Hospitalization following pediatric kidney transplantation: An international comparison among a Canadian pediatric transplant center, North American Pediatric Renal Trials and Collaborative Studies, and Cooperative European Pediatric Renal Transplant Initiative registry data.

BACKGROUND: There are several databases across the world that collect pediatric KT data. We compare the hospitalization outcomes for pediatric KT recipients from a large Canadian transplant center (SickKids database; The Hospital for Sick Children Kidney Transplantation Institutional Database), United States (NAPRTCS), and Europe (CERTAIN registry). METHODS: An institutional retrospective review of KT was performed between 2000 and 2015. Baseline characteristics, duration of initial hospitalization/readmission at 1-5 and 6- to 11-month posttransplant, and 1-year graft survival data were collected. Corresponding data from the NAPRTCS 2014 Annual Transplant Report and CERTAIN registry were compared. RESULTS: Posttransplant, patients from NAPRTCS had the shortest duration of hospitalization within the first month (10.4 days, SE 0.2), followed by SickKids (20.3 days, SE 0.7) and CERTAIN (25.5 days, SE 0.7). For both living and deceased donor populations, patients from SickKids were most likely to be hospitalized at 1- to 5-month posttransplant (82.4% [89/108]; 72.1% [98/136]), followed by Europe (52.1% [198/380]; 61.6% [501/813]) and United States (45.4% [2379/5241]; 51.4% [2517/4896]). Patients from Europe were most likely to be hospitalized at 6- to 12-month posttransplant (42.1% [160/380]; 51.7% [420/813]), followed by SickKids (35.2% [38/108]; 37.5% [51/136]) and United States (28.3% [1387/4901]; 31.6% [1411/4465]). Across all databases, the most commonly addressed issues during readmissions were infectious complications. CONCLUSION: The differences observed in this investigation may reflect the local reimbursement models, resources for outpatient management, and practice variations across a large Canadian transplant center, United States, and European countries.

Omental Procedures During Peritoneal Dialysis Insertion: A Systematic Review and Meta-Analysis.

OBJECTIVES: Peritoneal dialysis (PD) is an option for ultrafiltration for patients with end-stage renal disease. Once placed, PD catheters may malfunction often due to omental wrapping. Omental procedures such as omentectomy and omentopexy may reduce this risk. This investigation aims to perform a systematic review and meta-analysis of the literature on the role of omental procedures on PD catheter insertions. METHODS: Following protocol registration on PROSPERO (CRD42020218950), a systematic review was performed in accordance with the Cochrane Collaboration. A literature search was performed in February 2021 across Medline, EMBASE, Scopus, and Cochrane Library. Records with patients who underwent PD catheter insertion with and without omental manipulation were included. The records underwent screening, full-text review, and data extraction. Study qualities were assessed using RoBINS-I and RoB2. Effect estimates were extracted as risk ratios and corresponding 95% confidence intervals (CI) were pooled using inverse variance method with random-effect model. RESULTS: Of 510 records identified, 15 studies were included in the meta-analysis (1 RCT, 2 prospective, 12 retrospective). With omental procedures, there was decreased the likelihood of failure requiring removal of PD catheter (RR 0.47, 95% CI 0.38, 0.58) and PD catheter obstruction (RR 0.23, 95% CI 0.14, 0.39); there was no difference in likelihood of catheter malposition or migration (RR 0.87, 95% CI 0.23, 3.29) or peritonitis (RR 0.74, 95% CI 0.40, 1.35). CONCLUSION: Based on the current low to moderate quality of evidence, omental manipulation at the time of PD catheter insertion confers benefits of decreased obstruction and failure requiring removal.

Impact of native nephrectomy on hypertension outcomes in pediatric kidney transplant recipients: a 10-year institutional experience.

