Bowel preparation prior to reconstructive urologic surgery in pediatric myelomeningocele patients.

INTRODUCTION: Mechanical bowel preparation (MBP) has historically been the standard of care for patients undergoing reconstructive urologic surgery, including urinary diversion. To date, several studies have examined the role of mechanical bowel preparation in postoperative outcomes in pediatric patients undergoing augmentation cystoplasty. However, these patient populations have been heterogeneous in nature, with no studies dedicated to examining the role of MBP prior to reconstructive urologic surgery in pediatric patients with myelomenginoceles. Thus, our objective was to retrospectively assess perioperative measures and postoperative complications after reconstructive urologic surgery with or without mechanical bowel preparation in pediatric myelomeningocele patients. MATERIALS AND METHODS: From 2008 to 2013, 80 patients with myelomeningocele underwent reconstructive urologic surgery involving the use of bowel. Seventy patients underwent a preoperative MBP while 10 did not. Perioperative measures and postoperative complications for these two cohorts were assessed. RESULTS: Eighty patients with myelomeningocele were identified; 70 patients underwent MBP while 10 patients did not. There were no statistically significant differences in demographics or operative time. There were no statistically significant differences in postoperative outcomes including time to first bowel movement and time to tolerating diet. There was also no significant difference in overall complication rate; patients with MBP had 31/70 (44%) complications while 2/10 (20%) of those without MBP had complications (p = 0.18). CONCLUSION: There was no significant difference in perioperative measures and postoperative complications for patients who did not receive a mechanical bowel preparation. Our findings indicate that it is safe and warranted to perform a prospective, randomized study to better characterize the risks and benefits of preoperative bowel preparation for patients with myelomeningocele.

The Clavien-Dindo Classification of Surgical Complications is Not a Statistically Reliable System for Grading Morbidity in Pediatric Urology.

PURPOSE: Although the Clavien-Dindo classification of surgical complications has been evaluated using adult surgical patients, it is being applied to pediatric populations. We hypothesized that this instrument is not well suited to children and sought to determine the reliability of the tool in a pediatric urological population. MATERIALS AND METHODS: We replaced adult surgical cases in the "Survey to Assess Acceptability and Reproducibility of the Classification" from the original Clavien-Dindo study with pediatric urology cases and mimicked original study methods. The survey was distributed with the REDCap (Research Electronic Data Capture) tool, and Krippendorff α coefficients of reliability were calculated from the responses. RESULTS: There were 51 respondents and 40 complete responses. The Krippendorff α coefficient of reliability for the Clavien-Dindo classification (α = 0.487) did not achieve the minimum level of acceptable agreement (α = 0.667) with the pediatric urological cases, even when the disability suffix (α = 0.266) was excluded from the analysis (α = 0.632). The accuracy of the grading system with the pediatric urological surgical cases when excluding the disability suffix (410 of 550, 75%) was significantly less than the accuracy had been with the original adult cases (1,816 of 2,016, 90%, p <0.0001). While 89% of respondents (32 of 36) thought the system was appropriate for adults, only 49% (17 of 35) found it appropriate for children (p <0.001). CONCLUSIONS: The Clavien-Dindo classification of surgical complications is not a reliable tool for use in pediatric urology, where its accuracy is significantly decreased compared to adult surgical cases. Further study is needed to determine if findings are similar across all pediatric surgical groups.

The Role of Prophylactic Antibiotics After Minimally Invasive Pyeloplasty With Ureteral Stent Placement in Children.

OBJECTIVE: To determine whether children discharged with prophylactic antibiotics following laparoscopic pyeloplasty with indwelling ureteral stent have a decrease risk of postoperative urinary tract infections (UTIs) compared to those discharged without antibiotics. MATERIALS AND METHODS: A retrospective review of all minimally invasive pyeloplasties performed at our institution from January 2009 to March 2015 was conducted. Patients were discharged home with or without daily prophylactic-dose antibiotics continued until 3 days after ureteral stent removal per surgeon preference. The primary outcome was incidence of culture-positive UTI. Secondary outcomes included bacteriuria at time of stent removal and adverse events associated with extended antibiotic therapy. RESULTS: Of 163 pyeloplasties (106 robotic and 57 pure laparoscopic) performed over the study period, 126 patients were discharged on prophylactic antibiotics whereas 37 patients were discharged without prophylaxis. Groups were different with respect to median age (7.1 vs 12.0 years, P = .03) and median duration of ureteral stent (35 days vs 28 days, P = .02). The incidence of culture-positive UTI between the time of discharge and stent removal was comparably low between groups; 2/126 (1.6%) in the prophylaxis group and 1/37 (2.7%) in the group not on prophylaxis. At time of stent removal, perioperative urine culture was positive in 2/20 (10.0 %) patients who received prophylactic antibiotics and in 1/25 (4.0%) patients who did not (P = .54). CONCLUSION: The administration of extended prophylactic antibiotics showed no significant impact on the rate of UTI following minimally invasive pyeloplasty.

Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation.

PURPOSE: We performed a multi-institutional assessment of the outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux in children. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation as done by 1 of 5 surgeons at Children's Medical Center, Dallas, Texas, or Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, from 2010 to 2013. Procedure failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram and/or the need for reoperation. Multivariate logistic regression was done to identify possible risk factors for failure using STATA®, version 11. RESULTS: A total of 61 patients (93 ureters) with a mean age of 6.7 years (range 0.6 to 18.0) underwent a procedure, of which 32 (52%) were bilateral. Ten patients (16%) underwent previous subureteral injection for vesicoureteral reflux. At a mean followup of 11.7 months the procedure was successful in 44 of 61 patients (72%). There were 14 cases of persistent vesicoureteral reflux (23%), 6 complications (10%) and 9 reoperations (11%). Multivariate logistic regression identified no factor that increased the risk of failure (p = 0.737). CONCLUSIONS: Compared to the literature we found a notably lower success rate for robot-assisted laparoscopic extravesical ureteral reimplantation in the hands of 5 fellowship trained, robotically experienced pediatric urologists. More than 10% of patients required at least 1 reoperation for persistent vesicoureteral reflux or a surgical complication. Our experience suggests a higher complication rate and a lower success rate for robot-assisted laparoscopic ureteral reimplantation compared to the gold standard of open reimplantation.

Calyceal diverticulum with a large extra-renal extension in a 5-year-old child.

Calyceal diverticula are rare findings in children, often identified due to symptomatic presentation. We present the unique case of an incidentally found calyceal diverticula in a 5-year-old girl with a large extra-renal component, which was successfully excised in a robot-assisted laparoscopic procedure that was without complication.

Sacral neuromodulation for the dysfunctional elimination syndrome: a 10-year single-center experience with 105 consecutive children.

OBJECTIVE: To evaluate our initial experience using sacral neuromodulation via implanted pulse generator as a treatment for children with dysfunctional elimination syndrome and symptoms refractory to maximum medical therapy. MATERIALS AND METHODS: There were 105 consecutive patients who underwent a 2-stage procedure with a trial period (n = 89) or a single procedure (n = 16) for device implantation. They were followed up prospectively for a median of 2.72 years (average, 3.18 years; range, 0.01-9.63 years) for symptom improvement and resolution. RESULTS: Nearly all children (99 of 105 [94%]) experienced improvement of at least 1 symptom; 12 of 105 patients (11%) had at least 1 symptom worsen. Urinary incontinence, constipation, frequency and/or urgency, and nocturnal enuresis improved in 89 of 101 (88%), 73 of 92 (79%), 54 of 81 (67%), and 59 of 89 (66%) children, respectively, and resolved in 41 of 101 (41%), 37 of 92 (40%), 23 of 81 (28%), and 25 of 89 (28%) children, respectively. Outcomes among patients who did and did not undergo the trial were not significantly different (P = .19-1.00), and only 2 of 88 patients did not undergo permanent implantation. Reoperations (n = 85) occurred in 59 of 105 children (56%), mainly for device malfunction (n = 42), whereas explantation was performed in 36 of 104 children (35%) at an average of 2.68 years since implantation (median, 2.36 years; range, 0.03-9.04 years), mainly for complete symptom resolution (n = 12). Explantation for any reason was less common after single-stage procedures (1 of 16 [6%] vs 35 of 88 [40%] patients; P = .01). CONCLUSION: Sacral neuromodulation should be considered for children with dysfunctional elimination syndrome whose symptoms are refractory to maximum medical therapy understanding that the risk of reoperation is >50%. Elimination of the trial period reduces the number of general anesthetics without sacrificing outcomes.

Febrile urinary tract infections after ureteroneocystostomy and subureteral injection of dextranomer/hyaluronic acid for vesicoureteral reflux--do choice of procedure and success matter?

