Inter-disciplinary provider development of an online, interactive adolescent varicocele decision aid prototype.

BACKGROUND: Decision-making regarding varicocele management can be a complex process for patients and families. However, to date, no studies have presented ways to mitigate the decisional conflict surrounding varicoceles. OBJECTIVE: To facilitate a discussion among physicians in order to develop a framework of the decision-making process regarding adolescent varicocele management, which will inform the development of the first online, interactive decision aid. MATERIALS AND METHODS: Semi-structured interviews with pediatric urologists and interventional radiologists were conducted to discuss their rationale for varicocele decision-making. Interviews were audio recorded, transcribed, and coded. Key themes were identified, grouped, and then qualitatively analyzed using thematic analysis. Utilizing the common themes identified and the Ottawa Decision Support Framework, a decision aid prototype was developed and transformed into a user-friendly website: varicoceledecisionaid.com. RESULTS: Pediatric urologists (n = 10) and interventional radiologists (n = 2) were interviewed. Key themes identified included: (1) definition/epidemiology; (2) observation as an appropriate management choice; (3) reasons to recommend repair; (4) types of repair; (5) reasons to recommend one repair over another; (6) shared decision-making; and (7) appropriate counseling. With this insight, a varicocele decision aid prototype was developed that engages patients and parents in the decision-making process. DISCUSSION AND CONCLUSIONS: This is the first interactive and easily accessible varicocele decision aid prototype developed by inter-disciplinary physicians for patients. This tool aids in decision-making surrounding varicocele surgery. It can be used before or after consultation to help families understand more about varicoceles and their repair, and why intervention may or may not be offered. It also considers a patient and family's personal values. Future studies will incorporate the patient and family perspective into the decision-making aid as well as implement and test the usability of this decision aid prototype in practice and in the wider urologic community.

Internal hernia with volvulus after major abdominal reconstructions in pediatric urology - An infrequently reported and potentially devastating complication.

INTRODUCTION: Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and appendicocecostomy (APC) can facilitate continence and prevent renal damage for patients with congenital urologic or bowel disease. Bowel obstruction is a well-documented complication of these procedures, and the etiology of obstruction is variable. The aim of this study is to determine the incidence and describe the presentation, surgical findings, and outcomes of bowel obstruction from internal herniation due to these reconstructions. METHODS: In this single institution retrospective cohort study patients who underwent EC, APV, and/or an APC between 1/2011 and 4/2022 were identified via CPT codes within the institutional billing database. Records for any subsequent exploratory laparotomy during this same timeframe were reviewed. The primary outcome was an internal hernia of bowel into the potential space between the reconstruction and the posterior or anterior abdominal wall. RESULTS: Two hundred fifty seven index procedures were performed in 139 patients. These patients were followed for a median of 60 months (IQR 35-104 months). Nineteen patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/257). The complications occurred between 19 months and 9 years after their index procedure (median 5 years). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. One complication was caused by small bowel and cecum passing around the APC and subsequently volvulizing. A second was caused by bowel herniating behind the EC's mesentery and the posterior abdominal wall. A third was caused by bowel herniating behind the APV mesentery and subsequently volvulizing. The exact etiology of fourth internal herniation is unknown. Of the three surviving patients, all required resection of ischemic bowel and 2 required resection of the involved reconstruction. One patient died intraoperatively from cardiac arrest. Only 1 patient required a subsequent procedure to regain lost function. CONCLUSION: Internal herniation caused by small or large bowel passing through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 257 reconstructions performed over 11 years. This complication can arise many years after abdominal reconstruction, resulting in bowel resection and possibly takedown of the reconstruction. When anatomically possible and technically feasible, the surgeon should close any potential spaces created during the initial abdominal reconstruction.

An optoacoustic imaging feature set to characterise blood vessels surrounding benign and malignant breast lesions.

