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Siegal AR, Mbaye F, Chin CP, Ferrer FA, Malhotra NR, Makari JH. Contemporary disparities in progression to orchiopexy for cryptorchidism as reported in the Pediatric Health Information System (PHIS) database. J Pediatr Urol 2024:S1477-5131(24)00088-3. [PMID: 38431462 DOI: 10.1016/j.jpurol.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION When evaluating the timeliness of orchiopexy for cryptorchidism, health disparities are apparent among Hispanic and African American males and those with public insurance. Since the publication of these data, the COVID-19 pandemic has stressed our healthcare system and significantly affected the provision of pediatric urology care. OBJECTIVE We sought to assess if certain groups were disproportionately affected in progression to orchiopexy after the diagnosis of cryptorchidism during and after the pandemic in US freestanding children's hospitals. STUDY DESIGN Using the PHIS database, pediatric patients ≤5 years who underwent orchiopexy between January 2018 and December 2022 were retrospectively analyzed. Exclusion criteria included prematurity, retractile testes, and testicular torsion. Primary outcomes were age at orchiopexy and the proportion of individuals undergoing timely orchiopexy for cryptorchidism. RESULTS Over the study period 3140 patients ≤5 years old underwent orchiopexy for cryptorchidism. Non-Hispanic Blacks and Hispanics were significantly less likely to have timely orchiopexy and underwent orchiopexy 2.13 and 3.60 months later compared to whites (p < 0.01). As compared to pre-COVID-19, during the pandemic the proportion of patients who had timely surgery was higher and the median age was significantly lower (p = 0.01 and p < 0.01, respectively) in white patients only. Over the study period, patients with public insurance were less likely to have timely orchiopexy and underwent orchiopexy 2.94 months later (p < 0.01) than patients with private insurance. Compared to during the pandemic, post-pandemic a significantly lower proportion of publicly insured patients have since undergone timely orchiopexy (p = 0.04). Patients in the West were less likely to have timely orchiopexy and had a higher age at time of orchiopexy (p < 0.01) than other regions. However, in the West during the pandemic, the proportion of children who had timely surgery was higher compared to pre-and post-COVID-19 (p < 0.01). DISCUSSION Overall, regardless of insurance status, race, or location, a significant proportion of patients did not undergo timely orchiopexy. During the pandemic white patients had a lower median age and an increased proportion underwent timely orchiopexy, despite the number of orchiopexies remaining constant. Disparities in the post-COVID-19 era have been further exacerbated for publicly insured patients, who a significantly lower proportion of have since undergone timely orchiopexy. Specific efforts are required across the United States to increase timely orchiopexy for all boys. CONCLUSIONS Progression to timely orchiopexy remains low for all boys in the era surrounding COVID-19; certain groups appear to be more adversely affected.
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Affiliation(s)
- Alexandra R Siegal
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Farimata Mbaye
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chih Peng Chin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fernando A Ferrer
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Division of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Neha R Malhotra
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Division of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - John H Makari
- Department of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE, USA; Division of Urology, University of Nebraska Medical Center, Omaha, NE, USA
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Smith CJ, Raval MV, Simon MA, Henry MCW. Addressing pediatric surgical health inequities through quality improvement efforts. Semin Pediatr Surg 2023; 32:151280. [PMID: 37147217 DOI: 10.1016/j.sempedsurg.2023.151280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Concepts of healthcare quality and health equity should be inextricably linked but are often pursued separately. Quality improvement (QI) can serve as a powerful means to eliminate health inequities by adopting an equity-focused lens to diagnose and address baseline disparities among pediatric populations using targeted interventions. QI and pediatric surgery practitioners should integrate concepts of equity at every stage of formulating a QI project including conceptualization, planning, and execution. Early adaptation of an equity conscious perspective using QI methodology can prevent exacerbation of preexisting disparities while improving overall outcomes.
