validated patient satisfaction tools have now been incorporated into routine practice. This process has been much slower and is significantly less standardized in pediatric populations. OBJECTIVE: The objective of this analysis was to evaluate various factors that predict patient satisfaction in pediatric urology settings. MATERIALS AND METHODS: Data from the National Research Corporation (NRC) Health Patient Survey were collected from children receiving urological care between 2017 and 2019. Survey data were merged with demographic and visit-related information from electronic health records (EHR). Rating of provider on the NCR Health survey was chosen as the primary outcome. Two multivariable models were analyzed by logistic regression. The first model contained only demographic and clinic-based predictor variables. The second model contained the NRC survey questions. RESULTS: This analysis includes a total of 3232 surveys. Multivariable analysis of EHR demographic and visit data found that low income insurance (Medicaid) (OR = 1.3, p = 0.035), primary language Spanish (OR = 1.5, p = 0.012), and shorter in-office wait time (OR = 0.94, p < 0.001) were predictors for higher patient satisfaction scores. Multivariable analysis of NCR Health survey data identified physician explanation, listening, respect for patient, time spent with patient and communication between physicians and nurses as highly significant predictors of satisfaction (p < 0.001). DISCUSSION: This analysis has identified several modifiable and non-modifiable variables that predict patient satisfaction in a population of children receiving care in a pediatric urology clinic. Limitations of this study include the possibility for response bias and lack of data on other potentially important but unmeasured factors. CONCLUSIONS: Certain patient populations are more satisfied with the outpatient urology clinic experience. Several factors related to physician-patient communication are modifiable areas to improve patient satisfaction. Further intervention studies focusing on the modifiable areas are needed to increase patient satisfaction in pediatric urology.

Heterogenous effect of androgen receptor CAG tract length on testicular germ cell tumor risk: shorter repeats associated with seminoma but not other histologic types.

Increasing rates of testicular germ cells tumors (TGCTs) overtime suggest that environmental factors are involved in disease etiology, but familial risk and genome-wide association studies implicate genetic factors as well. We investigated whether variation in the functional CAG(n) polymorphism in the androgen receptor (AR) gene is associated with TGCT risk, using data from a population-based family study. We estimated odds ratios (OR) and 95% confidence intervals (CI) for the association of CAG repeat length and TGCT risk using matched pairs logistic regression. Analyses of 273 TGCT case-mother pairs revealed no association between AR CAG repeat length and overall TGCT risk. However, risk of seminoma was significantly associated with shorter CAG repeat length [CAG 20-21 versus CAG ≤ 19: OR = 0.82 (95% CI: 0.43-1.58), CAG 22-23 versus CAG ≤ 19: OR = 0.39 (95% CI: 0.19-0.83) and CAG ≥ 24 versus CAG ≤ 19: OR = 0.42 (95% CI: 0.20-0.86)], with a highly significant trend over these four categories of decreasing CAG repeat length (P(trend) = 0.0030). This is the first report of a statistically significant association between AR CAG repeat length and seminoma risk, suggesting that increased AR transactivation may be involved in development of seminoma and/or progression of carcinoma in situ/intratubular germ cell neoplasia unclassified to seminoma. This result provides a rationale whereby androgenic environmental compounds could contribute to increases in TGCT incidence, and identifies for the first time a potential biological pathway influencing whether TGCTs achieve seminomatous versus nonseminomatous histology, a clinically and biologically important distinction.

Lower risk in parous women suggests that hormonal factors are important in bladder cancer etiology.

BACKGROUND: Urinary bladder cancer is two to four times more common among men than among women, a difference in risk not fully explained by established risk factors. Our objective was to determine whether hormonal and reproductive factors are involved in female bladder cancer. METHODS: We analyzed data from two population-based studies: the Los Angeles-Shanghai Bladder Cancer Study, with 349 female case-control pairs enrolled in Los Angeles and 131 female cases and 138 frequency-matched controls enrolled in Shanghai, and the California Teachers Study (CTS), a cohort of 120,857 women with 196 incident cases of bladder urothelial carcinoma diagnosed between 1995 and 2005. We also conducted a meta-analysis summarizing associations from our primary analyses together with published results. RESULTS: In primary data analyses, parous women experienced at least 30% reduced risk of developing bladder cancer compared with nulliparous women (Shanghai: OR = 0.38, 95% CI: 0.13-1.10; CTS: RR = 0.69, 95% CI: 0.50-0.95) consistent with results of a meta-analysis of nine studies (summary RR = 0.73, 95% CI: 0.63-0.85). The CTS, which queried formulation of menopausal hormone therapy (HT), revealed a protective effect for use of combined estrogen and progestin compared with no HT (RR = 0.60, 95% CI: 0.37-0.98). Meta-analysis of three studies provided a similar effect estimate (summary RR = 0.65, 95% CI: 0.48-0.88). CONCLUSIONS: A consistent pattern of reduced bladder cancer risk was found among parous women and those who used estrogen and progestin for HT. IMPACT: These results suggest that more research is warranted to investigate hormonal and reproductive factors as possible contributors to bladder cancer risk.