OBJECTIVE: To assess the role native nephrectomy (NN) in hypertension-related outcomes for pediatric patients undergoing renal transplantation (RT). METHODS: Renal transplants (RT) performed at our institution between 2006 and 2015 were reviewed. RT recipients who underwent NN were compared to those who did not. Primary outcomes were hypertension-related: use/number of medications pre-/post-transplant and hypertension-related readmissions. Secondary outcomes were 1-year outcomes of: readmissions, eGFR, Clavien-Dindo classification ≥ 3 complications, and graft loss. RESULTS: 135 patients were evaluated. 24 underwent NN (Group 1) and 111 did not (Group 2). Baseline characteristics were similar between Groups 1 and 2. The majority of NN indications were hypertension (10/39 kidneys) and proteinuria (12/39 kidneys). There were no differences in use/number of anti-hypertensive medications pre- or post-transplant. However, between Group 2 and subgroup of patients who underwent NN for hypertension, a significant difference was seen in medication use/numbers but not post-transplant. Number of readmissions due to hypertension was similar (7.2% vs. 12.5%). The only difference in secondary outcomes was higher readmission rates with bacterial infections for group 1 (45.8% vs. 23.4%, p = 0.041). CONCLUSION: NN, when offered to patients at higher risk of post-RT hypertension, may allow high-risk patients to achieve similar hypertension outcomes as those at lower risk.

Ultrasonographical features of perinatal testicular torsion: an assessment of interobserver variability among radiologists and pediatric urologists.

PURPOSE: To retrospectively compare interpretations of Doppler ultrasound (US) in newborns with confirmed perinatal testicular torsion (PTT) by an experienced faculty (staff) pediatric radiologist (SPR), pediatric radiology fellow (PRF), pediatric urology fellow (PUF) and staff pediatric urologist (SPU). METHODS: US images of 27 consecutive males with PTT between May 2000 and July 2020 were retrieved. The testicles were classified as affected or non-affected by PTT. We performed a blinded comparison of interpretation by four assessors (SPR, PRF, PUF, SPU), with respect to the US features of PTT. Paired inter-rater agreement was calculated using Cohen's Kappa (κ) and overall agreement was assessed using Fleiss' kappa. RESULTS: Overall comparison using Fleiss' kappa found fair agreement for most features except testicular echogenicity and echogenic foci at interface for which there was poor agreement. Paired comparisons revealed better agreement between the SPR and PRF compared to the remaining two pairs, suggesting a need for the pediatric urologists (PUF and SPU) to acquaint themselves with testicular ultrasonography as this may have an impact on patient risk stratification and the quality of information given to parents. CONCLUSION: This study highlights the need for focused training program for pediatric urologists to attain similar agreement as the radiologists, suggesting a need for the pediatric urologists (PUF and SPU) to acquaint themselves with testicular ultrasonography as this may have an impact on patient risk stratification and the quality of information given to parents.

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.

Utility of pre-transplant lower urinary tract investigation in pediatric renal transplant population after referral: A 16-year institutional experience.

To evaluate the clinical utility of pre-renal transplant LUT investigations in pediatric populations after their referral for transplant evaluation based on the etiology of their ESRD. A 16 year retrospective review of patients undergoing RT performed at our institution was performed. Patients were stratified into two groups: Group 1-non-urologic and Group 2-urologic etiology for ESRD. Baseline characteristics, pre-transplant LUT investigations, and urologic interventions were assessed. One-year clinical outcomes were compared between those with and without LUT investigations following referral for renal transplantation (RT). 227 patients and 97 patients were identified for Groups 1 and 2, respectively. 19% of Group 1 and 73% of Group 2 had VCUG, while 1% and 13%, respectively, had UDS ordered following referral for RT. In both groups, >50% of VCUG and UDS were ordered without specific clinical concerns. These had low likelihood of prompting interventions, both pre-transplant (Group 1-VCUG 0%, UDS 0%; Group 2-VCUG 0%, UDS 8%) or post-transplant (Group 1-0%, Group 2-5%). In both groups, LUT investigation following referral for RT did not lead to differences in 1 year outcomes assessed. In anticipation of pediatric RT, LUT investigations ordered without clinical indications did not provide information that altered management prior to transplantation.

Do post-operative phone calls enhance family satisfaction and outcomes after outpatient pediatric urological surgeries? A prospective study.

