Is it time to reconsider how we document pediatric uroflow studies?: A study from the SPU Voiding Dysfunction task force

BACKGROUND

Uroflowmetry is a non-invasive study used in the diagnosis and monitoring of treatment response for lower urinary tract disorders. For optimal clinical utility, uroflow studies rely on careful clinical interpretation by a trained provider, but currently there is a lack of accepted standardized normal values for the measured uroflow parameters in children. The International Children's Continence Society proposed standardizing the terminology for uroflow curve shapes. However, the patterning of curves is largely at the physician's subjective discretion.

OBJECTIVES

The aims of this study were to understand inter-rater reliability in interpreting uroflow curves and to define characteristics of uroflow curves that could be used to provide definitive criteria for uroflowmetry parameters.

METHODS

All members of the SPU Voiding dysfunction Task Force were invited to contribute deidentified uroflows to a centralized HIPAA complaint receiving database. All studies were then distributed to all raters for review. Each observer's findings were recorded according to ICCS criteria (ICCS), additional readings were done using a previously reported system which defined curves as smooth or fractionated (SF) and whether the shape resembled a bell, tower, or plateau (BTP). Flow indexes (Qact/Qest) (FI) for Qmax and Qavg were generated using formulas previously reported for children 4-12 and for patients≥12 years.

RESULTS

A total of 119 uroflow studies were read by 7 raters and curves were contributed from 5 sites. Kappa scores for the 5 readers from different institutions were 0.34 and 0.28 for the ICCS and BTP methods, respectively (both considered fair agreement). Kappa for smooth and fractionated curves was 0.70 (for each; considered substantial agreement), which were the two highest agreement scores obtained throughout the study. Discriminant analysis (DA) revealed that the FI Qmax was the dominant vector, and that the ICCS uroflow parameters have a total of 42.8% prediction rate in the training sample. Using DA of a smooth/fractionated system, the total prediction rates were 72% and 65.5% for smooth and fractionated, respectively.

DISCUSSION

Given the poor inter-rater agreement for analyzing uroflow curve pattern based on ICCS criteria in this study and others, one may find it reasonable to consider alternative approaches to describing and characterizing uroflow curves. Our study is limited by lack of EMG and post-void residual data.

CONCLUSIONS

For a more objective uroflow interpretation and comparison of studies among different centers, we recommend using our proposed system (based on FI, and smooth vs. fractionated curve pattern), which is more reliable.

Feasibility of establishing a multi-center research database using the electronic health record: The PURSUIT network

BACKGROUND

Although multi-center research is needed in pediatric urology, collaboration is impeded by differences in physician documentation and research resources. Electronic health record (EHR) tools offer a promising avenue to overcome these barriers.

OBJECTIVE

To assess the accuracy, completeness, and utilization of structured data elements across multiple practices.

STUDY DESIGN

A standardized template was developed and implemented at five academic pediatric urology practices to document clinic visits for patients with congenital hydronephrosis and/or vesicoureteral reflux. Data from standardized elements in the template and from pre-existing EHR fields were extracted into a secure database. A 20% random sample of infants with data from structured elements from 1/1/2020 and 4/30/2021 were identified and compared to manual chart review at sites with >100 charts; all other sites reviewed at least 20 charts. Manual chart review was standardized across sites and included: clinic and operative notes, orders linked to the clinic encounter, radiology results, and active medications. Accuracy of data extraction was evaluated by computing the kappa statistic and percentage agreement. For sites that had adopted the templates prior to 6/1/2019 (early adopters), a list of eligible patients with an initial clinic visit from 1/1/2020-7/27/2020 was generated using standardized reporting techniques and confirmed by manual chart review. Physician utilization of the template was then calculated by comparing patients with data obtained from the note template to the generated list of eligible patients.

RESULTS

230 patient records met study criteria. Agreement between manual chart review and data extracted from the EHR was high (>85%). Race, ethnicity and insurance data were misclassified in about 10-15% of cases; this was due to site-specific differences in how these fields were coded. Renal ultrasound was misclassified 12% of the time; this was primarily due to outside images documented in radiology results but not included in the clinical note. All other data elements had >90% agreement (Figure). Template utilization for early adopters was >75% (75.5-87.5%).

DISCUSSION

This is the first study in urology to demonstrate that use of structured data elements can support multi-center research. Limitations include: inclusion of only academic sites with the Epic EHR and lack of data on utilization and sustainability at sites without a prior history of structured template use.

