Posterior urethral valves in patients with trisomy 21: Similar renal outcomes and rates of volitional voiding.

INTRODUCTION: Posterior urethral valves (PUV) occur in patients with Down Syndrome (DS) at a rate of 3-4%; far higher than the general population. Our understanding of the relationship between PUVs and DS is in its infancy, with the majority of the literature consisting of case reports. In this study, we present the largest known series of DS patients with PUVs. AIM: We hypothesized that patients with DS and PUVs would have worse functional bladder outcomes and renal outcomes when compared to PUV patients without DS. STUDY DESIGN: We queried our prospectively managed multi-institutional database of PUV patients from 1990 to 2021. We identified patients with a concomitant diagnosis of DS and PUV. In addition, we performed a systematic review of the literature describing the presentation of children with PUV and DS. Patient demographics, renal outcomes, voiding habits, surgical interventions, and radiologic images were aggregated and analyzed. RESULTS: Out of the 537 patients in our PUV database, we identified 18 patients with a concomitant diagnosis of PUV and DS, as well as 14 patients with a concomitant diagnosis of PUV and DS from the literature. DS and non-DS patients had a similar age at presentation, 31.5 days (2-731) and 17 (4-846), and length of follow up 6.32 years (2-11.2) and 6.98 (1-13). Both groups had similar nadir creatinines DS 0.43 (0.4-0.8), non-DS 0.31 (0.2-0.5) and similar rates of renal failure (DS 11.1% and non-DS 14.5%). With respect to bladder outcomes, a similar percentage of patients were volitionally voiding at last follow up (DS 72.2% and non-DS 72.3%). Our literature review corroborated these findings. CONCLUSIONS: Patients with DS and PUV have similar renal outcomes to other PUV patients in terms of renal function, progression to renal failure, and probability of volitional voiding with continence. Given the increased rate of PUVs in the DS population, physicians should have a high index of suspicion for PUV when patients with DS present with voiding dysfunction.

Automated Society of Fetal Urology (SFU) grading of hydronephrosis on ultrasound imaging using a convolutional neural network.

INTRODUCTION: Grading of hydronephrosis severity on postnatal renal ultrasound guides management decisions in antenatal hydronephrosis (ANH). Multiple systems exist to help standardize hydronephrosis grading, yet poor inter-observer reliability persists. Machine learning methods may provide tools to improve the efficiency and accuracy of hydronephrosis grading. OBJECTIVE: To develop an automated convolutional neural network (CNN) model to classify hydronephrosis on renal ultrasound imaging according to the Society of Fetal Urology (SFU) system as potential clinical adjunct. STUDY DESIGN: A cross-sectional, single-institution cohort of postnatal renal ultrasounds with radiologist SFU grading from pediatric patients with and without hydronephrosis of stable severity was obtained. Imaging labels were used to automatedly select sagittal and transverse grey-scale renal images from all available studies from each patient. A VGG16 pre-trained ImageNet CNN model analyzed these preprocessed images. Three-fold stratified cross-validation was used to build and evaluate the model that was used to classify renal ultrasounds on a per patient basis into five classes based on the SFU system (normal, SFU I, SFU II, SFU III, or SFU IV). These predictions were compared to radiologist grading. Confusion matrices evaluated model performance. Gradient class activation mapping demonstrated imaging features driving model predictions. RESULTS: We identified 710 patients with 4659 postnatal renal ultrasound series. Per radiologist grading, 183 were normal, 157 were SFU I, 132 were SFU II, 100 were SFU III, and 138 were SFU IV. The machine learning model predicted hydronephrosis grade with 82.0% (95% CI: 75-83%) overall accuracy and classified 97.6% (95% CI: 95-98%) of the patients correctly or within one grade of the radiologist grade. The model classified 92.3% (95% CI: 86-95%) normal, 73.2% (95% CI: 69-76%) SFU I, 73.5% (95% CI: 67-75%) SFU II, 79.0% (95% CI: 73-82%) SFU III, and 88.4% (95% CI: 85-92%) SFU IV patients accurately. Gradient class activation mapping demonstrated that the ultrasound appearance of the renal collecting system drove the model's predictions. DISCUSSION: The CNN-based model classified hydronephrosis on renal ultrasounds automatically and accurately based on the expected imaging features in the SFU system. Compared to prior studies, the model functioned more automatically with greater accuracy. Limitations include the retrospective, relatively small cohort, and averaging across multiple imaging studies per patient. CONCLUSIONS: An automated CNN-based system classified hydronephrosis on renal ultrasounds according to the SFU system with promising accuracy based on appropriate imaging features. These findings suggest a possible adjunctive role for machine learning systems in the grading of ANH.