Combining optoacoustic (OA) imaging with ultrasound (US) enables visualisation of functional blood vasculature in breast lesions by OA to be overlaid with the morphological information of US. Here, we develop a simple OA feature set to differentiate benign and malignant breast lesions. 94 female patients with benign, indeterminate or suspicious lesions were recruited and underwent OA-US. An OA-US imaging feature set was developed using images from the first 38 patients, which contained 14 malignant and 8 benign solid lesions. Two independent radiologists blindly scored the OA-US images of a further 56 patients, which included 31 malignant and 13 benign solid lesions, with a sensitivity of 96.8% and specificity of 84.6%. Our findings indicate that OA-US can reveal vascular patterns of breast lesions that indicate malignancy using a simple feature set based on single wavelength OA data, which is therefore amenable to application in low resource settings for breast cancer management.

National Trends and Outcomes in the Use of Intravesical Botulinum Toxin and Enterocystoplasty Among Patients With Myelomeningocele.

OBJECTIVE: To compare trends in the treatment of patients with myelomeningocele receiving intravesical Botulinum (IVB) toxin and enterocystoplasty. METHODS: We identified patients with myelomeningocele in a commercial insurance database from 2008-2017 and stratified them into adult and pediatric samples. Index procedure was identified as either IVB toxin injection or enterocystoplasty. The annual rate of treatments was measured and a change in treatment rate was identified. Time to enterocysplasty was calculated using survival analysis and factors associated with clinical outcomes up to 10 years after index procedure were determined using multivariate Poisson regression. RESULTS: We identified 60,983 patients with myelomeningocele. Nearly twice as many pediatric patients had an enterocystoplasty (n = 317) compared to IVB (n = 138). Very few adult patients underwent enterocystoplasty (n = 25) compared to IVB (n = 116). We identified a significant increase in the annual rate of IVB use around mid-2010 among pediatric patients and around mid-2009 among adults. Twelve pediatric patients (8.6%) and 5 adults (4.3%) went on to receive an enterocystoplasty. Patients who received IVB as the index procedure experienced significantly lower rates of hospitalization days (RR 0.64; 95% CI 0.53-0.78), emergency department visits (RR 0.72; 95% CI 0.63-0.82), and an increased rate of urologic procedures (RR 1.44; 95% CI 1.28-1.62). CONCLUSION: The annual rate of IVB use has increased among patients with myelomeningocele. Nearly 1 in 10 pediatric patients and 1 in 20 adults go on to receive enterocystoplasty. Patients who receive IVB experience lower rates of hospitalization and emergency department visits compared to patients who receive enterocystoplasty.

Outcomes of male patients attending the symptomatic breast unit: adherence to local and national imaging guidelines and effectiveness of clinical examination and imaging in detecting male breast cancer.

AIM: To review outcomes of male patients attending the breast unit, evaluate effectiveness of imaging and examination in detecting breast cancer and review adherence to guidelines for male breast imaging. MATERIALS AND METHODS: A retrospective review was undertaken of male patients attending Cambridge Breast Unit from 1 January 2015 to 31 December 2019. Patient electronic records and imaging were reviewed to establish demographics, clinical findings, imaging, biopsy, and pathology outcomes. RESULTS: Of 1,362 male patients attending the breast unit, 1,028 (75%) had imaging performed. Biopsy was performed in 41 men (3%), with 14 cancers diagnosed (1%). Clinical examination showed 42.7% sensitivity, 99.6% specificity, 54.6% positive predictive value (PPV) and 99.4% negative predictive value (NPV) for detection of cancer. Mammogram demonstrated 84.6% sensitivity, 99.4% specificity, 69.8% PPV, and 99.8% NPV for detection of malignancy. Ultrasound demonstrated 78.6% sensitivity, 98.9% specificity, 73.3% PPV and 99.2% NPV for detection of cancer. Forty-one percent of patients <40 years and 51% < 50 years were imaged, who according to local and Royal College of Radiologists (RCR) guidelines did not require imaging based on age and clinical score. CONCLUSION: Male patients account for a small proportion of referrals to the breast unit but generate significant workload. Imaging protocols, incorporating clinical score and age cut-off at 40 years remains robust for detecting malignancy. Clinician awareness of the imaging protocol, and close liaison with radiologists is essential to minimise additional radiology workload.

