Do healthcare disparities play a role in pediatric testicular torsion? - Analysis of a single large pediatric center.

INTRODUCTION: Healthcare disparities have been shown to impact outcomes of various acute pediatric conditions. We sought to examine the impact of race, ethnicity and insurance status on the presentation, management and outcome of testicular torsion. MATERIALS AND METHODS: A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤18 years of age evaluated in our pediatric institution's emergency room between April 2016-April 2020 with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant. RESULTS: A total of 206 patients were included. 114 (56.2%) were Black or African American (Black/AA), 43 were (21.2%) Hispanic/Latino, 22 (10.8%) were Caucasian, and 24 (11.8%) were designated as Other races. Ninety-eight (48.3%) patients had Medicaid, 90 (44.3%) had private insurance, and 15 (7.4%) patients were uninsured. Sixty-eight (33.0%) presented in a delayed fashion (>24 h). Compared to the Caucasian patients, Black/AA patients were 2.1 years (95% CI: 0.5, 3.8; P = 0.010) older at the time of presentation. When compared to those with Medicaid insurance, uninsured patients had 6.26 times (95% CI: 1.58, 41.88; P = 0.021) higher odds to be referred from an outside hospital for management. In those patients presenting acutely (<24 h, N = 138), there were no significant differences in the odds of orchiectomy for Black/AA or Hispanic/Latino patients when compared to Caucasian patients, however, the odds of orchiectomy in Other races (non-Caucasian, non-Black/AA, non-Hispanic/Latino) was significantly higher (OR: 10.38; 95% CI: 1.13, 246.96; P = 0.049). While the mean time in minutes from ED to OR was longer in those with Medicaid insurance (141 vs 125.4 private vs 115 uninsured, p = 0.042), this did not impact orchiectomy rate (39.8% vs 40.9% vs 46.7%, p = 0.88). CONCLUSIONS: We found no differences in the orchiectomy rates by race with the exception of a higher rate in the diverse and heterogeneous Other race (non-Caucasian, non-Black/AA, non-Hispanic/Latino) group. Those uninsured had a higher referral rate highlighting the potential existence of disparities for those uninsured and the need for further investigation.

Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion.

BACKGROUND: Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. OBJECTIVE: We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. STUDY DESIGN: Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control. RESULTS: Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137-249 min) to 127 min (IQR 100-148 min; P < 0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P = NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. DISCUSSION: In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. CONCLUSIONS: The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected.

Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned?

Diuresis renography (DR) is widely used in the evaluation of hydronephrosis and hydroureter in infants and children. The goal of this provocative nuclear imaging examination should be to detect the hydronephrotic kidneys at risk for loss of function and development of pain, hematuria, and urinary tract infection. The reliability of DR is dependent on the acquisition and processing of the data as well as interpretation and utilization of the results. In this review, the key concepts of standardized DR and pitfalls to avoid are highlighted.

Factors Associated with Delayed Presentation and Misdiagnosis of Testicular Torsion: A Case-Control Study.

We identified factors associated with delay in presentation and misdiagnosis of testicular torsion. Compared with acute cases, delayed presentations were more likely to report isolated abdominal pain, developmental disorders, and history of recent genital trauma. Failure to perform a genitourinary examination or scrotal imaging was associated with misdiagnosis.

Testicular Torsion Presentation Trends before and after Pediatric Urology Subspecialty Certification.

PURPOSE: We examined testicular torsion presentation and referral trends at our institution before and after pediatric urology subspecialty certification. MATERIALS AND METHODS: We reviewed patients with testicular torsion presenting directly to our pediatric hospital emergency department ("direct") or transferred urgently from an outside institution ("referred") who underwent detorsion and orchiopexy or orchiectomy between 2005 and 2015. Presentations were considered acute (less than 24 hours) or delayed (24 hours or greater) based on time from symptom onset. Primary outcomes were case volume and presentation trends through time. Secondary outcomes were effect of presenting location and transport variables on orchiectomy rate. RESULTS: Incidence of testicular torsion increased from 15 cases in 2005 to 32 in 2015. Annual incidence of direct cases increased slightly during the study period from 12 to 17, whereas incidence of referred cases increased from 3 in 2005 to 15 in 2015. Proportion of referred acute cases markedly increased from precertification (4 of 63, 6.3%) to postcertification period (42 of 155, 27.1%; p <0.01). The majority of referred cases (59 of 83, 71.1%) presented during weekday nights or weekends compared to a minority of direct cases (59 of 135, 43.7%; p <0.01). Orchiectomy rates were similar between direct and referred cases across all study periods and were not significantly impacted by presentation location, transport distance or transport modality (all p >0.05). CONCLUSIONS: Patients with testicular torsion have been increasingly referred to our institution, with the majority presenting on weekday nights and weekends. Our data do not support routinely transferring these patients to dedicated pediatric hospitals.

