A comparative study of experimental urinary catheters containing silver and zinc for biofilm inhibition.

Both commercial and experimental antibacterial urinary catheters were investigated for their efficacy in preventing planktonic growth and biofilm formation of Escherichia Coli bacteria in a synthetic urine solution. Experimental antibacterial catheters having thin (<500 µm) dispersions of Ag, Ag/Ag2O, or Zn/Ag2O in polydimethylsiloxane (PDMS) binder all exhibited significant antimicrobial activity, outperforming traditional commercial antibacterial catheters. All experimental catheters prevented planktonic growth of bacteria and did not exhibit biofilm formation during a six-day test period using a colony forming unit (CFU) measurement method. On the other hand, the best performing commercial catheters demonstrated efficacy for only 3 days in planktonic growth tests and formed multiple bacterial colonies in CFU measurements. The Zn/Ag2O/PDMS experimental catheter was the only catheter observed to produce hydrogen peroxide, a reactive oxygen species known to inhibit biofilm formation; lack of detectable hydrogen peroxide production by the Ag2O/PDMS and Ag/Ag2O/PDMS experimental catheters suggests that bactericidal action most likely arises from release of silver ions present in the PDMS coatings.

Cost analysis of removing pediatric ureteral stents with and without a retrieval string.

BACKGROUND: Indwelling ureteral stents are commonly placed in urologic surgeries where optimal urinary drainage is necessary. In the pediatric population, removing a stent without retrieval string (SWOS) requires a secondary operation and additional anesthetic exposure. Although these burdens can be mitigated through the placement of a stent with retrieval string (SWS), fears of complications may prevent widespread adoption of this practice by pediatric urologists. OBJECTIVE: The authors sought to assess the differential cost of removing SWS and SWOS. It was hypothesized that costs associated with removing SWS are significantly lower than those associated with removing SWOS, without increasing complications. STUDY DESIGN: A retrospective chart review was performed on pediatric patients undergoing common urologic surgeries with concurrent stent placement at a single tertiary referral center. Charges and healthcare costs surrounding the removal of ureteral stents were evaluated using the institution-specific ratio of cost to charges, by estimating lost wages, and by exploring differences in poststent healthcare-related events that incur additional cost. RESULTS: A total of 109 patients with a median age of 5 years (range: 6 months-20 years) were reviewed. A total of 29 patients had SWS, and 80 had SWOS. The theoretical cost of SWS removal in clinic was $400.48 compared with $2290.86 ± $119.30 for operative removal of SWOS, with mean difference of $1890.38 (P < 0.01). The mean stent duration of SWOS was 34.0 ± 13.2 days vs. 10.1 ± 4.9 days for SWS (P < 0.01). Subgroup analysis of the ureteral reconstruction group showed no difference in any complications (35% vs 27%, respectively), early dislodgment (7% vs 7%, respectively) or costly healthcare utilization (23% vs 20%, respectively) among patients with SWOS compared with those with SWS. In SWS group with early dislodgment, neither required a secondary procedure. DISCUSSION: With rising healthcare expenditures, physicians must be able to provide cost-effective treatment while not compromising safety or outcomes. Unlike prior analyses of cost related to the type of the stent used, the present study specifically reviewed costs of removing SWS versus SWOS and evaluated rates of costly complications. The study findings provide a preliminary basis for advocating the more economical use of SWS when indicated. Lack of power and heterogeneity of the groups need to be addressed in future analyses with larger, matched cohorts. CONCLUSION: Removal of SWS is more cost-effective than that of SWOS while maintaining similar safety outcomes and should be considered in certain pediatric urology cases to decrease healthcare cost. SWS should be preferred for uncomplicated ureteroscopy, but benefits are less certain in ureteral reconstruction; further studies are needed.

Reducing Opioid Prescriptions in Outpatient Pediatric Urological Surgery.

