Children with spinal abnormalities have an increased health burden from upper tract urolithiasis

OBJECTIVE

To examine the epidemiology and health care burden of upper tract urolithiasis in children with spinal abnormalities using a large, national database. Children with spinal dysraphism are predisposed to urolithiasis for many reasons, including immobility, bacteriuria, and urinary stasis. No large epidemiologic studies exist regarding stones in this specific group. Isolated spinal curvature may lead to hypercalciuria from immobility; however, urolithiasis rates are unknown.

METHODS

We extracted data from the Pediatric Health Information Systems database over an 8-year period. Hospitals reporting inpatient visits, emergency room visits, and ambulatory surgery visits were included. Using International Classification of Diseases, Ninth Revision codes and Current Procedural Terminology codes, we identified children with upper tract urolithiasis, spinal dysraphism, and spinal curvature. Data regarding demographics, prevalence, surgical procedures, costs related to stone procedures were extracted.

RESULTS

A total of 11,987 patients had urolithiasis. Prevalence of stones in patients with normal spines was 0.24% compared with 1.40% and 4.03% among children with spinal curvature and spinal dysraphism, respectively (P<.001). Children with spinal curvature and spinal dysraphism were more likely to have multiple procedures for stones than those without spinal abnormalities (25% vs 25.7% vs 13.1%, P<.001). Costs per patient were significantly higher for children with spinal abnormalities compared with those with normal spines.

CONCLUSION

Children with spinal curvature and spinal dysraphism have a much greater rate of upper tract urolithiasis, resulting in more procedures and related costs. Urolithiasis represents a significant, chronic health burden for children with spinal abnormalities. Screening and preventive care may reduce the impact of urolithiasis in these patients.

Minimal incision laparoscopy assisted open pediatric pyeloplasty

Minimal incision laparoscopy-assisted open pyeloplasty (MILAP) incorporates elements of open pyeloplasty (OP) and single incision laparoscopy to improve technical ease and cosmetic outcomes. Six MILAP procedures were performed using a single transumbilical incision through which the ureteropelvic junction (UPJ) is mobilized with standard laparoscopic instrumentation. The UPJ is brought extracorporeally through a 1-cm flank incision, and a traditional Anderson-Hynes open pyeloplasty is performed. Compared with OP, perioperative outcomes were similar. Follow-up renal scans all showed improvement of obstruction. A 1-cm flank incision is the only obvious scar.

Early clean intermittent catheterization may not prevent dimercaptosuccinic acid renal scan abnormalities in children with spinal dysraphism

OBJECTIVES

To determine whether early initiation of clean intermittent catheterization is associated with increased renal preservation in children with spinal dysraphism based on dimercaptosuccinic acid (DMSA) renal scans.

METHODS

A retrospective review was performed of 100 patients from a pediatric spinal defects clinic from June 2007 to October 2011 who were followed with routine studies including DMSA scans, voiding cystourethrograms, renal/bladder ultrasounds, and urodynamics. DMSA scans were reviewed for evidence of renal cortical loss as defined by presence of scarring or difference in differential function greater than 15%. Multivariate analysis was performed for risk factors for upper tract damage.

RESULTS

Renal cortical loss on DMSA scan was found in 43/100 (43%) of patients. CIC was started at birth in 17/100 (17%) of patients with the rest starting at a median age of 5 years (IQR 3-9). Upon multivariate regression analysis, age at DMSA scan (OR 1.21; 95% CI 1.08-1.36), history of VUR (OR 8.64; 95% CI 2.52-29.57), history of hydronephrosis (OR 3.44; 95% CI 1.12-10.5), and CIC from birth (OR 9.26; 95% CI 1.99-43.18) were statistically significant predictors of kidney damage.

CONCLUSION

Early initiation of CIC may not reduce the incidence of DMSA abnormalities in pediatric patients with spinal dysraphism.

Can we predict a national profile of non-attendance paediatric urology patients: a multi-institutional electronic health record study

BACKGROUND

Non-attendance at paediatric urology outpatient appointments results in the patient's failure to receive medical care and wastes health care resources.

