Enhanced recovery program in ambulatory pediatric urology: A quality improvement initiative.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) was established in 2001 for adult patients undergoing complex procedures. ERAS in adult ambulatory surgery later followed with similar positive outcomes. For the pediatric population, ERAS implementation has shown promising results in complex surgeries such as bladder reconstruction. Its application in pediatric ambulatory surgery has only recently been reported. We hereby report a Quality Improvement initiative in implementing an Enhanced Recovery Protocol (ERP) for pediatric urology in an ambulatory surgery center. METHODS: A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used. RESULTS: The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged. CONCLUSIONS: This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.

Transforming into a Learning Health System: A Quality Improvement Initiative.

Background: The Institute of Medicine introduced the Learning Healthcare System concept in 2006. The system emphasizes quality, safety, and value to improve patient outcomes. The Bellevue Clinic and Surgical Center is an ambulatory surgical center that embraces continuous quality improvement to provide exceptional patient-centered care to the pediatric surgical population. Methods: We used statistical process control charts to study the hospital's electronic health record data. Over the past 7 years, we have focused on the following areas: efficiency (surgical block time use), effectiveness (providing adequate analgesia after transitioning to an opioid-sparing protocol), efficacy (creating a pediatric enhanced recovery program), equity (evaluating for racial disparities in surgical readmission rates), and finally, environmental safety (tracking and reducing our facility's greenhouse gas emissions from inhaled anesthetics). Results: We have seen improvement in urology surgery efficiency, resulting in a 37% increase in monthly surgical volume, continued adaptation to our opioid-sparing protocol to further reduce postanesthesia care unit opioid administration for tonsillectomy and adenoidectomy cases, successful implementation of an enhanced recovery program, continued work to ensure equitable healthcare for our patients, and more than 85% reduction in our facility's greenhouse gas emissions from inhaled anesthetics. Conclusions: The Bellevue Clinic and Surgical Center facility is a living example of a learning health system, which has evolved over the years through continued patient-centered QI work. Our areas of emphasis, including efficiency, effectiveness, efficacy, equity, and environmental safety, will continue to impact the community we serve positively.

Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study.

INTRODUCTION/BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE: We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN: Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS: A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION: The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS: ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

Association between YouTube® videos and health literacy with postoperative healthcare utilization following pediatric urologic surgery: A randomized trial.

INTRODUCTION: Limited caregiver health literacy has been associated with poorer health outcomes in pediatric patients and may limit caregiver understanding of printed education resources. Postoperative healthcare utilization may be related to confusion about instructions or complications. OBJECTIVE: To correlate caregiver health literacy and educational video intervention with postoperative healthcare utilization following ambulatory pediatric urologic surgery. STUDY DESIGN: From July through December 2021, a randomized double-blinded trial assessed postoperative healthcare utilization following pediatric urologic surgery. Caregivers were randomized to receive standardized postoperative counseling and printed instructions (control) or access to English-language educational YouTube® videos with standardized postoperative counseling and printed instructions (intervention). Medical record abstraction was completed 30 days following surgery to identify postoperative healthcare utilization with calls, messages, add-on clinic visits, or presentation for urgent or emergent care, and postoperative complications. RESULTS: Target enrollment was achieved with 400 caregivers with 204 in the intervention and 196 in the control groups. There was a 32.5 % overall rate of postoperative healthcare utilization. Health literacy was inversely associated with total postoperative healthcare utilization (p < 0.001). There was no difference in the incidence of postoperative healthcare utilization between the control and intervention groups (p = 0.623). However, on sub-analysis of caregivers with postoperative healthcare utilization (Summary Figure), there were fewer total occurrences in the intervention group (intervention median 1, IQR 1,2.3; control median 2, IQR 1,3; p < 0.001). For caregivers with limited health literacy, there was a greater associated reduction in median calls from 2 (IQR 0,2) to 0 (IQR 0,0.5) with video intervention (p = 0.016). On multivariate analysis, total postoperative healthcare utilization was significantly associated with limited caregiver health literacy (OR 1.08; p = 0.004), English as preferred language (OR 0.68; p = 0.018), and older patient age (OR 0.95; p = 0.001). DISCUSSION: Current resources for postoperative education are limited as resources can be written above recommended reading levels and families can have difficulty recalling information discussed during postoperative counseling. Video intervention is an underutilized resource that can provide an additional resource to families with visual and auditory aids and be accessed as needed. CONCLUSION: Caregiver health literacy was inversely associated with postoperative healthcare utilization. There was no difference in the incidence of postoperative healthcare utilization with video intervention. However, on subgroup analysis, supplemental videos were associated with fewer occurrences of postoperative healthcare utilization, especially in caregivers with limited health literacy. On multivariate regression, health literacy, preferred language, and patient age were significantly associated with total postoperative healthcare utilization.

