Association of Hospital Altitude and Postoperative Infectious Complications After Major Operations.

Introduction: The relationship between altitude during treatment and common postoperative infections remains to be established. Based on the inverse relationship between oxygen partial pressure and altitude, we hypothesized that hospital elevation would correlate positively with postoperative infectious complication rates, including surgical site infection (SSI), urinary tract infection (UTI), and pneumonia. Methods: We used an event-enriched population of general, urologic, vascular, plastic-reconstructive, orthopedic, and thoracic patients within the 2016 ACS National Surgical Quality Improvement Program (NSQIP) dataset who underwent procedures with high risk of infectious complications. This yielded 82,172, 175,409, and 88,856 patients from 571, 577, and 570 hospitals for the study of 30-day postoperative SSI, UTI, and pneumonia outcomes respectively. Hospital altitudes were determined using Google Maps. Data were analyzed using univariate (altitude) and multivariate logistic regression, with altitude forced into the model, and forward-selection of NSQIP variables, with adjustment for clustering by hospital. Results: When compared in 1000-foot increments above sea level, hospital altitude had no significant effect on SSI or UTI (odds ratio [OR] = 1.0, p > 0.05). The risk of postoperative pneumonia decreased with increased altitude (OR = 0.93, 95% confidence interval: 0.87-0.99, p = 0.03). Conclusions: Patients and providers should be reassured that there is no increased risk of SSI or UTI at higher altitudes. The decreased risk of postoperative pneumonia was surprising and there exist potential explanations warranting future investigation.

Clean intermittent catheterization as an initial management strategy provides for adequate preservation of renal function in newborns with persistent cloaca.

INTRODUCTION: Persistent cloaca is a rare, congenital anomaly involving the genital, urinary, and rectal organ systems. While prompt bowel diversion is the standard of care, the optimal method of genitourinary decompression is unclear. Bladder outlet obstruction and hydrometrocolpos are common complications that can lead to obstructive uropathy, abdominal distention, infection, perforation, and acidosis. Proposed management strategies include early surgical diversion (vesicostomy, vaginostomy, ureterostomy, nephrostomy) or clean intermittent catheterization (CIC) of the common channel. We hypothesized that CIC is an adequate means of genitourinary decompression and preservation of renal function, regardless of the severity of cloacal anomaly. METHODS: We reviewed all patients with persistent cloaca from a single, tertiary care center from 1995 to 2013. We collected data regarding renal function (serial serum creatinine prior to definitive reconstruction, and baseline estimated glomerular filtration rate [GFR]), presence of hydrocolpos, hydronephrosis, vesicoureteral reflux (VUR) or renal dysplasia, and length of the common channel. A linear mixed model was used to calculate creatinine change over time in relation to method of management and child age. Estimated GFR was calculated using the Schwartz equation for neonates = 0.45 × height in cm/serum creatinine in mg/dL. The t test was used for continuous data and Fisher's exact test was used for binomial data. A p value <0.05 was considered significant. RESULTS: Twenty-five patients were identified. Nine (36%) patients underwent early surgical diversion versus 16 (64%) managed by CIC prior to formal reconstruction. Seven had short common channels (<3 cm) and 18 had long common channels (≥3 cm). Hydrocolpos was present in 14 (56%) of the patients. When comparing the two management groups, there was no significant difference in hydronephrosis, high-grade hydronephrosis (grades III-IV, p = 0.62), any VUR (p = 0.33), high-grade VUR (grades III-V, p = 0.62), hydrocolpos (p = 0.21), or renal dysplasia (p = 0.42). No significant differences were found between mean baseline GFR for diversion (22.9 mL/min per 1.73 m(2)) versus CIC (39.2 mL/min per 1.73 m(2), p = 0.22). There was no difference in creatinine trend between the two groups. DISCUSSION: Currently, there is no consensus on the initial management of obstructive uropathy and resulting hydrocolpos in newborns with persistent cloaca. In addition to CIC, management strategies include surgical options such as vesicostomy, vaginostomy, or upper tract diversions such as ureterostomy or nephrostomy. Our results suggest that CIC is similar to these other proposed diversion procedures while minimizing morbidity. Creatinine trends over time were similar between the two groups and reached comparable nadirs. Limitations of our study include the retrospective nature of a small sample size. The primary risk is differences between the two groups that we were not able to appreciate. Furthermore, we did not attempt to assess the morbidity of the two different strategies. CONCLUSIONS: CIC is an adequate initial management strategy to decompress the genitourinary tract in patients with persistent cloaca. CIC preserves renal function similar to early surgical decompression.

Distal hypospadias repair in infants without a postoperative stent.

PURPOSE: To review our experience with infants undergoing distal hypospadias repair without a postoperative stent to determine if an unacceptable complication rate might justify its use. METHODS: Children <1 year of age who underwent distal hypospadias repair by a single surgeon were identified through a prospectively maintained database. The use of a postoperative urethral stent was recorded for each case. Demographics, meatus position, operative technique and complications were also recorded. Patients older than 1 year or with hypospadias proximal to a subcoronal position were excluded. RESULTS: Eighty-nine patients without a stent were identified in addition to 21 patients who had a stent for a minimum of 3 days. At 3 months follow-up, 4/89 (4.49 %) patients in the stentless group required circumcision revision. 1 patient experienced urinary retention. 1/21 (4.76 %) patients with a postoperative stent required reoperation for meatal stenosis. CONCLUSIONS: The complication rate for infants undergoing distal hypospadias repair is low, does not appear to be significantly increased by forgoing a postoperative urethral stent. Avoiding a stent likely reduces a variety of associated adverse events and needs for short-term follow-up.

Discovery of hypospadias during newborn circumcision should not preclude completion of the procedure.

OBJECTIVE: To test the hypothesis that completion of newborn circumcision does not complicate hypospadias repair, and that circumcision will minimize future operations. STUDY DESIGN: Children referred for distal hypospadias over a 5-year period were grouped by presentation. Children with an aborted circumcision owing to concerns for hypospadias were subdivided into patients who underwent hypospadias repair (group 1a) and those who underwent circumcision (group 1b). Group 2 consisted of patients with a completed circumcision who underwent hypospadias repair. Children with traditionally recognized distal hypospadias served as controls. RESULTS: A total of 93 newborns had an aborted newborn circumcision. Of these, 28 underwent hypospadias repair (group 1a), and 47 underwent circumcision completion under general anesthesia (group 1b). The remaining 18 either deferred surgery or underwent in-office circumcision. Ten patients with hypospadias and an intact prepuce had a completed circumcision and subsequently underwent repair (group 2). The control group comprised 151 patients. No patients with a completed circumcision experienced complications after hypospadias repair, whereas the control group had a 5.3% rate of complications. CONCLUSION: Performing circumcision in newborns with hypospadias and an intact prepuce did not affect repair or the risk of complications. These findings, along with previous results, demonstrate that newborn circumcision can be safely completed in children with an intact prepuce. Furthermore, aborting a newborn circumcision after dorsal slit will expose a substantial number of children to additional procedures under general anesthesia.