Urodynamic characteristics of neurogenic bladder in newborns with myelomeningocele and refinement of the definition of bladder hostility: Findings from the UMPIRE multi-center study.

INTRODUCTION: Infants with myelomeningocele are at risk for chronic kidney disease caused by neurogenic bladder dysfunction. Urodynamic evaluation plays a key role to risk stratify individuals for renal deterioration. OBJECTIVE: To present baseline urodynamic findings from the Urologic Management to Preserve Initial Renal function for young children with spina bifida (UMPIRE) protocol, to present the process that showed inadequacies of our original classification scheme, and to propose a refined definition of bladder hostility and categorization. STUDY DESIGN: The UMPIRE protocol follows a cohort of newborns with myelomeningocele at nine children's hospitals in the United States. Infants are started on clean intermittent catheterization shortly after birth. If residual volumes are low and there is no or mild hydronephrosis, catheterization is discontinued. Baseline urodynamics are obtained at or before 3 months of age to determine further management. Based on protocol-specific definitions, urodynamic studies were reviewed by the clinical site in addition to a central review team; and if necessary, by all site urologists to achieve 100% concurrence. RESULTS: We reviewed 157 newborn urodynamic studies performed between May 2015 and September 2017. Of these 157 infants, 54.8% were boys (86/157). Myelomeningocele closure was performed in-utero in 18.4% (29/157) and postnatally in 81.5% (128/157) of newborns. After primary review, reviewers agreed on overall bladder categorization in 50% (79/157) of studies. Concurrence ultimately reached 100% with further standardization of interpretation. We found that it was not possible to reliably differentiate a bladder contraction due to detrusor overactivity from a volitional voiding contraction in an infant. We revised our categorization system to group the "normal" and "safe" categories together as "low risk". Additionally, diagnosis of detrusor sphincter dyssynergia (DSD) with surface patch electrodes could not be supported by other elements of the urodynamics study. We excluded DSD from our revised high risk category. The final categorizations were high risk in 15% (23/157); intermediate risk in 61% (96/157); and low risk in 24% (38/157). CONCLUSION: We found pitfalls with our original categorization for bladder hostility. Notably, DSD could not be reliably measured with surface patch of electrodes. The effect of this change on future renal outcomes remains to be defined.

Incidence of Urinary Tract Infections in Newborns with Spina Bifida-Is Antibiotic Prophylaxis Necessary?

PURPOSE: Urinary tract infections commonly occur in patients with spina bifida and pose a risk of renal scarring. Routine antibiotic prophylaxis has been utilized in newborns with spina bifida to prevent urinary tract infections. We hypothesized that prophylaxis can safely be withheld in newborns with spina bifida until clinical assessment allows for risk stratification. MATERIALS AND METHODS: Newborns with myelomeningocele at 9 institutions were prospectively enrolled in the UMPIRE study and managed by a standardized protocol with a strict definition of urinary tract infection. Patient data were collected regarding details of reported urinary tract infection, baseline renal ultrasound findings, vesicoureteral reflux, use of clean intermittent catheterization and circumcision status in boys. Risk ratios and corresponding 95% confidence intervals were calculated using log-binomial models. RESULTS: From February 2015 through August 2019 data were available on 299 newborns (50.5% male). During the first 4 months of life, 48 newborns (16.1%) were treated for urinary tract infection with 23 (7.7%) having positive cultures; however, only 12 (4.0%) met the strict definition of urinary tract infection. Infants with grade 3-4 hydronephrosis had an increased risk of urinary tract infection compared to infants with no hydronephrosis (RR=10.1; 95% CI=2.8, 36.3). Infants on clean intermittent catheterization also had an increased risk of urinary tract infection (RR=3.3; 95% CI=1.0, 10.5). CONCLUSIONS: The incidence of a culture positive, symptomatic urinary tract infection among newborns with spina bifida in the first 4 months of life was low. Patients with high grades of hydronephrosis or those on clean intermittent catheterization had a significantly greater incidence of urinary tract infection. Our findings suggest that routine antibiotic prophylaxis may not be necessary for most newborns with spina bifida.

An analysis of screen-detected invasive cancers by grade in the English breast cancer screening programme: are we failing to detect sufficient small grade 3 cancers?