INTRODUCTION: This study assesses whether post-operative check-in phone calls (POPC) performed within 48 h of outpatient pediatric urological surgeries by a non-medical professional (NMP) would increase patient/family satisfaction and minimize extraneous resource use by increasing email/telephone communication, while reducing emergency department (ED) visits within 30 days of that procedure. METHODS: Families of patients undergoing ambulatory pediatric urology surgeries were enrolled over 8 weeks. Group 1 did not receive POPC. Group 2 received a POPC within 48 h of their operation by a NMP. Both groups received a phone-call survey 2 weeks after surgery to assess families' perioperative satisfaction. RESULTS: In total, 74 families were enrolled (Group 1 = 44, Group 2 = 31). The response rates to phone surveys for Groups 1 and 2 were 59.1% and 77.4%, respectively. POPC did not improve perioperative satisfaction, nor did it significantly promote the use of nursing email/telephone communication (19.2% vs. 4.2%, p = 0.128) or reduce ED visits (15.4% vs. 0.0%, p = 0.111). However, all families in Group 2 thought POPC was timed appropriately and 79.1% perceived it to be helpful in reducing post-operative anxiety. CONCLUSION: POPC by a NMP within 48 h of surgery may not affect perioperative satisfaction of families of patients undergoing same-day pediatric urology surgery but may have an impact in reducing post-operative anxiety.

Comparative outcome analysis of pediatric kidney transplant in posterior urethral valves children with or without pretransplant Mitrofanoff procedure.

BACKGROUND: Urinary diversion using catheterizable channel among posterior urethral valve (PUV) patients may help to alleviate the functional concerns of the bladder on the allograft. Herein, we review our series of PUV patients undergoing renal transplants at a single institution to determine outcomes between those with and without pretransplant Mitrofanoff. METHODS: PUV cases in our transplant database from 2000 to 2017 were identified. Data collected included clinical demographics, presentation of PUV, bladder function, implementation of dialysis and donor type. Post-transplant variables included graft function, and bladder function including incontinence and UTI development. Comparison between with vs without pretransplant Mitrofanoff patient groups was performed using Fisher's exact and t test analysis. RESULTS: Overall, 22 cases were analyzed. The majority (77%) had a prenatal diagnosis of PUV, and 23% had a symptomatic presentation. Pretransplant Mitrofanoffs were performed in 40.9% of cases. The overall age at transplant was 10 ± 5 years. Five percent experienced post-transplant incontinence and 23% UTIs. No difference between groups was noted in variables including age at transplant, the timing of PUV diagnosis. Mitrofanoff group patients had more symptomatic febrile UTIs than those without Mitrofanoff (67% vs 15%; P = .03); however, there was no difference in post-transplant UTI development. Furthermore, the Mitrofanoff group seems to have later onset of dialysis or need for transplant (age at the start of dialysis 36 ± 56 vs 156 ± 25 months, P < .001). CONCLUSION: Our study suggests that patients with early PUV diagnoses who develop symptomatic UTI may benefit from early creation of a Mitrofanoff cathetherizable channel, which is associated with delayed ESRD progression and need for dialysis.

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.

Increased hand digit length ratio (2D:4D) is associated with increased severity of hypospadias in pre-pubertal boys.

INTRODUCTION: Hypospadias is a common congenital male disorder, with much research focusing on prenatal androgen exposure as a causative factor. Whilst digit length ratios were apparent in sexual dimorphism since the nineteenth century, their role in hypospadias remains unknown. The objective of our study was to determine the correlation between digit length (2D:4D) ratio, hypospadias severity, and anogenital distance. METHODS: Pre-pubertal boys (<3 years old) seen intra/postoperatively following hypospadias repair (June 2018-January 2019 inc.) were included. These were age-matched to non-hypospadias controls. Anthropomorphic measurements of digit lengths, penile/glans width, and anogenital distance were measured using digital calipers. RESULTS: Data measurements were collected for 105 boys with hypospadias (60 distal; 45 proximal) and 55 controls. There were significant differences in 2D:4D ratios in each hand (p < 0.001), as well as individual digits (p < 0.001), and a reduced anogenital distance (p < 0.001), when comparing the proximal group with distal or control groups. There were no significant differences in glans width, or between term- and preterm births. CONCLUSIONS: This study is the first to demonstrate increased 2D:4D ratios with proximal hypospadias, which also correlate with a shortened anogenital distance. This may provide a non-invasive, potentially antenatal, anthropomorphic measurement, as an indirect indicator of aberrant urogenital development.