CONCLUSIONS

Multi-center research collaboration using EHR-based data collection tools is feasible with generally high accuracy compared to manual chart review. Additionally, sites with a long history of template adoption have high levels of provider utilization.

Treatment of infants with ureteropelvic junction obstruction: findings from the PURSUIT network

PURPOSE

Studies based on administrative databases show that infant pyeloplasty is associated with minority race/ethnicity but lack clinical data that may influence treatment. Our objective was to identify clinical and demographic factors associated with pyeloplasty in infants from three large tertiary centers.

METHODS

We reviewed infants with unilateral Society for Fetal Urology (SFU) grade 3-4 hydronephrosis seen at three tertiary centers from 2/1/2018 to 9/30/2019. Patients were excluded if > 6 months old or treated surgically prior to the initial visit. Outcomes were: pyeloplasty < age 1 year and SFU grade on most recent ultrasound (US) within the first year. Covariables included: age at the initial visit, race/ethnicity, treating site, insurance type, febrile UTI, and initial imaging findings. Univariable and multivariable analyses were performed using log-rank tests and Cox proportional hazards models, respectively.

RESULTS

197 patients met study criteria; 19.3% underwent pyeloplasty. Pyeloplasty was associated with: treating site (p = 0.03), SFU 4 on initial US (p = 0.001), MAG-3 (p < 0.001), and T½ > 20 min (p < 0.001) in patients undergoing a MAG-3 (n = 107). MAG-3 (p < 0.001) and location (p = 0.08) were associated with earlier time to pyeloplasty on multivariable Cox analysis. In infants with follow-up US (n = 115), initial SFU grade, MAG-3 evaluation or findings, and pyeloplasty were not associated with improvement of hydronephrosis.

CONCLUSIONS

We found that infant pyeloplasty rates vary between sites. Prolonged T½ was associated with surgery despite prior studies suggesting this is a poor predictor of worsening dilation or function. These findings suggest the need to standardize evaluation and indications for intervention in infants with suspected UPJ obstruction.

Body size data collected non-invasively from drone images indicate a morphologically distinct Chilean blue whale (Balaenoptera musculus) taxon

The blue whale Balaenoptera musculus (Linnaeus, 1758) was the target of intense commercial whaling in the 20th century, and current populations remain drastically below pre-whaling abundances. Reducing uncertainty in subspecific taxonomy would enable targeted conservation strategies for the recovery of unique intraspecific diversity. Currently, there are 2 named blue whale subspecies in the temperate to polar Southern Hemisphere: the Antarctic blue whale B. m. intermedia and the pygmy blue whale B. m. brevicauda. These subspecies have distinct morphologies, genetics, and acoustics. In 2019, the Society for Marine Mammalogy’s Committee on Taxonomy agreed that evidence supports a third (and presently unnamed) subspecies of Southern Hemisphere blue whale subspecies, the Chilean blue whale. Whaling data indicate that the Chilean blue whale is intermediate in body length between pygmy and Antarctic blue whales. We collected body size data from blue whales in the Gulfo Corcovado, Chile, during the austral summers of 2015 and 2017 using aerial photogrammetry from a remotely controlled drone to test the hypothesis that the Chilean blue whale is morphologically distinct from other Southern Hemisphere blue whale subspecies. We found the Chilean whale to be morphologically intermediate in both overall body length and relative tail length, thereby joining other diverse data in supporting the Chilean blue whale as a unique subspecific taxon. Additional photogrammetry studies of Antarctic, pygmy, and Chilean blue whales will help examine unique morphological variation within this species of conservation concern. To our knowledge, this is the first non-invasive small drone study to test a hypothesis for systematic biology.

Evaluation and Long-term Management of Neurogenic Bladder in Spinal Dysraphism

Spinal dysraphism, which includes conditions such as myelomeningocele and sacral agenesis, is one of the most common causes of congenital lower urinary tract dysfunction. Early evaluation of the neurogenic bladder serves to minimize renal damage, and the main goals of management include preserving renal function, achieving acceptable continence, and optimizing quality of life. The survival of patients with such conditions has improved to greater than 80% reaching adulthood, owing to advances in diagnostic and therapeutic modalities. The result is a real, and unfortunately often unmet, need for successful transitional care in this complex patient population. Clinicians must be able to identify the unique challenges encountered by patients with neurogenic bladder as they shift through different stages of their life.

