Correlation between surgical booking by a PA and surgical procedure performed.

OBJECTIVE: This study evaluated the concordance between clinical evaluation and diagnosis by a physician associate/assistant (PA) and the preoperative and intraoperative evaluations by a pediatric urologic surgeon. METHODS: A retrospective chart review was performed for patients independently evaluated and scheduled for surgery by a single PA between 2017 and 2020. Concordance was measured by comparing the PA's office note with the surgeon's preoperative note and operative report. RESULTS: Of the 242 patients scheduled for surgery, 11 underwent an operative report procedure change and 11 others underwent a preoperative note procedure change. Concordance increased from 89.09% in 2017 to 92.31% in 2020; this was not statistically significant ( P = .230). Urologic conditions evaluated demonstrated an increase in the variety and complexity of conditions. CONCLUSIONS: A supervisory/collaborative model involving a well-trained PA yields excellent outcomes in terms of concordance with surgical scheduling and procedure performed.

A large urachal cyst presenting with lower urinary tract symptoms and a falsely elevated post-void residual on bladder scan.

The urachus is an embryologic remnant that connects the bladder to the umbilicus and typically obliterates during gestation. Urachal cysts are one of the most common congenital urachal anomalies. Urachal cysts may be found incidentally on imaging or present as a palpable mass with abdominal pain and fever. We present a case of a young male with a urachal cyst who presented with lower urinary tract symptoms and a falsely elevated post void residual (PVR) volume on bladder scan. This case illustrates an atypical presentation of a large urachal cyst and highlights the limitations of bladder scanner post-void residual determination.

Inguinal Polyorchidism Found Incidentally During Orchiopexy in 9-Year-Old Male: A Case Report and Review of Orchiopexy of Nonscrotal Supernumerary Testes.

Polyorchidism, the presence of more than two testes, usually presents as a painless scrotal mass or is diagnosed incidentally during the management of another condition.1 It is a rare congenital abnormality with approximately 200 reported cases in the literature. Most cases are found on the left side within the scrotum. We report a case of right-sided polyorchidism in a 9-year-old patient found incidentally during inguinal orchiopexy. As there is debate on the management of polyorchidism, a careful approach is required as the surgeon must decide between either scrotal fixation or the removal of the supernumerary testis. This case report will discuss the anatomical and clinical considerations when making this decision.

Management of urachal anomalies in pediatric patients: A comparison of treatment strategies between pediatric urology and general surgery.

INTRODUCTION: Persistence of embryonic urachal structures due to a failure of the urachus to involute into the median umbilical ligament is known as a urachal anomaly (UA). UAs may remain asymptomatic or lead to abdominal pain and recurrent infections. Management of UAs in pediatric patients has historically lacked a clear consensus between conservative and surgical management. While both urologists and general surgeons manage this pathology, a comparison of management style and outcomes between these specialties has not been published to our knowledge. OBJECTIVE: To (1) evaluate trends in management of UAs among pediatric urologists and general surgeons across three tertiary care children's hospitals and (2) identify factors that place patients at higher risk for requiring surgery. STUDY DESIGN: All patients diagnosed with a UA from 2016 to 2020 at our multi-site institution were identified by ICD-10 code Q64.4 "malformation of the urachus" and retrospectively reviewed. Patient demographics, treatment specialty, remnant subtype, and management strategy were recorded. Data was dichotomized between both urology and general surgery as well as between surgical and nonsurgical intervention to identify and compare management strategies. RESULTS: Overall, 143 patients diagnosed with UAs were identified. Of these patients, 74 were treated by urology and 69 were treated by general surgery. Patients who were treated by urology were significantly more likely to receive conservative treatment (66.2% treated conservatively vs. 33.8% treated surgically), while patients treated by general surgery were significantly more likely to undergo surgery (84.1% treated surgically vs. 15.9% treated conservatively, p < .0001). Though, urology was more likely to treat patients who presented incidentally (p < .01), and general surgery was more likely to treat patients who presented with an infected remnant (p < .01). Patients of male sex were more likely overall to receive surgery compared to female patients (p < .01). DISCUSSION: Management of UAs by urologists was more conservative than general surgeons. However, both specialties treat distinctly different patient presentations, with urology managing more incidental remnants and general surgery operating on more emergent, infected urachi. Limitations of the study included its retrospective nature and the insufficient reporting of urachal remnant subtypes and presence of infection among patients. CONCLUSIONS: Management strategies of UAs differ among urology and general surgery, but surgical and conservative treatments are necessary to appropriately treat their distinct patient populations. This study provides valuable insight into current practices of UA management and may help to inform future treatment.