How Female Is the Future of Urology? Projecting Various Trajectories of the United States Urology Workforce.

OBJECTIVE: To project the number and proportion of women in the urology workforce using recent demographic trends and develop an app to explore updated projections using future data. METHODS: Demographic data were obtained from AUA Censuses and ACGME Data Resource Books. The proportion of female graduating urology residents was characterized with a logistic growth model. "Stock and Flow" models were used to project future population numbers and proportions of female practicing urologists, accounting for trainee demographics, retirement trends, and growth in the field. RESULTS: Assuming growth in urology graduate numbers and continued logistic growth in the proportion of women, 10,957 practicing urologists (38%) will be female by 2062. If the rate of women entering urology residency stagnates, 7038 urologists (24%) will be female. If the retirement rates for women in urology change to mirror those of men and the proportion of female residents continues to experience logistic growth, 11,178 urologists (38%) will be female. An interactive app was designed to allow for a range of assumptions and future data: https://stephenrho.shinyapps.io/uro-workforce/. CONCLUSION: Workforce projections should incorporate recent growth in numbers of female residents. If current growth continues, 38% of urologists will be female by 2062. The app allows for exploration of different scenarios and can be updated with new data. The projections demonstrate the need for targeted efforts to recruit women into urology, address disparities within the field, and work toward retaining female urologists. We must continue working toward an equitable future workforce that can address the impending shortage of urologists.

Multi-institutional Validation of Improved Vesicoureteral Reflux Assessment With Simple and Machine Learning Approaches.

PURPOSE: Vesicoureteral reflux grading from voiding cystourethrograms is highly subjective with low reliability. We aimed to demonstrate improved reliability for vesicoureteral reflux grading with simple and machine learning approaches using ureteral tortuosity and dilatation on voiding cystourethrograms. MATERIALS AND METHODS: Voiding cystourethrograms were collected from our institution for training and 5 external data sets for validation. Each voiding cystourethrogram was graded by 5-7 raters to determine a consensus vesicoureteral reflux grade label and inter- and intra-rater reliability was assessed. Each voiding cystourethrogram was assessed for 4 features: ureteral tortuosity, proximal, distal, and maximum ureteral dilatation. The labels were then assigned to the combination of the 4 features. A machine learning-based model, qVUR, was trained to predict vesicoureteral reflux grade from these features and model performance was assessed by AUROC (area under the receiver-operator-characteristic). RESULTS: A total of 1,492 kidneys and ureters were collected from voiding cystourethrograms resulting in a total of 8,230 independent gradings. The internal inter-rater reliability for vesicoureteral reflux grading was 0.44 with a median percent agreement of 0.71 and low intra-rater reliability. Higher values for each feature were associated with higher vesicoureteral reflux grade. qVUR performed with an accuracy of 0.62 (AUROC=0.84) with stable performance across all external data sets. The model improved vesicoureteral reflux grade reliability by 3.6-fold compared to traditional grading (P < .001). CONCLUSIONS: In a large pediatric population from multiple institutions, we show that machine learning-based assessment for vesicoureteral reflux improves reliability compared to current grading methods. qVUR is generalizable and robust with similar accuracy to clinicians but the added prognostic value of quantitative measures warrants further study.

Where to draw the line? Understanding preferences in mucosal collar length after circumcision: A crowdsourced survey from the U.S. general population.