Cost analysis of removing pediatric ureteral stents with and without a retrieval string

BACKGROUND

Indwelling ureteral stents are commonly placed in urologic surgeries where optimal urinary drainage is necessary. In the pediatric population, removing a stent without retrieval string (SWOS) requires a secondary operation and additional anesthetic exposure. Although these burdens can be mitigated through the placement of a stent with retrieval string (SWS), fears of complications may prevent widespread adoption of this practice by pediatric urologists.

OBJECTIVE

The authors sought to assess the differential cost of removing SWS and SWOS. It was hypothesized that costs associated with removing SWS are significantly lower than those associated with removing SWOS, without increasing complications.

STUDY DESIGN

A retrospective chart review was performed on pediatric patients undergoing common urologic surgeries with concurrent stent placement at a single tertiary referral center. Charges and healthcare costs surrounding the removal of ureteral stents were evaluated using the institution-specific ratio of cost to charges, by estimating lost wages, and by exploring differences in poststent healthcare-related events that incur additional cost.

RESULTS

A total of 109 patients with a median age of 5 years (range: 6 months-20 years) were reviewed. A total of 29 patients had SWS, and 80 had SWOS. The theoretical cost of SWS removal in clinic was $400.48 compared with $2290.86 ± $119.30 for operative removal of SWOS, with mean difference of $1890.38 (P < 0.01). The mean stent duration of SWOS was 34.0 ± 13.2 days vs. 10.1 ± 4.9 days for SWS (P < 0.01). Subgroup analysis of the ureteral reconstruction group showed no difference in any complications (35% vs 27%, respectively), early dislodgment (7% vs 7%, respectively) or costly healthcare utilization (23% vs 20%, respectively) among patients with SWOS compared with those with SWS. In SWS group with early dislodgment, neither required a secondary procedure.

DISCUSSION

With rising healthcare expenditures, physicians must be able to provide cost-effective treatment while not compromising safety or outcomes. Unlike prior analyses of cost related to the type of the stent used, the present study specifically reviewed costs of removing SWS versus SWOS and evaluated rates of costly complications. The study findings provide a preliminary basis for advocating the more economical use of SWS when indicated. Lack of power and heterogeneity of the groups need to be addressed in future analyses with larger, matched cohorts.

CONCLUSION

Removal of SWS is more cost-effective than that of SWOS while maintaining similar safety outcomes and should be considered in certain pediatric urology cases to decrease healthcare cost. SWS should be preferred for uncomplicated ureteroscopy, but benefits are less certain in ureteral reconstruction; further studies are needed.

A Randomized, Controlled Trial of the Analytic and Diagnostic Performance of Singleton and Trio, Rapid Genome and Exome Sequencing in Ill Infants

The second Newborn Sequencing in Genomic Medicine and Public Health study was a randomized, controlled trial of the effectiveness of rapid whole-genome or -exome sequencing (rWGS or rWES, respectively) in seriously ill infants with diseases of unknown etiology. Here we report comparisons of analytic and diagnostic performance. Of 1,248 ill inpatient infants, 578 (46%) had diseases of unknown etiology. 213 infants (37% of those eligible) were enrolled within 96 h of admission. 24 infants (11%) were very ill and received ultra-rapid whole-genome sequencing (urWGS). The remaining infants were randomized, 95 to rWES and 94 to rWGS. The analytic performance of rWGS was superior to rWES, including variants likely to affect protein function, and ClinVar pathogenic/likely pathogenic variants (p < 0.0001). The diagnostic performance of rWGS and rWES were similar (18 diagnoses in 94 infants [19%] versus 19 diagnoses in 95 infants [20%], respectively), as was time to result (median 11.0 versus 11.2 days, respectively). However, the proportion diagnosed by urWGS (11 of 24 [46%]) was higher than rWES/rWGS (p = 0.004) and time to result was less (median 4.6 days, p < 0.0001). The incremental diagnostic yield of reflexing to trio after negative proband analysis was 0.7% (1 of 147). In conclusion, rapid genomic sequencing can be performed as a first-tier diagnostic test in inpatient infants. urWGS had the shortest time to result, which was important in unstable infants, and those in whom a genetic diagnosis was likely to impact immediate management. Further comparison of urWGS and rWES is warranted because genomic technologies and knowledge of variant pathogenicity are evolving rapidly.