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network.

BACKGROUND: Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. OBJECTIVE: With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. STUDY DESIGN: A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. RESULTS: Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. CONCLUSION: Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS: A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS: The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS: This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

Racial and ethnic disparities in the timing of orchiopexy for cryptorchidism.

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.

Engagement of common pediatric urologic conditions on social media.

INTRODUCTION: As social media use continues to increase, parents and caregivers report using social media platforms as a source of health information. However, there are minimal regulations for social media content and health misinformation has been shared for various medical issues and urologic conditions. While internet content related to pediatric urology has been previously described, social media engagement for various pediatric urologic conditions have yet to be described. OBJECTIVE: To evaluate the evidence supporting articles engaged on social media that are related to common pediatric urologic conditions. STUDY DESIGN: A social media analysis tool was used to identify articles engaged through Facebook, Reddit, Twitter, and Pinterest between July 2020-2021. The top 5 articles related to toilet training, circumcision, cryptorchidism, testicular torsion, and hypospadias were identified. Article citations were reviewed and classified by Oxford levels of evidence. The content of each article was then reviewed and compared against supporting evidence on an independent literature search. Statistical analysis was completed with descriptive statistics, Mann-Whitney U, Wilcoxon signed rank, and bivariate correlation. RESULTS: Of the 25 articles reviewed, 8 (32%) were affiliated with medical journals, hospitals, or academic institutions and 17 (68%) were on non-affiliated websites with advertisements. There was greater social media engagement for articles related to toilet training and circumcision than testicular torsion, hypospadias, and cryptorchidism. No articles cited level 1 evidence and 32% of articles cited no evidence. Literature search for article content demonstrated a discrepancy between the level of evidence cited by articles compared to the evidence available in the literature to support article content. There was greater social media engagement for articles with no cited or supporting evidence and those not affiliated with medical journals, hospitals, or academic institutions. DISCUSSION: The findings in this study are consistent with trends reported for other urologic conditions, including genitourinary malignancy, female pelvic medicine and reconstructive surgery, nephrolithiasis, and sexual function. Parents without a medical background may have difficulty identifying whether articles shared on social media can be a reliable resource for health information. It is important to understand how information related to pediatric urologic conditions is engaged on social media so that misinformation can be addressed in clinical, online, and regulatory settings. CONCLUSION: There was greater social media engagement for articles with no cited or supporting evidence and those not affiliated with medical journals, hospitals, or academic institutions.

A survey of adult and pediatric urologists on current practice in antibiotic prophylaxis for ureteral stent removal.

