Cost-Utility of Antimicrobial Prophylaxis for Treatment of Children With Vesicoureteral Reflux.

Objective: Antimicrobial prophylaxis for children with vesicoureteral reflux (VUR) reduces recurrences of urinary tract infection (UTI) but requires daily antimicrobials for extended periods. We used a cost-utility model to evaluate whether the benefits of antimicrobial prophylaxis outweigh its risks and, if so, to investigate whether the benefits and risks vary according to grade of VUR. Methods: We compared the cost per quality-adjusted life-year (QALY) gained in four treatment strategies in children aged <6 years diagnosed with VUR after a first UTI, considering these treatment strategies: (1) prophylaxis for all children with VUR, (2) prophylaxis for children with Grade III or Grade IV VUR, (3) prophylaxis for children with Grade IV VUR, and (4) no prophylaxis. Costs and effectiveness were estimated over the patient's lifetime. We used $100,000/QALY gained as the threshold for considering a treatment strategy cost effective. Results: Based on current data and plausible ranges to account for data uncertainty, prophylaxis of children with Grades IV VUR costs $37,903 per QALY gained. Treating children with Grade III and IV VUR costs an additional $302,024 per QALY gained. Treating children with all grades of VUR costs an additional $339,740 per QALY gained. Conclusions: Treating children with Grades I, II, and III VUR with long-term antimicrobial prophylaxis costs substantially more than interventions typically considered economically reasonable. Prophylaxis in children with Grade IV VUR is cost effective.

Impact of Implementation of Electronically Transmitted Referrals on Pediatric Subspecialty Visit Attendance.

OBJECTIVE: One barrier to timely access to outpatient pediatric subspecialty care is the complexity of scheduling processes. We evaluated the impact of implementing electronically transmitted referrals on subspecialty visit attendance. METHODS: Through collaboration with stakeholders, an electronically transmitted referral order system was designed, piloted, and implemented in 15 general pediatrics practices, with 24 additional practices serving as controls. We used statistical process control methods and difference-in-differences analysis to examine visits attended, appointments scheduled, appointment nonattendance, and referral volume. Electronically transmitted referrals then were expanded to all 39 practices. We surveyed referring pediatricians at all practices before and after implementation. RESULTS: From April 2015 through September 2016 there were 33,485 referral orders across all practices (7770 before the pilot, 11,776 during the pilot, 13,939 after full implementation). At pilot practices, there was a significant and sustained improvement in subspecialty visits attended within 4 weeks of referral (10.9% to 20.0%; P < .001). Relative to control practices, pilot practices experienced an 8.6% improvement (P = .001). After implementation at control practices, rates of visits attended also improved but to a smaller degree: 11.8% to 14.7% (P < .001). In survey responses, referring pediatricians noted improved scheduling processes but had continued concerns with appointment availability and referral tracking. CONCLUSIONS: While electronically transmitted referrals improved visit attendance after pediatric subspecialty referral, the sizable percentage of children without attended visits, the muted effect at control practices, and pediatrician survey responses indicate that additional work is needed to address barriers to pediatric subspecialty care.

Vesicoureteral reflux is a phenotype, not a disease: A population-centered approach to pediatric urinary tract infection.

We performed a review of the recent literature concerning urinary tract infection (UTI) evaluation and management. In modeling options for management, one overriding conclusion became apparent: in most affected children, the presence of vesicoureteral reflux (VUR) is inconsequential since it has no bearing on optimal management or outcome. In fact, knowing that a child does not have reflux might bias the provider to withhold potentially helpful therapeutic modalities to decrease UTI morbidity, such as antibiotic prophylaxis. In this review, we will propose that evaluation for VUR is not necessary or helpful except in the small subset of children whose UTIs have proven refractory to management of their other risk factors.

Recurrent Urinary Tract Infections in Children With Bladder and Bowel Dysfunction.