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Affiliation(s)
- Charesa J Smith
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Northwestern Quality Improvement, Research, & Education in Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Northwestern Quality Improvement, Research, & Education in Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Center for Health Equity Transformation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Marion C W Henry
- Division of Pediatric Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Williamson SH, Davis-Dao CA, Huen KH, Ehwerhemuepha L, Chuang KW, Stephany HA, Wehbi EJ, Kain ZN. Timely orchiopexy by 18 months of age: Are we meeting the standards defined by the 2014 AUA guidelines? J Pediatr Urol 2022; 18:683.e1-683.e7. [PMID: 35981940 DOI: 10.1016/j.jpurol.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cryptorchidism is one of the most common reasons for pediatric urology referral and one of the few pediatric urologic conditions in which there are established AUA guidelines that recommend orchiopexy be performed before 18 months of age. While access to timely orchiopexy has been studied previously, there is no current study with data from a national clinical database evaluating timely orchiopexy after the AUA guidelines were published. Additionally, prior studies on delayed orchiopexy may have included patients with an ascended testis, which is a distinct population from those with true undescended testicles. OBJECTIVES To evaluate in a national, clinical database if timely orchiopexy improved after the AUA guidelines were published in 2014. In particular, we aim to evaluate a younger group of patients, 0-5 years of age, in an effort to account for potential ascending testes. STUDY DESIGN Using Cerner Real-World Data™, a national, de-identified database of 153 million individuals, we analyzed pediatric patients undergoing orchiopexy in the United States from 2000 to 2021. We included males 0-18 years old and further focused on the subset 0-5 years. Primary outcome was timely orchiopexy, defined as age at orchiopexy less than 18 months. Predictor variables included race, ethnicity and insurance status. Statistical analyses were performed using logistic regression. RESULTS Of the total 17,012 individuals identified as undergoing orchiopexy, 9274 were ages 0-5 at the time of surgery. Comparing time periods pre and post AUA guidelines (2000-2014 versus 2015-2021), we found a significant difference in the proportion of timely orchiopexy (51% versus 56%, respectively; p < 0.0001) (Figure). In multivariable analyses, Hispanic (OR = 0.65, p < 0.0001), African American (OR = 0.74, p < 0.0001), and Native American males (OR = 0.66, p = 0.008) were less likely to have timely orchiopexy compared to non-Hispanic White males. Individuals without insurance (OR = 0.81, p = 0.03) or with public insurance (OR = 0.88, p = 0.02) were less likely to have timely orchiopexy as compared to those with private insurance. CONCLUSIONS Nearly a decade after publication of the AUA cryptorchidism guidelines, a large proportion of patients are still not undergoing orchiopexy by 18 months of age. This is the first study to show that timely orchiopexy has improved among patients 0-5 years, but the majority of patients are still not undergoing timely orchiopexy. Health disparities were apparent among Hispanic, African American, Native American, and uninsured males, highlighting the need for further progress in access to pediatric surgical care.
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Affiliation(s)
- Sarah H Williamson
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange CA, USA
| | - Carol A Davis-Dao
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange CA, USA.
| | - Kathy H Huen
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange CA, USA
| | | | - Kai-Wen Chuang
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange CA, USA
| | - Heidi A Stephany
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange CA, USA
| | - Elias J Wehbi
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange CA, USA
| | - Zeev N Kain
- Center on Stress and Health, University of California-Irvine School of Medicine, Orange CA, USA; Department of Anesthesiology & Perioperative Medicine, University of California-Irvine School of Medicine, Orange CA, USA; Child Study Center, Yale University School of Medicine
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Factors which delay surgery for undescended testis in Ontario: A retrospective population based cohort study on timing of orchidopexy between 2006 and 2012. J Pediatr Urol 2022; 18:695.e1-695.e7. [PMID: 35970738 DOI: 10.1016/j.jpurol.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delays in performing orchidopexy (OP) for undescended testis (UDT) result in loss of germ cells. Despite practice guidelines recommending OP by 18 months of age, significant delays in OP occur. This delay may impact fertility and increase the risk of testicular malignancy in boys with UDT. OBJECTIVE The objective of this study is to identify factors associated with delayed OP with the goal of identifying modifiable risk factors. STUDY DESIGN A population-based, retrospective cohort study was conducted using linked databases held at ICES to evaluate factors associated with timing of OP in Ontario for 4339 male newborns undergoing their first OP between 2006 and 2012. Primary outcome was delayed OP (>18 months). Multivariable logistic regression analysis was performed to identify patient, physician, and hospital risk factors for delayed OP. RESULTS Median age at OP was 24 months, while median age at first surgical consult was 20 months (IQR 10-60 months). Older age at first surgical consult (>12 months vs. <9 months, OR 17.83) was identified as the primary risk factor for delayed OP, besides ICU hospitalization (OR 3.42), associated hypospadias (OR 2.30), higher hospital OP volume (OR 1.91), more healthcare visits in first year of life (OR 1.05), and older surgeon age (OR 1.02). DISCUSSION Our findings support reports that OP is often performed past guideline recommendations. Interventions that result in earlier referral for UDT (<6 months) may result in timely OP. Limitations for this study include potential misclassification or missing data within the utilized databases. CONCLUSION The most important barrier to timely OP is delay in first surgical consultation. Aiming for an earlier referral through guideline modifications or education to referring providers may help achieve the goal of timely OP.