INTRODUCTION: Recommendations for antibiotic prophylaxis prior to cystourethroscopy with manipulation are based on limited evidence and may not be applicable to procedures without tissue resection such as ureteral stent removal. OBJECTIVES: Our objectives were to investigate and compare practice patterns among adult and pediatric urologists on antibiotic prophylaxis for stent removal. STUDY DESIGN: An online survey was distributed to members of the Endourological Society (EUS) and Societies for Pediatric Urology (SPU) including questions about provider demographics and practice patterns. Adult urologists were defined as EUS member respondents and pediatric urologists were defined as SPU member respondents. Comparisons were made using Pearson's Chi-Square analysis. RESULTS: Of 2544 adult urologists surveyed, 258 (10%) completed the survey and of 714 pediatric urologists surveyed, 180 (25%) completed the survey (Table 1). Pediatric urologists report using antibiotic prophylaxis "most of the time" (i.e. ≥ 75% of the time) more often than adult urologist when removing stents by string or operating room cystoscopy but less often when removing stents by office cystoscopy. Pediatric urologists report using antibiotic prophylaxis "most of the time" more often than adult urologists after pyeloplasty, ureteroscopy and ureteral reimplantation. There is no difference in reported duration of prophylaxis between adult and pediatric urologists, with 64% giving a single dose. Pediatric urologists report obtaining a urine culture (UC) "most of the time" more often than adult urologists (32% vs 15%, p < 0.001), but there is no difference in reported use of antibiotic treatment by UC result. Sixty-four percent of survey respondents report giving patients with negative UC antibiotic treatment, and 93% of survey respondents report treating patients with asymptomatic bacteriuria (defined as patients with a positive urine culture but no symptoms) with antibiotics. DISCUSSION: There is variation in reported practice among surveyed adult and pediatric urologists regarding antibiotic prophylaxis prior to stent removal. Overall, pediatric urologists report using antibiotic prophylaxis prior to stent removal more often than adult urologists. CONCLUSIONS: This variation in practice combined with lack of evidence to support the use of antibiotic prophylaxis prior to ureteral stent removal underscores the need for additional research to guide the development of evidence-driven guidelines for both adult and pediatric patients.

Antireflux Surgery at National Surgical Quality Improvement Program-Pediatric Hospitals.

PURPOSE: This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data. MATERIALS AND METHODS: Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures). RESULTS: In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections. CONCLUSIONS: Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

Postoperative Imaging Patterns of Pediatric Nephrolithiasis: Opportunities for Improvement.

PURPOSE: Imaging following surgical intervention for nephrolithiasis is important to define operative success and ensure the absence of silent obstruction. We assessed nationwide postoperative imaging patterns in children undergoing ureteroscopy and shock wave lithotripsy. MATERIALS AND METHODS: We reviewed the MarketScan® Commercial Claims and Encounters database from 2007 to 2013 for patients 1 to 18 years old undergoing ureteroscopy or shock wave lithotripsy. We assessed imaging exposure following index procedure within 90 days as a primary analysis and 180 days as a secondary analysis of the index procedure. Univariate and multivariate statistical analyses were performed to assess factors associated with undergoing postoperative imaging. RESULTS: A total of 4,251 children met inclusion criteria, of whom 1,647 had undergone shock wave lithotripsy and 2,604 had undergone ureteroscopy. Postoperative imaging was performed in 57.5% of the cohort, with a higher proportion of children undergong imaging following shock wave lithotripsy compared to ureteroscopy (73% vs 47.8%, p <0.001). Noncomputerized tomographic imaging modalities were most common following ureteroscopy (70.8%) and shock wave lithotripsy (84.6%). Younger children and those with complex medical conditions or complicated postoperative courses were more likely to undergo followup imaging. Computerized tomography was more commonly used in older children and females. At 180-day followup 63% of the cohort had undergone any imaging, again more frequently following shock wave lithotripsy (77.0%) vs ureteroscopy (45.0%). CONCLUSIONS: A large percentage of children with nephrolithiasis do not undergo followup imaging after shock wave lithotripsy, and even fewer undergo imaging after ureteroscopy. Most followup imaging is done within 90 days of surgery. Further work is needed to define appropriate postoperative imaging practices in this population.

Availability of Common Pediatric Radiology Studies: Are Rural Patients at a Disadvantage?