BACKGROUND: Little generalizable information is available on the outcomes of children diagnosed with bladder and bowel dysfunction (BBD) after a urinary tract infection (UTI). Our objectives were to describe the clinical characteristics of children with BBD and to examine the effects of BBD on patient outcomes in children with and without vesicoureteral reflux (VUR). METHODS: We combined data from 2 longitudinal studies (Randomized Intervention for Children With Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation) in which children <6 years of age with a first or second UTI were followed for 2 years. We compared outcomes for children with and without BBD, children with and without VUR, and children with VUR randomly assigned to prophylaxis or placebo. The outcomes examined were incidence of recurrent UTIs, renal scarring, surgical intervention, resolution of VUR, and treatment failure. RESULTS: BBD was present at baseline in 54% of the 181 toilet-trained children included; 94% of children with BBD reported daytime wetting, withholding maneuvers, or constipation. In children not on antimicrobial prophylaxis, 51% of those with both BBD and VUR experienced recurrent UTIs, compared with 20% of those with VUR alone, 35% with BBD alone, and 32% with neither BBD nor VUR. BBD was not associated with any of the other outcomes investigated. CONCLUSIONS: Among toilet-trained children, those with both BBD and VUR are at higher risk of developing recurrent UTIs than children with isolated VUR or children with isolated BBD and, accordingly, exhibit the greatest benefit from antimicrobial prophylaxis.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in infants.

PURPOSE: Laparoscopic pyeloplasty and open pyeloplasty have comparable efficacy for ureteropelvic junction obstruction in pediatric patients. The role of laparoscopic pyeloplasty in infants is less well defined. We present our updated experience with laparoscopic pyeloplasty in children younger than 1 year. MATERIALS AND METHODS: We retrospectively reviewed the records of all 29 infants treated with transperitoneal laparoscopic pyeloplasty for symptomatic and/or radiographic ureteropelvic junction obstruction from May 2005 to February 2012. Patients were followed with renal ultrasound at regular intervals. Treatment failure was defined as the inability to complete the intended procedure, persistent radiographic evidence of obstruction and/or the need for definitive adjunctive procedures. RESULTS: Transperitoneal laparoscopic pyeloplasty was performed in 29 infants 2 to 11 months old (mean age 6.0 months) weighing 4.1 to 10.9 kg (mean ± SD 7.9 ± 1.6). Followup was available in all except 5 patients (median 13.9 months, IQR 7.7-23.8). Mean operative time was 245 ± 44 minutes. All cases were completed laparoscopically. Three postoperative complications were reported, including ileus, superficial wound infection and pyelonephritis. Two patients had persistent symptomatic and/or radiographic evidence of obstruction, and required reoperative pyeloplasty. The overall success rate was 92%. CONCLUSIONS: Laparoscopic pyeloplasty in infants remains a technically challenging procedure limited to select centers. Our early experience revealed a success rate comparable to that of other treatment modalities with minimal morbidity.

"I meant that med for Baylee not Bailey!": a mixed method study to identify incidence and risk factors for CPOE patient misidentification.

Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.

Cloacal exstrophy variant with intravesical phallus: further description of anatomy and implications for gender reassignment.

Variant presentations of cloacal exstrophy are exceedingly rare. Historically, genetic males with cloacal extrophy were re-assigned to the female gender due to phallic inadequacy. Early recognition of intravesical phallic structures in cloacal exstrophy cases may impact gender reassignment discussions and long-term gender outcomes. We report the case of a male infant with cloacal exstrophy presenting with an intravesical phallus, review and compare the presenting anatomical features of the three previously reported cases, and discuss the potential impact of these findings on gender reassignment in these complex children.

Orchiopexy after prior inguinal surgery: a distal approach.

PURPOSE: Undescended testicle after groin surgery is a condition traditionally approached through an inguinal incision with en bloc mobilization of the spermatic cord and external oblique fascia, and extensive dissection of the proximal spermatic vessels. We report on a single surgeon series of orchiopexies after prior inguinal surgery approached through a single scrotal incision. MATERIALS AND METHODS: From November 2001 to February 2007, 24 patients with a mean age of 6.4 years (range 1.3 to 16.2) presented with 27 undescended testicles. All patients had undergone previous groin surgery including 13 inguinal hernia repairs, 3 orchiopexies and 3 hernia repairs with orchiopexy. Of the 27 testicles 24 (21 patients) were successfully approached through a single scrotal incision (89%). If the scrotum could not be manipulated over or near the relatively fixed testicle, an inguinal incision was made (11%). Charts were retrospectively reviewed for technique and operative outcomes. RESULTS: A mean followup of 12 months was available for 20 of 21 patients. A patent processus vaginalis was found in 3 (12.5%) patients and hernia repair was performed through the scrotal incision in these patients. There were no intraoperative complications. In 1 (4.2%) patient the testicular position was unacceptable and subsequently successful repeat scrotal orchiopexy was performed. At last followup all testes were in a satisfactory scrotal position without hydrocele, hernia or testicular atrophy. CONCLUSIONS: The majority of orchiopexies after prior inguinal surgery can be approached through a single scrotal incision. Retrograde serial dissection of adhesions to the distal cord usually reveals adequate vessel length, thus avoiding extensive inguinal and/or retroperitoneal dissection.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in children.