Split prepuce in situ onlay hypospadias repair: 17 years of experience.

PURPOSE: We report our 17-year experience using split prepuce in situ onlay hypospadias repair, including long-term followup of the first 100 patients initially reported on in 1998. MATERIALS AND METHODS: We identified 421 patients who underwent in situ onlay repair. Charts were retrospectively reviewed to determine preoperative management, intraoperative details and complications. RESULTS: In situ onlay repair was used to repair glanular hypospadias in 22 cases (5.2%), coronal hypospadias in 184 (43.7%), distal shaft hypospadias in 152 (36.1%), mid shaft hypospadias in 51 (12.1%), proximal shaft hypospadias in 7 (1.6%) and hypospadias in the penoscrotal region in 5 (1.2%). Repair was successful with 1 procedure in 376 patients (89.4%), which increased to 99.8% after a second procedure. Complications were defined as any problem that gave the surgeon or family reason for concern. Functional complications requiring reoperation occurred in 45 patients (10.6%). Minor complications requiring simple procedures or early postoperative evaluation occurred in 17 patients (4%). Concerns not requiring intervention occurred in 27 patients (6.4%). There were no urethral strictures. Three patients (0.7%) were lost to followup. Repair is pending in 1 patient. CONCLUSIONS: In situ onlay repair preserves the urethral plate and allows the formation of a well vascularized flap with adequate tissue to completely cover the neourethra, resulting in a low rate of major complications. With longer followup, inclusion of more mid shaft repairs and expansion to more proximal degrees of hypospadias our complication rates are higher than previously reported but there have been no urethral strictures in 17 years of experience. Since complications present at a median of 158 days (mean 570) after the procedure, long-term followup is indicated.

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center.

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.

High-intensity, short-term biofeedback in children with Hinman's syndrome (non-neuropathic voiding dyssynergia).

OBJECTIVE: To evaluate the long-term response to high-intensity, short-term biofeedback in children with severe voiding dysfunction. PATIENTS AND METHODS: We retrospectively reviewed patients who underwent short-term, high-intensity biofeedback therapy from 1996 to 2004. Improvement was classified based on clinical and radiographic findings. Patients were categorized as having Hinman's syndrome when, in addition to urinary incontinence, at least four of the following categories were present: sphincter dyssynergia, bladder trabeculation, large post-void residual (PVR), hydronephrosis, vesicoureteral reflux (VUR) and urinary tract infections. There were 14 patients (eight males and six females), 13 of whom had Hinman's syndrome. Age when biofeedback was initiated varied from 5.6 to 12.9 years (mu=8.9+/-2.2). Before biofeedback, all had large PVRs, bladder trabeculation and sphincter dyssynergia. Nine had hydronephrosis and five had VUR. One patient had renal failure. RESULTS: Before biofeedback, the mean PVR was 109 ml (25-270 ml); after biofeedback, this decreased to 21 ml (0-150 ml), including two patients who eventually failed treatment. All 14 patients were able to relax their external sphincter and reduce the PVR during biofeedback and on short-term follow up. Long-term follow up (mu=59.4 months) in 12 patients established that seven had a durable response with remission of symptoms, reduced PVR and radiographic improvement. In three, symptoms partially recurred over time and two failed treatment completely. CONCLUSION: Short-term, high-intensity biofeedback achieves a durable response in the majority of children with Hinman's syndrome. Long-term follow up is needed to assure compliance.

Parental preferences in the management of vesicoureteral reflux.