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Ahn JJ, Garrison MM, Merguerian PA, Shnorhavorian M. Racial and ethnic disparities in the timing of orchiopexy for cryptorchidism. J Pediatr Urol 2022; 18:696.e1-696.e6. [PMID: 36175288 PMCID: PMC9771941 DOI: 10.1016/j.jpurol.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/12/2022] [Accepted: 09/07/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Many children do not undergo surgery for cryptorchidism in a timely fashion, increasing risk of infertility and malignancy. Racial and ethnic disparities in surgery timing has been suggested in other specialties, but has not been well-explored in Pediatric Urology. OBJECTIVES Our aim was to investigate the association of race and ethnicity with age at orchiopexy. MATERIALS AND METHODS We performed a retrospective cohort study of individuals <18 years of age as captured in the NSQIPP PUF from 2012 to 2016. Those with cancer were excluded. The primary outcome of interest was age at time of surgery. Secondary outcome was the proportion of individuals undergoing surgery by recommended age. Generalized linear models and logistic regression models were created for the outcomes of interest. RESULTS The median age at orchiopexy was 17.4 months (10.7, 43.0) and overall, 51% of subjects underwent orchiopexy by 18 months of age. Non-Hispanic white individuals were most likely to have undergone orchiopexy by 18 months of age, at 56%, compared with only 44% of non-Hispanic black individuals (p < 0.001). When adjusting for co-morbidities and developmental delay, Hispanic patients underwent orchiopexy 5 months later than white patients, on average, and black patients had a delay of 7 months compared to white patients. DISCUSSION These data suggest that orchiopexy is happening at younger ages compared to prior large-scale studies. However, minority patients are on average older at time of orchiopexy, potentially increasing future risk of infertility or malignancy. While an estimated average delay of 5-7 months may not seem high, studies suggest there is an appreciable change in risk with a 6-month delay. Patient, provider, and system-level factors likely all contribute, and these need to be further elucidated. CONCLUSIONS Many racial and ethnic minorities with cryptorchidism have later orchiopexies, and are more likely to have surgery outside the recommended timeframe. Further investigation is warranted to determine the factors contributing to these disparities.
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Affiliation(s)
- Jennifer J Ahn
- University of Washington, Department of Urology, USA; Seattle Children's Hospital, Division of Pediatric Urology, USA.
| | - Michelle M Garrison
- University of Washington School of Public Health, Department of Health Services, USA
| | - Paul A Merguerian
- University of Washington, Department of Urology, USA; Seattle Children's Hospital, Division of Pediatric Urology, USA
| | - Margarett Shnorhavorian
- University of Washington, Department of Urology, USA; Seattle Children's Hospital, Division of Pediatric Urology, USA
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Gates RL, Shelton J, Diefenbach KA, Arnold M, St Peter SD, Renaud EJ, Slidell MB, Sømme S, Valusek P, Villalona GA, McAteer JP, Beres AL, Baerg J, Rentea RM, Kelley-Quon L, Kawaguchi AL, Hu YY, Miniati D, Ricca R, Baird R. Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review. J Pediatr Surg 2022; 57:1293-1308. [PMID: 35151498 DOI: 10.1016/j.jpedsurg.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. METHODS A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. RESULTS A total of 825 articles were identified in the initial search, and 260 were included in the final review. CONCLUSIONS Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.