INTRODUCTION: Male circumcision is a polarizing and prevalent procedure. Little understanding exists regarding patient preferences for circumcision appearance. Our objective was to elicit how mucosal collar length may be perceived in terms of overall cosmesis and desirability among adults. METHODS: A questionnaire using REDCap was created and distributed through Amazon Mechanical Turk. Respondents provided demographic information and circumcision status before being challenged with artistic representations of circumcised penises with increasing lengths of mucosal collar. Participants were asked to select the most and least esthetically pleasing image, as well as rate the "importance of appearance" from 0-100. Responses were analyzed with ordinal regression models. RESULTS: Preference for shorter mucosal collars were seen in respondents with a postgraduate education (p=0.013) and no religious affiliation (p=0.034). In contrast, participants reporting a religious affiliation preferred longer mucosal collars (p=0.034). Circumcised males rated appearance as being more important (p=0.001) in contrast to uncircumcised males who did not (p=0.001). Circumcised fathers were more likely to circumcise their sons relative to uncircumcised fathers (p<0.05) and women preferred circumcision (p<0.05). CONCLUSIONS: Our study revealed polarized esthetic preferences in the sample as a whole, with large proportions of respondents selecting the longest or shortest collar length. Preferences regarding mucosal collar length appear to be most influenced by education and religion. Overall, our study did not observe a predominant preference for mucosal collar length following circumcision. Surgeons should engage patients and/or caregivers/parents preoperatively in discussions regarding preferences and desired cosmetic outcomes.

Quadratus Lumborum Block for Upper Tract Urological Surgery in Pediatric Patients / Bloqueo del cuadrado lumbar para cirugía urológica del tracto superior en pacientes pediátricos

Objective Among regional blocks, the quadratus lumborum fascial plane block (QLB) has been well described, but the description of its use and efficacy for pediatric patients undergoing upper abdominal urologic surgery is limited. We present a case series examining the use of the QLB for postoperative pain management in children undergoing upper tract surgery. Methods From August 2019 to August 2020, through a chart review, we identified 5 patients who had undergone a QLB for upper urinary tract surgery via a flank incision. Posterior QLB was performed after induction of general anesthesia. A single injection of 0.5mL/kg of either 0.25% or 0.5% ropivacaine with 1mcg/kg of clonidine was administered. Patients received fentanyl IV (1 mcg/kg), and acetaminophen IV (15mg/kg) as adjuvants during the operation. Postoperative pain was managed with oral acetaminophen and ibuprofen. Results The average postoperative pain score during the entire admission was 1, with the lowest being 0 and highest, 3. No administration of rescue narcotics was required in the postanesthesia care unit or on the floor. The average length of stay ranged from 0 to 1 day. No complications associated with the regional QLB were identified. Conclusions Our series suggests the QLB may be considered as a regional anesthetic option to minimize narcotic requirements for children undergoing upper abdominal urological surgery via flank incision. Additional studies are needed to compare the efficacy of the QLB versus alternate regional anesthetic blocks for upper tract urological surgery via flank incision in children and to determine effective dosing and use of adjuvants

Objetivo Entre los bloqueos regionales, el bloqueo del plano fascial del cuadrado lumbar (BCL) ha sido bien descrito; sin embargo, tiene una descripción limitada de su uso y eficacia en pacientes pediátricos sometidos a cirugía urológica abdominal superior. Presentamos una serie de casos que examinan el uso del BCL en el manejo del dolor posoperatorio en niños sometidos a cirugía urológica del tracto superior. Métodos De agosto de 2019 a agosto de 2020, mediante revisión de historias clínicas, se identificaron 5 pacientes sometidos al BCL para cirugía del tracto urinario superior por incisión en el flanco. El BCL posterior se realizó después de la inducción de la anestesia general. Solo se administró una inyección de 0,5 ml/kg de ropivacaína al 0,25% o al 0,5% con 1 mcg/kg de clonidina. Los pacientes recibieron fentanilo IV (1 mcg/kg) y acetaminofén IV (15 mg/kg) como adyuvantes durante la operación. El dolor posoperatorio se manejó con acetaminofén e ibuprofeno oral. Resultados El puntaje promedio de dolor posoperatorio para todo el ingreso fue de 1, siendo el más bajo 0 y el más alto, 3. No se requirieron administraciones de narcóticos de rescate en la unidad de recuperación posanestésica ni en la planta de hospitalización. La estancia media fue de 0 a 1 día. No se identificaron complicaciones asociadas con el BCL regional. Conclusiones Nuestra revisión sugiere que el BCL puede ser considerado una opción anestésica regional para minimizar los requerimientos de narcóticos en niños sometidos a cirugía urológica abdominal superior por incisión en el flanco. Se necesitan estudios adicionales para comparar la eficacia de BCL en comparación con la de los bloqueos anestésicos regionales alternativos para la cirugía urológica del tracto superior por incisión en el flanco en niños y para determinar la efectividad de la dosificación y del uso de adyuvantes.