PURPOSE: To examine our experience of laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction (UPJO) in the pediatric population. METHODS: From November 2001 to June 2009, 112 patients underwent transperitoneal laparoscopic pyeloplasty for the treatment of symptomatic or radiographic UPJO. Data were collected retrospectively. Patients were followed at regular intervals with imaging and symptom assessment. Failure was defined as inability to complete the intended procedure, persistent flank pain, radiographic evidence of obstruction, or the need for definitive adjunctive procedures. RESULTS: Mean patient age was 9.4 years (0.2-20.5 years), and follow-up was available on all 112 patients with a mean duration of 15.3 months (0.6-84.5 months). There was one open conversion in the series. Mean operative time was 254 minutes (102-525 minutes). There was one minor intraoperative complication reported (0.8%). There were 12 (10.8%) postoperative complications; most were relatively minor with complete resolution and without long-term sequelae. Postoperative ultrasonography has been performed in 102 patients, with 99 (97%) patients demonstrating improvement of the UPJO. Three patients (3%) continued to have symptomatic and/or radiographic evidence of obstruction that necessitated the need for adjunctive procedures, which included laser endopyelotomy in 2 patients, and a re-do open pyeloplasty in 1 patient. Of those cases that were completed laparoscopicaly, the overall success rate was 97.2%. CONCLUSIONS: Laparoscopic pyeloplasty for UPJO in the pediatric population is technically challenging; however, with experience, one can expect excellent success rates comparable to open pyeloplasty, with minor complications with reasonable operative times.

Contemporary surgical management of pediatric urolithiasis.

With miniaturization of instruments and refinement of surgical technique, the management of pediatric stone disease has undergone a dramatic evolution. While shock wave lithotripsy (SWL) is still commonly used to treat upper tract calculi, the use of ureteroscopy (URS) has dramatically increased and is now the procedure of choice for upper tract stone burdens less than 1.5cm at centers with significant experience. Percutaneous nephrolithotomy (PCNL) has replaced open surgical techniques for the treatment of large stone burdens greater than 2cm, with efficacy and complication rates similar to the adult population. Large institutional series demonstrate comparable stone-free and complication rates with SWL, URS, and PCNL, but concerns remain with these techniques regarding renal development and damage to the pediatric urinary tract. Randomized controlled trials comparing the efficacy of SWL and URS for upper tract stone burdens are needed to reach consensus regarding the most effective primary treatment modality in children.

Single-site laparoscopic orchidopexy in an infant.

We describe a laparoscopic orchidopexy performed on an 18-month-old child through a single infraumbilical site.

Enterococcus faecalis cellulitis/fasciitis after hypospadias surgery.

We describe a case of Enterococcus faecalis-associated cellulitis/fasciitis after hypospadias surgery.

Laparoscopic nephrectomy in children: systematic review of transperitoneal and retroperitoneal approaches.

OBJECTIVES: To perform a systematic review of the available medical data concerning laparoscopic nephrectomy in children. For many pediatric urologists, the laparoscopic approach to nephrectomy has become the standard of care. Access can be obtained using a retroperitoneal (RP) or transperitoneal (TP) approach. Previously, debates have argued the advantage of each technique relative to the other. METHODS: We performed a data search through MEDLINE and PubMed to find reports of laparoscopic nephrectomy, nephroureterectomy, and partial nephrectomy in children. We analyzed the operative time, hospital stay, and rate of complication with each approach. Specifically, we assessed the rate of vascular, solid organ, and bowel injuries. RESULTS: We found 51 articles that reported the outcomes of 689 pediatric nephrectomies. Of these, 401 were RP and 288 were TP laparoscopic renal surgeries in children. The mean patient age for RP and TP was 5.4 years and 4.8 years, respectively. The mean operative time was 129 minutes for RP and 154 minutes for TP. The hospital stay was 2.5 days for RP and 2.3 days for TP. The overall complication rate for RP was 4.3% and for TP was 3.5% (P = .58). The number of vascular injuries for RP was 2 and for TP was 0 (P = .12). The number of bowel injuries for RP was 2 and for TP was 1 (P = .68). CONCLUSIONS: According to the available published data, no significant advantage is gained by a RP or TP approach for laparoscopic nephrectomy. Although the operative time for RP was slightly shorter than for TP, the types of cases performed were not directly matched and thus were more challenging to compare. The incidence of vascular and bowel injuries was rare for both approaches. Therefore, the choice of approach should be determined by surgeon preference, patient anatomy, or the procedure to be performed.