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Affiliation(s)
- Robert L Gates
- University of South Carolina School of Medicine - Greenville, Greenville, SC, United States
| | - Julia Shelton
- University of Iowa, Stead Family Children's Hospital, Iowa City, IA, United States
| | - Karen A Diefenbach
- Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States
| | - Meghan Arnold
- University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | | | - Elizabeth J Renaud
- Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, RI, United States
| | - Mark B Slidell
- Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Stig Sømme
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Patricia Valusek
- Pediatric Surgical Associates, Children's Minnesota, Minneapolis, MN, United States
| | | | - Jarod P McAteer
- Providence Pediatric Surgery, Sacred Heart Children's Hospital, Spokane, WA, United States
| | - Alana L Beres
- University of California, Davis, Sacramento CA, United States
| | - Joanne Baerg
- Loma Linda University Children's Hospital, Loma Linda, CA, United States
| | | | - Lorraine Kelley-Quon
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Akemi L Kawaguchi
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yue-Yung Hu
- Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children's Center, Roseville, CA, United States
| | - Robert Ricca
- University of South Carolina School of Medicine - Greenville, Greenville, SC, United States.
| | - Robert Baird
- Division of Pediatric Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, United States
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Zhao T, Deng F, Jia W, Gao X, Li Z, Tang X, Li D, Zhou R, Shu F, Zhang J, Zhang Z, Fu W, Liu G. Ambulatory Orchidopexy Is a Potential Solution to Improve the Rate of Timely Repair in Cryptorchid Boys: An 8 Year Retrospective Study of 4,972 Cases. Front Pediatr 2021; 9:671578. [PMID: 34017811 PMCID: PMC8129512 DOI: 10.3389/fped.2021.671578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Cryptorchidism is the most common congenital anomaly in pediatric urology. Although early surgery on cryptorchid boys is recommended by pediatric urologists worldwide, the actual age at orchidopexy is often older than the recommended age. Our medical center has started performing ambulatory orchidopexy since March 2016 at the ambulatory surgery center. We aimed to investigate whether ambulatory orchidopexy can improve the timely repair rate. Methods: A retrospective analysis was conducted from 2012 to 2019 at our medical center. Ambulatory orchidopexy was started at our medical center on March 24, 2016. Boys born on or after September 24, 2015 were classified into the "with ambulatory medical resource" group, and boys born before September 24, 2014, were classified into the "without ambulatory medical resource" group. The timely repair rates were calculated and compared. Results: A total of 4,972 cryptorchidism cases were included in the final study. Approximately 33.0% of cryptorchid boys received timely surgery (orchidopexy by the age of 18 months), and only 6.8% of all cryptorchid boys underwent surgery before the age of 1 year. After the performance of ambulatory orchidopexy, the timely repair rate increased from 25.7 to 37.0% (P < 0.001), and the percentage of patients receiving surgery before the age of 1 year increased significantly from 3.5 to 8.6% (P < 0.001). The proportion of timely repair in patients with ambulatory medical resources was significantly higher than that in patients without ambulatory medical resources (15.6% vs. 58.2%, P < 0.001). Significant changes in the rate of surgery before 12 months of age were also found between the two groups (2.4% vs. 14.8%, P < 0.001). Conclusions: After the performance of ambulatory orchidopexy in our medical center, the rates of both timely repair and receiving surgery before the age of 1 year increased significantly. Ambulatory orchidopexy is a potential solution to improve the rate of timely repair in cryptorchid boys, and it is worthy of promotion in developing countries and regions.