Presence of organochlorine pollutants in fat and scats of pinnipeds from the Antarctic Peninsula and South Shetland Islands, and their relationship to trophic position

Antarctica is still considered one of the few pristine areas in the globe. Despite this, several studies have shown phased out organic pollutants are present in several environmental abiotic and biological compartments. This study, based on blubber and fecal samples collected from five species of Antarctic pinnipeds, assessed the relationship between organochlorine pesticide (OCs) levels and trophic characterization using stable isotope analysis (δ¹³C and δ¹⁵N). The prevailing pollutants found in blubber were hexachlorocyclohexane isomers (HCHs), hexachlorobenzene (HCB), Heptachlor and Aldrin (0.84-564.11 ng g^-1 l.w.). We also report a high presence of HCHs, Endrin, Dichlorodiphenyltrichloroethane (DDTs) and Methoxychlor (4.50-363.86 ng g^-1 d.w.) in feces suggesting a detoxification mechanism. All the species tend towards high trophic positions (3.4-4.9), but with considerable variation in trophic niche and organochlorine pesticide concentrations per sampling site. This finding suggests that differences in pesticide levels in individuals are associated to foraging ecology.

Vesicostomy button: how is it placed, in whom, and how is quality of life affected?

Purpose

The vesicostomy button has been shown to be a safe and effective bladder management strategy for short- or medium-term use when CIC cannot be instituted. This study reports our use with the vesicostomy button, highlighting the pros and cons of its use and complications. We then compared the quality or life in patients with vesicostomy button to those performing clean intermittent catheterization.

Materials and Methods

Retrospective chart review was conducted on children who had a vesicostomy button placed between 2011 and 2015. Placement was through existing vesicostomy, open or endoscopically. We then evaluated placement procedure and complications. A validated quality of life questionnaire was given to patients with vesicostomy button and to a matched cohort of patients performing clean intermittent catheterization.

Results

Thirteen children have had a vesicostomy button placed at our institution in the 4 year period, ages 7 months to 18 years. Indications for placement included neurogenic bladder (5), non-neurogenic neurogenic bladder (3), and valve bladders (5). Five out of 7 placed via existing vesicostomy had leakage around button. None of the endoscopically placed buttons had leakage. Complications were minor including UTI (3), wound infection (1), and button malfunction/leakage (3). QOL was equal and preserved in patients living with vesicostomy buttons when compared to CIC.

Conclusion

The vesicostomy button is an acceptable alternative to traditional vesicostomy and CIC. The morbidity of the button is quite low. Endoscopic insertion is the optimal technique. QOL is equivalent in patients with vesicostomy button and those who perform CIC.

Laparoendoscopic single site surgery in pediatric urology: does it require specialized tools?

PURPOSE

To describe our experience utilizing Laparoendoscopic single site (LESS) surgery in pediatric urology.

MATERIALS AND METHODS

Retrospective chart review was performed on LESS urologic procedures from November 2009 through March 2013. A total of 44 patients underwent 54 procedures including: nephrectomy (23), orchiopexy (14), varicocelectomy (9), orchiectomy (2), urachal cyst excision (3), and antegrade continence enema (3) (ACE).

RESULTS

Median patient age was 6.9 years old. Estimated blood loss (EBL), ranged from less than 5cc to 47cc for a bilateral nephrectomy. Operative time varied from 56 mins for varicocelectomy to a median of 360 minutes for a bilateral nephroureterectomy. Incision length ranged between 2 and 2.5cm. In our initial experience we used a commercial port. However, as we progressed, we were able to perform the majority of our procedures via adjacent fascial punctures for instrumentation at the single incision site. One patient did require conversion to an open procedure as a result of bleeding. Three complications were noted (6.8%), with two Clavien Grade 3b complications. Two patients required additional procedures at 1-year follow-up.

CONCLUSIONS

The use of LESS applies to many pediatric urologic procedures, ideally for ablative procedures or simple reconstructive efforts. The use of adjacent fascial puncture sites for instrumentation can obviate the need for a commercial port or multiple trocars.

National multi-institutional cooperative on urolithiasis in children: Age is a significant predictor of urine abnormalities

INTRODUCTION

Pediatric nephrolithiasis is a growing problem and prior studies have shown the greatest increase in nephrolithiasis in the adolescent population. Metabolic abnormalities have historically been cited as the primary cause of pediatric nephrolithiasis; however, dietary and other factors such as obesity have also been studied with mixed results.