OBJECTIVE

To determine the utility of using routinely collected electronic health record (EHR) data for multi-centre analysis of variables predictive of patient noshows (NS) to identify areas for future intervention.

METHODS

Data were obtained from Children's Hospital Colorado, Rady Children's Hospital San Diego and University of Virginia Hospital paediatric urology practices, which use the Epic® EHR system. Data were extracted for all urology outpatient appointments scheduled from 1 October 2010 to 30 September 2011 using automated electronic data extraction techniques. Data included appointment type; date; provider type and days from scheduling to appointment. All data were de-identified prior to analysis. Predictor variables identified using χ(2) and analysis of variance were modelled using multivariate logistic regression.

RESULTS

A total of 2994 NS patients were identified within a population of 28,715, with a mean NS rate of 10.4%. Multivariate logistic regression determined that an appointment with mid-level provider (odds ratio (OR) 1.70 95% CI (1.56, 1.85)) and an increased number of days between scheduling and appointment (15-28 days OR 1.24 (1.09, 1.41); 29+ days OR 1.70 (1.53, 1.89)) were significantly associated with NS appointments.

CONCLUSION

We demonstrated sufficient interoperability among institutions to obtain data rapidly and efficiently for use in 1) interventions; 2) further study and 3) more complex analysis. Demographic and potentially modifiable clinic characteristics were associated with NS to the outpatient clinic. The analysis also demonstrated that available data are dependent on the clinical data collection systems and practices.

Urologic findings on computed tomography of the abdomen and pelvis in a pediatric population

OBJECTIVES

(1) Determine the number of urologic conditions diagnosed by computed tomography (CT) in children in the emergency department setting. (2) Identify which diagnoses were incidental. (3) Determine how often there was urologic follow-up by a local pediatric urologist.

PATIENTS AND METHODS

We reviewed the charts and radiologist interpretations of all CT scans of the abdomen and pelvis performed within 2 days of admission via our emergency department from July 2007 to June 2009. Patients were included if the diagnosis was new. If a urologic finding was noted on final read, the CT was re-examined by one of our urologists to verify the finding.

RESULTS

Among 2991 CT scans (one CT scan per patient), there were 213 (7%) new urologic findings: 124 were incidental; 144 patients (68% of patients with urologic findings) did not receive follow-up. Renal abnormalities were present in 127. The most common finding was renal cyst (69 patients). Ureteral abnormalities were present in 47. The most common ureteral finding was hydroureteronephrosis (40). Other anomalies identified included bladder (7) and scrotal (14) abnormalities, stones (13), and adrenal lesions (5).

CONCLUSION

Many urologic diagnoses are revealed during CT scans of the abdomen and pelvis. The majority are cysts, hydroureteronephrosis, and pyelonephritis. Many incidental findings have also been revealed in the emergency department setting.

Urologic outcomes of pediatric pelvic neuroblastoma presenting in acute urinary retention

PURPOSE

To evaluate long-term urologic outcomes of patients with pelvic neuroblastoma (NB) presenting with urinary retention.

METHODS

Five cases of pelvic NB presenting with urinary retention were identified between 1971 and 2011. Clinical presentation, treatment, survival and long-term voiding outcomes were analyzed.

RESULTS

All five patients presented with acute urinary retention and pelvic outlet dysfunction including bladder perforation (20%), constipation (40%), or fecal incontinence (20%). The presenting age ranged from 7 days to 4 years with female to male ratio of 3:2. Two patients presented with bilateral hydronephrosis and three patients were stage 4 at presentation. All required debulking surgery, four patients required combined anterior and posterior approaches for tumor resection, with two patients requiring concurrent laminectomy. Adjuvant or neoadjuvant chemoradiation was used in four of five cases. Follow-up ranged from 2 to 41 years. Although the long-term oncological outcome is favorable, urologic outcomes of these patients ranged from normal bladder function to the need significant reconstructive procedures.

CONCLUSION

Urologic outcomes are related to pelvic nerve and organ preservation during resection more than the severity of urinary symptoms at presentation.