Reducing costs of referrals for non-neonatal circumcision in Florida Medicaid population.

INTRODUCTION: Florida Medicaid will only cover a non-neonatal circumcision if it meets the specified Medicaid medical indications or the patient is 3 years or older and has failed a 6-week trial of topical steroid therapy (TST). Referral of children who do not meet guideline criteria results in unnecessary costs. OBJECTIVE: We sought to evaluate the cost savings if the initial evaluation and management were performed by the primary care provider (PCP) with referral to a pediatric urologist of only those males meeting the guidelines. STUDY DESIGN: An institutional review board-approved retrospective chart review of all male pediatric patients ≥3 years of age presenting for phimosis/circumcision from September 2016 to September 2019 at our institution was performed. Data extracted included (1) presence of phimosis, (2) presence of medical indication for circumcision on presentation, (3) circumcision performed without meeting criteria, (4) use of topical steroid therapy prior to referral. The population was stratified into 2 groups based on whether criteria were met at the time of referral. Those with a defined medical indication on presentation were excluded from cost analysis. Cost savings were based on costs incurred for PCP visit(s) versus initial referral to a urologist using estimated Medicaid reimbursement rates. RESULTS: Of the 763 males, 76.1% (581) did not meet Medicaid criteria for circumcision on presentation. Of these, 67 had a retractable foreskin with no medical indication, 514 had phimosis with no documented topical steroid therapy (TST) failure. A savings of $95,704.16 would have been incurred if the PCP initiated the evaluation and management and referred only those who met the criteria (Table 2). DISCUSSION: These savings would only be feasible if there were proper education of PCPs in the evaluation of phimosis and the role of TST. Limitations are assuming cost savings in the setting of well-educated pediatricians for clinical exam and believing they are aware of and comply with the guidelines. CONCLUSIONS: Education of PCPs on the role of TST in phimosis and current Medicaid guidelines may reduce unnecessary office visits, health care costs, and family burden. The most impactful method to reduce the cost of non-neonatal circumcision would be for states that do not currently cover neonatal circumcision to acknowledge affirmative policies from the American Academy of Pediatrics regarding circumcision and realize the cost savings associated with providing coverage for neonatal circumcision and reducing significantly the number of more expensive non-neonatal circumcisions.

Solitary Intrascrotal Plexiform Neurofibroma in a 10-Year-Old Male.

Intrascrotal neurofibromas are extensive tumors that grow from peripheral nerves within the scrotum and are exceedingly rare among the benign extratesticular tumors. Though the risk is low, potential for malignancy and patient discomfort make diagnosis and surgical evaluation imperative. Pediatric neurofibromas are typically only associated with neurofibromatosis type 1. However, herein, we describe a rare case of a benign, intrascrotal plexiform neurofibroma in a 10-year-old male who lacks any stigmata associated with this genetic disorder. Diagnostic and surgical challenges as well as histopathological findings are discussed.

Impact of Florida Medicaid guidelines on frequency and cost of delayed circumcision at Nemours Children's hospital.

INTRODUCTION: In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at Nemours Children's Hospital. STUDY DESIGN: We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥3 years seen at NCH for phimosis/circumcision from Sept. 2016-Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS. RESULTS: Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs. CONCLUSIONS: The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits, and returns to operating room. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.

Progression of asymptomatic nephrolithiasis in children: How often should patients receive follow-up ultrasound imaging?

INTRODUCTION: The natural history of asymptomatic nephrolithiasis (AN) in children is not well defined. Furthermore, there is no guidance on the utility of repeated renal ultrasound evaluations in this same population. Follow-up ultrasound studies are often obtained as frequently as every 6 months. The goal of this study is to assess the follow-up ultrasound interval in the management of these patients. METHODS: A retrospective IRB approved chart review was performed for patients seen for non-cysteine AN between 2012 and 2019. AN was defined as patients without obstructive uropathy abdominal, flank pain and/or gross hematuria. Asymptomatic stones were discovered incidentally or after an acute stone event. Patients with pre-existing renal anomalies and the timepoints with stone passage or stone procedure were excluded. Descriptive statistics were used for demographic information. Multiple linear regression was used to analyze risk factors. Statistical significance was set to p < 0.05. RESULTS: Twenty-nine patients had 90 ultrasounds. The average age at diagnosis was 10.8 ± 6.2 years. The average number of ultrasound studies per patient was 3.2 ± 1.7. The median time between follow-up ultrasounds was 5.2 months [IQR 2.8-10.0]. Median follow-up of patients was 10.6 months [IQR 4.9-21.9]. The change in total stone burden occurred at a rate of 0.11 mm/month (CI [-0.06-0.28], p = 0.20, r2 = 0.42) or 0.66 mm/6 months. Patients with more renal stones had almost a threefold increase in stone burden compared to patients with fewer renal stones (2.98 [CI 1.34-4.62], p=0.001, r2=0.33). Patients with a family history of stones had a twofold increase in the size of their largest stone when compared to patients without a family history (1.97 [CI 0.26-3.68], p=0.02, r2=0.60. CONCLUSION: A complex interplay of multiple factors influence the progression of AN in children. Children with a greater number of stones have a higher increase in total stone burden and children with a family history of stones have a faster increase in largest stone size. These patients may require more frequent imaging studies. The small change in stone size over time favors a longer than 6-month interval for many children.