PURPOSE: Despite success rates favoring ureteroneocystostomy over subureteral injection of dextranomer/hyaluronic acid for correction of vesicoureteral reflux, the reported incidence of postoperative febrile urinary tract infection favors the latter. We evaluated contemporary treatment cohorts for an association between correction of vesicoureteral reflux and risk of postoperative febrile urinary tract infection. MATERIALS AND METHODS: We retrospectively reviewed the records of 396 consecutive patients who underwent ureteroneocystostomy or subureteral injection of dextranomer/hyaluronic acid between 1994 and 2008. Time to event multivariate analyses included preoperative grade of vesicoureteral reflux and bladder/bowel dysfunction. RESULTS: Of 316 patients meeting study criteria 210 underwent ureteroneocystostomy (356 ureters) and 106 underwent subureteral injection of dextranomer/hyaluronic acid (167). Median patient age was 5.7 years (IQR 3.4 to 8.3). Median followup was 28 months (IQR 8 to 61). Ureteral success was significantly greater after ureteroneocystostomy (88%, 314 of 356 cases) vs subureteral injection of dextranomer/hyaluronic acid (74%, 124 of 167, p = 0.0001). When controlling for preoperative grade of vesicoureteral reflux and bladder/bowel dysfunction, the risk of persistent reflux was 2.8 times greater after subureteral injection of dextranomer/hyaluronic acid (95% CI 1.7-4.7, p <0.0001). The incidence of febrile urinary tract infection did not significantly differ between ureteroneocystostomy (8%, 16 of 210 cases) and subureteral injection of dextranomer/hyaluronic acid (4%, 4 of 106; HR 1.96, 95% CI 0.64-5.9, p = 0.24) even when controlling for preoperative grade of vesicoureteral reflux, a predictor of postoperative febrile urinary tract infection on multivariate analysis (HR 2.2 per increase in grade, 95% CI 1.3-3.6, p = 0.0022). Persistent reflux was not a predictor of postoperative febrile urinary tract infection (HR 0.81, 95% CI 0.22-2.9, p = 0.75 for ureteroneocystostomy vs HR 1.8, 95% CI 0.2-17.3, p = 0.6 for subureteral injection of dextranomer/hyaluronic acid and HR 1.8, 95% CI 0.3-3.3, p = 0.6 for both). CONCLUSIONS: The incidence of postoperative febrile urinary tract infection may be independent of radiographic procedural success.

Temporal trends in incidence of kidney stones among children: a 25-year population based study.

PURPOSE: We conducted a population based pediatric study to determine the incidence of symptomatic kidney stones during a 25-year period and to identify factors related to variation in stone incidence during this period. MATERIALS AND METHODS: The Rochester Epidemiology Project was used to identify all patients younger than 18 years who were diagnosed with kidney stones in Olmsted County, Minnesota from 1984 to 2008. Medical records were reviewed to validate first time symptomatic stone formers with identification of age appropriate symptoms plus stone confirmation by imaging or passage. The incidence of symptomatic stones by age, gender and study period was compared. Clinical characteristics of incident stone formers were described. RESULTS: A total of 207 children received a diagnostic code for kidney stones, of whom 84 (41%) were validated as incident stone formers. The incidence rate increased 4% per calendar year (p = 0.01) throughout the 25-year period. This finding was due to a 6% yearly increased incidence in children 12 to 17 years old (p = 0.02 for age × calendar year interaction) with an increase from 13 per 100,000 person-years between 1984 and 1990 to 36 per 100,000 person-years between 2003 and 2008. Computerized tomography identified the stone in 6% of adolescent stone formers (1 of 18) from 1984 to 1996 vs 76% (34 of 45) from 1997 to 2008. The incidence of spontaneous stone passage in adolescents did not increase significantly between these 2 periods (16 vs 18 per 100,000 person-years, p = 0.30). CONCLUSIONS: The incidence of kidney stones increased dramatically among adolescents in the general population during a 25-year period. The exact cause of this finding remains to be determined.

Normal penile, scrotal, and perineal anatomy with reconstructive considerations.

A broad overview is provided of the normal anatomy of the male genitalia to offer the best surgical outcomes in cases related to congenital abnormalities, trauma, cancer-related extirpation, and aesthetics. Neural and vascular anatomy is discussed in depth due to its critical role in maintaining function and in assuring tissue viability.