Turning a new "page": ways to decrease the number of pages after hours without compromising patient care

Background: Pages to house staff after hours, especially overnight, lead to interrupted sleep and fatigue the next day. Although some pages are urgent, others may not need an immediate response. In this study we aimed to identify unwarranted pages and to establish ways to reduce them. Methods: Over 2 months, all pages to the Department of Pediatric Urology at the Hospital for Sick Children in Toronto, Canada, during call hours were documented, including the assessment of the responding physicians of their medical necessity. After analyzing the reasons for inappropriate pages, we took several steps to try to reduce them without impairing patient care. One year later, pages were tracked again to evaluate the efficacy of our interventions. Results: In the initial measurement period, no calls from parents and approximately 50% of the in-hospital pages (15 of 36 pages from the wards, 27 of 49 pages from the emergency department, 17 of 31 pages requesting consultations, and 8 of 8 pages from the inhouse pharmacy and outside pharmacies) were considered medically urgent. The reasons for unwarranted pages were inconsistent parent teaching, lack of adequate triaging and prioritizing on the ward and lack of awareness of the structure of the on-call provisions among different services in the hospital. Several steps were taken to streamline the teaching of parents and nurses, standardize information, provide alternative means of communication within the hospital and restrict parents' access by phone to the urologist on call. One year later, the number of pages had decreased by 70%. Conclusion: Although physician coverage throughout the day and night is necessary for high-quality and safe patient care, communication with on-call physicians should be only for appropriate reasons. The provision of consistent teaching and alternative communication channels can improve patient care as well as decrease the number of after-hour pages.

Contexte: Les appels au personnel interne par téléavertisseur, surtout la nuit, perturbent le sommeil et entraînent de la fatigue le lendemain. Même si certains de ces appels sont urgents, d'autres ne nécessitent pas de réponse immédiate. Avec cette étude nous avons voulu identifier les appels par téléavertisseur qui sont injustifiés et trouver des façons d'en réduire le nombre. Méthodes: Sur une période 2 mois, nous avons documenté tous les appels par téléavertisseur adressés durant les heures de garde au service d'urologie pédiatrique de l'Hôpital SickKids de Toronto, au Canada, et demandé aux médecins y ayant répondu d'en évaluer le bien-fondé au plan médical. Après avoir analysé les raisons des appels jugés injustifiés, nous avons adopté plusieurs mesures pour en réduire le nombre sans compromettre les soins. Un an plus tard, nous avons de nouveau comptabilisé les appels par téléavertisseur pour mesurer l'efficacité de nos interventions. Résultats: Durant la période de mesure initiale, aucun appel des parents n'a été considéré médicalement urgent, tout comme environ 50 % des appels provenant de l'hôpital même (15 appels sur 36 des unités de soins, 27 appels sur 49 du service des urgences, 17 appels sur 31 pour des demandes de consultation et 8 appels sur 8 de la pharmacie de l'hôpital ou de pharmacies de l'extérieur). Les raisons des appels injustifiés étaient entre autres incohérence dans l'enseignement aux parents, triage et priorisation inadéquats à l'unité de soin et méconnaissance des différents services de l'hôpital quant à la structure et au fonctionnement du système de garde. Plusieurs mesures ont été prises pour simplifier l'enseignement aux parents et au personnel infirmier, standardiser l'information, fournir d'autres moyens de communication dans l'hôpital même et restreindre l'accès des parents à l'urologue de garde par téléphone. Un an plus tard, le nombre d'appels avait diminué de 70 %. Conclusion: Même si les médecins doivent être joignables jour et nuit pour assurer la qualité des soins et la sécurité des patients, les raisons de communiquer avec eux doivent être appropriées. Le rappel des consignes et le recours à d'autres canaux de communication peuvent améliorer les soins aux patients et réduire le nombre d'appels le soir et la nuit.

"Inverted" positioning of renal allograft during kidney transplantation in children and adolescents: A single-institution comparative analysis.