OBJECTIVE

We reviewed the charts of pediatric patients with a history of nephrolithiasis to determine the number and types of metabolic abnormalities present on 24-h urine analysis.

STUDY DESIGN

We retrospectively reviewed the charts of all pediatric patients with a history of nephrolithiasis from 1999-2013 across four different institutions. The subjects were excluded if they had a history of spina bifida, neurogenic bladder, cerebral palsy, isolated bladder stones, or if they were on medical therapy for nephrolithiasis before the first 24-h urine collection.

RESULTS

There were 206 subjects included in the analysis with an average age of 13 (±3.9) years. The patients were stratified into two age groups based on an apparent bimodal distribution of metabolic abnormalities, ≤10 years and >10 years of age. Metabolic abnormalities were present in 130 children (63.1%) and there was a difference between the groups, with children ≤10 years more likely to have a metabolic abnormality compared with those >10 years of age (75% vs. 60.6%, p = 0.0443) on univariate analysis. In children ≤10 years hypercalciuria was the most common disorder present (48.4%), and in children >10 years hypocitraturia was the most common disorder present (26.1%). Children ≤10 years of age were more likely to have normal volume (p = 0.006), elevated urinary oxalate (p = 0.0351), elevated urinary calcium (p < 0.001), elevated supersaturation of calcium phosphate (p < 0.001), and elevated supersaturation of calcium oxalate (p = 0.002). On multivariate analysis, children ≤10 years of age were more likely to have normal volume, hyperoxaluria, elevated supersaturation of calcium phosphate and a trend towards hypercalciuria (Table).

DISCUSSION

Our study reveals that younger children are more likely to have a metabolic abnormality present on 24-h urine analysis. This has important implications when deciding on treatment options, with younger children potentially requiring more aggressive management with medical therapy. Older children were more likely to have low urinary volume and their most common metabolic abnormality was hypocitraturia. Although dietary factors have not been established as the definitive reason behind the rising incidence of nephrolithiasis in the adolescent population, older children may benefit more from diet modification with a strong focus on increasing volume intake.

CONCLUSION

We found differences in younger compared with older age groups in terms of the number and types of metabolic disorders present. Children ≤10 years of age were more likely to have a metabolic disorder including elevations in calcium, oxalate and supersaturation of calcium phosphate, while children >10 years of age were more likely to have low urinary volume. These differences have important implications for future investigative studies on the rising incidence as well as the best course of treatment for children with nephrolithiasis.

National risk factors and estimated costs for redo ureteroneocystostomy after pediatric renal transplant

Approximately 800 pediatric renal transplants are performed annually in the United States. VUR or obstruction may cause graft failure requiring redo ureteroneocystostomy. We examined possible risk factors and cost using the PHIS national database. We examined the PHIS for 8.5 yr to determine the association between redo ureteroneocystostomy following pediatric renal transplant to demographics, comorbidities, GU conditions, insurance status, and hospital characteristics, and looked at relative costs using descriptive and comparative statistics. A total of 2390 pediatric renal transplants were identified, of which 69 (2.3%) underwent redo ureteroneocystostomy (median 11.6 months post-transplant). Risk factors for redo ureteroneocystostomy are younger age (p = 0.048), PUVs (p < 0.001), female gender (p = 0.005), race (p = 0.014), insurance type (p < 0.027), region (p = 0.045), and transplant surgery volume (p = 0.048). Redo ureteroneocystostomy after transplant does not significantly increase the overall cost of transplant (p = 0.175). We confirmed previous findings that younger age and PUVs increase the risk of post-transplant redo ureteroneocystostomy, with a five-yr plateau. We found an association with gender, race, insurance status, and hospital characteristics. Redo ureteroneocystostomy, which increases costs, does not statistically significantly increase overall cost of individual treatment in this database, although costs may be underreported.

Examining trends in the treatment of ureterocele yields no definitive solution

INTRODUCTION

The surgical management of ureteroceles is extremely variable. Some have hypothesized that if these patients were treated with 'definitive' staged surgical intervention, the need for further revision surgery would be eliminated.

OBJECTIVE

The present study sought to determine if the rate of revision surgery differed among patients who have undergone different surgical approaches for the ureterocele complex.