PURPOSE: We determined parental preferences for the treatment of vesicoureteral reflux in their child. MATERIALS AND METHODS: Parents of children with vesicoureteral reflux were prospectively recruited to evaluate choices in reflux management. In each case a standard questionnaire that described the treatment options for reflux was administered. Parents were asked to choose between long-term antibacterial prophylaxis with annual radiography studies and open or endoscopic treatment at each of 1 to 5 years of followup. They were also given the choice between open or endoscopic treatment. Annual resolution and/or correction rates provided for medical, surgical and endoscopic management were 20%, 95% to 100% and 80% after 1 or 2 injections, respectively. RESULTS: We queried 91 families of female (81%) and male (19%) patients. Average duration of reflux followup was 2 years and mean patient age was 49.8 months. At diagnosis reflux was grades I to II in 65% of cases, grade III in 26% and grades IV to V in 9%. The majority of parents chose daily antibiotics over surgery if the child was predicted to have vesicoureteral reflux for 1 to 4 years. However, the majority chose ureteral reimplantation over daily antibiotics and yearly x-ray if a 5-year course was predicted. In contrast, parents chose daily antibiotics rather than endoscopic treatment if the anticipated interval was 1 to 3 years. After 3 years the majority preferred the endoscopic approach. Also, 60% of parents stated that they would choose endoscopic treatment over reimplantation, although the child may require repeat endoscopic treatment and there was a 20% chance of persistent vesicoureteral reflux. CONCLUSIONS: Parents of children with vesicoureteral reflux prefer antibiotic prophylaxis as initial treatment. However, when daily antibiotics and yearly cystography may be required beyond 3 to 4 years, most parents would choose definitive correction. While endoscopic treatment is less effective than surgery, parents prefer endoscopic treatment, most likely because it is less invasive. Also, when compared directly against each other, the majority of parents stated that they would choose endoscopic treatment over surgery, although it has a lower success rate.

Early diuresis renogram findings predict success following pyeloplasty.

PURPOSE: We sought to determine whether drainage across the ureteropelvic junction, as indicated by diuretic renography 3 months after pyeloplasty, is an adequate predictor of surgical success. MATERIALS AND METHODS: The medical records of 150 children who underwent pyeloplasty from 1986 to 1995 were reviewed. After excluding nonevaluable cases a total of 127 renal units remained for investigation. Preoperatively each renal unit was examined with a standardized (well-tempered) furosemide stimulated renal scan. Postoperatively 60 renal units were evaluated with standardized diuretic renal scans at 3 and 12 months, 33 renal units at 3 months only and 34 renal units at 12 months only. Surgical success was defined by half-time less than 20 minutes on a standardized diuretic renogram. RESULTS: Of the 33 renal units with a single postoperative study at 3 months 32 (97%) had halftime less than 20 minutes on diuretic renography. The remaining patient in this group with half-time greater than 20 minutes showed 60% improvement in half-time and did not require reoperation. Excluding those without delayed followup, surgical success was obtained in 93 of the 94 (99%) renal units. Among the 60 renal units evaluated with 2 postoperative renal scans success was noted in 48 (80%) and 59 (98%) at 3 and 12 months, respectively. Stenosis did not recur in 48 renal units with half-time less than 20 minutes 3 months after repair. In 1 case that had been treated for postoperative urinoma half-time was greater than 40 minutes at 3 months and repeat pyeloplasty was required. CONCLUSIONS: Half-time less than 20 minutes 3 months after pyeloplasty predicts surgical success. Most renal units that improve but still have half-times greater than 20 minutes on an early diuretic renogram will demonstrate continued improvement in drainage patterns at 12 months. Those renal units that show no improvement at 3 months may require reoperation and those with half-time less than 20 minutes at 3 months do not require further evaluation.

Is the vanished testis always a scrotal event?

OBJECTIVE: To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum. PATIENTS AND METHODS: The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted. RESULTS: The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration. CONCLUSIONS: Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.

Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model.