Ureteroscopy in pediatric patients with spinal abnormalities

BACKGROUND AND PURPOSE

Ureteroscopy (URS) is considered a safe and effective treatment modality for ureteral stones in the pediatric population. Patients with scoliosis or spinal hardware, however, may have anatomic variability that makes URS challenging because of ureteral deviation or tortuosity. We reviewed 130 ureteroscopic procedures at our institution to determine if presence of spinal hardware or severe spinal deformities was associated with increased complications or worsened treatment efficacy.

PATIENTS AND METHODS

A retrospective chart review was performed on 130 ureteroscopic procedures in 102 patients. Patients were divided into two groups: Those with normal spinal anatomy and those with spinal abnormalities including spinal hardware or moderate to severe scoliosis. Parameters evaluated included patient demographics, stone burden, intraoperative complications (including urinary extravasation, bleeding, or need to abort procedure), and stone-free status.

RESULTS

Of 130 ureteroscopic procedures between 2002 and 2010, 25 URS were performed for purposes other than stone disease (gross hematuria, filling defects, or encrusted ureteral stents). The remainder of URS (105) were performed for stone disease. Nine patients had spinal hardware or significant spinal deformities including moderate to severe scoliosis. When comparing both the intraoperative complications as well as stone-free status, there was a difference between those patients with spinal abnormalities and those without. Of 90 URS performed for stones in normal anatomy patients, the stone-free rate was 61%, compared with 35.7% in patients with spinal deformities. There were 13 total complications (Satava grade I or II): 40% in spinal deformity patients compared with 6.1% in normal anatomy patients.

CONCLUSION

Spinal hardware and spinal deformities contribute to increased complications and worsened stone-free rates during pediatric URS compared with pediatric patients with normal anatomy. Our experience with URS in patients with spinal deformities suggests it may not be as safe or efficacious as in the general pediatric population but it can still be used as a primary modality.

Laparoendoscopic single-site (LESS) bilateral nephrectomy in the pretransplant pediatric population

End-stage renal failure management in children may require bilateral kidney removal prior to transplantation secondary to recurrent urinary tract infections, renin-dependent hypertension, vesicoureteral reflux, proteinuria, risk of malignancy (Denys-Drash), or high output renal failure. Conventional laparoscopy or open nephrectomy has been employed to date. However, we present our method of bilateral nephrectomy in four patients via the SILS Covidien © system. Patient age ranged from 18 months to 18 years. Operative time ranged from 308 to 370 minutes. Estimated blood loss was minimal, all cases were completed via the single incision and no cases were converted to open. Laparoendoscopic single-site bilateral nephrectomy is safe and feasible in children and well-suited for the pre-transplant population.

Management of ectopic ureterocele with horseshoe kidney

The combination of a horseshoe kidney and ureterocele is a rare complex with no definite genetic or developmental association. Only two cases have been reported historically. Diagnosis and treatment of such a complex can be varied amongst providers. We performed a partial nephrectomy with lower pole reimplant after marsupialization of the ureterocele. The patient currently has no evidence of reflux and has been infection free.

Lung metastases after liver resection or cryotherapy for hepatic metastasis from colorectal cancer--there is a difference!

BACKGROUND

The most common site of colorectal extra-abdominal metastases is the lung. The relative risk of lung metastases after resection and cryotherapy has not previously been compared.

METHODS

All patients underwent an extensive preoperative staging including clinical examination, abdominal computed tomography (CT) and abdominal angio-CT to assess their hepatic disease. Two groups of patients were compared in this study (hepatic resection alone and hepatic cryotherapy with or without resection). A retrospective analysis of prospectively collected data was performed to assess the incidence and disease-free interval of pulmonary metastasis after surgical treatment of colorectal liver metastasis.

RESULTS

This paper clearly shows two differences regarding pulmonary metastases between patients treated with resection only and cryotherapy with or without resection. Among the 10 clinical variables, cryotherapy had the greatest correlation with pulmonary metastases (p=0.004). A patient who undergoes hepatic resection only has a probability of 35% for developing pulmonary recurrence, compared with 51% following cryotherapy. Cryotherapy was also independently associated with shorter pulmonary disease-free interval (p=0.036).