BACKGROUND: Many families wish to have radiologic tests performed locally, especially when obtaining these tests in specialized pediatric centers would require long-distance travel with associated costs and inconveniences. The differential availability of specialized and common pediatric uroradiographic tests in rural and urban areas has not been described. We undertook this study to describe the availability of common radiographic tests ordered by pediatric urologists, and to identify disparities in the availability of radiographic tests between urban and rural locations. MATERIALS AND METHODS: We surveyed all freestanding hospitals in Washington State on the availability of flat-plate abdominal radiograph (AXR), renal-bladder ultrasounds (RBUS), voiding cystourethrograms (VCUG), MAG-3 renal scans, and nuclear cystograms (NC) for children, as well as testing restrictions, availability of sedation for urology tests, and presence of onsite radiologists. Rural and urban hospitals were compared on these characteristics. RESULTS: The survey was completed by 74 of 88 institutions (84.1%); 17 (23.0%) were rural (population <2500), 32 (43.2%) were in urban clusters (population 2500-50,000), and 25 (33.8%) were in urban areas (population >50,000). Seventy-three (98.6%) institutions offered AXR, 68 (91.9%) offered RBUS, 44 (59.5%) offered VCUG, 26 (35.1%) offered MAG-3, and 15 (20.3%) offered NC to children. All urban and most (16/17; 94.1%) rural institutions had shareable digital imaging capability. AXR (100% versus 96%, P = 0.88) and RBUS (70.6% versus 96%, P = 0.15) availability was similar in rural and urban settings, whereas VCUG (11.8% versus 72%, P = 0.001), MAG-3 (5.9% versus 60%, P = 0.006), and NC (0% versus 44%, P = 0.017) were more commonly available in urban settings. Fewer rural hospitals employed full-time, in-house radiologists (35.3% versus 96%, P < 0.0001) or offered sedation (6.3% versus 36%, P = 0.01) for testing, but an equal proportion had age restrictions on the tests offered (40% versus 17.6%, P = 0.50). Fellowship-trained pediatric radiologists (0% versus 16%, P = 0.39) and child life specialists (0% versus 20%, P = 0.28) worked exclusively in urban settings. Most hospitals offering specialized radiographic tests (VCUG: 90.9%; P < 0.0001 and MAG-3: 92.3%; P = 0.002) had onsite radiologists. CONCLUSIONS: The geographically widespread availability of AXR and RBUS may represent an opportunity to offer families care closer to home, realizing cost and time savings. Anxious children and those requiring more specialized studies may benefit from referral to urban centers. The lack of rural radiologists may be an actionable barrier to availability of specialized radiology testing.

Neonatal Circumcision and Urinary Tract Infections in Infants With Hydronephrosis.

BACKGROUND: Boys with urinary tract abnormalities may derive a greater benefit from newborn circumcision for prevention of urinary tract infection (UTI) than the general population. However, the effect of newborn circumcision on UTI is not well characterized across the etiological spectrum of hydronephrosis. We hypothesized that boys with an early diagnosis of hydronephrosis who undergo newborn circumcision will have reduced rates of UTI. METHODS: The MarketScan data set, an employer-based claims database, was used to identify boys with hydronephrosis or hydronephrosis-related diagnoses within the first 30 days of life. The primary outcome was the rate of UTIs within the first year of life, comparing circumcised boys with uncircumcised boys and adjusting for region, insurance type, year of birth, and infant comorbidity. RESULTS: A total of 5561 boys met inclusion criteria, including 2386 (42.9%) undergoing newborn circumcision and 3175 (57.1%) uncircumcised boys. On multivariate analysis, circumcision was associated with a decreased risk of UTI in both boys with hydronephrosis and healthy cohorts: odds ratio (OR) 0.36 (95% confidence interval [CI] 0.29-0.44) and OR 0.32 (95% CI 0.21-0.48), respectively. To prevent 1 UTI, 10 patients with hydronephrosis would have to undergo circumcision compared with 83 healthy boys. Among specific hydronephrosis diagnoses, circumcision was associated with a reduced risk of UTI for those with isolated hydronephrosis (OR 0.35 [95% CI 0.26-0.46]), vesicoureteral reflux (OR 0.35 [95% CI 0.23-0.54]), and ureteropelvic junction obstruction (OR 0.35 [95% CI 0.20-0.61]). CONCLUSIONS: Newborn circumcision is associated with a significantly lower rate of UTI among infant boys with hydronephrosis.