PURPOSE: To compare the sensitivity and specificity of technetium-99m dimercaptosuccinic acid (DMSA) single photon emission computed tomography (SPECT), spiral computed tomography (CT), magnetic resonance (MR) imaging, and power Doppler ultrasonography (US) for the detection and localization of acute pyelonephritis by using histopathologic findings as the standard of reference. MATERIALS AND METHODS: Bilateral vesicoureteric reflux was surgically created in 35 piglets (70 kidneys). One week later, a liquid bacterial culture of Escherichia coli was injected into the bladder. Three days after induction of urinary infection, imaging studies were performed, and the kidneys were removed for histopathologic examination. SPECT images were obtained 2-3 hours after injection of 99mTc-DMSA. Transverse and coronal MR images were obtained with gadolinium-enhanced fast inversion recovery. Transverse CT images were obtained before and after injection of contrast agent. Power Doppler US was performed in longitudinal, transverse, and coronal planes. Each kidney was divided into three zones for correlation of findings. RESULTS: Histopathologic examination revealed pyelonephritis in 102 zones in 38 kidneys. Sensitivity and specificity for detecting pyelonephritis in the kidneys were 92.1% and 93.8% for SPECT, 89.5% and 87.5% for MR imaging, 86.8% and 87.5% for CT, and 74.3% and 56.7% for US. Sensitivity and specificity for detecting pyelonephritis in the zones were 94.1% and 95.4% for SPECT, 91.2% and 92.6% for MR imaging, 88.2% and 93.5% for CT, and 56.6% and 81.4% for US. The pairwise comparison of these modalities showed no statistically significant difference among them except for US. CONCLUSION: 99mTc-DMSA SPECT, spiral CT, and MR imaging appear to be equally sensitive and reliable for the detection of acute pyelonephritis; power Doppler US is significantly less accurate.

Diagnosis and management of teratomas and epidermoid cysts.

One can strongly suspect a benign lesion in a prepubertal child on the basis of preoperative sonographic, biochemical, and clinical evaluation; however, when considering a testis-sparing enucleation, the definitive diagnosis must be established by pathologic frozen section of the tumor. The high incidence of benign testicular lesions in the prepubertal patient, the absence of associated carcinoma in situ in prepubertal germ cell tumors, and the universally benign behavior of the specific tumors described in this article are supportive evidence for testis-sparing surgery versus orchiectomy, for these benign lesions.

Adjunctive oral corticosteroids reduce renal scarring: the piglet model of reflux and acute experimental pyelonephritis.

PURPOSE: We investigate the efficacy of antibiotics combined with corticosteroid in diminishing post-pyelonephritic renal scarring compared to standard antibiotic therapy. MATERIALS AND METHODS: Bilateral vesicoureteral reflux was surgically created in 36 piglets (72 kidneys). A week later each bladder was inoculated by percutaneous injection with a standardized broth culture of Escherichia coli and molten paraffin. 99mTechnetium dimercapto-succinic acid (DMSA) scintigraphy was performed 3 days after introduction of urinary infection to detect the presence of acute pyelonephritis. Acute pyelonephritic lesions seen on DMSA scans were graded according to the percentage of renal zone involvement as grade 1--less than 33%, grade 2--33 to 66% and grade 3--greater than 66% involved. When pyelonephritis was present, piglets were randomized to receive either standard antibiotics or antibiotics and 2 mg./kg. prednisolone daily. 99mTechnetium-DMSA scintigraphy was repeated 2 months after completion of therapy, and the kidneys were harvested for gross and histopathological examination. Each kidney was divided into upper, middle and lower zones for correlation of pathological and imaging findings. Severity of renal scarring was then assessed using histopathological confirmation of gross anatomical findings as grade 1--less than 1, grade 2-1 to 2 and grade 3-greater than 2 cm. RESULTS: Acute pyelonephritis was induced in 136 of 216 renal zones. The sites of renal scarring corresponded anatomically to sites of acute pyelonephritis in all but 5 cases. Overall, the prevalence of post-pyelonephritic scarring was 56.6% (77 of 136) of renal zones. The severity of scarring in both groups correlated with the severity of the initial pyelonephritic lesion. Of the 31 zones that formed grade 3 renal scars the distribution of grades 1, 2 and 3 acute pyelonephritis on the initial DMSA scan was 3, 26 and 71%, respectively. Grade 3 acute pyelonephritis was more likely to result in severe (grade 3) renal scars in the control compared to the steroid treated group (59 versus 31%). Overall, acute pyelonephritis completely resolved in 40% of controls and 51% of steroid treated animals. However, only 9% of control animals with grade 3 acute pyelonephritis demonstrated complete resolution, as opposed to 28% of those receiving steroids. CONCLUSIONS: The risk of renal scarring is greatest after severe acute pyelonephritis involving greater than 66% of a renal zone. Adjunctive oral prednisolone appears to be effective in diminishing renal scarring in severely affected kidneys. In kidneys with mild and moderate acute pyelonephritis antibiotics alone appear to be equally effective in preventing scarring.