Lean: Introduction of a Quality Improvement Concept into Percutaneous Nephrolithotomy to Improve Efficiency while Maintaining Safety / Lean: introducción de un concepto en la nefrolitotomía percutánea para mejorar la eficiencia mientras se mantiene la seguridad

Introduction and objective Standardization of surgical interventions reduces complications and costs and positively impacts intra and postoperative outcomes. Implementation of the lean concept, initially proposed in the auto industry, now becomes an interesting approach in the surgical setting. We want to present the results of how percutaneous nephrolithotripsy (PCNL) in a high-level center can be positively impacted by implementing the lean concept. Methods We evaluated a total of 140 PCNL procedures. Group 1 included all cases operated prior to implementing the lean concept and group 2 was composed of those operated after implementing the lean concept. We looked for all seven sources of waste to identify and modify our practice to improve efficiency and safety. We then collected intraoperative times and compared the ones prior to those after the implementation. Results After implementing the lean concept, with an average of six PCNL cases per day, a comparison was made to an equivalent number of cases prior to the lean implementation (group 1). The average total operative time for PCNL preintervention was 138 (confidence interval [CI]: 79 to 170) minutes and postlean intervention was 71.1 (CI: 43 to 157) minutes. Surgical time (cystoscopy to skin closure) was 36.1 (CI: 25 to 50) minutes prelean and 50 minutes postlean (CI: 23 to 154). For this last one, bilateral procedures were performed. Operative room turnover time was 27.8 (CI: 21 to 38) minutes prelean and 5.67 (CI: 3.5 to 12) minutes postlean. Induction time was 16.5 (CI: 5 to 55) minutes prelean and 5.4 (CI: 3.5 to 7.5) minutes postlean. Conclusion Implementation of the lean concept enables optimization of the surgical procedure, allowing hospitals to reduce costs and standardization.

Introducción y objetivo La estandarización de los procedimientos quirúrgicos reduce complicaciones, costos, y mejora resultados intra y postoperatorios. El concepto lean fue utilizado por primera vez en la industria automotriz. El presente trabajo busca implementar el concepto lean para optimizar el procedimiento de nefrolitotomía percutánea (NLP) en nuestro medio. Métodos Se realizaron 140 procedimientos de nefrolitotomía percutánea, los cuales se dividieron en 2 grupos: uno en el cual se registraron los tiempos intraoperatorios, y el segundo en que se registraron los tiempos luego de la implementación del concepto lean. Resultados Durante el período estudiado, se realizaron 70 procedimientos luego de la implementación del concepto lean, y se logró realizar un promedio de 6 procedimientos por día. Se compararon los tiempos operatorios, y se encontró un tiempo operatorio total promedio de 138 (intervalo de confianza [IC]: 79 a 170) minutos pre-lean, y de 71,1 (IC: 43 a 157) minutos post-lean. El tiempo quirúrgico (cistoscopia a cierre de piel) pre-lean fue de 36,1 (IC: 25 a 50) minutos, y el post-lean fue de 50 (IC: 23 a 154) minutos. Para este último, se trató de procedimientos bilaterales. El cambio de sala fue de 27,8 (IC: 21a 38) minutos pre-lean, y de 5,67 (IC: 3.5 a 12) minutos post-lean. El tiempo de inducción fue de 16.5 (IC: 5 a 55) minutos pre-lean, y de 5.4 (IC: 3.5 a 7.5) minutos post-lean. Conclusiones La implementación del concepto lean permite optimizar el procedimiento, con reducción de costos y estandarización del modelo de atención para cualquier centro asistencial. La movilización de los especialistas en nuestro modelo de atención permite un mayor cubrimiento poblacional de alta calidad.

Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty.

OBJECTIVE: To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits. METHODS: We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits. RESULTS: A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD. CONCLUSION: Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.