Digital assessment of the reproductive tract versus colposcopy for directing biopsies in women with abnormal Pap smears.

OBJECTIVE: This study aimed to compare digital camera assessment of the reproductive tract (DART) to colposcopy for the evaluation of abnormal Pap smears. MATERIALS AND METHODS: Participants included 207 women with abnormal Pap smears. Colposcopy and DART were performed on each patient by separate examiners with the goal of lesion detection. Analysis was performed per patient and per biopsy. RESULTS: Patients had an average of 2.9 biopsies. Forty-two patients and 81 biopsies were positive for cervical intraepithelial neoplasia 2+. Both DART and colposcopy detected 41 (97.6%) of 42 patients (95% CI = 85.9%-99.9%). Digital camera assessment of the reproductive tract detected 66/81 (81.4%; CI = 70.7%-88.9%) and colposcopy detected 69/81 (85.2%; CI = 73.2%-92.4%) of biopsies that were cervical intraepithelial neoplasia 2+. CONCLUSIONS: Digital camera assessment of the reproductive tract detects high-grade lesions of the cervix with similar sensitivity to colposcopy. It holds great promise to expand cervical cancer precursor lesion detection in areas with limited resources.

Effect of cervicitis on visual inspection with acetic acid.

OBJECTIVE: The objective of this study was to determine whether the presence of cervicitis influenced the accuracy of visual inspection with acetic acid (VIA). MATERIALS AND METHODS: In a pilot study, 502 women from rural El Salvador were screened for cervical cancer using methods including colposcopy and VIA. The presence of cervicitis was assessed by grading the amount of inflammation on each woman's cervical biopsy. Data from 495 women found to be free of cervical neoplasia were analyzed for the present study. RESULTS: In this study population, 74% of women were classified as having cervicitis. Both the result of visual inspection and the result of colposcopy were highly associated with the presence of cervicitis (p =.007 and p =.006, respectively). Women with cervicitis were twice as likely to have a positive VIA result as women without cervicitis (odds ratio = 2.0, 95% CI: 1.0-3.7). CONCLUSIONS: The presence of cervicitis may influence the accuracy of results obtained from colposcopy and VIA. This observation may be of particular importance in low-resource settings such as El Salvador where visual inspection methods are more commonly used in screening for cervical cancer.

Male infertility and variation in CAG repeat length in the androgen receptor gene: a meta-analysis.

CONTEXT: Many studies have investigated the association between male infertility and trinucleotide repeat polymorphisms in the androgen receptor (AR) gene, but no comprehensive meta-analysis of all published studies has been conducted. OBJECTIVE: Our goals were to summarize published data on associations between AR CAG and GGC repeat lengths and male infertility and investigate sources of variation between study results. DATA SOURCES: We searched for reports published before October 2006 using Medline, PubMed, and Web of Science. STUDY SELECTION: All selected studies included the following: a case group with infertility as measured by semen parameters, a control group of known or presumed fertile men, and measurement of CAG and/or GGC repeat lengths among cases and controls. Thirty-nine reports were selected based on these criteria, and 33 were ultimately included in the meta-analysis. DATA EXTRACTION: One investigator extracted data on sample size, mean and sd of trinucleotide repeat length, and study characteristics. DATA SYNTHESIS: Estimates of the standardized mean difference (95% confidence interval) were 0.19 (0.09-0.29) for the 33 studies and 0.31 (0.14-0.47) for a subset of 13 studies that used more stringent case and control selection criteria. Thus, in both groups, cases had statistically significantly longer CAG repeat length than controls. Publication date appeared to be a significant source of variation between studies. CONCLUSIONS: This meta-analysis provides support for an association between increased androgen receptor CAG length and idiopathic male infertility, suggesting that even subtle disruptions in the androgen axis may compromise male fertility.