PURPOSE: We assessed the impact of a 2-phase Plan-Do-Study-Act cycle to decrease opioid prescriptions following pediatric urological surgery. MATERIALS AND METHODS: Parents of children undergoing outpatient urological procedures were given questionnaires to assess opioid dosing and pain scores using the Parents' Postoperative Pain Measure scale. Age, procedure and opioid prescription data were recorded, as well as volume of medication administered. During the first phase of data collection children received an opioid prescription for 10 doses. In the second phase opioid prescriptions were reduced by 50%. Nonparametric tests and Fisher exact test were used for analysis. RESULTS: Of 250 eligible children 98 (39%) with a median age of 3.0 years (IQR 7.0) participated. In the 81 patients prescribed opioids a median of 2 doses (IQR 3.6) were used in the preintervention and postintervention groups (p = 0.68). Using nonparametric statistical testing, no significant differences were found between pain scores in the 5-dose group (31 patients) and the 10-dose group (24 patients; p = 0.05 for day 1, p = 0.07 for day 2, p = 0.06 for day 3). There was no association between age and percent opioid used (p = 0.83). There were no significant differences in median pain scores or median doses among procedure types. CONCLUSIONS: In outpatient pediatric surgical practice opioid prescriptions can be decreased without increasing pain scores. Physician prescribing practices may contribute more to opioid consumption than actual pain patterns.

Reflux Timing Is a Predictor of Successful Endoscopic Treatment of Vesicoureteral Reflux.

OBJECTIVE: To determine whether vesicoureteral reflux (VUR) that occurs during either the filling or voiding phase on voiding cystourethrogram (VCUG) has prognostic significance on successful endoscopic treatment. MATERIALS AND METHODS: A retrospective review was performed of 299 patients (438 ureters) with VUR who underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux) at a single institution from 2010 to 2013. Success was defined as absence of VUR on 3-month follow-up VCUG. Preoperative VCUGs were analyzed to determine whether the onset of VUR occurred during the filling or voiding phase. Predictor variables to determine success were analyzed, with a specific focus on VUR timing. RESULTS: Success rate was 319/438 (72.8%) by ureter and 202/299 (67.6%) by patient. Reflux was seen during the filling and voiding phases in 290 and 148 ureters, respectively. Success rate was 203/290 (78%) for filling VUR and 116/148 (70%) for voiding VUR. Univariable analysis revealed voiding VUR had significantly increased odds of success (odds ratio [OR] 3.2, P = .049), while high-grade reflux (OR 0.53, P = .005) had significantly decreased odds of success. Multivariable analysis showed that voiding VUR (OR 3.2, P = .005) had significantly higher odds of success while those with high grade reflux (OR 0.42, P = .017) had significantly decreased odds of success. CONCLUSION: The timing of VUR on preoperative VCUG appears to be an important independent predictor of successful endoscopic treatment of VUR. This has important clinical considerations when selecting VUR patients who would be best candidates for endoscopic treatment.

Unilateral extravesical ureteral reimplantation via inguinal incision for the correction of vesicoureteral reflux: a 10-year experience

ABSTRACT Introduction and Objective: Multiple options exist for the surgical management of vesicoureteral reflux (VUR). We report on our 10-year experience using the inguinal approach to extravesical ureteral reimplantation (EVR). Materials and Methods: Patient characteristics of age, gender, and reflux grade were obtained and outcomes of operative time, hospital stay, and radiographic resolution were assessed. Results: 71 girls and 20 boys with a mean age of 74 months (range 14-164) underwent inguinal EVR via a 3.5-cm inguinal mini-incision. Mean follow up was 10.9 months (range 0.4-69.7). Average grade of reflux was 2.80. Average operative time was 91 minutes (range 51-268). The procedure was successful in 87 of 91 patients (95.6%). The 3 cases of reflux that persisted were all grade 1 and managed expectantly. Contralateral reflux developed in 9 cases, all of which resolved after treatment with either Deflux or ureteral reimplant. There were 4 case of urinary retention that resolved after a brief period of CIC or indwelling catheterization. There were no cases of ureteral obstruction. Most patients were discharged on post-operative day 1 (85/91) and no hospitalization extended beyond 3 days. Conclusions: The inguinal approach to extravesical ureteral reimplantation should be considered as a potentially minimally invasive alternative to endoscopic and robotic treatment of VUR with a success rate more comparable to traditional open approaches. We feel it is the method of choice in cases of unilateral VUR requiring surgical correction.

