Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children. OBJECTIVE: The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls. STUDY DESIGN: Institutional Review Board approval was obtained to prospectively enroll patients aged <18 years if they had undergone urologic reconstruction that included a bowel anastomosis. ERAS included: no bowel preparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery. RESULTS: A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P < 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P < 0.001), and early feeding (P < 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations. DISCUSSION: Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding. CONCLUSION: ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS.

Trends in pediatric urologic consultations in a tertiary care hospital setting.

BACKGROUND: There is growing interest in the general activities of a pediatric urologist, whose specialty remains young in the spectrum of modern, organized medicine. Unplanned activities, which are more commonly referred to as consultations, can represent significant additional workload for the urologist seeing scheduled clinic patients or completing elective operative cases. OBJECTIVES: This study sought to better understand the practice patterns surrounding inpatient consultations of pediatric urology, and to describe patterns in reasons, timing, patient and service factors that may lead to patient intervention. STUDY DESIGN: Consultations at a tertiary care center were prospectively tracked using a consult note template with embedded data collection fields directly within the Epic electronic medical record. Bivariate and multivariate logistic regression were used to predict need for intervention. RESULTS: A total of 351 eligible consultations were completed during the 15-month study period. A total of 174 (50%) consultations originated from the emergency department, with 26% of those having been transferred from another institution (Figure). Consults occurred more frequently at the beginning of the week than at the end of the week (R2 = 0.7545) and at the end of the day rather than the beginning (R2 = 0.2504). Of these consults, 36% required an intervention, defined as bedside procedure, operative procedure or study in interventional radiology. Factors associated with intervention on multivariate analysis included consultation from the emergency department, pertinent radiologic or laboratory findings, and consultation after hours. DISCUSSION: With the introduction of subspecialty certification in pediatric urology there has been growing concern about a shift in the number and type of consultations seen by pediatric urology. Unlike prior examinations of pediatric urology consultation, the present study recorded diagnoses that appeared to more commonly result in urology consultation than in the past, such as testicular torsion. It highlighted a small subset of children with medical complexity and who were frequently admitted to the hospital, and accounted for nearly one fifth of all consultations. Repeat consultations underscored a need for ongoing education of the family, primary care and emergency department providers, and other services who interface with complex patients with ongoing healthcare needs. CONCLUSIONS: The pediatric urology service averaged about one formal consultation per day, with the most common diagnoses being hydronephrosis, urinary tract infection, urolithiasis, testicular torsion, and retention. One third of consults required intervention. Improved understanding of pediatric urology consultation would be helpful to facilitate physician education and improve service efficiency in the hospital setting.

Systematic review of bladder cancer outcomes in patients with spina bifida.

BACKGROUND: In patients with congenital bladder anomalies, bladder augmentation is used as a last resort to reduce intravesical pressure, but concerns about malignant transformation in augmented patients were first raised in the 1980s. The best evidence to date indicates that augmentation does not appear to increase the risk of bladder cancer in spina bifida patients. To date, oncologic outcomes from patients with spina bifida with and without augmentation have only been available in small case reports. OBJECTIVE: To systematically evaluate factors in myelomeningocele patients with bladder cancer, including bladder augmentation, that contribute to overall survival (OS). STUDY DESIGN: A systematic review using PubMed was conducted by cross referencing terms 'myelomeningocele,' 'cystoplasty,' 'bladder cancer' and respective synonyms according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were studies with patients with an underlying diagnosis of myelomeningocele and bladder cancer with data on age, stage, and mortality status. Studies were excluded for spinal cord injury, history of tuberculosis or schistosomiasis, or prior ureterosigmoidostomy. RESULTS: Fifty-two patients were identified from 28 studies with a median age at bladder cancer diagnosis of 41 years (range 13-73); 37 (71%) presented with stage III or IV bladder cancer. Overall survival at 1 year and 2 years was 48.5% and 31.5%, respectively. Overall survival was different between those with and without augmentation (P = 0.009) by log-rank analysis. No between-group differences in OS were seen based on age, management with indwelling catheter, diversion with ileal conduit or being on a surveillance program. Only stage remained a significant predictor of OS on multivariate analysis (HR 2.011, 95% CI 1.063-3.804, P = 0.032). Secondary analysis was performed after removing patients with gastric augmentation (n = 8), and no difference in OS was seen between patients with (n = 8) and without augmentation (n = 36, P = 0.112). Of augmented patients, latency to development of bladder cancer was variable (Summary Figure). DISCUSSION: Bladder cancer is a deadly diagnosis in patients with congenital bladder anomalies like spina bifida, and while overall prevalence of the two conditions occurring together is low, bladder cancer will go on to affect 2-4% of spina bifida patients. The present study examined overall survival, and further characterized outcomes in these patients. Presence of a bladder augment did not appear to worsen overall survival. CONCLUSIONS: Patients with myelomeningocele who developed bladder cancer had aggressive disease. Augmentation did not worsen OS, based on cases reported in the literature. Risk of bladder cancer should be discussed with all myelomeningocele patients.

Dutasteride: novel milestones in prostate cancer chemoprevention.

Prostate cancer (PCa) remains the most-diagnosed cancer and the second leading cause of cancer death among men in the Unites States with over 32,000 deaths estimated in 2010 alone (1). Since the beginning of the prostate-specific antigen era, the incidence of biopsy-detected PCa has increased significantly, resulting in a stage migration towards indolent, slow-growing cancers and ensuring that relatively few men present at advanced stages of disease (2). These issues highlight the need to not only consider the approach to secondary prevention (clinical screening) but also explore the potential of primary chemoprevention for this disease that affects 1 in 6 men over their lifetimes. Out of experiences with the landmark Prostate Cancer Prevention Trial (PCPT) and the REduction by DUtasteride of prostate Cancer Events (REDUCE) trial, we have learned of promising abilities to reduce the prevalence of PCa with a class of medications called 5α-reductase inhibitors (3, 4). This review will address the basis for chemoprevention, examine the role of serum and prostatic androgens in prostate growth and development of PCa, review unanswered questions from the PCPT, discuss results of the recently released REDUCE trial that looked at the ability of dutasteride to decrease the prevalence of PCa, and explore future clinical roles for these medications and chemoprevention in general.