Bladder Agenesis and Bilateral Ectopic Ureters in an Infant Male With Cystic Renal Dysplasia, Imperforate Anus, and Penoscrotal Transposition.

Bladder agenesis is a rare congenital anomaly infrequently reported in the literature, with an incidence of 1/600,000 patients.1 Commonly associated with other fatal malformations, the condition is often incompatible with life.2 Prior reports estimate that over 90% of living children born with this malformation are female, owing to renal preservation resulting from low pressure drainage of urine into the vagina, uterus, and vestibule.3,4 Herein we report a rare case of an infant male born with penoscrotal transposition and end stage renal disease secondary to bilateral cystic renal dysplasia found to have concurrent bladder agenesis and bilateral ureteral ectopia.

Vascular inflow after renal transplantation: Does the arteriotomy technique impact early allograft perfusion and function?

BACKGROUND: There are two main techniques for arterial reconstruction in RT: TA using a stab longitudinal incision which creates an elliptical opening and AP which fashions a circular defect. We hypothesized that AP creates a natural anastomosis lumen, similar to the donor renal artery, which optimizes RT perfusion. METHODS: A retrospective review of a single-institution database was performed between 2000 and 2018. Twenty patients who underwent AP arteriotomy were compared to 40 TA-matched controls. Data were collected on creatinine (preoperative, nadir, and time to nadir), and DUS RI and PSV at 1 week, 3 months, and 6-12 months post-RT. RESULTS: ttNC was shorter in the AP group (5 ± 4 vs 12 ± 13 days; P = .03). PSV at 1 week was lower in the AP group (186 ± 65 cm/s vs 232 ± 89 cm/s; P = .04). There was no difference in nadir creatinine value (P = .26), preoperative creatinine (P = .66), and initial postoperative creatinine (P = .80). RI at week 1 were not different between groups (P = .37). Follow-up DUS showed the difference in PSV between groups became non-significant (1 month P = .50 and 6-12 months P = .53). CONCLUSIONS: AP arteriotomy in RT improves early perfusion and function parameters (ttNC and initial PSV) as compared to TA. AP arteriotomy optimizes early allograft reperfusion, which may have important long-term implications and deserves further evaluation.

Trends and relevance in the bladder and bowel dysfunction literature: PlumX metrics contrasted with fragility indicators.

INTRODUCTION: The concepts of fragility index (FI) and fragility quotient (FQ) have been previously described. PlumX metrics encompass online "footprints" of research in addition to traditional citations. Herein we explore PlumX metrics against the quality of BBD literature. OBJECTIVE: To explore altmetrics against the quality of bladder and bowel dysfunction (BBD) literature. STUDY DESIGN: A literature search was conducted using Pubmed, Medline, Embase for BBD and related terms. A total of 54,045 abstracts were screened, followed by 693 full text reviews and data extraction from 126. Studies were included if they reported on 2 groups being compared, had dichotomous outcomes, and had significant results. RESULTS: The median FI score was 4 (0-500) and there were 20 studies which had a FI of 0. The FQ had a median of 0.04 (0-0.32). PlumX usage was 263 ± 540, captures were 45 ± 60 and social media attention was 2 ± 2. Overall, 42% of papers were clinical trials (RCTs). When compared to other study designs, we noted a significant difference in PlumX captures (57 ± 72 RCT vs. 35 ± 47 other; p = 0.03). RCTs had higher usage, social media engagement and citations however, the differences were not significant. H-Index had a significant correlation with FI (p = 0.036), however correlations for PlumX usage and captures, while modestly positive (0.04-0.10) for the FI and FQ, were not significant. A comparison of FI and FQ by topic can be reviewed in the Summary Table. DISCUSSION: When considering the FI and FQ robustness indicators of the BBD literature, we found similarities when compared to other studies. It was reported that overall, the hydronephrosis literature was fragile with many studies requiring only a few events to nullify significance, regardless of the study design. Similarly, in a review of pediatric vesicoureteral reflux (VUR) clinical trials, results were also fragile. When comparing fragility measures to altmetric variables we noted that despite the growing popularity of altmetrics, citation counts, and h-indices remain the traditional measures to monitor research consumption. There has been a reported correlation between manuscript citation counts, author h-index, altmetrics measures in several specialties and across many domains of research including medical sciences, arts, and the humanities, however in the present study only weak correlations were noted. CONCLUSION: The body of BBD comparative studies is fragile in keeping with other pediatric urology literature populations. Despite fragile results, RCTs generate slightly moreattention as measured by select PlumX metrics. These results suggest the need for including fragility measures in our literature, aiming to focus attention towards more robust articles.