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Affiliation(s)
- Tianxin Zhao
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Fuming Deng
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wei Jia
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaofeng Gao
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhongmin Li
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiangliang Tang
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Dian Li
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Rui Zhou
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Fangpeng Shu
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jin Zhang
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhengtao Zhang
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wen Fu
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Guochang Liu
- Department of Pediatric Urology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Pediatric Surgery, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Omling E, Bergbrant S, Persson A, Björk J, Hagander L. How boys and testicles wander to surgery: a nationwide cohort study of surgical delay in Sweden. BMJ Paediatr Open 2020; 4:e000741. [PMID: 33024834 PMCID: PMC7509961 DOI: 10.1136/bmjpo-2020-000741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Early orchidopexy is recommended for cryptorchidism and the surgery is increasingly centralised. The objectives were to determine the incidence, risk factors and if distance to treating hospital impacted on timely treatment of cryptorchidism. METHODS In this observational study, all boys born in Sweden from 2001 to 2014 were followed in national registers to determine the incidence of cryptorchidism by levels of birth-related risk factors and social determinants. Travel time to hospital was used as the primary exposure in multivariable survival analysis, with age at surgery as main outcome. RESULTS Of 748 678 boys at risk for cryptorchidism, 7351 were treated and evaluated for timing of surgery (cumulative childhood incidence 1.4%, 95% CI 1.3% to 1.5%). The incidence was clearly associated with prematurity and overdue pregnancy (HR for <32 weeks 2.77 (95% CI 2.39 to 3.21); 32-36 weeks HR 1.36 (95% CI 1.24 to 1.49); >41 weeks HR 1.19 (95% CI 1.10 to 1.29)), low birth weight (<1000 g HR 3.94 (95% CI 3.15 to 4.92); 1000-1499 g HR 3.70 (95% CI 3.07 to 4.46); 1500-2500 g HR 1.69 (95% CI 1.52 to 1.88)) and intrauterine growth restriction (small for gestational age HR 2.38 (95% CI 2.14 to 2.65); large for gestational age HR 1.26 (95% CI 1.13 to 1.42)), but not with smoking or maternal age. Each 30 min increase in travel time was associated with a reduced probability of timely treatment (HR for being treated by age 3 adjusted for risk factors and socioeconomic determinants: 0.91 (95% CI 0.88 to 0.95)). Lower income and financial support were also associated with treatment delays (adjusted HR for lowest income quintile 0.82 (95% CI 0.72 to 0.93) and for families with financial support 0.85 (95% CI 0.73 to 0.97)). CONCLUSIONS Travel distance to treating hospital was associated with delayed treatment. 'Not all those who wander are lost', but these findings suggest a trade-off between centralisation benefits and barriers of geography also in elective paediatric surgery.
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Affiliation(s)
- Erik Omling
- Pediatric Surgery, Skåne University Hospital Lund, Lund, Sweden
- Department of Pediatrics, Lund University Clinical Sciences, Lund, Sweden
| | - Sanna Bergbrant
- Department of Pediatrics, Lund University Clinical Sciences, Lund, Sweden
| | - Andreas Persson
- GIS Centre, Lund University, Lund, Sweden
- Department of Physical Geography and Ecosystem Sciences, Lund University, Lund, Sweden
| | - Jonas Björk
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Clinical Studies Sweden, Forum South, Skåne University Hospital Lund, Lund, Skåne, Sweden
| | - Lars Hagander
- Pediatric Surgery, Skåne University Hospital Lund, Lund, Sweden
- Department of Pediatrics, Lund University Clinical Sciences, Lund, Sweden
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9
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Carpenter CP, Johnston D, Tourville E, Sharadin C, Alzubaidi AN, Giel DW. Inappropriate imaging for management of cryptorchidism: Has the choosing Wisely® recommendation reduced occurrence? J Pediatr Urol 2020; 16:462.e1-462.e6. [PMID: 32674979 DOI: 10.1016/j.jpurol.2020.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/06/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cryptorchidism is one of the most common referral diagnoses to pediatric urologists. It is well recognized in the urologic community that diagnostic imaging is unnecessary in the work-up of these patients, and the Choosing Wisely® recommendation (CWR) on this subject re-emphasized this in 2013. Many boys, however, still are sent for testing prior to referral. OBJECTIVE The purpose of our study was dual in nature. We pursued, first, to identify any factors that make patients more likely to be sent for imaging prior to referral, and second, to determine if rates of diagnostic imaging for cryptorchidism decreased after the release of the CWR. STUDY DESIGN We included all boys who had surgery for cryptorchidism by Urology at our institution between January 2007 and August 2018. Demographics and clinical data were collected including height, weight, race, insurance type, pre-referral imaging status, testis location at time of surgery, and distance from our medical center. Chi-squared analysis was utilized to compare imaging use before and after CWR. Influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using chi-squared and two-sample t tests. Those found to be significant at the 0.2 level were analyzed in multivariate logistic regression. Significance was set at 0.05. RESULTS 1010 boys were available for analysis. Of the 256 patients (25.3%) with pre-referral studies, 7 had axial exams (CT or MRI), and the remainder underwent ultrasounds. Children living closer to the medical center were more likely to undergo imaging (p < 0.01) as were boys with testes not found in the inguinal canal at the time of surgery (p = 0.007). Race, insurance status, age at first visit, and increased body mass index were not found to be influential. Similarly, the release of CWR had no impact on the imaging usage (p = 0.61). CONCLUSION Utilization of pre-referral diagnostic imaging remains inappropriately high despite evidence demonstrating the ineffectiveness of the studies. Boys living closer to the medical center and those with non-inguinal testes are more likely to undergo these studies, but no other factors were found to have an effect. Further, the Choosing Wisely® recommendation has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Our findings indicate the need for increased efforts to disseminate this evidence-based guideline more widely to primary care providers in order to promote more cost-effective and timely care of boys with undescended testes.