STUDY DESIGN

A large retrospective chart review was conducted, identifying all patients having undergone ureterocele surgery at a single institution over the past 41 years. The cohort was divided into four groups based on surgical approach: upper tract approach (UTA), lower tract reconstruction (LTR), simultaneous upper and lower tract approach (ULTA), and staged lower tract reconstruction (SLTR). Demographics, the presence of preoperative/postoperative VUR, postoperative morbidity and the need for revision surgery were compared using the Chi- squared test, Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U test (Bonferroni correction), logistic regression modeling and survival analyses (Kaplan-Meier and Cox proportional Hazards regression with unplanned revision operation as the outcome event).

RESULTS

Between 1969 and 2010, 180 patients were identified as having undergone surgical management of ureteroceles, of which 120 had complete demographic data available for analysis. The median age at the time of initial surgical intervention was 5.8 months and the majority of patients (83.3%) were female. The median follow-up was 33.1 months. Surgical management was as follows: 18 (15.0%) patients underwent UTA, 47 (39.2%) underwent LTR, 23 (19.2%) underwent ULTA, and 32 (26.6%) underwent SLTR. Among these groups, the only difference in median age was between the LTR and SLTR groups (6.3 months vs 3.7 months, P=0.012). Additional revision surgery was required in: nine (50.0%) of UTA, ten (21.3%) of LTR, four (17.4%) of ULTA, and three (9.4%) of SLTR. The only statistically significant difference in unplanned revision surgery was noted in the UTA group versus each of the other groups with VUR as the predominant indication (88.9%). The likelihood of requiring revision surgery in comparison to the SLTR group was significantly increased in the UTA group (OR 9.67, CI 2.15-43.56), but not in the LTR (OR 2.61, CI 0.66-10.37) or the ULTA group (OR 2.04, CI 0.41-10.13). Obstruction, recurring UTIs and VUR were the main indications for revision surgery overall.

DISCUSSION

There is a large body of literature examining the surgical management of ureteroceles. It most recently primarily focuses on an endoscopic approach to the lower tract. The present retrospective review examined the need for re-operative intervention by comparing four different surgical approaches, and found that there is no panacea. Although heminephrectomy (UTA) was a definitive procedure in some patients without reflux at presentation, many who underwent heminephrectomy, went on to require later bladder surgery for either recurrent UTI or persistent reflux. The present study has multiple limitations. Although VUR was an indication for revision surgery in the early part of the series, the current treatment of VUR is not necessarily as stringent. In addition, no distinction was made between an orthotopic or ectopic ureterocele, although some authors have reported differing outcomes in these two groups. However, it is felt that given the large data set of a relatively uncommon condition, the lack of superiority of one approach is apparent.

CONCLUSION

There is no definitive surgical repair for the ureterocele complex. All groups except UTA had statistically similar rates of revision surgery. The widespread variability in current management echoes the lack of one superior approach found in this comprehensive series.

Two Sessions of Behavioral Urotherapy for Bowel and Bladder Dysfunction: Does It Get Any Better?

This study sets to determine the optimal duration of behavioral urotherapy necessary to achieve maximal improvement in the management of pediatric bowel and bladder dysfunction.

Lack of improvement: a national assessment of readmission rates after pediatric bladder reconstruction

Background:

Bladder reconstruction in the pediatric population is challenging for many reasons, including perioperative complications and readmissions.

Objectives:

On a national scale, determine readmission rates at 30, 60 and 90 days after bladder reconstruction in a pediatric population over a 7-year period, evaluating the influence of hospital and patient-specific variables.

Patients and Methods:

Using the Pediatric Health Information System database, we identified patients 0-17 years of age, from 2004-2010, undergoing bladder reconstruction using ICD-9 procedure codes. Descriptive statistics characterized demographics, prevalence of surgeries, and readmission rates. Surgery prevalence over time was examined using linear regression. Readmission rates were compared using the Chi2 test. Regression was used to evaluate the influence of variables on readmission risk.

Results:

We identified 1,985 patients for inclusion, of which 52.7% were female. Median age was 9 years. There has been no change in the prevalence of bladder reconstruction surgeries (P = 0.327). There was no change in 30-day (P = 0.272), 60-day (P = 0.788) or 90-day readmission rates (P = 0.924). Despite surgical volume adjustment, 90-day readmission rates did not significantly vary among the majority of hospitals. Initial LOS > 7 days (P < 0.001) and complex chronic condition males (P < 0.001) were significantly associated with 90-day readmission.

Conclusions:

No improvement in readmission rates after pediatric bladder reconstruction was observed during the study period. Nearly all centers have a similar readmission rate despite volume adjustment.

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.