Endourological management of pediatric stone disease: present status.

PURPOSE: The incidence of nephrolithiasis in the pediatric population has been steadily increasing. The miniaturization of endoscopic instruments and improvement in imaging modalities have facilitated safe and effective endourological treatment in this patient population. We reviewed the current status of pediatric stone disease management. MATERIALS AND METHODS: A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the indications, techniques, complications and efficacy of endourological stone management in children. RESULTS: In the 1980s shock wave lithotripsy revolutionized stone management in children, becoming the procedure of choice for treating upper tract calculi less than 1.5 cm. Percutaneous nephrolithotomy has replaced open surgical techniques for the treatment of stone burdens greater than 1.5 cm with efficacy and complication rates mirroring those in the adult population. However, at an increasing number of centers ureteroscopy is now being performed in cases that previously would have been treated with shock wave lithotripsy or percutaneous nephrolithotomy. Results from recent retrospective series demonstrate that stone-free rates and complication rates with ureteroscopy are comparable to percutaneous nephrolithotomy and shock wave lithotripsy. Although concerns remain with all endoscopic techniques in children regarding damage to the urinary tract and renal development, neither short-term nor long-term adverse effects have been consistently reported. CONCLUSIONS: Shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopy are highly effective endourological techniques to treat stone disease in the pediatric population. A lack of prospective randomized trials comparing treatment modalities coupled with a vast disparity in the access to resources worldwide continues to individualize rather than standardize stone treatment in children.

Minimally invasive treatment of vesicoureteral reflux.

Vesicoureteral reflux (VUR) is a common problem in childhood, affecting approximately 1% to 2% of the pediatric population. Mild cases of VUR are likely to resolve spontaneously, but high-grade VUR may require surgical correction. Pediatric urologists are familiar with open antireflux operations, which can be accomplished with minimal operative morbidity. Minimally invasive endoscopic and laparoscopic techniques that now exist may serve to reduce morbidity further. This article reviews the endoscopic materials, techniques, and outcomes in the treatment of VUR in addition to the techniques and outcomes of laparoscopic and robotic ureteroneocystotomy.

When is prior ureteral stent placement necessary to access the upper urinary tract in prepubertal children?

PURPOSE: We studied the possibility that age, height, weight and body mass index could be used to predict the likelihood of successful ureteroscopic access to the upper urinary tract without previous stent placement in prepubertal children. MATERIALS AND METHODS: We retrospectively reviewed all ureteroscopic procedures for upper tract calculi in prepubertal children from 2003 to 2007. We compared age, height, weight and body mass index in patients who underwent successful primary flexible ureteroscopic access and in those who required initial stent placement to perform ureteroscopy. RESULTS: Successful primary ureteroscopic access to the upper tract was achieved in 18 of 30 patients (60%). There was no difference in mean age (9.9 vs 9.5 years, p = 0.8), height (132 vs 128 cm, p = 0.6), weight (37 vs 36 kg, p = 0.86) or body mass index (19.3 vs 20.5 kg/m(2), p = 0.55) between patients with successful vs unsuccessful upper tract access. Locations that prevented access to the upper urinary tract were evenly distributed among the ureteral orifice, iliac vessels and ureteropelvic junction. CONCLUSIONS: Age, height, weight and body mass index could not predict the likelihood of successful ureteroscopic access to the upper tract. Placement of a ureteral stent for passive ureteral dilation is not necessary for successful ureteroscopic access to the renal pelvis in prepubertal children. An initial attempt at ureteroscopy, with placement of a ureteral stent if upper tract access is unsuccessful, decreases the number of procedures while maintaining a low complication rate.