Renal transplantation is the treatment of choice in children with end-stage renal failure. Limitations in patient anatomy or a short donor renal vein may necessitate intraoperative inversion of the kidney. There is little evidence to support the use of this surgical technique, and no evidence in the pediatric population. This study identifies the perioperative and post-operative outcomes of inverted renal transplants in pediatric patients. We reviewed all patients having a renal transplant between January 2012 and December 2016 and collected short- and long-term outcomes of patients who received an inverted allograft. Early graft function was defined as the time to reach creatinine nadir. During this time, our hospital performed 81 transplants, and 50 (62%) were from deceased donors, including the 6 (12%) patients who received inverted renal grafts. Half (3/6) were female, 5/6 (83%) were dialysis-dependent, and the median age at surgery was 13 years (range 9-16 years). There was no significant difference in mean creatinine nadir values (P = 0.518) and the time to creatinine nadir mean values (P = 0.190) between the upright and inverted renal transplant groups. There were also no significant differences in rates of post-operative complications between the upright and inverted allograft recipients. Inversion of renal allografts in pediatric patients is a viable surgical technique to compensate for shortcomings in patient anatomy or in special cases of renal transplantation involving a short donor renal vein. Future research should focus on outcomes of a larger group of pediatric inverted renal transplant patients.

Is there a functional disadvantage to using the external iliac vessels for vascular anastomosis in children and adolescents undergoing renal transplantation?

PURPOSE: RT remains the best available strategy for addressing stage 5 chronic kidney disease in children and adolescents. Technical aspects of the procedure can have a clear impact on complications and health of the allograft, including DGF. Immediate optimal perfusion is paramount, thus choosing a target vessel has to take into account the flow demands imposed by an adult-size kidney in a proportionally smaller recipient. Herein, we explore the hypothesis that vascular anastomosis location can impact DGF adjusting for patient age and body size. METHODS: Retrospective review of a single institution referral center transplant database, including information on 156 patients. We collected data on patient characteristics (age, height, BSA, gender, preoperative need for dialysis), donor source (deceased vs living), WIT/CIT, hemodynamics during the procedure, use of inotropes or diuretics, and location of the arterial and venous anastomoses. The primary outcome, DGF, was assessed by measuring the ttNC (in days), adjusting for age and BSA. RESULTS: Location of the arterial anastomosis was clearly impacted by age and donor size (Figure 1A). On univariate analyses, longer ttNC was associated with deceased vs living donor (11.8 ± 11.5 and 4.3 ± 5.0; P < 0.001), preoperative need for dialysis (9.7 ± 11.0 and 6.5 ± 6.0, P = 0.02), location of arterial anastomosis (aorta [n = 21] 4.9 ± 6.1, common iliac [n = 93] 7.1 ± 7.3, external iliac 14.7 ± 14.5; P < 0.001, Figure 1B) and venous anastomosis (vena cava [n = 21] 5.6 ± 6.3, common iliac [n = 89] 7.1 ± 7.6, external iliac [n = 44] 13.8 ± 14); P < 0.001). On multivariable analysis, this association remained statistically significant when adjusting for recipient age, height, BSA, donor source, change in blood pressure with unclamping, and use of inotropes and preoperative dialysis. The detrimental effect on ttNC was more salient when comparing external iliac vs common iliac and aorta or vena cava. CONCLUSION: Our data suggest that anastomosis to a smaller caliber target vessel (ie, external iliac) in comparison with the common iliac or aorta/vena cava may be a risk factor for delayed return of graft function, independent of recipient size and donor source. This finding merit further evaluation, as it may help with intraoperative decision making during pediatric and adolescent RT.

Publication trends in pediatric renal transplantation: Bibliometric analysis of literature from 1950 to 2017.

INTRODUCTION: Pediatric renal transplantation has been heavily published since the 1950s. Herein, we describe the bibliometrics and impact of the 200 most-cited pediatric renal transplantation manuscripts. METHODS: We identified pediatric renal transplantation publications from 1900 onwards. Year, citations, h-index, geographic origin, impact factor, topic, and design of the 200 top-cited papers were extracted. Impact index was calculated, adjusting for citation volume and time since publication. RESULTS: Of the top 200 papers, mean citation count was 80 ± 40, impact factor 3.9 ± 3.7, h-index 35 ± 20, and impact index 25 ± 13. Studies were mostly retrospective (31%) or observational (32%). Most papers originated from the United States (58%), Germany (9%), and Italy (6%), which did not correlate with citation counts. Transplantation (18%), Pediatric Nephrology (16%), and American Journal of Transplantation (11%) had the highest publication volume, which did not correlate with citation count. The main topics were medical renal disease, drug monitoring, compliance, and viruses. Most of the top-cited papers (179; 90%) were published after 1991. The difference in the number of times cited between papers published before and after 1991 was insignificant (75 ± 24 vs 80 ± 42; P = 0.59). There was a difference in impact index for the same period (48 ± 15 vs 22 ± 10; P < 0.01). CONCLUSIONS: The most-cited papers were concentrated in three journals, but the top three cited papers were published elsewhere. Recent publications were more cited with a higher impact than older papers. Despite the importance of surgery in transplantation, there is a paucity of high-impact papers on this topic.