OBJECTIVE: Randomised controlled trials have shown a reduction in breast cancer mortality from mammography screening and it is the detection of high-grade invasive cancers that is responsible for much of this effect. We determined the detection rates of invasive cancers by grade, size and type of screen and estimated relative sensitivities with emphasis on grade 3 detection. METHODS: This observational study analysed data from over 11 million screening episodes (67,681 invasive cancers) from the English NHS breast screening programme over seven screening years 2009/2010 to 2015/2016 for women aged 45-70. RESULTS: At prevalent (first) screens (which are unaffected by screening interval), the detection rate of small (< 15 mm) invasive cancers was 0.95 per 1000 for grade 1, but for grade 3 only 0.30 per 1000. The ratio of small (< 15 mm) to large (≥ 15 mm) cancers was 1.8:1 for grade 1 but reversed to 0.5:1 for grade 3. We estimated that the relative sensitivity for grade 3 invasive cancers was 52% of that for grade 1 and the relative sensitivity for small (< 15 mm) grade 3 only 26% of that for small (< 15 mm) grade 1 invasive cancers. CONCLUSIONS: Sensitivity for small grade 3 invasive cancers is poor compared with that for grade 1 and 2 invasive cancers and larger grade 3 malignancies. This observation is likely a limitation of the current technology related to the absence of identifiable mammographic features for small high-grade cancers. Future work should focus on technologies and strategies to improve detection of these clinically most significant cancers. KEY POINTS: • The detection of small high-grade invasive cancers is vital to reduce breast cancer mortality. • We estimate the sensitivity for small grade 3 invasive cancers may be only 26% of that of small grade 1 invasive cancers. This is likely to be associated with the non-specific mammographic features for these cancers. • New technologies and appropriate strategies using current technology are required to maximise the detection of small grade 3 invasive cancers.

Continence outcomes following a modification of the Mitchell bladder neck reconstruction in myelomeningocele: A single institution experience.

BACKGROUND: Many surgical procedures have been developed to improve continence in myelomeningocele patients. Our modification of the Mitchell bladder neck reconstruction involves removal of a diamond-shaped wedge of the anterior bladder neck, tubularization of the bladder neck and urethra to increase outlet resistance, and addition of a bladder neck autologous fascial sling. OBJECTIVE: We aimed to evaluate rates of continence and re-operation in children with myelomeningocele undergoing this Modified Mitchell bladder neck reconstruction. STUDY DESIGN: We retrospectively identified children with myelomeningocele having undergone bladder neck reconstruction at our tertiary care referral center from 2012 to 2016. RESULTS: We identified twelve patients with myelomeningocele undergoing this modified bladder neck reconstruction with sling, four female and eight male, median age at the time of surgery was 7 years old. After initial bladder neck reconstruction with sling only 33% were dry. All patients with bothersome leakage after reconstruction underwent bladder neck bulking. Two patients of twelve (17%) ultimately underwent bladder neck closure and achieved dryness. 58% of patients ultimately achieved continence (Summary Figure). DISCUSSION: Our modification of the bladder neck reconstruction with autologous fascial sling showed midterm rates of incontinence near 60%, with initial post-operative continence at 33%. Our patients, however, required higher rates of reoperation (43%) than previous results would suggest (27%). The first line of re-treatment was bladder neck bulking, but this showed low success. While this procedure is minimally invasive and safe, reasonable expectations of efficacy should be established with families when offering this option. Two patients (17%) required bladder neck closure to achieve dryness. While bladder neck closure is often considered a procedure of last resort, both of these patients were immediately dry. Perhaps bladder neck closure should be considered earlier in our algorithm of surgical continence. CONCLUSION: Our rates of continence with the Modified Mitchell bladder neck reconstruction with a fascial sling were similar to prior bladder neck reconstructions. We did find higher rates of reoperation, and further modifications are warranted to continue to improve continence after surgical procedures in the myelomeningocele population. Select cases may warrant early consideration of bladder neck closure.

Correction to: An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme.

The original version of this article, published on 04 February 2019, unfortunately contained a mistake.