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Affiliation(s)
- Christina P Carpenter
- Department of Urology, Division of Pediatric Urology, Columbia University Irving Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA; Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | | | - Elizabeth Tourville
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia Sharadin
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ahmad N Alzubaidi
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dana W Giel
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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10
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Zhao TX, Liu B, Wei YX, Wei Y, Tang XL, Shen LJ, Long CL, Lin T, Wu SD, Wei GH. Clinical and socioeconomic factors associated with delayed orchidopexy in cryptorchid boys in China: a retrospective study of 2423 cases. Asian J Androl 2020; 21:304-308. [PMID: 30632485 PMCID: PMC6498732 DOI: 10.4103/aja.aja_106_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We investigated the associations of clinical and socioeconomic factors with delayed orchidopexy for cryptorchidism in China. A retrospective study was conducted on cryptorchid boys who underwent orchidopexy at Children's Hospital at Chongqing Medical University in China from January 2012 to December 2017. Of 2423 patients, 410 (16.9%) received timely repair by 18 months of age, beyond which surgery was considered delayed. Univariate analysis suggested that the laterality of cryptorchidism (P = 0.001), comorbidities including inguinal hernia/scrotal hydrocele (P < 0.001) or urinary tract disease (P = 0.016), and whether patients lived in a poverty county (P < 0.001) could influence whether orchidopexy was timely or delayed. Logistic regression analysis suggested that the following factors were associated with delayed repair: unilateral rather than bilateral cryptorchidism (odds ratio [OR] = 1.752, P < 0.001), absence of inguinal hernia or hydrocele (OR = 2.027, P = 0.019), absence of urinary tract disease (OR = 3.712, P < 0.001), and living in a poverty county (OR = 2.005, P < 0.001). The duration of postoperative hospital stay and hospital costs increased with the patient's age at the time of surgery.
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Affiliation(s)
- Tian-Xin Zhao
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Bin Liu
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Yue-Xin Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China
| | - Yi Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Xiang-Liang Tang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Lian-Ju Shen
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Chun-Lan Long
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Tao Lin
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China
| | - Sheng-De Wu
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Guang-Hui Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
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Abstract
AIM The aim of this study was to investigate whether racial disparities in healthcare exist within a New Zealand pediatric surgical outreach service in a high indigenous Māori population. METHODOLOGY This retrospective study assessed all pediatric surgical procedures performed within a secondary center in New Zealand between May 2014 and May 2016. The days between the date of surgery booking on the waiting list and actual date of surgery were calculated and compared to their corresponding elective surgery waiting target times set by the New Zealand Ministry of Health (MoH). Patient demographic data were collated to then identify any discrepancy between ethnic groups. RESULTS A total of 203 pediatric surgical procedures were performed on 193 patients. Of the 194 (95%) procedures that were included in the study, 30 breached a maximum waiting time. Though this represented a small proportion of patients, Māori were significantly over represented in this group. CONCLUSION The majority of our patients with delayed elective surgery were of Māori ethnicity, for reasons not entirely accounted for by common socioeconomic determinants of health. Our study suggests the possibility of innate systemic causes not detected by standard models of health. However, further research with larger cohorts is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Canaan Aumua
- Waikato District Health Board, Department of Pediatric Surgery, New Zealand; University of Auckland, New Zealand
| | | | - Udaya Samarakkody
- Waikato District Health Board, Department of Pediatric Surgery, New Zealand; University of Auckland, New Zealand; Lakes District Health Board, Department of Pediatrics, New Zealand.
| | - Danny de Lore
- Waikato District Health Board, Department of Pediatric Surgery, New Zealand; Lakes District Health Board, Department of Pediatrics, New Zealand
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