A comparison of post-transplant renal function in pre-emptive and post-dialysis pediatric kidney transplant recipients.

PURPOSE: Little is known regarding post-transplant renal function following pediatric pre-emptive KT. Therefore, this study aims to determine whether there is a difference in 1 year post-transplant renal function outcomes between pre-emptive and post-dialysis KT in pediatric transplant recipients. METHODS: A retrospective review of patients who underwent kidney transplant at our institution between 2000 and 2015 was performed. Kidney transplant recipients were divided into four groups: pre-DD, post-DD, pre-LD, and post-LD. The clinical outcomes, measured in eGFR (mL/min/1.73 m2 ), acute rejection episodes within 1 year, and hospitalization within 1 year were compared to between groups in their respective donor types (pre-DD vs post-DD; pre-LD vs post-LD). RESULTS: The 324 patients were identified (21 pre-DD, 151 post-DD, 54 pre-LD, and 98 post-LD). Post-DD group had more females (P = 0.018) and post-operative complications (P = 0.023), although there was no difference in complications requiring intervention (P = 0.129). Post-LD patients were more likely to be females (P = 0.017) and those with intrinsic renal (non-urological/structural) ESRD etiology (P = 0.003). The 1-year eGFR was similar between pre-DD and post-DD groups (70.3 [IQR 53.5-88.5] vs 74.3 [IQR 62.3-90.5], P = 0.613), as well as pre-LD and post-LD groups (66.6 [IQR 47.8-73.7] vs 63.9 [IQR 55.0-77.1], P = 0.600). There were no significant differences in rates of acute rejection episodes or hospitalization within 1 year of transplantation for in LD/DD groups. CONCLUSION: There is no significant difference in renal function at 1 year post-transplant in pediatric patients receiving pre-emptive or post-dialysis kidney transplants.

Assessment of prophylactic heparin infusion as a safe preventative measure for thrombotic complications in pediatric kidney transplant recipients weighing <20 kg.

Small-sized kidney recipients (<20 kg) are at high risk of allograft vessel thrombosis. HP has been used to mitigate this risk but may infer an increase in bleeding risks. Therefore, we aim to determine whether HP is a safe means to prevent thrombosis in small kidney transplant patients by comparing those who have received HP and those who have NHP. A retrospective review of patients < 20 kg who underwent kidney transplant in our institution from 2000 to 2015 was performed. At our institution, unfractionated heparin 10 units/kg/hour is used as HP since 2009. Patients at increased risk of thrombosis (previous thrombosis, thrombophilia, nephrotic syndrome) and bleeding (therapeutic doses of heparin, diagnosis of coagulopathy) were excluded. Fifty-six patients were identified (HP n = 46; NHP n = 10). Baseline demographics were similar between HP and NHP. There was no statistical difference in frequency of transfusions, surgical re-exploration, or thrombotic events between HP and NHP. The HP group was more likely to have drop in Hb > 20 g/L (67.4% vs 30.0%, P = 0.038), and those who had drop in Hb > 20 g/L were more likely to also require pRBC transfusions (63.0% vs 20.0%, P = 0.017). Within the HP group, those who had bleeding complications had similar Hb levels as those who did not at baseline and post-transplant. Outcomes in the HP and NHP groups were no different with respect to thrombosis or significant bleeding complications requiring pRBC transfusions or surgical intervention. Future prospective studies are required to investigate the balance of preventing thrombosis and risks of pRBC transfusions for small-sized kidney recipients.

Embracing change: the era for pediatric ERAS is here.