Follow-up imaging after acute evaluations for pediatric nephrolithiasis: Trends from a National database.

BACKGROUND: Overuse of computed tomography (CT) in the initial evaluation of children with upper urinary tract calculi (UUTC) has been well documented. Follow-up imaging patterns, however, remain undefined. Sequential imaging following an acute episode of UUTC represents additional opportunity for enacting good imaging stewardship, with the optimal goal to reduce unnecessary radiation exposure and cost while ensuring appropriate follow-up. OBJECTIVE: We explored nationwide imaging patterns for children following emergency department (ED) evaluations for UUTC, hypothesizing that initial imaging choice and complicated visits for UUTC increase the risk of follow-up CT scans. STUDY DESIGN: Claims from Marketscan (2007-2013), an employer-based dataset of privately insured patients, were used to assess children aged 1-18 years presenting to the ED an acute UUTC event. The primary outcome was any imaging within 90 days. Using logistic regression, odds for follow-up CT or plain film kidney-ureter-bladder/ultrasound (KUB/US) imaging were calculated adjusting for patient demographics, initial imaging modality, need for admission, and return ED visits. RESULTS: A total of 821 children met the inclusion criteria, of whom 261 (31.8%) received no follow-up imaging. Overall follow-up imaging patterns, including the proportions of children receiving CT scans, KUB/US imaging, or no imaging are shown in the Summary Table. Of the children receiving follow-up imaging, KUB/US was obtained in 363 (65.0%) and CT obtained in 197 (35.0%) children. Risk factors for follow-up CT imaging include hospital admission and return ED visits. Children with ureteral calculi and index US evaluation were more likely to receive KUB/US imaging only at follow-up. For children with ureteral calculi, the median time to first follow-up imaging was 9 days (25th-75th percentiles, 2-26 days). DISCUSSION: One-third of all children with follow-up imaging after an acute presentation for UUTC will receive a CT. Up to 28% of children with a ureteral calculus will not receive any follow-up imaging within 3 months of presentation. These findings suggest imaging strategies for children following acute evaluation for nephrolithiasis are suboptimal in two ways. First, children receive potentially unnecessary additional radiation burden, an alarming finding considering the high rates of CT scan in the index evaluation for these children. Second, many children with ureteral calculi fail to receive follow-up imaging to document stone passage. CONCLUSIONS: Our findings identify follow-up imaging as another area for quality improvement within the care of children with UUTC. Clinical pathways directing imaging strategies for pediatric nephrolithiasis should focus on follow-up imaging practices and initial evaluation, especially with for those children presenting with ureteral calculi.

Incidence and risk factors associated with 30-day post-operative venous thromboembolism: A NSQIP-pediatric analysis.

INTRO: Venous thromboembolism (VTE) is a rare event in children, but can cause significant morbidity and mortality. The majority of research on pediatric VTE has been in the trauma and critical care populations. The incidence of VTE after surgery in children is not well-established. OBJECTIVE: The objective was to evaluate the incidence of VTE in the 30 days after surgery, as well as associated risk factors. STUDY DESIGN: All cases in the National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 were assessed for presence of post-operative VTE. Demographic, clinical, and peri-operative characteristics were collected. Descriptive statistics were performed, and multiple logistic regression models were created to estimate associated risk of VTE. RESULTS: In a cohort of 267,299 surgical cases, the 30-day incidence of post-operative VTE was 12 per 10,000 cases (0.12%). VTE incidence followed a bi-modal distribution, highest in infants and adolescents (Figure). Malignancy, pre-operative illness, and greater anesthetic times were associated with increased risk of VTE. DISCUSSION: The incidence of post-operative VTE in NSQIPP is similar to that seen in pediatric trauma and critical care populations. Risk factors are also consistent, including baseline illness, immobility, and prolonged anesthetic time. CONCLUSION: Post-operative VTE in children occurs infrequently, yet certain individuals are at increased risk and thus guidelines for prophylaxis and treatment are needed.