Percutaneous removal of biliary stones post-liver transplant in a pediatric patient: Case report and review of the literature.

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.

Female Authorship Publishing Trends and Forecasting in Pediatric Urology: Are We Closer to Gender Equality?

OBJECTIVE: To review the literature of 5 pediatric urology topics and conduct gender based and forecasting analyses of first and corresponding authors. METHODS: A PubMed search was performed for hypospadias, hydronephrosis, vesicoureteral reflux, bladder and bowel dysfunction, and cryptorchidism over 3 decades from 1990 to 2019. The 50 most relevant "best match" papers from each decade were extracted by topic. Author gender, specialty, and advanced degrees, along with journal and publication variables were collected. Forecasting analyses were conducted through the Holt-Winters method. RESULTS: Among 750 papers analyzed, 78% of corresponding and 70% of first authors were male. A significant upward trend was observed for female-authored publications in both first and corresponding positions over time (P <.01). Forecasting analyses predicted a continuing upward trend for female corresponding (55%) and first authors (83%) by 2049. Most studies originated from pediatric urology (59%), followed by pediatric surgery (9%) and endocrinology/genetics (5%). Papers focused in The Journal of Urology (30%) with the majority originating from the United States (38%). Most were retrospective (44%) and discussed medical (54%) versus surgical management (20%). CONCLUSION: The majority of pediatric urology literature has been generated by male authors. A persistent, rising trend in female authorship across all examined pediatric urology topics was noted. These encouraging findings are projected to continue to increase in the future, suggesting a movement toward equal and fair gender representation in authorship in pediatric urology.

Quality improvement in pediatric urology-a historical perspective on street pumps, puerperal fever, surgical infection, and contemporary methodology.

Quality improvement and patient safety (QIPS) can trace its origin back to the court of Hammurabi (circa 1700BC). However, it did not begin its evolution into its present methodology until the mid-19th century. It was through the application of quantitative parameters around the time of World War I that the field of QIPS has matured and gained a significant presence in the practice of medicine. Herein, the authors present a historical overview of this increasingly important field and correlate the current pediatric urology literature that has arisen from it. Because QIPS research is likely to contribute to efficient, streamlined health care through rapid changes to routine clinical practices, it would behoove pediatric urologists to familiarize themselves with its history and fundamental concepts.

Testis-sparing Surgery for Pediatric Leydig Cell Tumors: Evidence of Favorable Outcomes Irrespective of Surgical Margins.

OBJECTIVE: To review our single institution experience, exploring the role of testis-sparing surgical resection in a cohort of children with Testicular Leydig cell tumors (LCTs). MATERIALS AND METHODS: We reviewed all consecutive children presenting with testicular tumors between 2003 and 2017 (n = 66), excluding patients with alternative pathologies (n = 57). Subsequently data were collected on age at surgery, laterality, type of surgery, operative time, presenting symptoms, serum markers, imaging findings, frozen section, final pathology, and follow-up. RESULTS: During the study period, a total of 9 (9/66; 14%) children were treated for LCT of the testis. Age at surgery was 8.4 ± 1.7 years and the majority (7/9; 77%) had unilateral disease. Most presented with a testicular mass, and 3 (33%) complained of testicular pain. None of the patients had elevated tumor markers. The primary method of management was ultrasound-guided testis-sparing surgery, with an operative time of 98.5 ± 58.7 minutes. Mean tumor size was 15 ± 10.8 mm (range 5-40 mm). In 2 of 6 patients with positive margins radical orchidectomy was performed without residual disease encountered. At a mean follow-up of 31.8 ± 26.3 months (range 2-87) none of the patients demonstrated disease recurrence. CONCLUSION: Our data suggest that LCT in children is associated with a good prognosis, and that TSS is a reasonable surgical approach without detrimental perioperative morbidity or negative long-term outcomes. Moreover, positive margins should not prompt a reflex decision for completion of orchidectomy.