The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues, but has been slow to crossover to pediatric surgical subspecialties. ERAS® improves outcomes through multiple, incremental steps that act synergistically throughout the entire surgical journey. In practice, ERAS® is a strategy of perioperative management that is defined by strong implementation and ongoing adherence to a patient-focused, multidisciplinary, and multimodal approach. There are increasing numbers of surgical teams exploring ERAS® in children and there is mounting evidence that this approach may improve surgical care for children across the globe. The first World Congress in Pediatric ERAS® in 2018 has set the stage for a new era in pediatric surgical safety.

Variability among Canadian pediatric surgeons and pediatric urologists in the management of cryptorchidism in boys before the publication of major guidelines: a retrospective review of a single tertiary centre

Background: Before 2014, there was a lack of recommendations on managing cryptorchidism, or undescended testis (UDT), from a large pediatric urological or surgical organization. We assessed the variability in management of UDT among pediatric urologists and pediatric surgeons at a single tertiary pediatric referral centre before publication of major guidelines. Methods: We performed a retrospective review of the electronic records of patients who underwent primary unilateral or bilateral orchidopexy at our centre between January 2012 and January 2014. Results: A total of 488 patients (616 testes) were identified, of whom 405 (83.0%) and 83 (17.0%) were managed by pediatric urologists and pediatric surgeons, respectively. There was no difference in baseline characteristics, including age seen in clinic or at surgery, testis location/palpability and availability of preoperative ultrasonograms, of patients seen by the 2 groups. Pediatric surgeons ordered preoperative ultrasonography more often than pediatric urologists (25.3% v. 3.7%, p < 0.001). With palpable UDTs, although both groups used open approaches, pediatric urologists preferred a scrotal approach (56.9%), and pediatric surgeons approached most testes inguinally (98.8%). With nonpalpable UDTs, laparoscopic approaches were preferred by both groups; however, pediatric urologists used a 2-stage Fowler­Stephens approach more often than pediatric surgeons (48.4% v. 15.8%, p < 0.001). Conclusion: There was wide variation in the management of primary UDT between pediatric urologists and pediatric surgeons before the publication of guidelines. The most prominent difference between the 2 groups was in the ordering of preoperative ultrasonography. Future assessment of change in practice patterns may elucidate whether guidelines are an effective tool for standardization of practice.

Contexte: Avant 2014, on ne disposait pas de recommandations émanant d'une grande organisation urologique ou chirurgicale pédiatrique pour la prise en charge de la cryptorchidie (absence d'un ou des deux testicules dans le scrotum). Nous avons évalué les divers types de prise en charge de la cryptorchidie chez les urologues et les chirurgiens pédiatriques dans un seul centre tertiaire de référence pédiatrique avant la publication de lignes directrices majeures. Méthodes: Nous avons procédé à une revue rétrospective des dossiers électroniques de patients ayant subi une orchidopexie unilatérale ou bilatérale primaire dans notre centre entre janvier 2012 et janvier 2014. Résultats: En tout, 488 patients (616 testicules) ont été identifiés, dont 405 (83,0 %) et 83 (17,0 %) ont été traités respectivement par des urologues et des chirurgiens pédiatriques. On n'a noté aucune différence quant aux caractéristiques de départ des patients vus par les 2 groupes, telles que l'âge lors de la consultation à la clinique ou lors de la chirurgie, la localisation/palpabilité des testicules et le recours à l'échographie préopératoire. Les chirurgiens pédiatriques ont demandé une échographie préopératoire plus souvent que les urologues pédiatriques (25,3 % c. 3,7 %, p < 0,001). En présence de cryptorchidie palpable, même si les 2 groupes ont utilisé une approche ouverte, les urologues pédiatriques ont préféré l'approche scrotale (55,4 %) et les chirurgiens pédiatriques l'approche inguinale (98,8 %). En présence de cryptorchidie non palpable, les approches laparoscopiques ont été privilégiées par les 2 groupes; toutefois, les urologues pédiatriques ont utilisé une approche Fowler­Stephens en 2 temps plus souvent que les chirurgiens pédiatriques (48,4 % c. 15,8 %, p < 0,001). Conclusion: On a noté une grande variation dans la prise en charge de la cryptorchidie primaire entre les urologues et les chirurgiens pédiatriques avant la publication des lignes directrices. La principale différence entre les 2 groupes concernait le recours à l'échographie préopératoire. L'évaluation future des changements affectant la pratique permettrait de déterminer si les lignes directrices sont un outil efficace pour sa standardisation.