Magnetic resonance imaging of Müllerian anomalies in girls: concepts and controversies.

Female Müllerian anomalies are the result of failure of formation, fusion or resorption of the Müllerian ducts and are relatively common, with a prevalence of 5.5-7.0% in the general population. While some of these anomalies are asymptomatic, those presenting with obstruction require accurate identification for optimal clinical management including potential surgical treatment. MRI is a useful adjunct to sonography in the evaluation of Müllerian anomalies, typically allowing a more complete characterization of the malformation. Technical aspects, embryologic concepts and controversies regarding classification systems are highlighted in this review. Several Müllerian anomalies are discussed and illustrated in more detail utilizing various cases with pelvic MRI studies.

Pelvic plexiform neurofibroma during bowel/bladder dysfunction in an NF1 pediatric patient: A case report.

Individuals with Neurofibromatosis I may develop plexiform neurofibromas throughout the body, however they are rarely seen in the pelvis. We present a 15-year-old patient with NF1 with a large unresectable neurofibroma located between the prostate and bladder discovered incidentally on renal/bladder ultrasound during the evaluation of bowel/bladder dysfunction. Despite the extensive nature of the mass, the patient presented with minimal symptoms and the lesion was thought to be stool or enlarged prostate on subsequent evaluations. Urologists should be aware of NF1 related pelvic masses in the evaluation of bowel bladder dysfunction and specify NF1 on radiologic requisitions.

Neonatal Circumcision Trends from a Pediatric Urology Perspective: Results from a Survey of Members of the Societies for Pediatric Urology.

INTRODUCTION: Neonatal circumcision remains controversial, with rates varying over the years. The Centers for Disease Control and Prevention and the American Academy of Pediatrics acknowledge the health benefits of neonatal circumcision and support access to the procedure for families who choose it. Although more commonly performed by nonurological providers, pediatric urologists are often involved with pre-procedural or post-procedural concerns. Neonatal circumcision trends and perspectives were evaluated as determined by members of the Societies for Pediatric Urology nationwide. METHODS: A 20-question survey was distributed electronically via SurveyMonkey to members of the Societies for Pediatric Urology. The survey was developed to assess pediatric urologists' roles in and criteria for neonatal circumcision as well as attitudes towards nonurological provider circumcisions. Of the 20 questions 16 formed the basis of this study. Four questions evaluated "perceptions" and were excluded from study analysis due to subjectivity. RESULTS: Of the surveys 223 (37.2%) were returned. Most responders (80.1%, 177) perform neonatal circumcision. Significant differences exist across geographical regions nationally including common practices, techniques, and financial coverage of neonatal circumcision. However, 70.6% of responders noted a maximum age at time of circumcision of 12 weeks or younger and 48.9% noted a maximum weight of 12 pounds (5.44 kilograms) or less. CONCLUSIONS: This study assessed pediatric urologists' roles in and criteria for neonatal circumcision. The development of universal best practices as determined by pediatric urologists, as experts in the field, may prove beneficial for optimizing patient care and nonurological circumcision provider education and training.

Acute vasitis presenting as a concerning paratesticular mass in an adolescent, a case report.

The differential diagnosis of scrotal pain and swelling in adolescent males includes testicular and appendage torsion, epididymitis, epididymo-orchitis, trauma and incarcerated hernia. Physical examination, ultrasound and urinalysis often can identify the etiology of the scrotal pain and swelling. We present a case of left scrotal pain and swelling that was initially concerning for a paratesticular mass. Repeat examination and further imaging during pre-operative assessment was consistent with left-sided vasitis. The diagnosis of vasitis is difficult with ultrasound and commonly requires CT or MRI to differentiate from incarcerated inguinal hernia. Recognition of this uncommonly reported condition may prevent unnecessary surgeries.

Experience and outcomes for PAs in a neonatal circumcision clinic.