The role of 99mtechnetium dimercapto-succinic acid renal scans in the evaluation of occult ectopic ureters in girls with paradoxical incontinence.

PURPOSE: We describe the use of 99mtechnetium (Tc) dimercapto-succinic acid (DMSA) renal scintigraphy to document poorly functioning and/or ectopic renal units associated with occult ectopic ureters. MATERIALS AND METHODS: During the last 8 years 6 toilet-trained girls were referred for lifelong continuous urinary dribbling. Initial radiological evaluation included renal and bladder sonography in 6, excretory urography in 4, a mercaptoacetyltriglycine-3 renal scan in 1 and cystovaginoscopy in 2. Ultimately a 99mTc-DMSA renal scan was performed in all 6 girls before surgical intervention. RESULTS: Sonography failed to establish the diagnosis of ureteral ectopia in all cases, and revealed a normal solitary kidney in 3, normal kidneys in 1, an apparently uncomplicated unilateral duplication without hydroureteronephrosis in 1 and a contralateral uncomplicated duplication in 1. Excretory urography in 4 cases was inconclusive and showed a solitary kidney in 1, ipsilateral duplication without a normal appearing upper pole collecting system in 1, contralateral uncomplicated duplication in 1 and normal kidneys in 1. A mercaptoacetyltriglycine-3 renal scan in another girl with a solitary kidney on sonography failed to demonstrate a contralateral small ectopic kidney. Cystovaginoscopy performed in 2 patients by other pediatric urologists was nondiagnostic. 99mTc-DMSA renal scintigraphy was diagnostic in all 6 cases, and revealed a small poorly functioning ectopic kidney in 3 and a poorly functioning dysplastic upper pole moiety in 3, which were consistent with a diagnosis of ureteral ectopia. An ectopic ureter was confirmed by cystoscopic and surgical findings in all girls. CONCLUSIONS: 99mTc-DMSA renal scintigraphy reliably detects and localizes hypoplastic ectopic kidneys and poorly functioning upper pole moieties associated with occult ectopic ureters in girls with continuous urinary leakage.

Bladder distention and pyelectasis in the male fetus: causes, comparisons, and contrasts.

The objective of this paper was to determine if prenatal sonographic findings can accurately differentiate between the causes of bladder distention and pyelectasis in the male fetus. Twenty-one cases were evaluated for the presence of oligohydramnios, posterior urethral dilation, bladder wall thickening, urachal patency, cortical thinning, cortical cysts, and increased renal echogenicity. Postnatal diagnosis included posterior urethral valves (10 cases), prune belly syndrome (four cases), vesicoureteral reflux (four cases), left ureterovesical junction obstruction (one case), and nonrefluxing, nonobstructive megacystis-megaureter (two cases). Oligohydramnios was present in eight of 10 cases of posterior urethral valves and in one of four cases of prune belly syndrome. A dilated posterior urethra was noted in seven of 10 cases of posterior urethral valves and transiently in two of four cases of prune belly syndrome. Bladder wall thickening developed in all cases of posterior urethral valves and was noted in two of four patients with prune belly syndrome. A patent urachus likewise was identified in two of four cases of prune belly syndrome. The presence of oligohydramnios, progressive bladder wall thickening, and dilated posterior urethra was most suggestive of posterior urethral valves, whereas the presence of a patent urachus was most suggestive of prune belly syndrome. The presence of pyelectasis and megacystis without additional amniotic fluid, bladder, urethral, or renal abnormalities was most suggestive of vesicoureteral reflux, ureterovesical junction obstruction, or nonrefluxing, nonobstructive megacystis-megaureter. Owing to the overlap and evolution of these findings, close follow-up evaluation is recommended.