Clinical Outcomes of the Upper Urinary Tract after Ureteral Clipping for Treatment of Low Functioning or Nonfunctioning Renal Moieties.

PURPOSE: A growing body of evidence suggests that it is safe to ligate the ureter of poorly functioning renal moieties during renal transplantation. We present clinical outcomes and data on hydronephrosis progression in pediatric cases associated with ectopic ureters and obstructive ureteroceles. MATERIALS AND METHODS: We prospectively collected data for 35 consecutive patients (23 females and 12 males) who underwent ureteral clipping between February 2011 and August 2016. Patients were divided into 4 groups consisting of 1) duplex system with ectopic ureter (45.7%), 2) duplex system with a large ureterocele (11.4%), 3) other duplex system (8.6%) and 4) single system kidneys (34.3%). Patients were followed for clinical outcomes and hydronephrosis trends. Comparisons included preoperative and postoperative anteroposterior diameter, maximal ureteral diameter and ureterocele size. RESULTS: Median age at surgery was 59 months (IQR 11 to 120, range 5 to 216). Median ± SD operative time was 108.9 ± 31.1 minutes (range 20 to 180) and median length of stay was 7.5 hours (IQR 6 to 19, range 5 to 336). Immediate resolution of urinary incontinence was observed in all 16 ectopic ureter cases. After a median ± SD followup of 20.8 ± 13.8 months (IQR 8.5 to 30, range 6 to 50) 97.2% of the patients remained asymptomatic. No significant differences were observed between initial and last anteroposterior diameter measurements except in group 1 (p = 0.001). All ureteroceles demonstrated a significant decrease in median ± SD size after clipping (from 2.7 ± 0.41 to 0.53 ± 0.92 cm, p = 0.003). Pyonephrosis developed in 1 patient, who underwent laparoscopic nephrectomy. CONCLUSIONS: Ureteral clipping appears to be a reasonable, safe and effective option for pediatric patients in the reported settings, with the potential to be simpler and quicker than extirpative or reconstructive procedures.

Impact of Adjuvant Urinary Diversion versus Valve Ablation Alone on Progression from Chronic to End Stage Renal Disease in Posterior Urethral Valves: A Single Institution 15-Year Time-to-Event Analysis.

PURPOSE: Long-term progression to end stage renal disease of valve ablation alone vs ablation followed by additional urinary diversion were compared among children with stage 3 chronic kidney disease due to posterior urethral valves. MATERIALS AND METHODS: We performed a retrospective study of children with posterior urethral valves and stage 3 chronic kidney disease treated at a single institution between 1986 and 2011. The 3 treatment groups were classified as group 1-valve ablation alone, group 2-ablation plus subsequent vesicostomy and group 3-ablation followed by ureterostomies and/or pyelostomies. Baseline demographic characteristics were analyzed. Statistical analyses compared the incidence of time to end stage renal disease among the intervention groups using the Fisher-Freeman-Halton exact test and Kaplan-Meier analysis with the log rank test. Cox regression was used to determine predictors of end stage renal disease progression. RESULTS: A total of 40 eligible patients were included in the study (group 1-14 patients, group 2-13 patients, group 3-13 patients). Baseline characteristics and post-intervention estimated glomerular filtration rate revealed no significant between-group differences. A statistically significant difference in progression to end stage renal disease was noted within 1 year after diagnosis of stage 3 chronic kidney disease among the treatment groups (log rank test p=0.02). However, cumulative end stage renal disease incidence at 15-year followup showed no statistical difference (log rank test p=0.628). Cox regression analysis determined that bilateral renal dysplasia (HR 2.76, 95% CI 1.21-6.30) and estimated glomerular filtration rate 60 ml/minute/1.73 m2 or greater after intervention (HR 0.23, 95% CI 0.09-0.61) were predictive of the likelihood of progression to end stage renal disease. CONCLUSIONS: Urinary diversion following valve ablation in children with stage 3 chronic kidney disease associated with posterior urethral valves may temporarily delay progression to end stage renal disease. However, no long-term benefit was noted from diversion in the ultimate incidence of end stage renal disease, suggesting that these interventions should be seen as a temporizing measure. Bilateral renal dysplasia and post-intervention estimated glomerular filtration rate are independent variables predicting overall chronic kidney disease progression.