OBJECTIVE: To evaluate the outcomes of neonatal circumcision performed by a PA in pediatric urology. METHODS: A retrospective review was performed of infants evaluated for neonatal circumcision by a single PA in pediatric urology over 30 months. Technique, age and weight at circumcision, presence or absence of genital anomalies, and complications were gathered. RESULTS: Of the 371 male infants evaluated for neonatal circumcision, 276 underwent the procedure. Complications included retained Plastibell (2.1%), penile adhesions (1.1%), swelling (1.8%), and cosmetic concerns (0.73%). Eighteen unanticipated postprocedure visits occurred-four in the ED and 14 in the outpatient clinic. No acute procedural complications occurred. One patient (0.3%) underwent lysis of penile adhesions at age 19 months. CONCLUSION: Neonatal circumcisions are commonly performed by nonsurgeons with variable formal circumcision training. These data support that well-trained PAs can perform neonatal circumcisions with low complication rates.

Routine circumcision? The role of prepuce in syndactyly repair.

Circumcisions are among the most commonly performed procedures in the pediatric population, but the value of the preputial skin often goes unrecognized as a potential graft (Ehrlichman et al., 2018). We highlight three patients who underwent coordinated circumcision and use of the excised preputial skin as a graft for syndactyly repair. Syndactyly, a condition where fingers are fused together, is often repaired utilizing skin from the groin region, which can result in unwanted hair growth and subcutaneous fat growth. The utilization of the prepuce is a convenient alternative that may have fewer undesirable qualities.

Cystic Dysplasia of the Rete Testis: Does Pathophysiology Guide Management?

Cystic dysplasia of the rete testis (CDT) is a rare, benign, cause of testicular mass in the pediatric population. The mass appears on sonography as multiple small cysts of varying size surrounded by normal or compressed testicular tissue. CDT is often associated with other genitourinary anomalies, commonly presenting with agenesis or dysplasia of the ipsilateral kidney. The pathophysiology and the management remains controversial. We report a case of a 3-year-old presenting with an enlarged testicular mass later presumed to be CDT associated with ipsilateral renal agenesis, review the literature, and propose an evaluation and management algorithm.

Scrotal abscess after a perforated appendicitis.

Although perforated appendicitis in pediatric patients can result in a diverse array of complications, scrotal abscess is a rarely documented phenomenon. We present a case of acute scrotum after laparoscopic appendectomy. A retrospective review of prior literature on scrotal abscess secondary to perforated appendicitis was performed via PubMed to review the clinical presentation, etiology, type of treatment and outcome of pediatric patients. Patients without a patent processus vaginalis still require vigilant follow-up postoperatively to ensure timely intervention if scrotal pain develops during recovery.

Pharmacologic therapies for the management of non-neurogenic urinary incontinence in children.

Introduction: Non-neurogenic urinary incontinence in children is a common condition that affects the quality of life for both patients and parents. Symptoms may occur in the daytime, nighttime, or both and may be the result of structural and functional anomalies. Evaluation and management of associated co-morbidities, such as constipation is critical to management. Behavioral therapy is a fist line therapy in most cases of non-neurogenic urinary incontinence and pharmacologic therapy a second-line therapy.Areas covered: In this review, the authors cover the pharmacologic agents, FDA approved and commonly used non-FDA approved, available for the treatment of four non-structural etiologies of non-neurogenic urinary incontinence in children. These include nocturnal enuresis, overactive bladder, giggle incontinence, and dysfunctional voiding.Expert opinion: Non-neurogenic causes of urinary incontinence in children represent a complicated medical condition that requires both pharmacologic and non-pharmacologic management. Limited FDA-approved therapies as well as suboptimal results with approved therapies due to a lack in the understanding of the underlying pathophysiology and patient selection may lead to the use of alternative non-FDA approved therapies.

Intermittent Urinary Incontinence Secondary to Inverted-Y Ureteral Duplication With Perianal Ectopia.

Inverted-Y ureteral duplication is one of the rarest anomalies of ureteral branching, which has been found to be more prevalent in females.2 Females commonly present with urinary incontinence often associated with distal limb ectopia to the bladder neck, uterus, or vagina.2 We present the case of a 7-year-old female with intermittent urinary incontinence who was found to have an inverted-Y ureteral duplication with perianal ectopia. We highlight the role of magnetic resonance urography in the evaluation of females with urinary incontinence and a normal renal/bladder ultrasound who are refractory to behavioral therapy.

Testicular Torsion: Current Evaluation and Management.

Testicular torsion is a urologic emergency, requiring prompt identification and management. Understanding the risk factors, presentation, and management is essential to decrease delays in diagnosis and intervention. This review discusses the prevalence, pathophysiology, management, and outcomes of testicular torsion.