Evidence for avoiding the biopsy of typical fibroadenomas in women aged 25-29 years.

AIM: To determine if any malignancies would have been missed in women aged 25-29 years in the absence of needle biopsy of sonographically typical fibroadenomas, and to present a non-biopsy protocol for fibroadenomas in this age group using strict criteria. MATERIALS AND METHODS: Women aged 25-29 years undergoing needle biopsies in three centres over a collective 16-year period were identified. Imaging, clinical information, needle biopsy, and surgical histopathology results were obtained from hospital medical records at each centre. RESULTS: Between January 2001 and December 2016, 885 women aged 25-29 years underwent core biopsy. Of 595 sonographically typical fibroadenomas, 549 were histologically confirmed fibroadenomas, 46 were other benign entities, none were cancers. All cancers were scored as indeterminate or suspicious on ultrasound. With a non-biopsy protocol in clinical practice in Centre A, between 2009 and 2018, 259 sonographically typical fibroadenomas met criteria for non-biopsy, and to date, no cancers have been missed. CONCLUSION: This study provides evidence for safe non-biopsy of typical fibroadenomas in women aged 25-29 years when the clinical and sonographic presentations meet strict criteria. A protocol for non-biopsy to include this age group is suggested on incorporation of these results into existing guidance for managing younger women.

Final Results of the Prospective FH02 Mammographic Surveillance Study of Women Aged 35-39 at Increased Familial Risk of Breast Cancer.

BACKGROUND: Many women who are at increased risk of breast cancer due to a mother or sister diagnosed with breast cancer aged under 40 do not currently qualify for surveillance before 40 years of age. There are almost no available data to assess whether mammography screening aged 35-39 years would be effective in this group, in terms of detection of breast cancer at an early stage or cost effective. METHODS: A cohort screening study (FH02) with annual mammography was devised for women aged 35-39 to assess the sensitivity and screening performance and potential survival of women with identified tumours. FINDINGS: 2899 women were recruited from 12/2006-12/2015. These women underwent 12,086 annual screening mammograms and were followed for 13,365.8 years. A total of 55 breast cancers in 54 women occurred during the study period (one bilateral) with 50 cancers (49 women) (15 CIS) adherent to the screening. Eighty percent (28/35) of invasive cancers were ≤ 2 cm and 80% also lymph node negative. Invasive cancers diagnosed in FH02 were significantly smaller than the comparable (POSH-unscreened prospective) study group (45% (131/293) ≤ 2 cm in POSH vs 80% (28/35) in FH02 p < 0.0001), and were less likely to be lymph-node positive (54% (158/290, 3 unknown) in POSH vs 20% (7/35) in FH02: p = 0.0002. Projected and actual survival were also better than POSH. Overall radiation dose was not higher than in an older screened population at mean dose on study per standard sized breast of 1.5 mGy. INTERPRETATION: Mammography screening aged 35-39 years detects breast cancer at an early stage and is likely to be as effective in reducing mortality as in women at increased breast cancer risk aged 40-49 years.

Baseline Urinary Tract Imaging in Infants Enrolled in the UMPIRE Protocol for Children with Spina Bifida.

PURPOSE: The lifetime risk of renal damage in children with spina bifida is high but only limited baseline imaging data are available for this population. We evaluated a large prospective cohort of infants with spina bifida to define their baseline imaging characteristics. MATERIALS AND METHODS: The UMPIRE Protocol for Young Children with Spina Bifida is an iterative quality improvement protocol that follows a cohort of newborns at 9 United States centers. Using descriptive statistics, we report the initial baseline imaging characteristics, specifically regarding renal bladder ultrasound, cystogram and dimercaptosuccinic acid nuclear medicine scan. RESULTS: Data on 193 infants from 2015 to 2018 were analyzed. Renal-bladder ultrasound was normal in 55.9% of infants, while 40.4% had Society for Fetal Urology grade 1 to 2 hydronephrosis in at least 1 kidney, 3.7% had grade 3 to 4 hydronephrosis in either kidney and 21.8% had grade 1 or higher bilateral hydronephrosis. There was no vesicoureteral reflux in 84.6% of infants. A third of enrolled infants underwent dimercaptosuccinic acid nuclear medicine renal scan, of whom 92.4% had no renal defects and 93.9% had a difference in differential function of less than 15%. CONCLUSIONS: The majority of infants born with spina bifida have normal baseline imaging characteristics and normal urinary tract anatomy at birth. This proactive protocol offers careful scheduled surveillance of the urinary tract with the goal of lifelong maintenance of normal renal function and healthy genitourinary development.