Risk factors for repeat surgical intervention in pediatric nephrolithiasis: A Pediatric Health Information System database study.

INTRODUCTION: Successful surgical therapy for pediatric upper urinary tract calculi (UUTC) minimizes the need for repeat surgical interventions. However, staged procedures, whether planned or unplanned, are sometimes necessary. We assessed predictors of repeat intervention for children with UUTC using a nationwide administrative dataset. METHODS: Using the Pediatric Health Information System (PHIS) dataset, we assessed children with UUTC undergoing shock wave lithotripsy (SWL) or ureteroscopy (URS) for an index stone from January 2010 to June 2015. Primary outcome was additional treatment for nephrolithiasis within 90 days. Patient and procedural variables were assessed as potential risks for retreatment. Multivariable logistic regression models were used to compare the risk of retreatment adjusting for potential confounding factors. RESULTS: A total of 2788 patients undergoing URS (2,216, 79.5%) and SWL (572, 20.5%) were identified. SWL, stenting at the index operation without pre-index stenting, chronic comorbidities, renal calculi, and age <5 years were independent risk factors for retreatment. Use of ureteral stenting, most commonly employed in URS, was also a strong predictor of retreatment. Odds for reintervention, adjusted by multivariate modeling, are shown in the Figure. CONCLUSIONS: Adjusting for measured confounders, SWL is associated with a 2.6-fold higher risk of repeat stone-related interventions. Additional patient-related factors also increase likelihood of retreatment. Intra-operative stent placement is a strong predictor of retreatment, perhaps serving as a marker for complex cases or planned staged procedures. Prospective studies are needed to assess comparative effectiveness of SWL and URS and improve mono-therapeutic success for children with UUTC.

Interrater Reliability in Interpretation of Neuropathic Pediatric Urodynamic Tracings: An Expanded Multicenter Study.

PURPOSE: Urodynamic findings often guide treatment for neuropathic bladder and are reported as objective data points in multi-institutional trials. However, urodynamic interpretation can be variable. In a pilot study pediatric urologists interpreting videourodynamics exhibited only moderate agreement despite similar training and practice patterns. We hypothesized the pilot study variability would be replicated in a multi-institutional study. MATERIALS AND METHODS: We developed an anonymous electronic survey that contained 20 scenarios, each with a brief patient history, 1 urodynamic tracing and fluoroscopic imagery. All videourodynamics were completed during routine care of patients with neuropathic bladder at a single institution. Pediatric urologists from Centers for Disease Control and Prevention Urologic Protocol sites were invited to complete an interpretation instrument for each scenario. Fleiss kappa and 95% confidence limits were reported, with Fleiss kappa 1.00 corresponding to perfect agreement. RESULTS: The survey was completed by 14 pediatric urologists at 7 institutions. Substantial agreement was seen for assessment of fluoroscopic bladder shape (Fleiss kappa 0.73), while moderate agreement was observed for assessment of bladder safety, end filling detrusor pressure and bladder capacity (Fleiss kappa 0.50, 0.56 and 0.54, respectively). Fair agreement was seen for electromyographic synergy and presence of detrusor overactivity (Fleiss kappa 0.21 and 0.35, respectively). CONCLUSIONS: Experienced pediatric urologists demonstrate variability during interpretation of videourodynamic tracings. Subjectivity of assessment of electromyographic activity and detrusor overactivity was confirmed in this expanded study. Future work to improve the reliability of videourodynamic interpretation would improve the quality of clinical care and the quality of multi-institutional studies that use urodynamic data points as outcomes.