Unilateral extravesical ureteral reimplantation via inguinal incision for the correction of vesicoureteral reflux: a 10-year experience.

INTRODUCTION AND OBJECTIVE: Multiple options exist for the surgical management of vesicoureteral reflux (VUR). We report on our 10-year experience using the inguinal approach to extravesical ureteral reimplantation (EVR). MATERIALS AND METHODS: Patient characteristics of age, gender, and reflux grade were obtained and outcomes of operative time, hospital stay, and radiographic resolution were assessed. RESULTS: 71 girls and 20 boys with a mean age of 74 months (range 14-164) underwent inguinal EVR via a 3.5-cm inguinal mini-incision. Mean follow up was 10.9 months (range 0.4-69.7). Average grade of reflux was 2.80. Average operative time was 91 minutes (range 51-268). The procedure was successful in 87 of 91 patients (95.6%). The 3 cases of reflux that persisted were all grade 1 and managed expectantly. Contralateral reflux developed in 9 cases, all of which resolved after treatment with either Deflux or ureteral reimplant. There were 4 case of urinary retention that resolved after a brief period of CIC or indwelling catheterization. There were no cases of ureteral obstruction. Most patients were discharged on post-operative day 1 (85/91) and no hospitalization extended beyond 3 days. CONCLUSIONS: The inguinal approach to extravesical ureteral reimplantation should be considered as a potentially minimally invasive alternative to endoscopic and robotic treatment of VUR with a success rate more comparable to traditional open approaches. We feel it is the method of choice in cases of unilateral VUR requiring surgical correction.

Comparison of laparoendoscopic single-site, conventional laparoscopic, and open nephrectomy in a pediatric population.

INTRODUCTION: We provide a single-institution comparison of open, conventional laparoscopic (CL) and laparoendoscopic single-site (LESS) nephrectomy in children. METHODS: We identified all nephrectomy cases occurring at Rady Children's Hospital from July 2007 to March 2010. Exclusion criteria included redo/bilateral operations, malignancy, transplant nephrectomy, or complex urogenital anomalies. We compared patient demographics, total operative times, estimated blood loss (EBL), length of stay (LOS), complication rates, postoperative pain score, narcotic usage, and total hospital costs. RESULTS: We identified 7 LESS, 11 CL, and 8 open nephrectomy patients who met our criteria. The mean age of patients was 8.5, 7.3, and 4.2 years for LESS, CL, and open nephrectomy, respectively (P=.217). Operative times were 192.2, 219.3, and 127.4 minutes for LESS, CL, and open nephrectomy, respectively (P=.076). EBL was 15, 13.2, and 12.5 mL, respectively, for these groups (P=.871). There were no complications in any of the groups, although 1 LESS patient required conversion to open nephrectomy for bleeding. Mean LOS was 46.8, 36.9, and 33.8 hours in the LESS, CL, and open nephrectomy groups (P=.308). Mean pain scores on postoperative day 1 were 2.3, 1.8, and 1.6 in each group, respectively (P=.518). Hospital costs were comparable between the LESS and CL groups. The mean cost for open nephrectomy was 54.4% the mean cost for CL, however (P=.001). CONCLUSIONS: LESS nephrectomy in children is safe and overall comparable with CL. In our experience, no modality confers a distinct advantage except for the decreased cost associated with open surgery.