An analysis of 11.3 million screening tests examining the association between needle biopsy rates and cancer detection rates in the English NHS Breast Cancer Screening Programme.

AIM: To examine the association between recall, needle biopsy, and cancer detection rates to inform the setting of target ranges to optimise the benefit to harm ratio of breast screening programmes. MATERIALS AND METHODS: Annual screening programme information from 2009/10 to 2015/16 for the 80 screening units of the English National Health Service Breast Screening Programme (totalling 11.3 million screening tests) was obtained from annual (KC62) returns. Linear regression models were used to examine the association between needle biopsy rates and recall rates and non-linear regression models to examine the association between cancer detection rates and needle biopsy rates. RESULTS: The models show and quantify the diminishing returns for prevalent screens with increasing biopsy rates. A biopsy rate increase from 10 to 20 per 1,000 increases the cancer detection rate by 2.13 per 1,000 with four extra biopsies per extra cancer detected. Increasing the biopsy rate from 40 to 50 per 1,000, increases the cancer detection rate by only 0.25 per 1,000, with 40 extra biopsies per extra cancer detected. Although diminishing returns are also seen at incident screens, screening is generally more efficient. CONCLUSIONS: Increasing needle biopsy rates leads to rapidly diminishing returns in cancer detection and a marked increase in non-malignant/benign needle biopsies. Much of the harms associated with screening in terms of false-positive recall rates and non-cancer biopsies occur at prevalent screens with much lower rates at incident screens. Needle biopsy rate targets should be considered together with recall rate targets to maximise benefit and minimise harm.

An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme.

OBJECTIVE: To develop methods to model the relationship between cancer detection and recall rates to inform professional standards. METHODS: Annual screening programme information for each of the 80 English NHSBSP units (totalling 11.3 million screening tests) for the seven screening years from 1 April 2009 to 31 March 2016 and some Dutch screening programme information were used to produce linear and non-linear models. The non-linear models estimated the modelled maximum values (MMV) for cancers detected at different grades and estimated how rapidly the MMV was reached (the modelled 'slope' (MS)). Main outcomes include the detection rate for combined invasive/micro-invasive and high-grade DCIS (IHG) detection rate and the low/intermediate grade DCIS (LIG) detection rate. RESULTS: At prevalent screens for IHG cancers, 99% of the MMV was reached at a recall rate of 7.0%. The LIG detection rate had no discernible plateau, increasing linearly at a rate of 0.12 per 1000 for every 1% increase in recall rate. At incident screens, 99% of the MMV for IHG cancer detection was 4.0%. LIG DCIS increased linearly at a rate of 0.18 per 1000 per 1% increase in recall rate. CONCLUSIONS: Our models demonstrate the diminishing returns associated with increasing recall rates. The screening programme in England could use the models to set recall rate ranges, and other countries could explore similar methodology. KEY POINTS: • Question: How can we determine optimum recall rates in breast cancer screening? • Findings: In this large observational study, we show that increases in recall rates above defined levels are almost exclusively associated with false positive recalls and a very small increase in low/intermediate grade DCIS. • Meaning: High recall rates are not associated with increases in detection of life-threatening cancers. The models developed in this paper can be used to help set recall rate ranges that maximise benefit and minimise harm.

Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy.

INTRODUCTION: Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR. OBJECTIVE: The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated. STUDY DESIGN: A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000 Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥ 101.5 F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure. RESULTS: A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P = 0.003), but this was not associated with a higher reoperation rate (P = 0.168). There were 11 total complications, with three grade 3 complications. DISCUSSION: This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective design and the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram. CONCLUSION: Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.