CONCLUSION

There clearly is a higher risk of pulmonary metastasis after cryotherapy than after resection, whether this is related to selection of patients or a direct deleterious procedural effect requires more study.

Ductal carcinoma in situ with spindle cells: a potential diagnostic pitfall in the evaluation of breast lesions

AIMS

To evaluate the morphological features of 11 cases of breast ductal carcinoma in situ (DCIS) with spindle cells and to propose an approach to distinguish it from benign mimics. The association with neuroendocrine differentiation was also investigated.

METHODS

Cases of breast DCIS with a spindle cell component diagnosed in the Department of Pathology, Singapore General Hospital, between June 1996 and January 2003, were included in the study. The histological characteristics were documented, and immunohistochemistry for neuroendocrine markers, hormone receptors, cerbB2, smooth muscle actin (SMA) and high-molecular-weight (HMW) cytokeratins, was carried out. Electron microscopy was carried out on reprocessed paraffin-embedded material in three cases.

RESULTS

Of 11 women diagnosed with DCIS with spindle cells, four presented with nipple discharge, six with a breast lump, while one was discovered to have a screen detected density. The tumour size ranged from 3 to 41 mm. The proportion of spindle cells varied from 10% to 80% of the in-situ tumour cell population. Nuclear grade was low in seven cases and intermediate in four. Necrosis was observed in two cases. Architectural pattern was papillary in six cases, and mixed in the rest. Microinvasion was present in two cases, with possible microinvasion in another two. Immunohistochemistry for neuroendocrine markers synaptophysin and chromogranin showed positive reactivity for at least one marker in all but three cases; one of these latter cases demonstrated ultrastructural neurosecretory granules. Oestrogen and progesterone receptors were expressed in 10 and nine cases, respectively, while cerbB2 was positive in only one case. HMW cytokeratin immunoprofile revealed a general lack of immunostaining within the abnormal cell population; likewise, no positivity for SMA of the cellular proliferation was detected.

CONCLUSIONS

Almost all DCIS lesions with spindle cells disclose neuroendocrine differentiation. Although the distinction from benign florid usual hyperplasia may pose a diagnostic histological problem, the presence of diffuse neuroendocrine expression, in conjunction with the pattern of HMW keratin profile on immunohistochemistry, supports an in-situ neoplastic process. The absence of SMA immunostaining, in conjunction with negative reactivity for cytokeratins 5/6 and 14, makes the possibility of a myoepithelial proliferation unlikely.

Correlation of nuclear morphometry with pathologic parameters in ductal carcinoma in situ of the breast

Morphometric features of nuclear perimeter, nuclear area, feret ratio, and feret circle were studied in a series of 64 cases of ductal carcinoma in situ (DCIS) of the breast in Singapore women. The results were compared with pathologic parameters of tumor size, nuclear grade, necrosis, cell polarization, and architectural pattern. There was statistically significant correlation between nuclear perimeter and area with all the pathologic parameters, with the strongest association observed for nuclear grade (P <.0001). Higher grade nuclei as assessed histologically were associated with larger nuclear area (44.14 microm(2) in low-grade lesions, 47.77 microm(2) in intermediate-grade lesions, and 72.05 microm(2) in high-grade lesions) and perimeter (25.94 microm in low-grade nuclei, 27.12 microm in intermediate-grade nuclei, and 33.66 microm in high-grade nuclei). DCIS lesions with necrosis and absence of polarization also revealed increased nuclear area and perimeter (P <.05). Comedo architecture was associated with larger nuclear area and perimeter (65.97 microm(2), 31.7 microm) than the papillary subtype (42.17 microm(2), 25.29 microm), with the mixed morphologic pattern disclosing intermediate values (54.83 microm(2), 29.43 microm). There was direct correlation for tumor size with nuclear area and perimeter (P <.01). No similar relationship was found between pathologic parameters and feret ratio or circle, indicating that nuclear roundness or lack of it did not factor as a significant component in the pathologic assessment.