Identification of filling versus voiding reflux as predictor of clinical outcome.

OBJECTIVES: In children diagnosed with vesicoureteral reflux (VUR), the identification of reflux is made during either the filling (filling reflux) or voiding (voiding reflux) phase of the voiding cystourethrogram. A retrospective study was performed to determine whether this radiologic distinction has prognostic significance. METHODS: A retrospective chart review was performed of patients who had undergone voiding cystourethrography from July 1999 to June 2004. Patient age, sex, and reflux grade (unilateral and bilateral) were independently examined in relation to spontaneous resolution, surgical intervention, or observation. These data were subjected to chi-square, analysis of variance with post hoc test, and Kaplan-Meier analysis. RESULTS: The diagnosis of primary VUR was identified in 218 patients, and sufficient chart information and hardcopy films to permit identification of filling versus voiding reflux were available for 201. Of 201 patients, 115 (57%) had filling reflux and 86 (43%) had voiding reflux. Of the 115 with filling reflux, 53 (46%) underwent surgery and 27 (23%) had spontaneous resolution (P <0.001). Of the 86 patients with voiding reflux, 12 (14%) underwent surgery and 57 (66%) had spontaneous resolution (P <0.0001). Advanced age and grade of reflux were independently associated with surgical intervention (P <0.0001 and P <0.04, respectively). CONCLUSIONS: Our results have shown that VUR that is first identified during the filling phase of the initial voiding cystourethrogram is more likely to require surgical intervention. In contrast, VUR that is first identified during the voiding phase was independently associated with a greater rate of spontaneous resolution. This radiologic distinction, in addition to reflux grade, might be useful in predicting the clinical outcome for children diagnosed with primary VUR.

Dietl's crisis: an under-recognized clinical entity in the pediatric population.

OBJECTIVE: To characterize and determine whether patients with recurrent abdominal symptoms and associated ureteropelvic junction obstruction (UPJO) (Dietl's crisis) are effectively treated by pyeloplasty and to determine criteria for evaluating UPJO in childhood abdominal pain. MATERIALS AND METHODS: A retrospective chart review from 1998 to 2001 was performed to identify patients with Dietl's crisis and associated UPJO. Chart review included presenting symptoms, location of lesion, condition of the affected renal unit, referral method, and surgery success. RESULTS: Eight patients (7 male and 1 female) were identified with Dietl's crisis. All eight were initially misdiagnosed and spent at least a year with significant pain symptoms before being properly diagnosed. Only one patient had associated urologic complaints. Renal scan split functions of the affected renal unit ranged from 34% to 51%. One nephrectomy and seven pyeloplasties were performed and resolution of all patients' abdominal symptoms, including pain, resolved. CONCLUSIONS: Children with Dietl's crisis often suffer a delay in diagnosis; the clinical entity appears to be under-diagnosed. Renal parenchyma is typically preserved, and there is a paucity of associated urologic complaints. Once properly diagnosed, patients are well served by a pyeloplasty. Children with periumbilical pain and vomiting, particularly males, would benefit from ultrasound imaging.

Dietl's crisis: an under-recognized clinical entity in the pediatric population

OBJECTIVE: To characterize and determine whether patients with recurrent abdominal symptoms and associated ureteropelvic junction obstruction (UPJO) (Dietl's crisis) are effectively treated by pyeloplasty and to determine criteria for evaluating UPJO in childhood abdominal pain. MATERIALS AND METHODS: A retrospective chart review from 1998 to 2001 was performed to identify patients with Dietl's crisis and associated UPJO. Chart review included presenting symptoms, location of lesion, condition of the affected renal unit, referral method, and surgery success. RESULTS: Eight patients (7 male and 1 female) were identified with Dietl's crisis. All eight were initially misdiagnosed and spent at least a year with significant pain symptoms before being properly diagnosed. Only one patient had associated urologic complaints. Renal scan split functions of the affected renal unit ranged from 34 percent to 51 percent. One nephrectomy and seven pyeloplasties were performed and resolution of all patients' abdominal symptoms, including pain, resolved. CONCLUSIONS: Children with Dietl's crisis often suffer a delay in diagnosis; the clinical entity appears to be under-diagnosed. Renal parenchyma is typically preserved, and there is a paucity of associated urologic complaints. Once properly diagnosed, patients are well served by a pyeloplasty. Children with periumbilical pain and vomiting, particularly males, would benefit from ultrasound imaging.

Traumatic adrenal injuries.

PURPOSE: We determined the prevalence, management and general prognosis of blunt isolated and nonisolated adrenal injuries in a pediatric population. MATERIAL AND METHODS: We analyzed trauma data from a pediatric institution for the period 1991 to 1998 to identify patients with blunt traumatic adrenal injuries diagnosed by computerized tomography. We then performed a detailed chart review to obtain data on the presence of concomitant intra-abdominal and extra-abdominal injuries, transfusion requirements, intensive care unit monitoring requirements, hospital course and the presence of followup studies. RESULTS: Among 9,199 pediatric trauma cases we identified 20 adrenal injuries (0.22%), of which 15 (75%) were nonisolated and 5 (25%) were isolated. The right adrenal gland was injured in 17 (85%) of the 20 patients. In the 15 nonisolated adrenal injuries concomitant injury to the liver (13 cases, 87%) and ipsilateral kidney (8 cases, 53%) were most common. Three (60%) of the 5 patients with isolated adrenal injury required transfusion for adrenal hemorrhage. No patient required intensive care unit monitoring or operative intervention. Only 2 (10%) of the 20 patients underwent followup computerized tomography, both of whom had resolution of the adrenal injury. CONCLUSIONS: In the pediatric population blunt adrenal injuries are rare and typically present as part of a multiorgan trauma. The right adrenal gland is more likely to be injured, with liver trauma as the most commonly associated injury, followed by ipsilateral renal injury. Although there is a possibility of significant adrenal hemorrhage requiring transfusion, adrenal trauma is typically self-limited and does not require intensive care monitoring or operative intervention.

Leydig cell tumor in a child with spermatocyte maturation and no pseudoprecocious puberty.

Leydig cell tumor in a child is uniformly associated with isosexual pseudoprecocity. We report a unique case of an 8-year-old boy diagnosed with Leydig cell tumor who had histologic evidence of discrete spermatocyte maturation and Sertoli cell hyperplasia along the periphery of his tumor but no clinical evidence of pseudoprecocious puberty.

Tubeless Barcat: a patient-friendly hypospadias procedure.

OBJECTIVES: To determine whether the distinct advantages of a catheter-free hypospadias repair can be obtained with a Barcat procedure without an adverse effect on surgical outcome. METHODS: A retrospective review was performed on consecutive patients who had undergone a catheter-free Barcat repair from July 1998 to May 2002. Patient records were examined for information regarding age, meatal location, primary or secondary procedure, operative time, postoperative follow-up, and complications. RESULTS: Thirty-six consecutive catheter-free Barcat hypospadias repairs were performed in the review period. Patient age ranged from 6 months to 9 years (mean 26 months). All patients either had a coronal meatus or a subcoronal meatus. Thirty-three patients (92%) underwent a primary repair. Three patients (8%) underwent the repair as a secondary procedure after a previous failed procedure. The mean follow-up was 25 months. One patient required a single catheterization in the immediate postoperative period for urinary retention. Another patient had glans separation and meatal retrusion requiring a revision procedure. All the other patients achieved a satisfactory cosmetic result with an orthotopic slit-like meatus. CONCLUSIONS: The Barcat hypospadias repair may be performed in patients with distal hypospadias without the use of a postoperative urethral catheter. Foregoing a catheter had no adverse effect on the surgical outcome with reduced patient discomfort.